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Attieh RM, Wadei HM, Mao MA, Mao SA, Pungpapong S, Taner CB, Jarmi T, Cheungpasitporn W, Leeaphorn N. The impact of induction therapy on the risk of posttransplant lymphoproliferative disorder in adult kidney transplant recipients with donor-recipient serological Epstein-Barr virus mismatch. Am J Transplant 2024:S1600-6135(24)00170-9. [PMID: 38447887 DOI: 10.1016/j.ajt.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/27/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
Posttransplant lymphoproliferative disorder (PTLD) poses a significant concern in Epstein-Barr virus (EBV)-negative patients transplanted from EBV-positive donors (EBV R-/D+). Previous studies investigating the association between different induction agents and PTLD in these patients have yielded conflicting results. Using the Organ Procurement and Transplant Network database, we identified EBV R-/D+ patients >18 years of age who underwent kidney-alone transplants between 2016 and 2022 and compared the risk of PTLD with rabbit antithymocyte globulin (ATG), basiliximab, and alemtuzumab inductions. Among the 6620 patients included, 64.0% received ATG, 23.4% received basiliximab, and 12.6% received alemtuzumab. The overall incidence of PTLD was 2.5% over a median follow-up period of 2.9 years. Multivariable analysis demonstrated that the risk of PTLD was significantly higher with ATG and alemtuzumab compared with basiliximab (adjusted subdistribution hazard ratio [aSHR] = 1.98, 95% confidence interval [CI] 1.29-3.04, P = .002 for ATG and aSHR = 1.80, 95% CI 1.04-3.11, P = .04 for alemtuzumab). However, PTLD risk was comparable between ATG and alemtuzumab inductions (aSHR = 1.13, 95% CI 0.72-1.77, P = .61). Therefore, the risk of PTLD must be taken into consideration when selecting the most appropriate induction therapy for this patient population.
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Affiliation(s)
- Rose Mary Attieh
- Department of Transplant, Mayo Clinic, Jacksonville, Florida, USA
| | - Hani M Wadei
- Department of Transplant, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael A Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida, USA
| | - Shennen A Mao
- Department of Transplant, Mayo Clinic, Jacksonville, Florida, USA
| | | | - C Burcin Taner
- Department of Transplant, Mayo Clinic, Jacksonville, Florida, USA
| | - Tambi Jarmi
- Department of Transplant, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Napat Leeaphorn
- Department of Transplant, Mayo Clinic, Jacksonville, Florida, USA.
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2
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Johnson MR. But Is All Post-Transplant Lymphoproliferative Disorder Created Equal? JACC. HEART FAILURE 2024; 12:406-408. [PMID: 38326003 DOI: 10.1016/j.jchf.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 02/09/2024]
Affiliation(s)
- Maryl R Johnson
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.
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3
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Chiodo Ortiz A, Petrossian G, Addonizio K, Hsiao A, Koizumi N, Yu Y, Plews R, Conti D, Ortiz J. Short-term decreased post transplant lymphoproliferative disorder risk after kidney transplantation using two novel regimens. Transpl Immunol 2023; 76:101774. [PMID: 36528248 DOI: 10.1016/j.trim.2022.101774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 12/06/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Belatacept is employed alongside calcineurin inhibitor (CNI) therapy to prevent graft rejection in kidney transplant patients who are Epstein-Barr virus (EBV) seropositive. Preliminary data suggested that rates of post-transplant lymphoproliferative disorder (PTLD) were higher in individuals treated with belatacept compared to CNI therapy alone. METHODS The records of 354 adults who underwent kidney only transplantation from January 2015 through September 2021 at one medical center were evaluated. Patients underwent treatment with either low-doses of mycophenolate, tacrolimus and sirolimus (B0, n = 235) or low-doses of mycophenolate, tacrolimus and belatacept (B1, n = 119). All recipients underwent induction with antithymocyte globulin and a rapid glucocorticosteroid taper. Relevant donor and recipient information were analyzed and endpoints of PTLD were assessed. RESULTS There were no cases of PTLD in either cohort within the study period. Recipients in the belatacept cohort experienced lower estimated glomerular filtration rates at 12 months (B0: 67.48 vs. B1: 59.10, p = 0.0014). Graft failure at 12 (B0: 1.28% vs. B1: 0.84%, p = 1.0) and 24 months (B0:2.55% vs. B1: 0.84%, p = 0.431) were similar. There was no difference in rejection rates at 12 (B0: 1.27% vs. B1: 2.52%, p = 0.408) or 24 months (B0: 2.12% vs. B1: 2.52%, p = 1.000). Both groups had similar rates of malignancy, mortality and CMV/BK viremia. CONCLUSION Non-belatacept (MMF, tacrolimus and sirolimus) and belatacept-based (MMF, tacrolimus and belatacept) regimens do not appear to pose any increased risk of early onset PTLD. Both cohorts benefited from low rates of rejection, malignancy, mortality and graft failure. Recipients will continue to be monitored as PTLD can manifest as a long-term complication.
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Affiliation(s)
- A Chiodo Ortiz
- Albany Medical Center, Albany, NY, United States of America.
| | - G Petrossian
- Albany Medical Center, Albany, NY, United States of America
| | - K Addonizio
- Albany Medical Center, Albany, NY, United States of America
| | - A Hsiao
- Albany Medical Center, Albany, NY, United States of America
| | - N Koizumi
- George Mason University, Fairfax, VA, United States of America
| | - Y Yu
- George Mason University, Fairfax, VA, United States of America
| | - R Plews
- Division of Renal and Pancreatic Transplant Services, Albany Medical Center, Albany, NY, United States of America
| | - D Conti
- Division of Renal and Pancreatic Transplant Services, Albany Medical Center, Albany, NY, United States of America
| | - J Ortiz
- Division of Renal and Pancreatic Transplant Services, Albany Medical Center, Albany, NY, United States of America
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 73] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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5
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Low dose rabbit antithymocyte globulin is non-inferior to higher dose in low-risk pediatric kidney transplant recipients. Pediatr Nephrol 2022; 37:2091-2098. [PMID: 35006359 DOI: 10.1007/s00467-021-05407-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 11/02/2021] [Accepted: 12/01/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Currently, there is no consensus among pediatric kidney transplant centers regarding the use and regimen for immunosuppressive induction therapy. METHODS In this single center, retrospective cohort study, pediatric kidney transplant recipients transplanted between 1 May 2013 and 1 May 2018 with rabbit antithymocyte globulin (rATG) induction were included. We stratified patients based on immunological risk, with high risk defined as those with repeat transplant, preformed donor specific antibody, current panel-reactive antibodies > 20%, 0 antigen match and/or African-American heritage. Outcome of interest was the incidence of biopsy proven acute rejection by 1 year. RESULTS A total of 166 patients met inclusion criteria. Age of patients was 12 years (11 mo-21 y), (median, range), 21.5% received a living donor transplant and 50.6% were female. Low-immunologic-risk patients were divided into 2 groups, those who received the lower cumulative rATG dose of ≤ 3.5 mg/kg (n = 52) versus the higher cumulative dose of > 3.5 mg/kg (n = 47). The median total dose in the lower dose group was 3.1 (IQR 0.3) and 4.4 (IQR 0.8) in the higher dose group, P < 0.001. Rejection rate did not differ significantly between the 2 treatment groups (7/52 vs. 6/47). None in the lower dose group developed BK nephropathy versus 3 in the higher dose group. Graft loss due to BK nephropathy occurred in 1 patient in the higher dose group. Graft loss in the whole cohort at 12 months was a rare event (n = 1) with 99.5% graft survival and 100% patient survival. CONCLUSIONS Reduced rATG dosing (≤ 3.5 mg/kg) when compared to higher dosing (> 3.5 mg/kg) is safe and effective in low-risk pediatric kidney transplant recipients without increasing risk of rejection. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Bubik RJ, Dierkhising RA, Mara KC, Daly RC, Kushwaha SS, Clavell AL, Bernard SA. Malignancy among adult heart transplant recipients following patient-tailored dosing of anti-thymocyte globulin: a retrospective, nested case-control study of individualized dosing. Transpl Int 2021; 34:2175-2183. [PMID: 34411345 DOI: 10.1111/tri.14012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/22/2021] [Accepted: 08/13/2021] [Indexed: 11/29/2022]
Abstract
Post-transplant malignancy is diagnosed in approximately 18% of heart transplant patients and is a leading cause of death post-transplant. One modifiable risk factor is the type and amount of immunosuppression received. Contemporary rabbit anti-thymocyte globulin (rATG) dosing strategy using T-cell-guided dosing, and its effect on malignancy in heart transplant patients is unclear. This was a single-center, retrospective chart review of heart transplant recipients receiving rATG for induction. Patients diagnosed with malignancy post-transplant were matched 1:2 to controls using a nested case-control design. The primary endpoint was to determine the relative risk of rATG exposure with the actual incidence of malignancy post-transplant. The secondary endpoint was the impact of maintenance immunosuppression on malignancy risk. Of the 126 patients included in the study, 25 developed malignancy and were matched to 50 control patients. The median cumulative rATG dose in milligrams (mg) between groups was 365 mg in malignancy cases and 480 mg in controls (OR 0.90, 95% CI 0.75-1.08, P = 0.28). In both the univariate and multivariable analysis, there was no statistically significant difference in malignancy risk found with any maintenance immunosuppressant. The results of this study showed that patient-tailored rATG dosing strategies may not be associated with malignancy development as previously thought.
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Affiliation(s)
| | - Ross A Dierkhising
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Richard C Daly
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA.,Divison of Transplantation Surgery, Mayo Clinic, Rochester, MN, USA
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Optimal Immunosuppression Strategy in the Sensitized Kidney Transplant Recipient. J Clin Med 2021; 10:jcm10163656. [PMID: 34441950 PMCID: PMC8396983 DOI: 10.3390/jcm10163656] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/09/2021] [Accepted: 08/15/2021] [Indexed: 01/10/2023] Open
Abstract
Patients with previous sensitization events against anti-human leukocyte antigens (HLA) often have circulating anti-HLA antibodies. Following organ transplantation, sensitized patients have higher rates of antibody-mediated rejection (AMR) compared to those who are non-sensitized. More stringent donor matching is required for these patients, which results in a reduced donor pool and increased time on the waitlist. Current approaches for sensitized patients focus on reducing preformed antibodies that preclude transplantation; however, this type of desensitization does not modulate the primed immune response in sensitized patients. Thus, an optimized maintenance immunosuppressive regimen is necessary for highly sensitized patients, which may be distinct from non-sensitized patients. In this review, we will discuss the currently available therapeutic options for induction, maintenance, and adjuvant immunosuppression for sensitized patients.
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Mudigonda P, Berardi C, Chetram V, Barac A, Cheng R. Implications of cancer prior to and after heart transplantation. Heart 2021; 108:414-421. [PMID: 34210749 DOI: 10.1136/heartjnl-2020-318139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 06/02/2021] [Indexed: 12/11/2022] Open
Abstract
Cancer and cardiovascular disease share many risk factors. Due to improved survival of patients with cancer, the cohort of cancer survivors with heart failure referred for heart transplantation (HT) is growing. Specific considerations include time interval between cancer treatment and HT, risk for recurrence and risk for de novo malignancy (dnM). dnM is an important cause of post-HT morbidity and mortality, with nearly a third diagnosed with malignancy by 10 years post-HT. Compared with the age-matched general population, HT recipients have an approximately 2.5-fold to 4-fold increased risk of developing cancer. HT recipients with prior malignancy show variable cancer recurrence rates, depending on years in remission before HT: 5% recurrence if >5 years in remission, 26% recurrence if 1-5 years in remission and 63% recurrence if <1 year in remission. A myriad of mechanisms influence oncogenesis following HT, including reduced host immunosurveillance from chronic immunosuppression, influence of oncogenic viruses, and the cumulative intensity and duration of immunosuppression. Conversely, protective factors include acyclovir prophylaxis, use of proliferation signal inhibitors (PSI) and female gender. Management involves reducing immunosuppression, incorporating a PSI for immunosuppression and heightened surveillance for allograft rejection. Cancer treatment, including immunotherapy, may be cardiotoxic and lead to graft failure or rejection. Additionally, there exists a competing risk to reduce immunosuppression to improve cancer outcomes, which may increase risk for rejection. A multidisciplinary cardio-oncology team approach is recommended to optimise care and should include an oncologist, transplant cardiologist, transplant pharmacist, palliative care, transplant coordinator and cardio-oncologist.
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Affiliation(s)
- Parvathi Mudigonda
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Cecilia Berardi
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Vishaka Chetram
- Department of Medicine, MedStar Washington Hospital Center, Georgetown University, Washington, DC, USA
| | - Ana Barac
- Department of Cardiology, MedStar Heart and Vascular Institute, Georgetown University, Washington, DC, USA
| | - Richard Cheng
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
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10
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Patil R, Prashar R, Patel A. Heterogeneous Manifestations of Posttransplant Lymphoma in Renal Transplant Recipients: A Case Series. Transplant Proc 2021; 53:1519-1527. [PMID: 34134932 DOI: 10.1016/j.transproceed.2021.04.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/05/2021] [Accepted: 04/19/2021] [Indexed: 01/07/2023]
Abstract
Posttransplant lymphoproliferative disorder (PTLD) occurs in 1% to 3% of adult renal transplant recipients (RTRs). PTLD has a heterogeneous presentation and is often associated with Epstein-Barr virus (EBV) and immunosuppression. We present a descriptive case series of 16 RTRs who demonstrate a variety of PTLD manifestations. Fifty-six percent received rabbit antithymocyte globulin induction, and 37.5% received basiliximab. Maintenance immunosuppression included glucocorticoids, tacrolimus, and mycophenolate mofetil. Median time from transplantation to PTLD diagnosis was 96.5 months. PTLD involved a single site in 44% of RTRs and multiple sites in 56%. PTLD was localized to the gastrointestinal tract in 9 RTRs, in lymph nodes in 9, central nervous system in 4, bone marrow in 3, skin in 3, lungs in 2, perinephric space in 2, mediastinum in 1, and native kidney in 1. PTLD was EBV positive in 8 RTRs, monomorphic/monoclonal in 14, and of B-cell lineage in 13. Three RTRs had T-cell PTLD. Immunosuppressive agents, except glucocorticoids, were discontinued at diagnosis. Treatment was chemotherapy either alone (in 14 RTRs) or in combination with radiation. Complete remission was achieved in 62.5% of RTRs. Renal dysfunction developed in 62.5% of RTRs, and 4 received dialysis. The overall mortality rate was 62.5%, with median time of death 6.5 months after diagnosis. PTLD that was EBV negative and had T-cell involvement presented with aggressive disease and a higher mortality. Clinicians should be aware of the various PTLD manifestations. Early diagnosis and a multidisciplinary approach to treatment is crucial for improved patient outcomes.
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Affiliation(s)
- Rujuta Patil
- Wayne State University School of Medicine, Detroit, Michigan
| | - Rohini Prashar
- Kidney and Pancreas Transplant Program, Henry Ford Transplant Institute, Detroit, Michigan
| | - Anita Patel
- Kidney and Pancreas Transplant Program, Henry Ford Transplant Institute, Detroit, Michigan.
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Liverman R, Chandran MM, Crowther B. Considerations and controversies of pharmacologic management of the pediatric kidney transplant recipient. Pharmacotherapy 2021; 41:77-102. [PMID: 33151553 DOI: 10.1002/phar.2483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/18/2020] [Accepted: 10/10/2020] [Indexed: 12/23/2022]
Abstract
Pediatric kidney transplantation has experienced considerable growth and improvement in patient and allograft outcomes over the past 20 years, in part due to advancements in immunosuppressive regimens and management. Despite this progress, care for this unique population can be challenging due to limited pediatric transplant data and trials, intricacies related to differences in children and adolescents compared with their adult counterparts, and limitations to long-term survival facing all solid organ transplant populations. Immunosuppression and infection prevention practices vary from one pediatric transplant center to another and clinical controversies exist surrounding treatment and dosing. This review aims to summarize key aspects of pharmacologic management in this population and present pertinent data that describe the influence of practice to serve as a resource for practitioners caring for this unique specialty patient population. Additionally, this review highlights select controversies that exist within pediatric kidney transplantation.
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Affiliation(s)
- Rochelle Liverman
- Department of Pharmacy, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Mary Moss Chandran
- Department of Pharmacy, Childeren's Hospital Colorado, Aurora, Colorado, USA
| | - Barrett Crowther
- Ambulatory Care Pharmacy Services, University of Colorado Hospital, Aurora, Colorado, USA
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Boucquemont J, Foucher Y, Masset C, Legendre C, Scemla A, Buron F, Morelon E, Garrigue V, Pernin V, Albano L, Sicard A, Girerd S, Ladrière M, Giral M, Dantal J. Induction therapy in kidney transplant recipients: Description of the practices according to the calendar period from the French multicentric DIVAT cohort. PLoS One 2020; 15:e0240929. [PMID: 33091057 PMCID: PMC7580969 DOI: 10.1371/journal.pone.0240929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 10/06/2020] [Indexed: 11/19/2022] Open
Abstract
Background There is extensive literature with comparisons between Anti-Thymocyte Globulin (ATG) and Basiliximab (BSX) as induction therapy in kidney transplant recipients. The purpose of our benchmarking study was to describe the consequences in terms of practices in 6 transplantation centers of a French prospective cohort. Methods We included adult patients who received a first or second kidney graft between 2013 and 2019 (n = 4157). We used logistic regressions to identify characteristics associated with the use of ATG or BSX. Results Use of ATG between the centers ranged from 41% to 75%. We observed different factors associated with the treatment decision. Compared to a first transplant, performing a second graft was the only factor significantly associated with the choice of ATG in all centers. The AUC ranged from 0.67 to 0.91, indicating that the centers seemed to define their own rules. As a result, for patients with the same low immunological risk, the probability of receiving ATG varied from 7% to 36%. We stratified the analyses according to two periods, from 2013 to 2015 and from 2016 to 2019. A similar heterogeneity was observed, and in some cases ATG indications between the centers were inverted. Conclusions The heterogeneity of induction therapy practices did not decrease in France, even if the reated literature is prolific. This illustrates the necessity to improve the literature by using meta-analyses of recent studies stratified by graft and patient profiles.
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Affiliation(s)
- Julie Boucquemont
- INSERM UMR 1246—SPHERE, Nantes University, Tours University, Nantes, France
- * E-mail: (JD); (JB)
| | - Yohann Foucher
- INSERM UMR 1246—SPHERE, Nantes University, Tours University, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Christophe Masset
- Centre Hospitalier Universitaire de Nantes, Nantes, France
- CRTI UMR 1064, Inserm, Université de Nantes; ITUN, CHU Nantes; RTRS « Centaure », Nantes, France
| | - Christophe Legendre
- Kidney Transplant Center, Necker University Hospital, APHP, RTRS « Centaure », Paris Descartes and Sorbonne Paris Cité Universities, Paris, France
| | - Anne Scemla
- Kidney Transplant Center, Necker University Hospital, APHP, RTRS « Centaure », Paris Descartes and Sorbonne Paris Cité Universities, Paris, France
| | - Fanny Buron
- Nephrology, Transplantation and Clinical Immunology Department, RTRS « Centaure », Edouard Herriot University Hospital, Hospices Civils, Lyon, France
| | - Emmanuel Morelon
- Nephrology, Transplantation and Clinical Immunology Department, RTRS « Centaure », Edouard Herriot University Hospital, Hospices Civils, Lyon, France
| | - Valérie Garrigue
- Nephrology, Dialysis and Transplantation Department, Lapeyronie University Hospital, Montpellier, France
| | - Vincent Pernin
- Nephrology, Dialysis and Transplantation Department, Lapeyronie University Hospital, Montpellier, France
| | - Laetitia Albano
- Department of Nephrology and Renal Transplantation, Hospital Pasteur, Nice, France
| | - Antoine Sicard
- Department of Nephrology and Renal Transplantation, Hospital Pasteur, Nice, France
| | - Sophie Girerd
- Renal Transplantation Department, Brabois University Hospital, Nancy, France
| | - Marc Ladrière
- Renal Transplantation Department, Brabois University Hospital, Nancy, France
| | - Magali Giral
- Centre Hospitalier Universitaire de Nantes, Nantes, France
- CRTI UMR 1064, Inserm, Université de Nantes; ITUN, CHU Nantes; RTRS « Centaure », Nantes, France
- Centre d’Investigation Clinique en Biothérapie, Nantes, France
| | - Jacques Dantal
- Centre Hospitalier Universitaire de Nantes, Nantes, France
- CRTI UMR 1064, Inserm, Université de Nantes; ITUN, CHU Nantes; RTRS « Centaure », Nantes, France
- * E-mail: (JD); (JB)
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Weisert M, Harake D, Hede S, Russell M, Alejos J, Menteer J. A multicenter survey on post-transplant lymphoproliferative disorders in pediatric heart transplant recipients: A case for development of consensus guidelines for screening, surveillance, and treatment? Pediatr Transplant 2020; 24:e13730. [PMID: 32416037 DOI: 10.1111/petr.13730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/23/2020] [Accepted: 04/13/2020] [Indexed: 01/29/2023]
Abstract
Post-transplant lymphoproliferative disorders (PTLD) are the main malignancy seen after pediatric heart transplant and are a significant cause of morbidity and mortality. Prior to the development of detailed guidelines, we sought to identify trends in screening, diagnosis, and treatment of pediatric PTLD. All Pediatric Heart Transplant Society (PHTS) institutions were surveyed. No identifiable patient information was shared. From 56 PHTS centers, 22 responses were received (39.3%). 100% agree PTLD cannot be diagnosed solely based on elevated Epstein-Barr virus (EBV) load. All respondents routinely screen for EBV by blood PCR, but frequency of screening varies. There was intermediate consensus regarding the use of computed tomography (CT) and/or positron emission tomography (PET) in surveillance management for PTLD. Most centers require a diagnostic biopsy before initiating new treatment for PTLD (14 of 18, 77.8%), but many reduce immune suppression based on elevated EBV without pathologic PTLD (16 of 22, 72.7%). Beyond immune modulation, rituximab is most commonly used (9 of 13, 69.2%). Consultation with oncology is common (17 of 17, 100%), but timing varies widely. Our survey highlights significant elements of agreement and significant practice variation among PHTS institutions regarding pediatric PTLD. Reduction of immune suppression prior to pathologic diagnosis of PTLD is a common management strategy. When this fails, rituximab is used, but is most often reserved until after confirmation of the diagnosis. Oncology subspecialists are commonly involved in these cases. Our findings highlight the need to develop improved guidelines for evaluation and treatment of pediatric PTLD.
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Affiliation(s)
- Molly Weisert
- Division of Pediatric Cardiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Danielle Harake
- Division of Pediatric Cardiology, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Sannya Hede
- Division of Pediatric Cardiology, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Matthew Russell
- Division of Pediatric Cardiology, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Juan Alejos
- Division of Pediatric Cardiology, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - JonDavid Menteer
- Division of Pediatric Cardiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
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Bhagra S, Parameshwar J. Outcomes following cardiac transplantation in adults. Indian J Thorac Cardiovasc Surg 2020; 36:166-174. [DOI: 10.1007/s12055-019-00796-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 01/10/2019] [Accepted: 01/16/2019] [Indexed: 10/27/2022] Open
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Abstract
Lung transplantation is an established therapeutic option for selected patients with advanced lung diseases. As early outcomes after lung transplantation have improved, chronic medical illnesses have emerged as significant obstacles to long-term survival. Among them is post-transplant malignancy, currently representing the 2nd most common cause of death 5–10 years after transplantation. Chronic immunosuppressive therapy and resulting impairment of anti-tumor immune surveillance is thought to have a central role in cancer development after solid organ transplantation (SOT). Lung transplant recipients receive more immunosuppression than other SOT populations, likely contributing to even higher risk of cancer among this group. The most common cancers in lung transplant recipients are non-melanoma skin cancers, followed by lung cancer and post-transplant lymphoproliferative disorder (PTLD). The purpose of this review is to outline the common malignancies following lung transplant, their risk factors, prognosis and current means for both prevention and treatment.
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Affiliation(s)
- Osnat Shtraichman
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Pulmonary Institute, Rabin Medical Center, Affiliated with Sackler School of Medicine Tel Aviv University, Petach Tikva, Israel
| | - Vivek N Ahya
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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16
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Sun ZJ, Hu XP, Fan BH, Wang W. Epstein-Barr virus-positive post-transplant lymphoproliferative disordepresenting as hematochezia and enterobrosis in renal transplant recipients in China: A report of two cases. World J Clin Cases 2019; 7:4334-4341. [PMID: 31911916 PMCID: PMC6940326 DOI: 10.12998/wjcc.v7.i24.4334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 10/22/2019] [Accepted: 11/13/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Post-transplant lymphoproliferative disorder (PTLD) is a rare severe complication after renal transplantation, with an incidence of approximately 0.3%-2.0% in patients undergoing renal transplantation. The clinical manifestations of PTLD are often nonspecific, leading to tremendous challenges in the clinical diagnosis and treatment of PTLD.
CASE SUMMARY We report two Epstein-Barr virus (EBV)-positive PTLD cases whose main clinical manifestations were digestive tract symptoms. Both of them admitted to our hospital because of extranodal infiltration symptoms and we did not suspect of PTLD until the pathology confirmation. Luckily, they responded well to the treatment of rituximab. We also discuss the virological monitoring, clinical characteristics, diagnosis, and treatment of PTLD.
CONCLUSION PTLD is a deceptive disease and difficult to diagnose. Once patients are confirmed with PTLD, immune suppressant dosage should be immediately reduced and rituximab should be used as first-line therapy.
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Affiliation(s)
- Ze-Jia Sun
- Institute of Urology, Capital Medical University, Department of Urology, Beijng Chao-Yang Hospital, Capital Medical University, Beijing 100030, China
| | - Xiao-Peng Hu
- Institute of Urology, Capital Medical University, Department of Urology, Beijng Chao-Yang Hospital, Capital Medical University, Beijing 100030, China
| | - Bo-Han Fan
- Institute of Urology, Capital Medical University, Department of Urology, Beijng Chao-Yang Hospital, Capital Medical University, Beijing 100030, China
| | - Wei Wang
- Institute of Urology, Capital Medical University, Department of Urology, Beijng Chao-Yang Hospital, Capital Medical University, Beijing 100030, China
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17
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Savassi-Ribas F, Gomes Dos Santos de Almeida S, Baez CF, Magalhães de Souza L, Wagner TCS, Matuck TA, Monteiro de Carvalho DDB, Marandino Guimarães MAA, Varella RB. Impact assessment and investigation of factors associated with herpesviruses viremia in the first year of renal transplantation. J Med Virol 2019; 92:107-112. [PMID: 31463932 DOI: 10.1002/jmv.25580] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 08/26/2019] [Indexed: 12/16/2022]
Abstract
The increased risk for opportunistic infections after a renal transplant requires monitoring of viral infections to avoid future complications. Our goal was to investigate the impact and factors associated with Epstein-Barr virus (EBV), human cytomegalovirus (HCMV) and human herpesvirus type 6 (HHV-6) viremia in renal transplant recipients. Whole blood samples were collected monthly from 82 patients during the first semester and then quarterly up to 1 year after transplantation. EBV, HCMV, and HHV-6 were detected and quantified by TaqMan real-time polymerase chain reaction. The results showed that EBV and HCMV viremia were detected in 32 patients (39% each), while HHV-6 viremia in only 3 patients (3.7%). EBV was significantly associated with age (P = .050), thymoglobuline induction (P = .019), mTOR inhibitor-based therapy (P = .003), and female gender (P = .044). HCMV was significantly associated with basiliximab induction (P = .015), mycophenolate mofetil (MMF)-based therapy (P = .003) and allograft acute rejection (P = .033). Moreover, HCMV-disease was correlated with MMF-based therapy (P = .021) and female gender (P = .003). In conclusion, EBV and HCMV viremia were associated with different immunosuppressive induction and maintenance strategies. Additionally, higher HCMV viremia (> 10 4 copies/mL) was related to acute allograft rejection.
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Affiliation(s)
- Flavia Savassi-Ribas
- Department of Microbiology and Parasitology, Biomedical Institute, Fluminense Federal University, Niteroi, Brazil
| | | | - Camila Freze Baez
- Department of Preventive Medicine, University Hospital Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leandro Magalhães de Souza
- Department of Preventive Medicine, University Hospital Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Tereza Cristina Simão Wagner
- Service of Renal Transplantation, Rio de Janeiro State Center of transplantation, São Francisco na Providência de Deus Hospital, Rio de Janeiro, Brazil
| | - Tereza Azevedo Matuck
- Service of Renal Transplantation, Rio de Janeiro State Center of transplantation, São Francisco na Providência de Deus Hospital, Rio de Janeiro, Brazil
| | - Deise De Boni Monteiro de Carvalho
- Service of Renal Transplantation, Rio de Janeiro State Center of transplantation, São Francisco na Providência de Deus Hospital, Rio de Janeiro, Brazil
| | | | - Rafael Brandão Varella
- Department of Microbiology and Parasitology, Biomedical Institute, Fluminense Federal University, Niteroi, Brazil
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18
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Induction Therapy in Elderly Kidney Transplant Recipients With Low Immunological Risk. Transplantation 2019; 104:613-622. [PMID: 31283665 DOI: 10.1097/tp.0000000000002804] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND In nonimmunized patients, similar rejection rates are observed for patients who have undergone thymoglobulin (antithymocyte globulins [ATG]) or basiliximab (BSX) therapy. While ATG may improve delayed graft function, it may also be associated with higher infection rates and malignancy risk. We compared survival and clinical outcomes in elderly recipients with low immunological risk according to their induction therapy. METHODS We conducted a multicentric study on nonimmunized patients ≥65 years of age receiving a first kidney transplant between 2010 and 2017. The principal outcome was patient and graft survival. Secondary outcomes were cumulative probabilities of infection, first acute rejection episode, malignancy, de novo donor specific antibody, posttransplant diabetes (PTD), cardiac complications, estimated glomerular filtration rate, and occurrence of delayed graft function. Cox, logistic, or linear statistical models were used depending on the outcome studied, and models were weighted on the propensity scores. RESULTS Two hundred and four patients were included in the BSX group and 179 in the ATG group with the average age of 71.0 and 70.5 years, respectively. Patient and graft survival at 3 years posttransplantation were 74% (95% CI, 65%-84%) and 68% (95% CI, 60%-78%) in ATG and BSX group, respectively, without significant difference. Occurrence of PTD was significatively higher in BSX group (23% versus 15%, P = 0.04) due to higher trough levels of Tacrolimus on month 3 (9.48 versus 7.30 ng/mL, P = 0.023). There was no difference in other evaluated outcomes. CONCLUSIONS In elderly recipients, ATG does not lead to poorer outcomes compared with BSX and could permit lower trough levels of Tacrolimus, thus reducing occurrence of PTD.
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19
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Liu M, Husain S, Famure O, Li Y, Kim SJ. Incidence, Risk Factors, Clinical Management, and Outcomes of Posttransplant Lymphoproliferative Disorder in Kidney Transplant Recipients. Prog Transplant 2019; 29:185-193. [PMID: 30845885 DOI: 10.1177/1526924819835834] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Posttransplant lymphoproliferative disorder (PTLD) is a severe complication after kidney transplantation. This study examined the incidence, risk factors, clinical management, and outcomes of PTLD in a cohort of kidney transplant recipients. DESIGN This single-center cohort study included 1642 patients transplanted from January 1, 2000, to December 31, 2012, with follow-up until December 31, 2013. The incidence and risk factors for PTLD were examined using a Cox proportional hazards model. A Cox model was also used to assess the association of PTLD and graft outcomes. RESULTS Sixteen recipients developed PTLD over follow-up. The incidence rate was 0.18 (95% confidence interval [CI]: 0.11-0.29) cases per 100 person-years. Four were from Epstein-Barr virus (EBV) mismatched (D+/R-) transplants and 12 from EBV-positive recipients (R+). Recipients with D+/R- matches were at a significantly higher risk of developing PTLD than R+ (hazard ratio [HR]: 7.52 [95% CI: 2.42-23.32]). Fifteen cases had immunosuppression reduced, 11 cases were supplemented with rituximab or ganciclovir, 6 cases required chemotherapy or radiation, and 6 cases had tumors excised. By the end of follow-up, 6 patients went into remission, 5 returned to chronic dialysis, and 5 patients died. Patients with PTLD were significantly more likely to have total graft failure (return to chronic dialysis, preemptive retransplant, or death with graft function) than patients without PTLD (HR: 3.41 [95% CI: 1.72-6.78). DISCUSSION Epstein-Barr virus mismatch continues to be a strong risk factor for developing PTLD after kidney transplantation. Recipients with PTLD have a poor prognosis, as the optimal management remains to be elucidated.
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Affiliation(s)
- Michelle Liu
- 1 Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shahid Husain
- 1 Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada.,2 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Olusegun Famure
- 1 Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Yanhong Li
- 1 Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - S Joseph Kim
- 1 Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada.,2 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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20
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Pape L. State-of-the-art immunosuppression protocols for pediatric renal transplant recipients. Pediatr Nephrol 2019; 34:187-194. [PMID: 29067527 DOI: 10.1007/s00467-017-3826-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 09/08/2017] [Accepted: 10/06/2017] [Indexed: 01/28/2023]
Abstract
Immunosuppressive protocols used in pediatric kidney transplantation have changed substantially within the last decade. Many transplant centers now focus on the use of tacrolimus and mycophenolate mofetil in combination with early steroid withdrawal, frequently combined with antibody induction therapy. However, this approach is mainly based on treatment efficacy and-compared to other immunosuppressive regimens used in this context-leads to higher rates of viral infections in patients. In this review I assess data from prospective, interventional trials of immunosuppressive therapy in pediatric kidney transplantation. However, since there is a paucity of randomized controlled trials, I also describe the results of studies with weaker designs. The advantages and disadvantages of different immunosuppressive strategies are discussed. Within this framework I suggest ideas for individualized immunosuppressive regimens based on different stratificators that could effect a change from a 'one size fits all' to a tailored approach for initial and maintenance immunosuppressive therapy after renal transplantation in the pediatric setting.
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Affiliation(s)
- Lars Pape
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany.
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21
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Sasaki N, Shimura K, Yoshida M, Uoshima N, Kiyota M, Hatsuse M, Uchiyama H, Chinen Y, Kobayashi T, Nakao M, Takahashi R, Nakano-Akamatsu S, Kaneko H, Kobayashi Y, Shimazaki C, Taniwaki M, Kuroda J. Immunosuppressive therapy with rabbit antithymocyte globulin therapy for acquired aplastic anemia: a multi-institutional retrospective study in Japanese adult patients. Int J Hematol 2019; 109:278-285. [PMID: 30627868 DOI: 10.1007/s12185-018-02583-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 12/19/2018] [Accepted: 12/26/2018] [Indexed: 12/11/2022]
Abstract
We retrospectively analyzed efficacy and safety of therapy with rabbit antithymocyte globulin (rATG) in combination with cyclosporine A (CsA) in 30 Japanese adult patients with acquired aplastic anemia (AA) in the Kyoto Clinical Hematology Study Group. The median observation period was 31 months and the median age of the patients was 54 years. The objective response rates (ORRs) to rATG plus CsA increased over time until 18 months after the start of treatment; the rate of achievement of better than partial response at 18 months was 66.7%. The 2-year overall survival (OS) rate was 79% in all patients. In eight patients aged ≥ 75 years old, the ORR was 62.5% and the 2-year OS rate of 50% was not significantly inferior to that in patients aged ≤ 74 years old. The overall mortality rate was 16.7% in our cohort, while the mortality rate in patients aged ≥ 75 years old was 37.5%, which was higher than that in patients aged ≤ 74 years old (9.1%), although the difference was not statistically significant. Collectively, rATG combined with CsA is an effective and feasible treatment for AA, while patients should be appropriately selected.
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Affiliation(s)
- Nana Sasaki
- Department of Hematology, Aiseikai Yamashina Hospital, Kyoto, Japan
- Department of Hematology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Kazuho Shimura
- Department of Hematology, Aiseikai Yamashina Hospital, Kyoto, Japan
| | - Mihoko Yoshida
- Department of Hematology, Aiseikai Yamashina Hospital, Kyoto, Japan
| | - Nobuhiko Uoshima
- Department of Hematology, Matsushita Memorial Hospital, Moriguchi, Japan
- Department of Hematology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Miki Kiyota
- Department of Hematology, Matsushita Memorial Hospital, Moriguchi, Japan
| | - Mayumi Hatsuse
- Department of Hematology, JCHO Kyoto Kuramaguchi Medical Center, Kyoto, Japan
| | - Hitoji Uchiyama
- Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Yoshiaki Chinen
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Tsutomu Kobayashi
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | | | - Ryoichi Takahashi
- Department of Hematology, Omihachiman Community Medical Center, Omihachiman, Japan
| | | | - Hiroto Kaneko
- Department of Hematology, Aiseikai Yamashina Hospital, Kyoto, Japan
| | - Yutaka Kobayashi
- Department of Hematology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Chihiro Shimazaki
- Department of Hematology, JCHO Kyoto Kuramaguchi Medical Center, Kyoto, Japan
| | - Masafumi Taniwaki
- Department of Hematology, Aiseikai Yamashina Hospital, Kyoto, Japan
- Center for Molecular Diagnostics and Therapeutics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Junya Kuroda
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan.
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22
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Does Rabbit Antithymocyte Globulin (Thymoglobuline®) Have a Role in Avoiding Delayed Graft Function in the Modern Era of Kidney Transplantation? J Transplant 2018; 2018:4524837. [PMID: 30112193 PMCID: PMC6077603 DOI: 10.1155/2018/4524837] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 06/20/2018] [Indexed: 12/16/2022] Open
Abstract
Delayed graft function (DGF) increases the risk of graft loss by up to 40%, and recent developments in kidney donation have increased the risk of its occurrence. Lowering the risk of DGF, however, is challenging due to a complicated etiology in which ischemia-reperfusion injury (IRI) leads to acute tubular necrosis. Among various strategies explored, the choice of induction therapy is one consideration. Rabbit antithymocyte globulin (rATG [Thymoglobuline]) has complex immunomodulatory effects that are relevant to DGF. In addition to a rapid and profound T-cell depletion, rATG inhibits leukocyte migration and adhesion. Experimental studies of rATG have demonstrated attenuated IRI-related tissue damage in reperfused tissues, consistent with histological evidence from transplant recipients. Starting rATG intraoperatively instead of postoperatively can improve kidney graft function and reduce the incidence of DGF. rATG is effective in preventing acute rejection in kidney transplant recipients at high immunological risk, supporting delayed calcineurin inhibitor (CNI) introduction which protects the graft from early insults. A reduced rate of DGF has been reported with rATG (started intraoperatively) and delayed CNI therapy compared to IL-2RA induction with immediate CNI in patients at high immunological risk, but not in lower-risk patients. Overall, induction with rATG induction is the preferred choice for supporting delayed introduction of CNI therapy to avoid DGF in high-risk patients but shows no benefit versus IL-2RA in lower-risk individuals. Evidence is growing that intraoperative rATG ameliorates IRI, and it seems reasonable to routinely start rATG before reperfusion.
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23
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Risk stratification to determine the impact of induction therapy on survival, rejection and adverse events after pediatric heart transplant: A multi-institutional study. J Heart Lung Transplant 2018; 37:458-466. [DOI: 10.1016/j.healun.2017.05.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 05/04/2017] [Accepted: 05/09/2017] [Indexed: 11/19/2022] Open
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24
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Bamoulid J, Staeck O, Crépin T, Halleck F, Saas P, Brakemeier S, Ducloux D, Budde K. Anti-thymocyte globulins in kidney transplantation: focus on current indications and long-term immunological side effects. Nephrol Dial Transplant 2018; 32:1601-1608. [PMID: 27798202 DOI: 10.1093/ndt/gfw368] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 09/12/2016] [Indexed: 11/12/2022] Open
Abstract
Antithymocyte globulins (ATGs) are part of the immunosuppression arsenal currently used by clinicians to prevent or treat acute rejection in solid organ transplantation. ATG is a mixture of non-specific anti-lymphocyte immunoglobulins targeting not only T cell subsets but also several other immune and non-immune cells, rendering its precise immunoglobulin composition difficult to appreciate or to compare from one preparation to another. Furthermore, several mechanisms of action have been described. Taken together, this probably explains the efficacy and the side effects associated with this drug. Recent data suggest a long-term negative impact on allograft and patient outcomes, pointing out the need to better characterize the potential toxicity and the benefit-risk balance associated to this immunosuppressive therapy within large clinical trials.
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Affiliation(s)
- Jamal Bamoulid
- Department of Nephrology, Dialysis, and Renal Transplantation, CHU Besançon, France.,UMR1098, Federation hospitalo-universitaire INCREASE, France.,Faculté de Médecine et de Pharmacie, Université de Franche-Comté, France.,Structure Fédérative de Recherche, SFR FED4234, France
| | - Oliver Staeck
- Department of Nephrology, Charité Universitätsmedizin Berlin, Germany
| | - Thomas Crépin
- Department of Nephrology, Dialysis, and Renal Transplantation, CHU Besançon, France.,UMR1098, Federation hospitalo-universitaire INCREASE, France.,Faculté de Médecine et de Pharmacie, Université de Franche-Comté, France.,Structure Fédérative de Recherche, SFR FED4234, France
| | - Fabian Halleck
- Department of Nephrology, Charité Universitätsmedizin Berlin, Germany
| | - Philippe Saas
- UMR1098, Federation hospitalo-universitaire INCREASE, France.,Faculté de Médecine et de Pharmacie, Université de Franche-Comté, France.,Structure Fédérative de Recherche, SFR FED4234, France
| | | | - Didier Ducloux
- Department of Nephrology, Dialysis, and Renal Transplantation, CHU Besançon, France.,UMR1098, Federation hospitalo-universitaire INCREASE, France.,Faculté de Médecine et de Pharmacie, Université de Franche-Comté, France.,Structure Fédérative de Recherche, SFR FED4234, France
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Germany
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25
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Rabbit anti-human thymocyte immunoglobulin for the rescue treatment of chronic antibody-mediated rejection after pediatric kidney transplantation. Pediatr Nephrol 2017; 32:2133-2142. [PMID: 28717935 DOI: 10.1007/s00467-017-3725-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 05/29/2017] [Accepted: 06/12/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Chronic antibody-mediated rejection (cAMR) is the leading cause of late kidney graft loss, but current therapies are often ineffective. Rabbit anti-human thymocyte immunoglobulin (rATG) may be helpful, but its use is virtually undocumented. METHODS Data were analyzed retrospectively from nine pediatric kidney transplant patients with cAMR were treated with rATG (1.5 mg/kg × 5 days) at our center after non-response to pulsed prednisolone, intravenous immunoglobulin, rituximab, and increased immunosuppressive intensity (including switching to belatacept in some cases), with or without bortezomib. RESULTS The median time from diagnosis to cAMR was 179 days. rATG was started 5-741 days after diagnosis. Median estimated glomerular filtration rate (eGFR) increased from 40 mL/min/1.73 m2 when rATG was started to 62 mL/min/1.73 m2 9 months later (p = 0.039). Four patients showed substantially higher eGFR after 9 months and 2 patients showed a small improvement; eGFR continued to decline in 3 patients after starting rATG. No grafts were lost during follow-up. At last follow-up, donor-specific antibodies (DSAs) were no longer detectable in 4 out of 8 patients for whom data were available, median fluorescence intensity had decreased substantially in 1 out of 8 patients; anti-HLA DQ DSAs persisted in 2 out of 8 patients. No adverse events with a suspected relation to rATG, including allergic reactions, leukocytopenia or infections, were observed in any of the patients. CONCLUSIONS In this small series of patients, rATG appears a promising treatment for unresponsive cAMR. Further evaluation, including earlier introduction of rATG, is warranted.
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26
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Daunting but Worthy Goal: Reducing the De Novo Cancer Incidence After Transplantation. Transplantation 2017; 100:2569-2583. [PMID: 27861286 DOI: 10.1097/tp.0000000000001428] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Solid-organ transplant recipients are at increased risk of developing de novo malignancies compared with the general population, and malignancies become a major limitation in achieving optimal outcomes. The prevention and the management of posttransplant malignancies must be considered as a main goal in our transplant programs. For these patients, immunosuppression plays a major role in oncogenesis by both impairement of immunosurveillance, enhancement of chronic viral infection, and by direct prooncogenic effects. It is essential to manage the recipient with a long-term adapted screening program beginning before transplantation to use a prophylaxis to decrease infection-related cancer, to propose a viral monitoring, and to modulate the immunosuppression toward lower doses especially for calcineurin inhibitors. Indeed, strategies to induce tolerance or to allow a dramatic reduction of the immunosuppression burden are the more promising approaches for the reduction of the posttransplant malignancies.
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27
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Leyssens A, Dierickx D, Verbeken EK, Tousseyn T, Verleden SE, Vanaudenaerde BM, Dupont LJ, Yserbyt J, Verleden GM, Van Raemdonck DE, Vos R. Post-transplant lymphoproliferative disease in lung transplantation: A nested case-control study. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.12983] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Annelies Leyssens
- Department of Respiratory Diseases; University Hospitals Leuven; Leuven Belgium
| | - Daan Dierickx
- Department of Hematology; University Hospitals Leuven; Leuven Belgium
| | | | | | - Stijn E. Verleden
- Department of Clinical and Experimental Medicine; Division of Respiratory Diseases; KULeuven; Leuven Belgium
| | - Bart M. Vanaudenaerde
- Department of Clinical and Experimental Medicine; Division of Respiratory Diseases; KULeuven; Leuven Belgium
| | - Lieven J. Dupont
- Department of Respiratory Diseases; University Hospitals Leuven; Leuven Belgium
- Department of Clinical and Experimental Medicine; Division of Respiratory Diseases; KULeuven; Leuven Belgium
| | - Jonas Yserbyt
- Department of Respiratory Diseases; University Hospitals Leuven; Leuven Belgium
| | - Geert M. Verleden
- Department of Respiratory Diseases; University Hospitals Leuven; Leuven Belgium
- Department of Clinical and Experimental Medicine; Division of Respiratory Diseases; KULeuven; Leuven Belgium
| | | | - Robin Vos
- Department of Respiratory Diseases; University Hospitals Leuven; Leuven Belgium
- Department of Clinical and Experimental Medicine; Division of Respiratory Diseases; KULeuven; Leuven Belgium
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28
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Hellemans R, Bosmans J, Abramowicz D. Induction Therapy for Kidney Transplant Recipients: Do We Still Need Anti-IL2 Receptor Monoclonal Antibodies? Am J Transplant 2017; 17:22-27. [PMID: 27223882 PMCID: PMC5215533 DOI: 10.1111/ajt.13884] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Revised: 05/19/2016] [Accepted: 05/19/2016] [Indexed: 01/25/2023]
Abstract
Induction therapy with antilymphocyte biological agents is widely used after kidney transplantation, most commonly T lymphocyte-depleting rabbit-derived antithymocyte globulin (rATG) or an IL-2 receptor antagonist (IL2RA). Early randomized trials showed that rATG or IL2RA induction reduces early acute rejection, prompting recommendations by Kidney Disease Improving Global Outcomes that IL2RA induction be used routinely in first-line therapy after kidney transplantation, with lymphocyte-depleting induction reserved for high-risk cases. These studies, however, mainly used outdated maintenance regimens. No large randomized trial has examined the effect of IL2RA or rATG induction versus no induction in patients receiving tacrolimus, mycophenolic acid and steroids. With this triple maintenance therapy, the addition of induction may achieve an absolute risk reduction for acute rejection of only 1-4% in standard-risk patients without improving graft or patient survival. In contrast, rATG induction lowers the relative risk of acute rejection by almost 50% versus IL2RA in patients with high immunological risk. These recent data raise questions about the need for IL2RA in kidney transplantation, as it may no longer be beneficial in standard-risk transplantation and may be inferior to rATG in high-risk situations. Updated evidence-based guidelines are necessary to support clinicians deciding whether and what induction therapy is required for their transplant patients today.
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Affiliation(s)
- R. Hellemans
- Dienst NefrologieUniversitair Ziekenhuis AntwerpenEdegemBelgium
| | - J.‐L. Bosmans
- Dienst NefrologieUniversitair Ziekenhuis AntwerpenEdegemBelgium
| | - D. Abramowicz
- Dienst NefrologieUniversitair Ziekenhuis AntwerpenEdegemBelgium
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Decision support environment for medical product safety surveillance. J Biomed Inform 2016; 64:354-362. [DOI: 10.1016/j.jbi.2016.07.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 07/22/2016] [Accepted: 07/27/2016] [Indexed: 02/04/2023]
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Tanriover B, Jaikaransingh V, MacConmara MP, Parekh JR, Levea SL, Ariyamuthu VK, Zhang S, Gao A, Ayvaci MU, Sandikci B, Rajora N, Ahmed V, Lu CY, Mohan S, Vazquez MA. Acute Rejection Rates and Graft Outcomes According to Induction Regimen among Recipients of Kidneys from Deceased Donors Treated with Tacrolimus and Mycophenolate. Clin J Am Soc Nephrol 2016; 11:1650-1661. [PMID: 27364616 PMCID: PMC5012491 DOI: 10.2215/cjn.13171215] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 05/30/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND OBJECTIVES IL-2 receptor antagonist (IL2-RA) is recommended as a first-line agent for induction therapy in renal transplantation. However, this remains controversial in deceased donor renal transplantation (DDRT) maintained on tacrolimus (TAC)/mycophenolic acid (MPA) with or without steroids. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We studied the United Network for Organ Sharing Registry for patients receiving DDRT from 2000 to 2012 maintained on TAC/MPA at transplantation hospital discharge (n=74,627) to compare outcomes of IL2-RA and other induction agents. We initially divided the cohort into two groups on the basis of steroid use at the time of discharge: steroid (n=59,010) versus no steroid (n=15,617). Each group was stratified into induction categories: IL2-RA, rabbit antithymocyte globulin (r-ATG), alemtuzumab, and no induction. The main outcomes were incidence of acute rejection within the first year and overall graft failure (defined as graft failure and/or death) post-transplantation. Propensity score (PS), specifically inverse probability of treatment weight, analysis was used to minimize selection bias caused by nonrandom assignment of induction therapies. RESULTS Median (25th, 75th percentiles) follow-up times were 3.9 (1.1, 5.9) and 3.2 (1.1, 4.9) years for steroid and no steroid groups, respectively. Acute rejection within the first year and overall graft failure within 5 years of transplantation were more common in the no induction category (13.3%; P<0.001 and 28%; P=0.01, respectively) in the steroid group and the IL2-RA category (11.1%; P=0.16 and 27.4%; P<0.001, respectively) in the no steroid group. Compared with IL2-RA, PS-weighted and covariate-adjusted multivariable logistic and Cox analyses showed that outcomes in the steroid group were similar among induction categories, except that acute rejection was significantly lower with r-ATG (odds ratio [OR], 0.68; 95% confidence interval [95% CI], 0.62 to 0.74). In the no steroid group, compared with IL2-RA, odds of acute rejection with r-ATG (OR, 0.80; 95% CI, 0.60 to 1.00) and alemtuzumab (OR, 0.68; 95% CI, 0.53 to 0.88) were lower, and r-ATG was associated with better graft survival (hazard ratio, 0.86; 95% CI, 0.75 to 0.99). CONCLUSIONS In DDRT, compared with IL2-RA induction, no induction was associated with similar outcomes when TAC/MPA/steroids were used. r-ATG seems to offer better graft survival over IL2-RA in steroid avoidance protocols.
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Affiliation(s)
| | | | | | | | | | | | - Song Zhang
- Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ang Gao
- Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mehmet U.S. Ayvaci
- Information Systems, Naveen Jindal School of Management, University of Texas at Dallas, Dallas, Texas
| | | | | | - Vaqar Ahmed
- Division of Nephrology, Texas Tech University Health Sciences Center, Lubbock, Texas; and
| | | | - Sumit Mohan
- Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York
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Park H, Kim JS, Kong JH, Kim SH, Park SW, Song SH, Yang JW, Han BG, Choi SO. Post-transplant Lymphoproliferative Disorder in Transplanted Kidney Causing Urinary Tract Obstruction. KOREAN JOURNAL OF TRANSPLANTATION 2016. [DOI: 10.4285/jkstn.2016.30.1.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Hyeoncheol Park
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jae Seok Kim
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jee Hyun Kong
- Department of Oncology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Hoon Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sang Wook Park
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Shin Han Song
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jae Won Yang
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Byoung Geun Han
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seung Ok Choi
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Korea
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Malvezzi P, Jouve T, Rostaing L. Induction by anti-thymocyte globulins in kidney transplantation: a review of the literature and current usage. J Nephropathol 2015; 4:110-5. [PMID: 26457257 PMCID: PMC4596294 DOI: 10.12860/jnp.2015.21] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Accepted: 07/25/2015] [Indexed: 01/28/2023] Open
Abstract
Context: Preventing acute rejection (AR) after kidney transplantation is of utmost importance because an AR can have a negative impact on long-term allograft survival.
Evidence Acquisition: Directory of Open Access Journals (DOAJ), Google Scholar, PubMed, EBSCO, and Web of Science have been searched.
Results: At the moment this can be done by using rabbit anti-thymocyte globulins (rATGs) as an induction therapy. However, because rATGs are associated with some deleterious side-effects, such as the opportunistic infections cytomegalovirus (CMV) and
de novo
post-transplant cancer, it is very important they are used optimally, i.e., at minimal doses that avoid many side-effects but still retain optimal treatment efficacy. Recent data show that the risk of CMV infection can be minimized using tacrolimus plus everolimus, and not tacrolimus plus mycophenolic acid, as the maintenance immunosuppression. The use of rATG is particularly valuable in; (a) sensitized patients;
(b)
in recipients from an expanded-criteria donor, thus enabling the introduction of calcineurin inhibitors at reduced doses; and
(c)
for patients where steroid avoidance is contemplated. However, we also need to consider that rATG may increase the risk of
de novo
cancer, even though recent data indicate this is unlikely and that any risk can be reduced by using mammalian target of rapamycin (mTOR) inhibitors instead of mycophenolic acid combined with low-dose calcineurin inhibitors.
Conclusions: Even though rATGs do not improve long-term kidney-allograft survival, they may help reduce calcineurin-inhibitor dosage during the early post-transplant period and minimize the risk of AR.
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Affiliation(s)
- Paolo Malvezzi
- Clinique de Néphrologie, University Hospital, Grenoble, France
| | - Thomas Jouve
- Clinique de Néphrologie, University Hospital, Grenoble, France
| | - Lionel Rostaing
- Department of Nephrology, Dialysis, and Organ Transplantation, CHU Rangueil, Toulouse University Hospital, Toulouse, France ; INSERM U563, IFR-BMT, CHU Purpan, Toulouse, France ; Université Paul Sabatier, Toulouse, France
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