1
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Jallah BP, Kuypers DRJ. Impact of Immunosenescence in Older Kidney Transplant Recipients: Associated Clinical Outcomes and Possible Risk Stratification for Immunosuppression Reduction. Drugs Aging 2024; 41:219-238. [PMID: 38386164 DOI: 10.1007/s40266-024-01100-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2024] [Indexed: 02/23/2024]
Abstract
The number of older individuals receiving a kidney transplant as replacement therapy has significantly increased in the past decades and this increase is expected to continue. Older patients have a lower rate of acute rejection but an increased incidence of death with a functioning graft. Several factors, including an increased incidence of infections, post-transplant malignancy and cardiovascular comorbidity and mortality, contribute to this increased risk. Notwithstanding, kidney transplantation is still the best form of kidney replacement therapy in all patients with chronic kidney disease, including in older individuals. The best form of immunosuppression and the optimal dose of these medications in older recipients remains a topic of discussion. Pharmacological studies have usually excluded older patients and when included, patients were highly selected and their numbers insignificant to draw a reasonable conclusion. The reduced incidence of acute rejection in older recipients has largely been attributed to immunosenescence. Immunosenescence refers to the aging of the innate and adaptive immunity, accumulating in phenotypic and functional changes. These changes influences the response of the immune system to new challenges. In older individuals, immunosenescence is associated with increased susceptibility to infectious pathogens, a decreased response after vaccinations, increased risk of malignancies and cardiovascular morbidity and mortality. Chronic kidney disease is associated with premature immunosenescent changes, and these are independent of aging. The immunosenescent state is associated with low-grade sterile inflammation termed inflammaging. This chronic low-grade inflammation triggers a compensatory immunosuppressive state to avoid further tissue damage, leaving older individuals with chronic kidney disease in an immune-impaired state before kidney transplantation. Immunosuppression after transplantation may further enhance progression of this immunosenescent state. This review covers the role of immunosenescence in older kidney transplant recipients and it details present knowledge of the changes in chronic kidney disease and after transplantation. The impact of immunosuppression on the progression and complications of an immunosenescent state are discussed, and the future direction of a possible clinical implementation of immunosenescence to individualize/reduce immunosuppression in older recipients is laid out.
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Affiliation(s)
- Borefore P Jallah
- Department of Nephrology and Renal Transplantation, University Hospital Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Dirk R J Kuypers
- Department of Nephrology and Renal Transplantation, University Hospital Leuven, Herestraat 49, 3000, Leuven, Belgium.
- Department of Microbiology, Immunology and Transplantation, University of Leuven, Leuven, Belgium.
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2
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McGovern KE, Sonar SA, Watanabe M, Coplen CP, Bradshaw CM, Nikolich JŽ. The aging of the immune system and its implications for transplantation. GeroScience 2023:10.1007/s11357-022-00720-2. [PMID: 36626019 PMCID: PMC9838392 DOI: 10.1007/s11357-022-00720-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 12/21/2022] [Indexed: 01/11/2023] Open
Abstract
By the last third of life, most mammals, including humans, exhibit a decline in immune cell numbers, immune organ structure, and immune defense of the organism, commonly known as immunosenescence. This decline leads to clinical manifestations of increased susceptibility to infections, particularly those caused by emerging and reemerging microorganisms, which can reach staggering levels-infection with SARS-CoV-2 has been 270-fold more lethal to older adults over 80 years of age, compared to their 18-39-year-old counterparts. However, while this would be expected to be beneficial to situations where hyporeactivity of the immune system may be desirable, this is not always the case. Here, we discuss the cellular and molecular underpinnings of immunosenescence as they pertain to outcomes of solid organ and hematopoietic transplantation.
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Affiliation(s)
- Kathryn E McGovern
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
- BIO5 Institute, University of Arizona, Tucson, AZ, USA
| | - Sandip A Sonar
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
| | - Makiko Watanabe
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
| | - Christopher P Coplen
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
| | - Christine M Bradshaw
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
| | - Janko Ž Nikolich
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA.
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA.
- BIO5 Institute, University of Arizona, Tucson, AZ, USA.
- The Aegis Consortium for Pandemic-free Future, University of Arizona Health Sciences, University of Arizona, Tucson, 85719, USA.
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3
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He A, Sarwar A, Thole LML, Siegle J, Sattler A, Ashraf MI, Proß V, Stahl C, Dornieden T, Bergmann Y, Ritschl PV, Ebner S, Hublitz KW, Stamatiades EG, Bülow RD, Boor P, Kotsch K. Renal inflamm-aging provokes intra-graft inflammation following experimental kidney transplantation. Am J Transplant 2022; 22:2529-2547. [PMID: 35851547 DOI: 10.1111/ajt.17154] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 06/14/2022] [Accepted: 07/14/2022] [Indexed: 01/25/2023]
Abstract
Donor age is a major risk factor for allograft outcome in kidney transplantation. The underlying cellular mechanisms and the recipient's immune response within an aged allograft have yet not been analyzed. A comprehensive immunophenotyping of naïve and transplanted young versus aged kidneys revealed that naïve aged murine kidneys harbor significantly higher frequencies of effector/memory T cells, whereas regulatory T cells were reduced. Aged kidney-derived CD8+ T cells produced more IFNγ than their young counterparts. Senescent renal CD8+ T and NK cells upregulated the cytotoxicity receptor NKG2D and the enrichment of memory-like CD49a+ CXCR6+ NK cells was documented in aged naïve kidneys. In the C57BL/6 to BALB/c kidney transplantation model, recipient-derived T cells infiltrating an aged graft produced significantly more IFNγ, granzyme B and perforin on day 7 post-transplantation, indicating an enhanced inflammatory, cytotoxic response towards the graft. Pre-treatment of aged kidney donors with the senolytic drug ABT-263 changed the recipient-derived effector molecule profile to significantly reduced levels of IFNγ and IL-10 compared to controls. Graft function after ABT-263 pre-treatment was significantly improved 28 days post kidney transplantation. In conclusion, renal senescence also occurs at the immunological level (inflamm-aging) and aged organs provoke an altered recipient-dominated immune response in the graft.
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Affiliation(s)
- An He
- Department of General- and Visceral Surgery, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Attia Sarwar
- Department of General- and Visceral Surgery, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Linda Marie Laura Thole
- Department of General- and Visceral Surgery, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Janine Siegle
- Department of General- and Visceral Surgery, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Arne Sattler
- Department of General- and Visceral Surgery, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Muhammad Imtiaz Ashraf
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Vanessa Proß
- Department of General- and Visceral Surgery, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Carolin Stahl
- Department of General- and Visceral Surgery, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Theresa Dornieden
- Department of General- and Visceral Surgery, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Yasmin Bergmann
- Department of General- and Visceral Surgery, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Paul Viktor Ritschl
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Susanne Ebner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Karolin Wiebke Hublitz
- Institute of Microbiology, Infectious Diseases and Immunology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Efstathios Gregorios Stamatiades
- Institute of Microbiology, Infectious Diseases and Immunology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Roman David Bülow
- Institute of Pathology & Department of Nephrology, University Clinic of RWTH Aachen, Aachen, Germany
| | - Peter Boor
- Institute of Pathology & Department of Nephrology, University Clinic of RWTH Aachen, Aachen, Germany
| | - Katja Kotsch
- Department of General- and Visceral Surgery, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
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4
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Pardinhas C, Leal R, Figueiredo C, Rodrigues L, Guedes M, Santos L, Romãozinho C, Sá H, Alves R, Figueiredo A. Kidney Retransplant: Not Too Old for a Second Chance. Transplant Proc 2022; 54:1242-1246. [DOI: 10.1016/j.transproceed.2022.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/22/2022] [Accepted: 04/02/2022] [Indexed: 11/16/2022]
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5
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Pearson R, Murray E, Thomson PC, Mark PB, Clancy MJ, Asher J. The New UK National Kidney Allocation Scheme With Maximized "R4-D4" Kidney Transplants: Better Patient-to-Graft Longevity Matching May Be at the Cost of More Resources. EXP CLIN TRANSPLANT 2021; 19:1133-1141. [PMID: 34812704 DOI: 10.6002/ect.2021.0129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES A new kidney matching scheme for allocation of deceased donor kidneys for transplantation was introduced in the United Kingdom in September 2019. Donors and recipients are stratified into quartiles derived from demographic and retrieval indices associated with risk of adverse outcome. We present data on 2 years of transplants, with the aim of understanding the potential impacts ofthe scheme on patient/transplant outcomes, hospitalization, and resource utilization. MATERIALS AND METHODS All deceased donortransplants from 2015 and 2016 were reclassified using the risk quartiles (D1-D4 for donor and R1-R4 for recipient, where 4 is highestrisk). Inpatientlength of stay, kidney function defined by estimated glomerular rate at 1 year, and patient survival data were collected. RESULTS Of the 195 deceased donor transplants analyzed, 144 recipients (73.4%) were in the highest risk R4 category, including 55 with R4-D4 combination (28.1%). Recipients in the R4 category had longer index admissions (mean of 12.4 vs 8.1 days for R1-R3; P = .002) and higher subsequent admission rates 90 days posttransplant(185.7 vs 122.7/1000 patient days for R1-R3; P < .001). Kidney transplant function at 1 year was lower for grafts categorized as D4 (mean estimated glomerular filtration rate of 35.7 vs 54.8 mL/min/1.73 m2 for D1-D3; P < .001). However, survival for R4 recipients with D4 kidneys was not significantly differentfrom R4 recipients with D1 to D3 kidneys (4-year patient survival rate with R4-D4 combination was 90.9%). CONCLUSIONS The principles ofthe allocation scheme in matching graft and patient survival were already largely being observed (matching higher risk deceased donor kidneys to higher risk recipients). However, an increase in D4 proportions in the R4 group may be associated with longer hospitalization posttransplant. Consideration should be given to mitigation strategies to address this. Despite poorer graft function, patient survival appears satisfactory.
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Affiliation(s)
- Robert Pearson
- From the Renal Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
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6
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Good Long-term Results Following Simultaneous Pancreas-kidney Transplantation in a 69-y-old Recipient: A Case Report. Transplant Direct 2021; 7:e773. [PMID: 34646936 PMCID: PMC8500590 DOI: 10.1097/txd.0000000000001204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/21/2021] [Accepted: 06/23/2021] [Indexed: 11/25/2022] Open
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7
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Fedulkina VA, Vatazin AV, Kildyushevskiy AV, Zulkarnayev AB, Gubina DV, Fedulkina MP. Immunosenescence as a reason of individualizing immunosuppressive therapy in kidney transplantation. RUSSIAN JOURNAL OF TRANSPLANTOLOGY AND ARTIFICIAL ORGANS 2021. [DOI: 10.15825/1995-1191-2021-3-171-179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Transplantation in elderly patients is obviously more challenging due to existing underlying diseases, changes in pharmacokinetics of immunosuppressive drugs, polypragmasy, and transformation of immunoreactivity (immunosenescence). Our review presents data on modification of adaptive and innate immunity during aging. It also considers the possibility of both reduced and adapted immunosuppressive therapy in elderly renal transplant recipients in achieving an optimal balance between efficacy and complications.
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Affiliation(s)
| | - A. V. Vatazin
- Vladimirsky Moscow Regional Research Clinical Institute
| | | | | | - D. V. Gubina
- Vladimirsky Moscow Regional Research Clinical Institute
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8
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Cossart AR, Isbel NM, Scuderi C, Campbell SB, Staatz CE. Pharmacokinetic and Pharmacodynamic Considerations in Relation to Calcineurin Usage in Elderly Kidney Transplant Recipients. Front Pharmacol 2021; 12:635165. [PMID: 33912051 PMCID: PMC8072471 DOI: 10.3389/fphar.2021.635165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 02/12/2021] [Indexed: 12/28/2022] Open
Abstract
This review summarizes how possible age-related changes in tacrolimus and cyclosporine pharmacokinetics and pharmacodynamics may influence drug dosing and monitoring in the elderly, and highlights how micro-sampling may be useful in this cohort in the future. Advancing biological age leads to physiological changes that can affect drug absorption, distribution, metabolism and excretion, as well as immune system responsiveness. Some studies have shown that elderly recipients may have higher dose-adjusted exposure and/or lower clearance of the calcineurin inhibitors, suggesting that doses may need to be lowered in elderly recipients. Only one study has examined how aging effects drug target enzyme activity and demonstrated that age does not correlate with the calcineurin inhibitor half-maximal inhibitory concentration. Several studies have shown elderly kidney transplant recipients have increased risk of both morbidity and mortality, compared to younger adults due to increased susceptibility to immunosuppressant side effects, particularly cardiovascular disease, infection and malignancy. Current immunosuppressant dosing and monitoring protocols often make no adjustments for age. Lower maintenance immunosuppressant targets in elderly recipients may decrease patient susceptibility to drug side effects, however, further studies are required and appropriate targets need to be established. Blood draw by micro-sampling may be useful for drug monitoring in this cohort in the future, as blood collection is minimally invasive and less painful than venepuncture. Micro-sampling could also make further pharmacokinetic, pharmacodynamics and outcome studies in the elderly more feasible.
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Affiliation(s)
- Amelia R Cossart
- School of Pharmacy, University of Queensland, Brisbane, QLD, Australia
| | - Nicole M Isbel
- Department of Nephrology, University of Queensland at the Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Carla Scuderi
- School of Pharmacy, University of Queensland, Brisbane, QLD, Australia.,Kidney Health Service, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Scott B Campbell
- Department of Nephrology, University of Queensland at the Princess Alexandra Hospital, Brisbane, QLD, Australia
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9
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Mehdorn AS, Reuter S, Suwelack B, Schütte-Nütgen K, Becker F, Senninger N, Palmes D, Vogel T, Bahde R. Comparison of kidney allograft survival in the Eurotransplant senior program after changing the allocation criteria in 2010-A single center experience. PLoS One 2020; 15:e0235680. [PMID: 32702005 PMCID: PMC7377418 DOI: 10.1371/journal.pone.0235680] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 06/21/2020] [Indexed: 12/22/2022] Open
Abstract
Aims The European Senior Program (ESP) aims to avoid waiting list competition between younger and elderly patients applying for renal transplantation. By listing patients ≥65 years on a separate waiting list and locally allocating of grafts ≥65 years exclusively to this cohort, waiting and cold ischemia times are predicted to be shortened, potentially resulting in improved kidney transplantation outcomes. This study compared a historic cohort of renal transplant recipients being simultaneously listed on the general and the ESP waiting lists with a collective exclusively listed on the ESP list in terms of surrogates of the transplantation outcome. Methods Total 151 eligible patients ≥ 65 years from Münster transplant Center, Germany, between 1999 and 2014 were included. Graft function, graft and patient survival were compared using surrogate markers of short- and long-term graft function. Patients were grouped according to their time of transplantation. Results Recipients and donors in the newESP (nESP) cohort were significantly older (69.6 ± 3.5 years vs 67.1 ± 2 years, p<0.05; 72.0 ± 5.0 years vs 70.3 ± 5.0 years, p = 0.039), had significantly shorter dialysis vintage (19.6 ± 21.7 months vs 60.2 ± 28.1 months, p<0.001) and suffered from significantly more comorbidities (2.2 ± 0.9 vs 1.8 ± 0.8, p = 0.009) than the historic cohort (HC). Five-year death-censored graft survival was better than in the HC, but 5-year graft and patient survival were better in the ESP cohort. After 2005, cold ischemia time between groups was comparable. nESP grafts showed more primary function and significantly better long-term graft function 18 months after transplantation and onwards. Conclusion nESP recipients received significantly older grafts, but experienced significantly shorter time on dialysis. Cold ischemia times were comparable, but graft function in the nESP cohort was significantly better in the long term.
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Affiliation(s)
- Anne-Sophie Mehdorn
- Department of General, Visceral and Transplant Surgery, Münster University Hospital, Münster, Germany
| | - Stefan Reuter
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, Münster University Hospital, Münster, Germany
- * E-mail:
| | - Barbara Suwelack
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, Münster University Hospital, Münster, Germany
| | - Katharina Schütte-Nütgen
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, Münster University Hospital, Münster, Germany
| | - Felix Becker
- Department of General, Visceral and Transplant Surgery, Münster University Hospital, Münster, Germany
| | - Norbert Senninger
- Department of General, Visceral and Transplant Surgery, Münster University Hospital, Münster, Germany
| | - Daniel Palmes
- Department of General, Visceral and Transplant Surgery, Münster University Hospital, Münster, Germany
| | - Thomas Vogel
- Department of General, Visceral and Transplant Surgery, Münster University Hospital, Münster, Germany
| | - Ralf Bahde
- Department of General, Visceral and Transplant Surgery, Münster University Hospital, Münster, Germany
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10
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Gerbase-DeLima M, de Marco R, Monteiro F, Tedesco-Silva H, Medina-Pestana JO, Mine KL. Impact of Combinations of Donor and Recipient Ages and Other Factors on Kidney Graft Outcomes. Front Immunol 2020; 11:954. [PMID: 32528472 PMCID: PMC7256929 DOI: 10.3389/fimmu.2020.00954] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/23/2020] [Indexed: 01/26/2023] Open
Abstract
As the availability of kidneys for transplantation continues to be outpaced by its growing demand, there has been an increasing utilization of older deceased donors in the last decades. Considering that definition of factors that influence deceased donor kidney transplant outcomes is important for allocation policies, as well as for individualization of post-transplant care, the purpose of this study was determine the risks for death censored graft survival and for patient survival conferred by older age of the donor in the context of the age of the recipient and of risk factors for graft and/or patient survival. The investigation was conducted in a single-center cohort of 5,359 consecutive first kidney transplants with adult deceased donors performed on non-prioritized adult recipients from January 1, 2002, to December 31, 2017. Death censored graft survival and patient survival were lower in older donors, whereas graft survival was higher and patient survival was lower in old recipients. The analyses of combinations of donor and recipient ages showed that death censored graft survival was lower in younger recipients in transplants from 18 to 59-year old donors, with standard or extended criteria, but no difference in graft survival was observed between younger and older recipients when the donor was ≥ 60-year old. Patient survival was higher in younger recipients in transplants with younger or older donors. Two to six HLA-A,B,DR mismatches, when compared to 0-1 MM, conferred risk for death-censored graft survival only in transplants from younger donors to younger recipients. Pre-transplant diabetes conferred risk for patient survival only in 50–59-year old recipients, irrespectively, of the age of the donor. Time on dialysis ≥ 10 years was a risk factor for patient survival in transplants with all donor-recipient age combinations, except in recipients with ≥ 60 years that received a kidney from an 18–49-year old donor. In conclusion, the results obtained in this study underline the importance of analyzing the impact of the age of the donor taking into consideration different scenarios.
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Affiliation(s)
- Maria Gerbase-DeLima
- Instituto de Imunogenética, Associação Fundo de Incentivo à Pesquisa, São Paulo, Brazil
| | - Renato de Marco
- Instituto de Imunogenética, Associação Fundo de Incentivo à Pesquisa, São Paulo, Brazil
| | | | | | - José O Medina-Pestana
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil.,Departamento de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Karina L Mine
- Instituto de Imunogenética, Associação Fundo de Incentivo à Pesquisa, São Paulo, Brazil
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11
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Dreyer GJ, de Fijter JW. Transplanting the Elderly: Mandatory Age- and Minimal Histocompatibility Matching. Front Immunol 2020; 11:359. [PMID: 32226428 PMCID: PMC7080649 DOI: 10.3389/fimmu.2020.00359] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/14/2020] [Indexed: 12/16/2022] Open
Abstract
Worldwide over 40% of patients receiving renal replacement therapy (RRT) are aged 65 years or older, a number that is still increasing. Renal transplantation is the preferred RRT, providing substantial survival benefit over those remaining on dialysis, including the elderly. Only 3% of patients aged 65 years or older accepted on the waiting list actually received a kidney transplant offer within the Eurotransplant allocation region. To increase the chance for elderly to receive a timely kidney transplant, the Eurotransplant Senior Program was introduced. The ESP supports local allocation of older kidneys to older donors in order to decrease cold ischemia time, while disregarding former exchange principles based on matching for HLA antigens. As a consequence, more elderly received a kidney transplant and a relative higher incidence of acute rejection resulted in additional courses of high steroids and/or depleting antibody therapy. Since death with a functioning graft due to infections is the dominant reason of graft loss in elderly, more intense clinical immunosuppression to prevent or treat acute rejection is not a very attractive option. Therefore in elderly kidney transplant candidates, we advocate reintroduction of minimal histocompatibility criteria (i.e., HLA-DR matching) followed by age-matching with mandatory local/regional allocation to also facilitate short cold ischemia.
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Affiliation(s)
- Geertje J Dreyer
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, Netherlands
| | - Johan W de Fijter
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, Netherlands
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12
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Noble J, Jouve T, Malvezzi P, Süsal C, Rostaing L. Transplantation of Marginal Organs: Immunological Aspects and Therapeutic Perspectives in Kidney Transplantation. Front Immunol 2020; 10:3142. [PMID: 32082306 PMCID: PMC7005052 DOI: 10.3389/fimmu.2019.03142] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 12/24/2019] [Indexed: 12/14/2022] Open
Abstract
Recent data from the World Population Prospects projects that, by 2050, nearly all regions in the world will have a quarter or more of the population aged 60 and above. Chronic kidney disease (CKD) has a high global prevalence (~13%) worldwide, and the prevalence of chronic kidney disease and end-stage kidney disease increase with age. Kidney transplantation remains the best therapeutic option for end-stage kidney disease, offering a survival benefit in comparison with dialysis maintenance for most patients. This review focuses on immunological aspects of kidney transplantation in older patients and marginal donors, i.e., 60 years or older deceased kidney donors or 50–59 years old deceased kidney donors with comorbidities. Clinical outcomes of kidney recipients in terms of renal and patient survival are more than acceptable even for patients over 70. In this population, the first cause of graft loss is death with a functional graft. However, the inherent issues of these transplantations are the acceptance or refusal of frail kidney from an old donor and the increased immunogenicity of these organs in balance with potential frail and immunosenescent recipients. Finally, the immunosuppressive regimen itself is a challenge for the future of the transplant, to prevent adverse effects such as nephrotoxicity and higher risk of infections or cancer in a population already at risk. Belatacept may have a good place in the immunosuppressive strategy to improve efficacy and the safety posttransplantation.
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Affiliation(s)
- Johan Noble
- Service de Néphrologie, Hémodialyse, Aphéréses et Transplantation Rénale, Centre Hospitalier Universitaire (CHU) de Grenoble-Alpes, Grenoble, France.,Université Grenoble Alpes, Grenoble, France
| | - Thomas Jouve
- Service de Néphrologie, Hémodialyse, Aphéréses et Transplantation Rénale, Centre Hospitalier Universitaire (CHU) de Grenoble-Alpes, Grenoble, France.,Université Grenoble Alpes, Grenoble, France
| | - Paolo Malvezzi
- Service de Néphrologie, Hémodialyse, Aphéréses et Transplantation Rénale, Centre Hospitalier Universitaire (CHU) de Grenoble-Alpes, Grenoble, France
| | - Caner Süsal
- Collaborative Transplant Study, Institute of Immunology, Heidelberg University, Heidelberg, Germany
| | - Lionel Rostaing
- Service de Néphrologie, Hémodialyse, Aphéréses et Transplantation Rénale, Centre Hospitalier Universitaire (CHU) de Grenoble-Alpes, Grenoble, France.,Université Grenoble Alpes, Grenoble, France
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13
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Quast LS, Grzella S, Lengenfeld T, Pillokeit N, Hummels M, Zgoura P, Westhoff TH, Viebahn R, Schenker P. Outcome of Kidney Transplantation Using Organs From Brain-dead Donors Older Than 75 Years. Transplant Proc 2019; 52:119-126. [PMID: 31901319 DOI: 10.1016/j.transproceed.2019.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/23/2019] [Accepted: 11/10/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE We investigated whether older donor kidneys aged >75 years have acceptable long-term function and if recipients can benefit sufficiently from the transplantation. METHODS This single-center study retrospectively analyzed patient data from 217 deceased donor kidney transplants performed between 1998 and 2014 as part of the Eurotransplant Senior Program, where the organ donors were ≥65 years old. Depending on donor age, the groups "older donors" (OD; n = 161) and "very old donors" (VOD; n = 56) received transplants from donors aged 65 to 75 years and >75 years, respectively. Donor and recipient clinical characteristics, delayed graft function, estimated glomerular filtration rate, 1-year rejection rate, patient and graft survival, and postoperative complications were investigated. RESULTS Comparing VOD group vs OD group, the 1-year, 3-year, and 5-year graft survival rates were 80.4% vs 76.4%, 62.5% vs 65.8%, and 42.6% vs 57.3%, respectively. Patient survival rates after 1, 3, and 5 years were 89.3% vs 88.2%, 71.4% vs 78.2%, and 57.5% vs 71.8%, respectively. There were no significant differences between the 2 groups (graft survival P = .107; patient survival P = .126). Kidney graft function after 1, 2, and 3 years was significantly better in the OD group than in the VOD group. No differences were found regarding postoperative complications, rejection rate, and delayed graft function. CONCLUSION The utilization of selected kidney-grafts from donors >75 years resulted in acceptable outcomes after kidney transplantation and could expand the donor pool. In contrast to the high mortality rate during dialysis, recipients in both groups benefited from transplantation.
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Affiliation(s)
- Louisa Sarah Quast
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Sascha Grzella
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Thorsten Lengenfeld
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Nina Pillokeit
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Marielle Hummels
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Panagiota Zgoura
- Medical Department I, University Hospital Marienhospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Timm H Westhoff
- Medical Department I, University Hospital Marienhospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Richard Viebahn
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Peter Schenker
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany.
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14
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Everolimus in de novo kidney transplant recipients participating in the Eurotransplant senior program: Results of a prospective randomized multicenter study (SENATOR). PLoS One 2019; 14:e0222730. [PMID: 31536556 PMCID: PMC6752944 DOI: 10.1371/journal.pone.0222730] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 09/05/2019] [Indexed: 01/17/2023] Open
Abstract
Early conversion to everolimus was assessed in kidney transplant recipients participating in the Eurotransplant Senior Program (ESP), a population in whom data are lacking. The SENATOR multicenter study enrolled 207 kidney transplant recipients undergoing steroid withdrawal at week 2 post-transplant (ClinicalTrials.gov [NCT00956293]). At week 7, patients were randomized (1:2 ratio) to continue the previous calcineurin inhibitor (CNI)-based regimen with mycophenolic acid (MPA) and cyclosporine or switch to a CNI-free regimen with MPA, everolimus (5–10 ng/mL) and basiliximab at weeks 7 and 12, then followed for 18 weeks to month 6 post-transplant. The primary endpoint was estimated GFR (eGFR). At week 7, 77/207 (37.2%) patients were randomized (53 everolimus, 24 control). At month 6, eGFR was comparable: 36.5±10.8ml/min with everolimus versus 42.0±13.0ml/min in the control group (p = 0.784). Discontinuation due to adverse events occurred in 27.8% of everolimus-treated patients and 0.0% of control patients (p = 0005). Efficacy profiles showed no difference. In conclusion, eGFR, safety and efficacy outcomes at month 6 post-transplant showed no difference between groups. The everolimus group experienced a higher rate of discontinuation due to adverse events. However, the high rate of non-randomization is highly relevant, indicating this to be a somewhat unstable patient population regardless of treatment.
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15
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Cossart AR, Cottrell WN, Campbell SB, Isbel NM, Staatz CE. Characterizing the pharmacokinetics and pharmacodynamics of immunosuppressant medicines and patient outcomes in elderly renal transplant patients. Transl Androl Urol 2019; 8:S198-S213. [PMID: 31236338 DOI: 10.21037/tau.2018.10.16] [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: 12/16/2022] Open
Abstract
This review examines what is currently known about the pharmacokinetics and pharmacodynamics of commonly prescribed immunosuppressant medicines, tacrolimus, cyclosporine, mycophenolate and prednisolone, in elderly renal transplant recipients, and reported patient outcomes in this cohort. Renal transplantation is increasing rapidly in the elderly, however, currently, long-term patient outcomes are relatively poor compared to younger adults. Some studies have suggested that elderly recipients may have higher dose-adjusted exposure and/or lower clearance of the calcineurin inhibitors tacrolimus and cyclosporine; with one study reporting up to 50% reduction in tacrolimus exposure in the elderly. Elderly transplant recipients do not appear to have higher dosage-adjusted exposure to mycophenolic acid (MPA). The effects of ageing on the pharmacokinetics of prednisolone are unknown. Only one study has examined how aging effects drug target enzymes, reporting no difference in baseline inosine 5'-monophosphate dehydrogenase (IMPDH) activity and MPA-induced IMPDH activity in elderly compared to younger adult renal transplant recipients. In elderly transplant recipients, immunosenescence likely lowers the risk of acute rejection, but increases the risk of drug-related adverse effects. Currently, the three main causes of death in elderly renal transplant recipients are cardiovascular disease, infection and malignancy. One study has showed that renal transplant recipients aged over 65 years are seven times more likely to die with a functioning graft compared with young adults (aged 18-29 years). This suggests that an optimal balance between immunosuppressant medicine efficacy and toxicity is not achieved in elderly recipients, and further studies are needed to foster long-term graft and patient survival. Lower maintenance immunosuppressant targets in elderly recipients may decrease patient susceptibility to drug side effects, however, further studies are required and appropriate targets need to be established.
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Affiliation(s)
- Amelia R Cossart
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - W Neil Cottrell
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Scott B Campbell
- Department of Nephrology, University of Queensland at the Princess Alexandra Hospital, Brisbane, Australia
| | - Nicole M Isbel
- Department of Nephrology, University of Queensland at the Princess Alexandra Hospital, Brisbane, Australia
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16
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Coemans M, Süsal C, Döhler B, Anglicheau D, Giral M, Bestard O, Legendre C, Emonds MP, Kuypers D, Molenberghs G, Verbeke G, Naesens M. Analyses of the short- and long-term graft survival after kidney transplantation in Europe between 1986 and 2015. Kidney Int 2018; 94:964-973. [PMID: 30049474 DOI: 10.1016/j.kint.2018.05.018] [Citation(s) in RCA: 171] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/26/2018] [Accepted: 05/17/2018] [Indexed: 12/21/2022]
Abstract
The evolution of kidney allograft survival remains insufficiently studied in the context of the changing donor and recipient demographics. Since European data are lacking we performed a cohort study (1986-2015) that, based on the Collaborative Transplant Study, included 108 787 recipients of brain-death kidney donors in 135 hospitals across 21 European countries. We analyzed the hazard rate of kidney failure after transplantation. Between 1986 and 1999, improvement in graft survival was more pronounced in the short term than in the long term: one-, five- and ten-year hazard rates after transplantation declined 64% (95% confidence interval, 61%-66%), 53% (49%-57%) and 45% (39%-50%), respectively. Between 2000 and 2015, hazard rates at one, five and ten years post-transplant declined respectively 22% (12-30%), 47% (36-56%) and 64% (45-76%). Improvement in graft survival in the first five years post-transplant was significantly less since 2000, while improvement after five years was comparable to before. During the 2000-2015 period improvement of graft survival was greater in the long than in the short term. These changes were independent of changing donor and recipient characteristics, and reflect the evolution in global kidney transplant management over the past decades. Unfortunately, after accounting for the evolution of donor and recipient characteristics, we found that short-term improvement in graft survival decreased since 2000, while long-term improvement remained unchanged in Europe. Thus, deceleration of short-term graft survival improvement in more recent years illustrates an unmet need for innovation.
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Affiliation(s)
- Maarten Coemans
- Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium; Leuven Biostatistics and Statistical Bioinformatics Centre, Leuven, Belgium
| | - Caner Süsal
- Institute of Immunology, University of Heidelberg, Heidelberg, Germany
| | - Bernd Döhler
- Institute of Immunology, University of Heidelberg, Heidelberg, Germany
| | - Dany Anglicheau
- Service de Néphrologie-Transplantation Adulte, Hôpital Necker, Paris, Université Paris Descartes & INSERM U 1151, Hôpital Necker, Paris, France
| | - Magali Giral
- Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM, Université de Nantes, Nantes, France
| | - Oriol Bestard
- Kidney Transplant Unit, Nephrology Department, Bellvitge University Hospital, Barcelona, Spain
| | - Christophe Legendre
- Service de Néphrologie-Transplantation Adulte, Hôpital Necker, Paris, Université Paris Descartes & INSERM U 1151, Hôpital Necker, Paris, France
| | - Marie-Paule Emonds
- Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium; Histocompatibility and Immunogenetic Laboratory, Red Cross Flanders, Mechelen, Belgium
| | - Dirk Kuypers
- Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Geert Molenberghs
- Leuven Biostatistics and Statistical Bioinformatics Centre, Leuven, Belgium
| | - Geert Verbeke
- Leuven Biostatistics and Statistical Bioinformatics Centre, Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.
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17
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Al Salmi I, Metry AM, Al Ismaili F, Hola A, Al Riyami M, Khamis F, Al-Abri S. Transplant tourism and invasive fungal infection. Int J Infect Dis 2018; 69:120-129. [PMID: 29428409 DOI: 10.1016/j.ijid.2018.01.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 01/27/2018] [Accepted: 01/29/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Deceased and live-related renal transplants (RTXs) are approved procedures that are performed widely throughout the world. In certain regions, commercial RTX has become popular, driven by financial greed. METHODS This retrospective, descriptive study was performed at the Royal Hospital from 2013 to 2015. Data were collected from the national kidney transplant registry of Oman. All transplant cases retrieved were divided into two groups: live-related RTX performed in Oman and commercial-unrelated RTX performed abroad. These groups were then divided again into those with and without evidence of fungal infection, either in the wound or renal graft. RESULTS A total of 198 RTX patients were identified, of whom 162 (81.8%) had undergone a commercial RTX that was done abroad. Invasive fungal infections (IFIs) were diagnosed in 8% of patients who had undergone a commercial RTX; of these patients, 76.9% underwent a nephrectomy and 23.1% continued with a functioning graft. None of the patients with RTXs performed at the Royal Hospital contracted an IFI. The most common fungal isolates were Aspergillus species (including Aspergillus flavus, Aspergillus fumigatus, Aspergillus nidulans, and Aspergillus nigricans), followed by Zygomycetes. However, there was no evidence of fungal infection including Aspergillus outside the graft site. Computed tomography (CT) findings showed infarction of the graft, renal artery thrombosis, aneurysmal dilatation of the external iliac artery, fungal ball, or just the presence of a perigraft collection. Of the total patients with IFIs, 23.1% died due to septic shock and 53.8% were alive and on hemodialysis. The remaining 23.1% who did not undergo nephrectomy demonstrated acceptable graft function. CONCLUSIONS This is the largest single-center study on commercial RTX reporting the highest number of patients with IFI acquired over a relatively short period of time. Aspergillus spp were the main culprit fungi, with no Candida spp being isolated. A high index of suspicion might be the most reasonable means to reduce the possible very poor outcomes. Improving legal transplant programs and strengthening the associated laws could prevent commercial transplant tourism.
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Affiliation(s)
- I Al Salmi
- The Renal Medicine Department, Royal Hospital, Muscat, Oman.
| | - A M Metry
- The Renal Medicine Department, Royal Hospital, Muscat, Oman.
| | - F Al Ismaili
- The Renal Medicine Department, Royal Hospital, Muscat, Oman.
| | - A Hola
- The Renal Medicine Department, Royal Hospital, Muscat, Oman.
| | - M Al Riyami
- Department of Pathology, Sultan Qaboos University Hospital, Muscat, Oman.
| | - F Khamis
- Infectious Disease Department, Royal Hospital, Muscat, Oman.
| | - S Al-Abri
- Infectious Disease Department, Royal Hospital, Muscat, Oman.
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18
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Peeters LEJ, Andrews LM, Hesselink DA, de Winter BCM, van Gelder T. Personalized immunosuppression in elderly renal transplant recipients. Pharmacol Res 2018; 130:303-307. [PMID: 29501679 DOI: 10.1016/j.phrs.2018.02.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/17/2018] [Accepted: 02/26/2018] [Indexed: 12/13/2022]
Abstract
The number of elderly people has increased considerably over the last decades, due to a rising life expectancy and ageing populations. As a result, an increased number of elderly with end-stage-renal-disease are diagnosed, for which the preferred treatment is renal transplantation. Over the past years the awareness of the elderly as a specific patient population has grown, which increases the importance of research in this group. Elderly patients often receive kidneys from elderly donors while younger donor kidneys are preferentially reserved for younger recipients. Although the rate of acute rejection after transplantation is lower in the elderly, these rejections may lead to graft loss more frequently, as kidneys from elderly donors have marginal reserve capacity. To prevent acute rejection, immunosuppressive therapy is needed. On the other hand, elderly patients have a higher risk to die from infectious complications, and thus less immunosuppression would be preferable. Immunosuppressive treatment in the elderly is complicated further by changes in the pharmacokinetics and pharmacodynamics, with increasing age. Adjustments in standard immunosuppressive regimes are therefore suggested for this population. An unmet need in transplantation medicine is a tool to guide a personalized approach to immunosuppression. Recently several promising biomarkers that identify injury to the graft at an early stage or predict acute rejection have been identified. Unfortunately, none of these biomarkers were tested specifically in the elderly. We believe there is an urgent need to perform clinical trials investigating novel immunosuppressive regimens in conjunction with biomarker studies in this specific population.
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Affiliation(s)
- L E J Peeters
- Departments of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - L M Andrews
- Departments of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - D A Hesselink
- Departments of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - B C M de Winter
- Departments of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - T van Gelder
- Departments of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, The Netherlands; Departments of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands.
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19
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Oldani G, Peloso A, Lacotte S, Meier R, Toso C. Xenogeneic chimera-Generated by blastocyst complementation-As a potential unlimited source of recipient-tailored organs. Xenotransplantation 2017; 24. [PMID: 28736957 DOI: 10.1111/xen.12327] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 07/05/2017] [Accepted: 07/08/2017] [Indexed: 12/13/2022]
Abstract
Blastocyst complementation refers to the injection of cells into a blastocyst. The technology allows for the creation of chimeric animals, which have the potential to be used as an unlimited source of organ donors. Pluripotent stem cells could be generated from a patient in need of a transplantation and injected into a large animal blastocyst (potentially of a pig), leading to the creation of organ(s) allowing immunosuppression-free transplantation. Various chimera combinations have already been generated, but one of the most recent steps leads to the creation of human-pig chimeras, which could be studied at an embryo stage. Although still far from clinical reality, the potential application is almost unlimited. The present review illustrates the historical steps of intra- and interspecific blastocyst complementation in rodents and large animals, specifically looking at its potential for generation of organ grafts. We also speculate on how it could change transplant indications, on its economic impact, and on the linked ethical concerns.
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Affiliation(s)
- Graziano Oldani
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,HepatoPancreato-Biliary Centre, Geneva University Hospitals, Geneva, Switzerland
| | - Andrea Peloso
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of General Surgery, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Stéphanie Lacotte
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Raphael Meier
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,HepatoPancreato-Biliary Centre, Geneva University Hospitals, Geneva, Switzerland
| | - Christian Toso
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,HepatoPancreato-Biliary Centre, Geneva University Hospitals, Geneva, Switzerland
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20
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Colvin MM, Smith CA, Tullius SG, Goldstein DR. Aging and the immune response to organ transplantation. J Clin Invest 2017; 127:2523-2529. [PMID: 28504651 DOI: 10.1172/jci90601] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
An increasing number of older people receive organ transplants for various end-stage conditions. Although organ transplantation is an effective therapy for older patients (i.e., older than 65 years of age), such as in end-stage renal disease, this therapy has not been optimized for older patients because of our lack of understanding of the effect of aging and the immune response to organ transplantation. Here, we provide an overview of the impact of aging on both the allograft and the recipient and its effect on the immune response to organ transplantation. We describe what has been determined to date, discuss existing gaps in our knowledge, and make suggestions on necessary future studies to optimize organ transplantation for older people.
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Affiliation(s)
- Monica M Colvin
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Candice A Smith
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Stefan G Tullius
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel R Goldstein
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Institute of Gerontology, University of Michigan, Ann Arbor, Michigan, USA
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21
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Criteria for and Appropriateness of Renal Transplantation in Elderly Patients With End-Stage Renal Disease. Transplantation 2016; 100:e55-65. [DOI: 10.1097/tp.0000000000001367] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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22
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Halleck F, Khadzhynov D, Liefeldt L, Schrezenmeier E, Lehner L, Duerr M, Schmidt D, Bamoulid J, Lachmann N, Waiser J, Budde K, Staeck O. Immunologic outcome in elderly kidney transplant recipients: is it time for HLA-DR matching? Nephrol Dial Transplant 2016; 31:2143-2149. [DOI: 10.1093/ndt/gfw248] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 05/20/2016] [Indexed: 01/15/2023] Open
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23
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Kim YH. Kidney Allocation: Present Status and Future Strategy. KOREAN JOURNAL OF TRANSPLANTATION 2016. [DOI: 10.4285/jkstn.2016.30.1.1] [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)
- Yeong Hoon Kim
- Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
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