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Massicotte-Azarniouch D, Detwiler RK, Hu Y, Falk RJ, Saha MK, van Duin D, Hogan SL, Derebail VK. Infections Following Kidney Transplantation After Exposure to Immunosuppression for Treatment of Glomerulonephritis. Am J Kidney Dis 2024; 83:784-793.e1. [PMID: 38160700 DOI: 10.1053/j.ajkd.2023.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 10/10/2023] [Accepted: 10/24/2023] [Indexed: 01/03/2024]
Abstract
RATIONALE & OBJECTIVE Kidney transplant patients with glomerulonephritis (GN) as their native disease commonly have received pretransplant immunosuppression (PTI). This may contribute to the immunosuppression burden potentially increasing the risk for infections after transplantation. STUDY DESIGN Single-center, retrospective cohort study. SETTING & PARTICIPANTS Recipients of a kidney transplant from January 2005 until May 2020 at a tertiary care university teaching hospital. EXPOSURE Patients with GN as their native kidney disease who received PTI for treatment of GN (n=184) were compared with nondiabetic recipients of kidney transplants who did not receive PTI (n = 579). OUTCOME First occurrence after transplantation of an infection outcome, either viral (BK or cytomegalovirus [CMV] infection) or bacterial. ANALYTICAL APPROACH Cox regression analysis adjusted for age at transplant, sex, race, donor type, year of transplant surgery, dialysis vintage, receipt of T-cell depleting induction, and CMV transplant status. RESULTS Over a median follow-up period of 5.7 years, patients with GN PTI were not at an increased risk for developing any first viral infection compared with controls (adjusted HR [AHR] 0.69 [95% CI, 0.52-0.91]) nor at increased risk for specific viral infections: BK infection 19.6% vs 26.3% (AHR 0.72 [95% CI, 0.50-1.05]) or CMV infection, 24.5% vs 29.0% (AHR, 0.76 [95% CI, 0.54-1.07]), respectively. There was also no increased risk of developing a first bacterial infection: 54.5% vs 57.5% (AHR, 0.90 [95% CI, 0.71-1.13]). These findings of no increased risk for infection were independent of the type of PTI used (cyclophosphamide, rituximab, mycophenolate mofetil, or calcineurin inhibitor) or the type of T-cell depleting induction therapy (alemtuzumab or antithymocyte globulin) administered. LIMITATIONS Single-center study, no data on methylprednisone use for PTI, unmeasured confounding. CONCLUSIONS Use of PTI for the treatment of GN was not associated with an increased risk of viral (BK or CMV) or bacterial infection after transplantation. Additional surveillance for infection after transplantation for patients who received PTI may not be necessary. PLAIN-LANGUAGE SUMMARY Many kidney transplant patients have glomerular disease as the cause of kidney failure. These patients may be exposed to immunosuppression before transplantation, which could increase the risk for infections after receipt of a transplanted kidney. We identified kidney transplant recipients at a university teaching hospital who received immunosuppression before transplant for the treatment of glomerular kidney disease. We examined their risk for infection after transplantation by comparing it with the risk among transplant patients who were not exposed to immunosuppression before transplant. We observed no increased risk for infection after exposure to prior immunosuppression. Therefore, patients exposed to significant amounts of immunosuppression before transplantation may not require special surveillance or medication adjustment for fear of infection after their receipt of a kidney transplant.
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Affiliation(s)
- David Massicotte-Azarniouch
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Division of Nephrology, Department of Medicine, University of Ottawa, Ontario, Canada.
| | - Randal K Detwiler
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Yichun Hu
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ronald J Falk
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Manish K Saha
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - David van Duin
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Susan L Hogan
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Vimal K Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Engen RM, Bartosh SM. Long-term outcomes of two-dose alemtuzumab induction in pediatric kidney transplantation. Pediatr Transplant 2024; 28:e14753. [PMID: 38623881 DOI: 10.1111/petr.14753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 03/15/2024] [Accepted: 03/26/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Alemtuzumab is a lymphocyte depleting agent used for induction in kidney transplant, but long-term information on its use in pediatric recipients remains sparse. METHODS We performed a single-center retrospective cohort study of 57 pediatric kidney transplant recipients receiving alemtuzumab 20 mg/m2/dose ×2 doses for induction immunosuppression. All patients underwent surveillance biopsies, and 91.3% underwent steroid withdrawal by day 4 post-transplant. Outcomes of interest included graft survival, development of donor specific antibodies (DSA), incidence of viremia and PTLD, and duration of lymphopenia. RESULTS Median follow-up time was 7.9 years (IQR 5-13.6 years). Median graft survival was 16.5 years (95% CI 11.6-unknown). DSA developed in 36.5% at a median of 944 days (IQR 252-2113 days). Incidences of BK polyomavirus DNAemia (BKPyV-DNAemia), CMV DNAemia, and EBV DNAemia were 38.6%, 22.8%, and 14%, respectively; one patient developed PTLD at 13.3 years post-transplant. Median duration of lymphopenia was 365 days (IQR 168-713 days); 19.3% of patients remained lymphopenic at 3 years post-transplant. There was no association between duration of lymphopenia and graft survival, rejection, DSA detection, or viremia. CONCLUSIONS A two-dose alemtuzumab induction protocol can have excellent outcomes with a steroid-free maintenance immunosuppression regimen. More comprehensive, multicenter, comparative studies of pediatric kidney transplant are needed to improve long-term outcomes.
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Affiliation(s)
- Rachel M Engen
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Sharon M Bartosh
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
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3
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Seifert ME, Mannon RB, Nellore A, Young J, Wiseman AC, Cohen DJ, Peddi VR, Brennan DC, Morgan CJ, Peri K, Aban I, Whitley RJ, Gnann JW. A multicenter prospective study to define the natural history of BK viral infections in kidney transplantation. Transpl Infect Dis 2024; 26:e14237. [PMID: 38341645 DOI: 10.1111/tid.14237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND BK polyomavirus (BKV) can cause permanent loss of allograft function due to BKV-associated nephropathy (BKVN) in kidney transplant recipients. Besides immunosuppression reduction, there are no consistently effective interventions for BKV infection. Study purpose was to define natural history of BKV infection, identify risk factors for BKV reactivation and BKVN in kidney transplant recipients, and inform the design/conduct of future clinical trials of BKV-targeted therapeutics. METHODS We conducted a multicenter prospective observational study of incident kidney transplant recipients at six U.S. transplant centers. Participants were monitored every 4 weeks for BKV reactivation and followed for up to 24 months post-transplant. We used regression models (logistic, survival, mixed models) to study relationships between BK viremia/BKVN, clinical characteristics, and allograft function. RESULTS We enrolled 335 participants. Fifty-eight (17%) developed BK viremia, 6 (2%) developed biopsy-proven BKVN, and 29 (9%) developed suspected/presumed BKVN (defined as BKV viral load > 10,000 copies/mL without biopsy). Male donor sex was associated with lower odds for BK viremia, whereas recipient Black race was associated with two-fold increased odds for BK viremia. Recipient female sex was associated with more rapid clearance of BK viremia. Persistent BK viremia/BKVN was associated with poorer allograft function by 24 months post-transplant. CONCLUSIONS We identified multiple donor and recipient demographic factors associated with risk for BKV infection and poorer allograft function by 24 months post-transplant. This may help design future clinical trials of therapies to prevent or mitigate the deleterious impact of BKV reactivation on kidney transplant outcomes.
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Affiliation(s)
- Michael E Seifert
- Heersink School of Medicine, University of Alabama, Birmingham, Alabama, USA
| | - Roslyn B Mannon
- Heersink School of Medicine, University of Alabama, Birmingham, Alabama, USA
| | - Anoma Nellore
- Heersink School of Medicine, University of Alabama, Birmingham, Alabama, USA
| | - JoAnne Young
- School of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - David J Cohen
- Columbia University Medical Center, New York, New York, USA
| | - V Ram Peddi
- California Pacific Medical Center, San Francisco, California, USA
| | - Daniel C Brennan
- School of Medicine, Washington University, St. Louis, Missouri, USA
| | - Charity J Morgan
- Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kalyani Peri
- Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Inmaculada Aban
- Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Richard J Whitley
- Heersink School of Medicine, University of Alabama, Birmingham, Alabama, USA
| | - John W Gnann
- Medical University of South Carolina, Charleston, South Carolina, USA
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4
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Fitzsimmons WE, Naesens M. Acute Rejection After Kidney Transplant-An Endpoint Not Predictive of Treatment Effect on Graft Survival. Transplantation 2024; 108:593-597. [PMID: 37322579 DOI: 10.1097/tp.0000000000004696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Affiliation(s)
- William E Fitzsimmons
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois, Chicago, IL
- Department of Physiology and Biophysics, College of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Maarten Naesens
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Department of Nephrology, UZ Leuven, Leuven, Belgium
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5
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Jones BP, Vali S, Saso S, Devaney A, Bracewell-Milnes T, Nicopoullos J, Thum MY, Kaur B, Roufosse C, Stewart V, Bharwani N, Ogbemudia A, Barnardo M, Dimitrov P, Klucniks A, Katz R, Johannesson L, Diaz Garcia C, Udupa V, Friend P, Quiroga I, Smith JR. Living donor uterus transplant in the UK: A case report. BJOG 2024; 131:372-377. [PMID: 37607687 DOI: 10.1111/1471-0528.17639] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/29/2023] [Accepted: 07/31/2023] [Indexed: 08/24/2023]
Affiliation(s)
- Benjamin P Jones
- West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Saaliha Vali
- West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
- Cutrale Perioperative and Ageing Group, Sir Michael Uren Hub, Imperial College London, London, UK
| | - Srdjan Saso
- West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Andrea Devaney
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Timothy Bracewell-Milnes
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Lister Fertility Clinic, The Lister Hospital, London, UK
| | - James Nicopoullos
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Lister Fertility Clinic, The Lister Hospital, London, UK
| | - Meen-Yau Thum
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Lister Fertility Clinic, The Lister Hospital, London, UK
| | - Baljeet Kaur
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- North West London Pathology, Charing Cross Hospital, Imperial College NHS Trust, London, UK
| | - Candice Roufosse
- North West London Pathology, Charing Cross Hospital, Imperial College NHS Trust, London, UK
- Centre for Inflammatory Disease, Department Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
| | - Victoria Stewart
- West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
| | - Nishat Bharwani
- West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
- Division of Surgery and Cancer, Imperial College London, London, UK
| | - Ann Ogbemudia
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Martin Barnardo
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Peter Dimitrov
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Andris Klucniks
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Richard Katz
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | | | - Cesar Diaz Garcia
- IVI London, IVIRMA Global, London, UK
- EGA Institute for Women's Health, University College London, London, UK
| | - Venkatesha Udupa
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Peter Friend
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Isabel Quiroga
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - J Richard Smith
- West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
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6
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Byrns JS, Sanoff SL. In Reply to Best Practice for Induction of Immunosuppression in Patients Treated With Daratumumab Is to Be Determined. Am J Kidney Dis 2024; 83:116-117. [PMID: 37657636 DOI: 10.1053/j.ajkd.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/17/2023] [Indexed: 09/03/2023]
Affiliation(s)
- Jennifer S Byrns
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina
| | - Scott L Sanoff
- Department of Medicine, Duke University Hospital, Durham, North Carolina
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7
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Montero N, Rodrigo E, Crespo M, Cruzado JM, Gutierrez-Dalmau A, Mazuecos A, Sancho A, Belmar L, Calatayud E, Mora P, Oliveras L, Solà E, Villanego F, Pascual J. The use of lymphocyte-depleting antibodies in specific populations of kidney transplant recipients: A systematic review and meta-analysis. Transplant Rev (Orlando) 2023; 37:100795. [PMID: 37774445 DOI: 10.1016/j.trre.2023.100795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/07/2023] [Accepted: 09/09/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Recommendations of the use of antibody induction treatments in kidney transplant recipients (KTR) are based on moderate quality and historical studies. This systematic review aims to reevaluate, based on actual studies, the effects of different antibody preparations when used in specific KTR subgroups. METHODS We searched MEDLINE and CENTRAL and selected randomized controlled trials (RCT) and observational studies looking at different antibody preparations used as induction in KTR. Comparisons were categorized into different KTR subgroups: standard, high risk of rejection, high risk of delayed graft function (DGF), living donor, and elderly KTR. Two authors independently assessed the risk of bias. RESULTS Thirty-seven RCT and 99 observational studies were finally included. Compared to anti-interleukin-2-receptor antibodies (IL2RA), anti-thymocyte globulin (ATG) reduced the risk of acute rejection at two years in standard KTR (RR 0.74, 95%CI 0.61-0.89) and high risk of rejection KTR (RR 0.55, 95%CI 0.43-0.72), but without decreasing the risk of graft loss. We did not find significant differences comparing ATG vs. alemtuzumab or different ATG dosages in any KTR group. CONCLUSIONS Despite many studies carried out on induction treatment in KTR, their heterogeneity and short follow-up preclude definitive conclusions to determine the optimal induction therapy. Compared with IL2RA, ATG reduced rejection in standard-risk, highly sensitized, and living donor graft recipients, but not in high DGF risk or elderly recipients. More studies are needed to demonstrate beneficial effects in other KTR subgroups and overall patient and graft survival.
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Affiliation(s)
- Nuria Montero
- Nephrology Department, Hospital Universitari de Bellvitge, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Emilio Rodrigo
- Nephrology Department, Hospital Universitario Marqués de Valdecilla/IDIVAL, Santander, Spain
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Josep M Cruzado
- Nephrology Department, Hospital Universitari de Bellvitge, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Alex Gutierrez-Dalmau
- Nephrology Department, Hospital Universitario Miguel Servet, Aragon Health Research Institute, Zaragoza, Spain
| | | | - Asunción Sancho
- Nephrology Department, Hospital Universitari Dr Peset, FISABIO, Valencia, Spain
| | - Lara Belmar
- Nephrology Department, Hospital Universitario Marqués de Valdecilla/IDIVAL, Santander, Spain
| | - Emma Calatayud
- Nephrology Department, Hospital Universitari Dr Peset, FISABIO, Valencia, Spain
| | - Paula Mora
- Nephrology Department, Hospital Universitario Miguel Servet, Aragon Health Research Institute, Zaragoza, Spain
| | - Laia Oliveras
- Nephrology Department, Hospital Universitari de Bellvitge, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Eulalia Solà
- Nephrology Department, Consorci Sanitari del Garraf, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | | | - Julio Pascual
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain.
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8
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van Vugt LK, van der Zwan M, Clahsen-van Groningen MC, van Agteren M, Hullegie-Peelen DM, De Winter BCM, Reinders MEJ, Miranda Afonso P, Hesselink DA. A Decade of Experience With Alemtuzumab Therapy for Severe or Glucocorticoid-Resistant Kidney Transplant Rejection. Transpl Int 2023; 36:11834. [PMID: 38020744 PMCID: PMC10660975 DOI: 10.3389/ti.2023.11834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023]
Abstract
Alemtuzumab is used as lymphocyte-depleting therapy for severe or glucocorticoid-resistant kidney transplant rejection. However, the long-term efficacy and toxicity of alemtuzumab therapy are unclear. Therefore, all cases of alemtuzumab anti-rejection therapy between 2012 and 2022 in our institution were investigated. Graft survival, graft function, lymphocyte depletion, serious infections, malignancies, and patient survival were analyzed and compared with a reference cohort of transplanted patients who did not require alemtuzumab anti-rejection therapy. A total of 225 patients treated with alemtuzumab were identified and compared with a reference cohort of 1,668 patients. Over 60% of grafts was salvaged with alemtuzumab therapy, but graft survival was significantly poorer compared to the reference cohort. The median time of profound T- and B lymphocyte depletion was 272 and 344 days, respectively. Serious infection rate after alemtuzumab therapy was 54.1/100 person-years. The risk of death (hazard ratio 1.75, 95%-CI 1.28-2.39) and infection-related death (hazard ratio 2.36, 95%-CI 1.35-4.11) were higher in the alemtuzumab-treated cohort. In conclusion, alemtuzumab is an effective treatment for severe kidney transplant rejection, but causes long-lasting lymphocyte depletion and is associated with frequent infections and worse patient survival outcomes.
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Affiliation(s)
- Lukas K. van Vugt
- Erasmus MC Transplant Institute, Rotterdam, Netherlands
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marieke van der Zwan
- Department of Internal Medicine, A. Schweitzer Hospital Dordrecht, Dordrecht, Netherlands
| | - Marian C. Clahsen-van Groningen
- Erasmus MC Transplant Institute, Rotterdam, Netherlands
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Madelon van Agteren
- Erasmus MC Transplant Institute, Rotterdam, Netherlands
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Daphne M. Hullegie-Peelen
- Erasmus MC Transplant Institute, Rotterdam, Netherlands
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Brenda C. M. De Winter
- Erasmus MC Transplant Institute, Rotterdam, Netherlands
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marlies E. J. Reinders
- Erasmus MC Transplant Institute, Rotterdam, Netherlands
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Pedro Miranda Afonso
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Dennis A. Hesselink
- Erasmus MC Transplant Institute, Rotterdam, Netherlands
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
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9
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Malhotra D, Jethwani P. Preventing Rejection of the Kidney Transplant. J Clin Med 2023; 12:5938. [PMID: 37762879 PMCID: PMC10532029 DOI: 10.3390/jcm12185938] [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: 07/28/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
With increasing knowledge of immunologic factors and with the advent of potent immunosuppressive agents, the last several decades have seen significantly improved kidney allograft survival. However, despite overall improved short to medium-term allograft survival, long-term allograft outcomes remain unsatisfactory. A large body of literature implicates acute and chronic rejection as independent risk factors for graft loss. In this article, we review measures taken at various stages in the kidney transplant process to minimize the risk of rejection. In the pre-transplant phase, it is imperative to minimize the risk of sensitization, aim for better HLA matching including eplet matching and use desensitization in carefully selected high-risk patients. The peri-transplant phase involves strategies to minimize cold ischemia times, individualize induction immunosuppression and make all efforts for better HLA matching. In the post-transplant phase, the focus should move towards individualizing maintenance immunosuppression and using innovative strategies to increase compliance. Acute rejection episodes are risk factors for significant graft injury and development of chronic rejection thus one should strive for early detection and aggressive treatment. Monitoring for DSA development, especially in high-risk populations, should be made part of transplant follow-up protocols. A host of new biomarkers are now commercially available, and these should be used for early detection of rejection, immunosuppression modulation, prevention of unnecessary biopsies and monitoring response to rejection treatment. There is a strong push needed for the development of new drugs, especially for the management of chronic or resistant rejections, to prolong graft survival. Prevention of rejection is key for the longevity of kidney allografts. This requires a multipronged approach and significant effort on the part of the recipients and transplant centers.
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Affiliation(s)
- Divyanshu Malhotra
- Johns Hopkins Medicine, Johns Hopkins Comprehensive Transplant Center, Baltimore, MD 21287, USA
| | - Priyanka Jethwani
- Methodist Transplant Institute, University of Tennessee Health Science Center, Knoxville, TN 37996, USA;
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10
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Swanson KJ, Bregman A, El-Rifai R, Jackson S, Kandaswamy R, Riad S. Second Kidney Transplant Outcomes in Dialysis Dependent Recipients by Induction Type in the United States. Transplant Proc 2023; 55:1535-1542. [PMID: 37419731 DOI: 10.1016/j.transproceed.2023.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 03/18/2023] [Accepted: 04/14/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND We examined the association between induction type for a second kidney transplant in dialysis-dependent recipients and the long-term outcomes. METHODS Using the Scientific Registry of Transplant Recipients, we identified all second kidney transplant recipients who returned to dialysis before re-transplantation. Exclusion criteria included: missing, unusual, or no-induction regimens, maintenance regimens other than tacrolimus and mycophenolate, and positive crossmatch status. We grouped recipients by induction type into 3 groups: the anti-thymocyte group (N = 9899), the alemtuzumab group (N = 1982), and the interleukin 2 receptor antagonist group (N = 1904). We analyzed recipient and death-censored graft survival (DCGS) using the Kaplan-Meier survival function with follow-up censored at 10 years post-transplant. We used Cox proportional hazard models to examine the association between induction and the outcomes of interest. To account for the center-specific effect, we included the center as a random effect. We adjusted the models for the pertinent recipient and organ variables. RESULTS In the Kaplan-Meier analyses, induction type did not alter recipient survival (log-rank P = .419) or DCGS (log-rank P = .146). Similarly, in the adjusted models, induction type was not a predictor of recipient or graft survival. Live-donor kidneys were associated with better recipient survival (HR 0.73, 95% CI [0.65, 0.83], P < .001) and graft survival (HR 0.72, 95% CI [0.64, 0.82], P < .001). Publicly insured recipients had worse recipient and allograft outcomes. CONCLUSION In this large cohort of average immunologic-risk dialysis-dependent second kidney transplant recipients, who were discharged on tacrolimus and mycophenolate maintenance, induction type did not influence the long-term outcomes of recipient or graft survival. Live-donor kidneys improved recipient and graft survival.
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Affiliation(s)
- Kurtis J Swanson
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, Minnesota; Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, Wisconsin
| | - Adam Bregman
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Rasha El-Rifai
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Scott Jackson
- Complex Care Analytics, MHealth Fairview, Minneapolis, Minnesota
| | - Raja Kandaswamy
- Division of Transplant Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Samy Riad
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, Minnesota; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota.
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11
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Massicotte-Azarniouch D, Detwiler RK, Hu Y, Falk RJ, Saha MK, Hogan SL, Derebail VK. Malignancy risk in kidney transplant recipients exposed to immunosuppression pre-transplant for the treatment of glomerulonephritis. Nephrol Dial Transplant 2023; 38:2009-2018. [PMID: 36549661 PMCID: PMC10468752 DOI: 10.1093/ndt/gfac337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Kidney transplant patients with glomerulonephritis (GN) as their native disease may receive significant amounts of pre-transplant immunosuppression (PTI), which could increase the risk for development of malignancy post-transplant. METHODS We conducted a single-center, retrospective study of kidney transplant recipients from January 2005 until May 2020. Patients with GN as their native kidney disease who received PTI for treatment of GN (n = 184) were compared with a control cohort (n = 579) of non-diabetic, non-PTI-receiving kidney transplant patients. We calculated hazard ratios (HR) with 95% confidence intervals (95% CI) for outcomes of first occurrence of solid or hematologic malignancy, non-melanoma skin cancer (NMSC) and post-transplant lymphoproliferative disorder (PTLD). RESULTS Over a median follow-up of 5.7 years, PTI for GN was associated with significantly increased risk for malignancy compared with controls [13.0% vs 9.7%, respectively; adjusted HR 1.82 (95% CI 1.10-3.00)], but not for NMSC [10.3% vs 11.4%, respectively; adjusted HR 1.09 (95% CI 0.64-1.83)] or PTLD [3.3% vs 3.1%, respectively; adjusted HR 1.02 (95% CI 0.40-2.61)]. The risk for malignancy was significantly increased in those who received cyclophosphamide [HR 2.59 (95% CI 1.48-4.55)] or rituximab [HR 3.82 (95% CI 1.69-8.65)] pre-transplant, and particularly in those who received both cyclophosphamide and rituximab, but not for calcineurin inhibitors or mycophenolate. CONCLUSION The use of PTI for treatment of GN, especially cyclophosphamide or even with rituximab, is associated with increased risk for development of solid or hematologic malignancy post-transplant. These data highlight potential risks with treatment of GN and underscore the importance of post-transplant malignancy surveillance in this patient population.
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Affiliation(s)
- David Massicotte-Azarniouch
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Randal K Detwiler
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yichun Hu
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ronald J Falk
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Manish K Saha
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Susan L Hogan
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Vimal K Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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12
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Santos E, Spensley K, Gunby N, Clarke C, Anand A, Roufosse C, Willicombe M. Steroid Sparing Maintenance Immunosuppression in Highly Sensitised Patients Receiving Alemtuzumab Induction. Transpl Int 2023; 36:11056. [PMID: 37334011 PMCID: PMC10272412 DOI: 10.3389/ti.2023.11056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 04/25/2023] [Indexed: 06/20/2023]
Abstract
This analysis reports on the outcomes of two different steroid sparing immunosuppression protocols used in the management of 120 highly sensitised patients (HSPs) with cRF>85% receiving Alemtuzumab induction, 53 maintained on tacrolimus (FK) monotherapy and 67 tacrolimus plus mycophenolate mofetil (FK + MMF). There was no difference in the median cRF or mode of sensitisation between the two groups, although the FK + MMF cohort received more poorly matched grafts. There was no difference in one-year patient or allograft survival, however rejection free survival was inferior with FK monotherapy compared with FK + MMF at 65.4% and 91.4% respectively, p < 0.01. DSA-free survival was comparable. Whilst there was no difference in rates of BK between the cohorts, CMV-free survival was inferior in the FK + MMF group at 86.0% compared with 98.1% in the FK group, p = 0.026. One-year post-transplant diabetes free survival was 89.6% and 100.0% in the FK and FK + MMF group respectively, p = 0.027, the difference attributed to the use of prednisolone to treat rejection in the FK cohort, p = 0.006. We report good outcomes in HSPs utilising a steroid sparing protocol with Alemtuzumab induction and FK + MMF maintenance and provide granular data on immunological and infectious complications to inform steroid avoidance in these patient groups.
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Affiliation(s)
- Eva Santos
- Histocompatibility and Immunogenetics Laboratory, Northwest London Pathology NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Katrina Spensley
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, United Kingdom
| | - Nicola Gunby
- Histocompatibility and Immunogenetics Laboratory, Northwest London Pathology NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Candice Clarke
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, United Kingdom
| | - Arthi Anand
- Histocompatibility and Immunogenetics Laboratory, Northwest London Pathology NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Candice Roufosse
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, United Kingdom
- Department of Histopathology, Northwest London Pathology NHS Trust, Charing Cross Hospital, London, United Kingdom
| | - Michelle Willicombe
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, United Kingdom
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13
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Mohamadou I, Matignon M, Malard S, Lombardi Y, Buob D, Moktefi A, Jamme M, Ouali N, Rafat C, François H, Petit-Hoang C, Rondeau E, Mesnard L, Grimbert P, Taupin JL, Luque Y. Additional Benefits of Rituximab and Plasma Exchange on Top of Standard Induction Therapy in Kidney Transplant Recipients With a Negative CDC Crossmatch but High Preformed Donor Specific Antibody Titer. Transpl Int 2023; 36:10844. [PMID: 37056357 PMCID: PMC10088221 DOI: 10.3389/ti.2023.10844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 02/28/2023] [Indexed: 03/30/2023]
Abstract
Optimal induction strategy in highly sensitized kidney transplant recipients (KTRs) is still a matter of debate. The place of therapies, such as plasma exchange and rituximab, with potential side effects and high cost, is not clearly established. We compared two induction strategies with (intensive) or without (standard) rituximab and plasma exchange in KTRs with high levels of preformed DSA transplanted between 2012 and 2019. Sixty KTRs with a mean age of 52.2 ± 12.2 years were included, 36 receiving standard and 24 intensive induction. Mean fluorescence intensity of immunodominant DSA in the cohort was 8,903 ± 5,469 pre-transplantation and similar in both groups. DSA level decrease was similar at 3 and 12 months after transplantation in the two groups. An intensive induction strategy was not associated with better graft or patient survival, nor more infectious complications. The proportion of patients with rejection during the first year was similar (33% in each group), but rejection occurred later in the intensive group (211 ± 188 days, vs. 79 ± 158 days in the standard group, p < 0.01). Our study suggests that an intensive induction therapy including rituximab and plasma exchanges in highly sensitized kidney recipients is not associated with better graft survival but may delay biopsy-proven rejection.
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Affiliation(s)
- Inna Mohamadou
- Service de Transplantation Rénale, Hôpital Pitié-Salpêtrière, Assistance Publique – Hôpitaux de Paris, Paris, France
- Sorbonne Université, Paris, France
- INSERM U1155 Des Maladies Rénales Rares Aux Maladies Fréquentes, Remodelage Et Réparation, Paris, France
- *Correspondence: Inna Mohamadou,
| | - Marie Matignon
- Service de Néphrologie, Hôpitaux Universitaires Henri Mondor, Créteil, France
- INSERM U955 Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
| | - Stéphanie Malard
- Laboratoire d’Immunologie et d’Histocompatibilité, Hôpital Saint-Louis, Paris, France
| | - Yannis Lombardi
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - David Buob
- Sorbonne Université, Paris, France
- INSERM U1155 Des Maladies Rénales Rares Aux Maladies Fréquentes, Remodelage Et Réparation, Paris, France
- Anatomie Pathologique, Hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Pairs, France
| | - Anissa Moktefi
- INSERM U955 Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
- Département de Pathologie, Hôpitaux Universitaires Henri Mondor, Assistance Publique – Hôpitaux de Paris, Créteil, France
| | - Matthieu Jamme
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Nacera Ouali
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Cedric Rafat
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Hélène François
- Sorbonne Université, Paris, France
- INSERM U1155 Des Maladies Rénales Rares Aux Maladies Fréquentes, Remodelage Et Réparation, Paris, France
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Camille Petit-Hoang
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Eric Rondeau
- Sorbonne Université, Paris, France
- INSERM U1155 Des Maladies Rénales Rares Aux Maladies Fréquentes, Remodelage Et Réparation, Paris, France
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Laurent Mesnard
- Sorbonne Université, Paris, France
- INSERM U1155 Des Maladies Rénales Rares Aux Maladies Fréquentes, Remodelage Et Réparation, Paris, France
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Philippe Grimbert
- Service de Néphrologie, Hôpitaux Universitaires Henri Mondor, Créteil, France
- INSERM U955 Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
| | - Jean-Luc Taupin
- Laboratoire d’Immunologie et d’Histocompatibilité, Hôpital Saint-Louis, Paris, France
| | - Yosu Luque
- Sorbonne Université, Paris, France
- INSERM U1155 Des Maladies Rénales Rares Aux Maladies Fréquentes, Remodelage Et Réparation, Paris, France
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
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14
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Frutos MÁ, Crespo M, Valentín MDLO, Alonso-Melgar Á, Alonso J, Fernández C, García-Erauzkin G, González E, González-Rinne AM, Guirado L, Gutiérrez-Dalmau A, Huguet J, Moral JLLD, Musquera M, Paredes D, Redondo D, Revuelta I, Hofstadt CJVD, Alcaraz A, Alonso-Hernández Á, Alonso M, Bernabeu P, Bernal G, Breda A, Cabello M, Caro-Oleas JL, Cid J, Diekmann F, Espinosa L, Facundo C, García M, Gil-Vernet S, Lozano M, Mahillo B, Martínez MJ, Miranda B, Oppenheimer F, Palou E, Pérez-Saez MJ, Peri L, Rodríguez O, Santiago C, Tabernero G, Hernández D, Domínguez-Gil B, Pascual J. Recommendations for living donor kidney transplantation. Nefrologia 2022; 42 Suppl 2:5-132. [PMID: 36503720 DOI: 10.1016/j.nefroe.2022.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/26/2021] [Indexed: 06/17/2023] Open
Abstract
This Guide for Living Donor Kidney Transplantation (LDKT) has been prepared with the sponsorship of the Spanish Society of Nephrology (SEN), the Spanish Transplant Society (SET), and the Spanish National Transplant Organization (ONT). It updates evidence to offer the best chronic renal failure treatment when a potential living donor is available. The core aim of this Guide is to supply clinicians who evaluate living donors and transplant recipients with the best decision-making tools, to optimise their outcomes. Moreover, the role of living donors in the current KT context should recover the level of importance it had until recently. To this end the new forms of incompatible HLA and/or ABO donation, as well as the paired donation which is possible in several hospitals with experience in LDKT, offer additional ways to treat renal patients with an incompatible donor. Good results in terms of patient and graft survival have expanded the range of circumstances under which living renal donors are accepted. Older donors are now accepted, as are others with factors that affect the decision, such as a borderline clinical history or alterations, which when evaluated may lead to an additional number of transplantations. This Guide does not forget that LDKT may lead to risk for the donor. Pre-donation evaluation has to centre on the problems which may arise over the short or long-term, and these have to be described to the potential donor so that they are able take them into account. Experience over recent years has led to progress in risk analysis, to protect donors' health. This aspect always has to be taken into account by LDKT programmes when evaluating potential donors. Finally, this Guide has been designed to aid decision-making, with recommendations and suggestions when uncertainties arise in pre-donation studies. Its overarching aim is to ensure that informed consent is based on high quality studies and information supplied to donors and recipients, offering the strongest possible guarantees.
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Affiliation(s)
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | | | | | - Juana Alonso
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | | | - Esther González
- Nephrology Department, Hospital Universitario 12 Octubre, Spain
| | | | - Lluis Guirado
- Nephrology Department, Fundacio Puigvert, Barcelona, Spain
| | | | - Jorge Huguet
- RT Surgical Team, Fundació Puigvert, Barcelona, Spain
| | | | - Mireia Musquera
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | - David Paredes
- Donation and Transplantation Coordination Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Ignacio Revuelta
- Nephrology and RT Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Antonio Alcaraz
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Manuel Alonso
- Regional Transplantation Coordination, Seville, Spain
| | | | - Gabriel Bernal
- Nephrology Department, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Alberto Breda
- RT Surgical Team, Fundació Puigvert, Barcelona, Spain
| | - Mercedes Cabello
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | - Joan Cid
- Apheresis and Cell Therapy Unit, Haemotherapy and Haemostasis Department, Hospital Clinic Universitari, Barcelona, Spain
| | - Fritz Diekmann
- Nephrology and RT Department, Hospital Clinic Universitari, Barcelona, Spain
| | - Laura Espinosa
- Paediatric Nephrology Department, Hospital La Paz, Madrid, Spain
| | - Carme Facundo
- Nephrology Department, Fundacio Puigvert, Barcelona, Spain
| | | | | | - Miquel Lozano
- Apheresis and Cell Therapy Unit, Haemotherapy and Haemostasis Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | | | | | | | - Eduard Palou
- Immunology Department, Hospital Clinic i Universitari, Barcelona, Spain
| | | | - Lluis Peri
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | | | | | - Domingo Hernández
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | - Julio Pascual
- Nephrology Department, Hospital del Mar, Barcelona, Spain.
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15
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Galeev SR, Gautier SV. Risks and ways of preventing kidney dysfunction in drug-induced immunosuppression in solid organ recipients. RUSSIAN JOURNAL OF TRANSPLANTOLOGY AND ARTIFICIAL ORGANS 2022. [DOI: 10.15825/1995-1191-2022-4-24-38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Immunosuppressive therapy (IMT) is the cornerstone of treatment after transplantation. The goal of immunosuppression is to prevent acute and chronic rejection while maximizing patient survival and long-term graft function. However, the expected effects of IMT must be balanced against the major adverse effects of these drugs and their toxicity. The purpose of this review is to summarize world experience on current immunosuppressive strategies and to assess their effects on renal function.
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Affiliation(s)
- Sh. R. Galeev
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - S. V. Gautier
- Shumakov National Medical Research Center of Transplantology and Artificial Organs; Sechenov University
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16
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Preemptive Second Kidney Transplant Outcomes by Induction Type in the United States. Transplant Proc 2022; 54:2125-2132. [PMID: 36210195 DOI: 10.1016/j.transproceed.2022.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/29/2022] [Indexed: 11/06/2022]
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17
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Preoperative CD52 Level Predicts Graft Survival following Kidney Transplantation. BIOMED RESEARCH INTERNATIONAL 2022. [DOI: 10.1155/2022/8949919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Several factors have been reported to affect graft survival following kidney transplantation. CD52 molecules may increase T cell proliferation and activation, which may contribute to acute graft rejection and graft survival. In the current study, we studied the possible value of preoperative CD52 levels in predicting graft survival following renal transplantation. Ninety-six patients with end-stage renal disease who had kidney transplantation were included in the study from our prospective cohort. Blood samples were taken one day before surgery, and plasma CD52 levels were measured using ELISA (Cloud-Clone Corp., Houston, TX, USA). Acute rejection, acute tubular necrosis, delayed graft function, graft loss, BK infection, cytomegalovirus infection, and graft survival were evaluated. The mean age of recipients was
, and 64.6% were male. The incidence of delayed graft function, acute rejection, graft loss (
), BK virus infection, and serum creatinine levels were significantly higher in recipients with high preoperative CD52 levels six months after transplantation (
). Kaplan–Meier analysis revealed that three-year graft survival was significantly higher in patients with low preoperative CD52 levels (
). Univariate and multivariate Cox regression analyses showed that serum creatinine levels (
,
), acute rejection (
,
), and preoperative CD52 levels (
,
) were independent prognostic factors for graft survival after kidney transplantation. We showed that high preoperative CD52 levels are associated with higher rates of acute rejection, delayed graft function, and BK virus infection and lower rates of graft survival after kidney transplantation.
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18
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The Role of Donor Sex in Females Undergoing Repeat Kidney Transplant: Does Prior Donor Sex Matter? Transplant Direct 2022; 8:e1352. [PMID: 37077730 PMCID: PMC10109158 DOI: 10.1097/txd.0000000000001352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/11/2022] [Accepted: 05/25/2022] [Indexed: 11/26/2022] Open
Abstract
Female recipients of male donor kidneys are at increased risk for graft failure because of the HY antigen effect. However, whether prior transplant with a male donor impacts subsequent transplant outcomes is unknown. Therefore, the purpose of this study was to determine whether prior male-current male donor sex is associated with an increased risk of graft failure in female recipients. Methods We performed a cohort study of adult female recipients undergoing a second kidney transplant (2000-2017), identified using the Scientific Registry of Transplant Recipients. Using multivariable Cox models, we analyzed the risk of death-censored graft loss (DCGL) if the second transplant was from a male versus female kidney donor, conditional on donor sex at the time of the first transplant. In a secondary analysis, we stratified results by recipient age (>50 or ≤50 y) at the time of retransplant. Results Of 5594 repeat kidney transplants, 1397 (25.0%) developed DCGL. Overall, there was no association between first and second donor sex pairing and DCGL. A prior and current female donor (FD1FD2) posed a higher risk for DCGL in recipients aged >50 y at second transplant (hazard ratio,≤0.67, confidence interval 0.46-0.98, for all other donor combinations), but posed a lower risk if aged ≤50 y at retransplant (hazard ratio, ≥1.37, confidence interval 1.04-1.80, for all other donor combinations). Conclusions Overall, past-current donor sex pairing was not associated with DCGL in female recipients undergoing second kidney transplant; however, the risk with a past and current female donor was increased in older, and decreased in younger, female recipients at retransplant.
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19
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Spasovski G, Trajceska L, Rambabova-Bushljetik I. Pharmacotherapeutic options for the prevention of kidney transplant rejection: the evidence to date. Expert Opin Pharmacother 2022; 23:1397-1412. [PMID: 35835450 DOI: 10.1080/14656566.2022.2102418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Although early rejection episodes are successfully controlled, the problem of unrecognized production of de novo anti HLA antibodies and associated chronic rejection still persists. AREAS COVERED In addition to the standard induction and maintenance therapy, we present a couple of new drugs as induction (Alemtuzumab), CNI free protocol (Belatacept, Sirolimus, Everolimus), maintenance treatment in transplant patients with various type of malignancies (T cell targeted immunomodulators blocking the immune checkpoints CTLA-4, PD1/PDL1) and TMA (aHUS) -eculizimab, and IL6 receptor antagonists in antibody mediated rejection (AMR). EXPERT OPINION There are couple of issues still preventing improvement in kidney transplant long-term outcomes with current and anticipated future immunosuppression: patient more susceptible to infection and CNI nephrotoxicity in kidneys obtained from elderly donors, highly sensitized patients with limited chances to get appropriate kidney and a higher risk for late AMR. A lower rate of CMV/BK virus infections has been observed in everolimus treated patients. Belatacept use has been justified only in EBV seropositive kidney transplants due to the increased risk of PTLD. Eculizumab upon recurrence of aHUS is a sole cost-effective option. A new IL-6 blocking drug (clazakizumab/tocilizumab) is promising option for prevention/treatment of AMR. Clinical experience in tailoring immunosuppression for as long as possible graft and patient survival is inevitable.
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Affiliation(s)
- Goce Spasovski
- University Department of Nephrology, Medical Faculty, University Sts Cyril and Methodius, Skopje, N. Macedonia
| | - Lada Trajceska
- University Department of Nephrology, Medical Faculty, University Sts Cyril and Methodius, Skopje, N. Macedonia
| | - Irena Rambabova-Bushljetik
- University Department of Nephrology, Medical Faculty, University Sts Cyril and Methodius, Skopje, N. Macedonia
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20
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Hesselink DA, Hullegie-Peelen DM, van Vugt LK. Personalized anti-rejection therapy with alemtuzumab for kidney transplant recipients. Pharmacogenomics 2022; 23:567-570. [PMID: 35763447 DOI: 10.2217/pgs-2022-0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Dennis A Hesselink
- Erasmus MC Transplant Institute, Rotterdam, The Netherlands.,Department of Internal Medicine, Division of Nephrology & Transplantation, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Daphne M Hullegie-Peelen
- Erasmus MC Transplant Institute, Rotterdam, The Netherlands.,Department of Internal Medicine, Division of Nephrology & Transplantation, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Lukas K van Vugt
- Erasmus MC Transplant Institute, Rotterdam, The Netherlands.,Department of Internal Medicine, Division of Nephrology & Transplantation, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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21
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Suhail SM. Tolerance protocol of living kidney transplant for developing countries through basic strategy of lymphocyte depletion. World J Transplant 2022; 12:112-119. [PMID: 35979538 PMCID: PMC9258266 DOI: 10.5500/wjt.v12.i6.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/28/2021] [Accepted: 05/07/2022] [Indexed: 02/06/2023] Open
Abstract
End-stage kidney failure (ESKD) is a global issue where kidney replacement therapy imposes enormous economic burden to people of developing countries, in addition to the severe limitations to the availability of hemodialysis and peritoneal dialysis technique. The best option of kidney transplantation also requires lifelong combination immunosuppressive medicines, the cost of which is equally comparable to lifelong dialysis. A strategy of achieving transplant tolerance that requires minimum immunosuppressive medicines, although in experimental stage, also requires state-of-art technology with costly medicines and interventions. This is evidently beyond the reach of ESKD patients of developing countries. Hence, globally in developing countries, a need for an innovative but cost-effective tolerance protocol is a burning need for a successful transplant program. In brief, transplant tolerance is defined as a state of donor-specific unresponsiveness to the allograft antigens without the need for ongoing pharmacologic immunosuppression or with a minimal need. Current state-of-art techniques involves: (1) A state of hematological chimera, for complete tolerance; (2) Prope or partial tolerance where immune-reactive T-lymphocytes are inhibited using monoclonal antibodies; and (3) Chimeric antigen receptor for T-regulatory (T-reg) cell therapy using genetically engineered T-reg cells targeting specific T-lymphocyte receptors for inducing anergy. From our real-world experience in transplant management in post-transplant lympho-proliferative disorders (PTLD), we noticed frequently a drastic reduction in the need of immunosuppressive medicines following lympho-ablative therapy for PTLD. We recently published a case study on a real-world experience transplant case where we explained a partial or prope tolerance that developed after lymphocyte ablation therapy, following which the allograft was maintained with low dose dual standard immunosuppressive medicines. Based on this publication, we propose here an innovative tolerance protocol for living related low risk kidney transplantation for developing countries, in this opinion review.
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Affiliation(s)
- Sufi M Suhail
- Department of Renal Medicine, Singapore General Hospital, Singapore 169856, Singapore
- Department of Clinical Research, Duke-NUS Graduate Medical School, Singapore 169856, Singapore
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22
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Aiyegbusi O, McGregor E, McManus SK, Stevens KI. Immunosuppression Therapy in Kidney Transplantation. Urol Clin North Am 2022; 49:345-360. [DOI: 10.1016/j.ucl.2021.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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23
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Hullegie-Peelen DM, van der Zwan M, Clahsen-van Groningen MC, Mustafa DAM, Baart SJ, Reinders MEJ, Baan CC, Hesselink DA. Clinical and Molecular Profiling to Develop a Potential Prediction Model for the Response to Alemtuzumab Therapy for Acute Kidney Transplant Rejection. Clin Pharmacol Ther 2022; 111:1155-1164. [PMID: 35202481 PMCID: PMC9314084 DOI: 10.1002/cpt.2566] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/21/2022] [Indexed: 02/06/2023]
Abstract
Alemtuzumab, a monoclonal antibody that depletes CD52‐bearing immune cells, is an effective drug for the treatment of severe or glucocorticoid‐resistant acute kidney transplant rejection (AR). Patient‐specific predictions on treatment response are, however, urgently needed, given the severe side effects of alemtuzumab. This study developed a multidimensional prediction model with the aim of generating clinically useful prognostic scores for the response to alemtuzumab. Clinical and histological characteristics were collected retrospectively from patients who were treated with alemtuzumab for AR. In addition, targeted gene expression profiling of AR biopsy tissues was performed. Least absolute shrinkage and selection operator (LASSO) logistic regression modeling was used to construct the ALEMtuzumab for Acute Rejection (ALEMAR) prognostic score. Response to alemtuzumab was defined as patient and allograft survival and at least once an estimated glomerular filtration rate (eGFR) > 30 mL/min/1.73 m2 during the first 6 months after treatment. One hundred fifteen patients were included, of which 84 (73%) had a response to alemtuzumab. The ALEMAR‐score accurately predicted the chance of response. Gene expression analysis identified 13 differentially expressed genes between responders and nonresponders. The combination of the ALEMAR‐score and selected genes resulted in improved predictions of treatment response. The present preliminary prediction model is potentially helpful for the development of stratified alemtuzumab treatment for acute kidney transplant rejection but requires validation.
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Affiliation(s)
- Daphne M Hullegie-Peelen
- Department of Internal Medicine, Division of Nephrology & Transplantation, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands.,Erasmus MC Transplant Institute, Rotterdam, The Netherlands
| | - Marieke van der Zwan
- Department of Internal Medicine, Division of Nephrology & Transplantation, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marian C Clahsen-van Groningen
- Erasmus MC Transplant Institute, Rotterdam, The Netherlands.,Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dana A M Mustafa
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,The Tumor Immuno-Pathology Laboratory, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sara J Baart
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marlies E J Reinders
- Department of Internal Medicine, Division of Nephrology & Transplantation, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands.,Erasmus MC Transplant Institute, Rotterdam, The Netherlands
| | - Carla C Baan
- Department of Internal Medicine, Division of Nephrology & Transplantation, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands.,Erasmus MC Transplant Institute, Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Division of Nephrology & Transplantation, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands.,Erasmus MC Transplant Institute, Rotterdam, The Netherlands
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24
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Recomendaciones para el trasplante renal de donante vivo. Nefrologia 2022. [DOI: 10.1016/j.nefro.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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25
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Gabarre P, Loens C, Tamzali Y, Barrou B, Jaisser F, Tourret J. Immunosuppressive therapy after solid organ transplantation and the gut microbiota: Bidirectional interactions with clinical consequences. Am J Transplant 2022; 22:1014-1030. [PMID: 34510717 DOI: 10.1111/ajt.16836] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 08/23/2021] [Accepted: 09/02/2021] [Indexed: 01/25/2023]
Abstract
Our understanding of the involvement of the gut microbiota (GM) in human health has expanded exponentially over the last few decades, particularly in the fields of metabolism, inflammation, and immunology. Immunosuppressive treatment (IST) prescribed to solid organ transplant (SOT) recipients produces GM changes that affect these different processes. This review aims at describing the current knowledge of how IST changes the GM. Overall, SOT followed by IST results in persistent changes in the GM, with a consistent increase in proteobacteria including opportunistic pathobionts. In mice, Tacrolimus induces dysbiosis and metabolic disorders, and alters the intestinal barrier. The transfer of the GM from Tacrolimus-treated hosts confers immunosuppressive properties, suggesting a contributory role for the GM in this drug's efficacy. Steroids induce dysbiosis and intestinal barrier alterations, and also seem to depend partly on the GM for their immunosuppressive and metabolic effects. Mycophenolate Mofetil, frequently responsible for digestive side effects such as diarrhea and colitis, is associated with pro-inflammatory dysbiosis and increased endotoxemia. Alemtuzumab, m-TOR inhibitors, and belatacept have shown more marginal impact on the GM. Most of these observations are descriptive. Future studies should explore the underlying mechanism of IST-induced dysbiosis in order to better understand their efficacy and safety characteristics.
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Affiliation(s)
- Paul Gabarre
- Centre de Recherche des Cordeliers, Team "Diabetes, metabolic diseases and comorbidities", Sorbonne Université, Université de Paris, INSERM, Paris, France
| | - Christopher Loens
- Centre de Recherche des Cordeliers, Team "Diabetes, metabolic diseases and comorbidities", Sorbonne Université, Université de Paris, INSERM, Paris, France
| | - Yanis Tamzali
- Centre de Recherche des Cordeliers, Team "Diabetes, metabolic diseases and comorbidities", Sorbonne Université, Université de Paris, INSERM, Paris, France
| | - Benoit Barrou
- Assistance Publique - Hôpitaux Paris APHP, Medical and Surgical Unit of Kidney Transplantation Unit, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris, France
| | - Frédéric Jaisser
- Centre de Recherche des Cordeliers, Team "Diabetes, metabolic diseases and comorbidities", Sorbonne Université, Université de Paris, INSERM, Paris, France
| | - Jérôme Tourret
- Centre de Recherche des Cordeliers, Team "Diabetes, metabolic diseases and comorbidities", Sorbonne Université, Université de Paris, INSERM, Paris, France.,Assistance Publique - Hôpitaux Paris APHP, Medical and Surgical Unit of Kidney Transplantation Unit, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris, France
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26
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Kidney Allograft and Recipient Survival After Heart Transplantation by Induction Type in the United States. Transplantation 2022; 106:633-640. [PMID: 33741841 DOI: 10.1097/tp.0000000000003758] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Induction choices for kidney-after-heart transplant recipients are variable. We examined the impact of kidney induction types on kidney graft and patient survival in heart transplant recipients. METHODS We analyzed the Scientific Registry of Transplant Recipient database from inception through the end of 2018 to study kidney and patient outcomes in the United States after heart transplantation. We only included recipients who were discharged on tacrolimus and mycophenolate maintenance. We grouped recipients by induction type into 3 groups: depletional (N = 307), nondepletional (n = 253), and no-induction (steroid only) (n = 57). We studied patients and kidney survival using Cox PH regression, with transplant centers included as a random effect. We adjusted the models for heart induction, recipient and donor age, gender, time between heart and kidney transplant, heart transplant indication, HLA mismatches, payor, live-donor kidney, transplant year, dialysis status, and diabetes mellitus at the time of kidney transplant. RESULTS The 1-y kidney rejection rates and creatinine levels were similar in all groups. The 1-y rehospitalization rate was higher in the depletional group (51.7%) and nondepletional group (50.7%) than in the no-induction group (39.1%) although this was not statistically significant. There were no differences in recipient or kidney survival by kidney induction type. Live-donor kidney was associated with improved patient (hazard ratio, 0.74; 95% confidence interval, 0.54-1.0; P = 0.05) and kidney survival (hazard ratio, 0.45; 95% confidence interval, 0.24-0.84; P = 0.012]. CONCLUSIONS Type of kidney induction did not influence patient or kidney graft survival in heart transplant recipients. No-induction may be the preferred choice due to the lack of clinical benefits associated with induction use.
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27
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Primum non Nocere: Induction in Kidney Transplantation After Heart Transplantation. Transplantation 2022; 106:455-456. [PMID: 33741843 DOI: 10.1097/tp.0000000000003759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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28
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Jain A, Daoud D, Kees-Folts D, Freeman MA, Butt F, Abendroth CS, Shike H, Kadry Z. Steroid-free maintenance immunosuppression using alemtuzumab in pediatric kidney transplantation: Long-term longitudinal follow-up. Pediatr Transplant 2022; 26:e14173. [PMID: 34687570 DOI: 10.1111/petr.14173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 08/17/2021] [Accepted: 10/05/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND There is a scarcity of long-term data on steroid-free immunosuppression using alemtuzumab in pediatric kidney transplantation (KTx). This study examines long-term outcomes with alemtuzumab without steroid maintenance therapy in pediatric KTx. METHODS From July 2005 to June 2015, 71 pediatric KTx recipients received alemtuzumab without steroid maintenance. They were followed from 4.1 to 14.1 years post KTx. RESULTS Patient survival: One child expired with a functioning graft from post-transplant lymphoproliferative disorder (PTLD). Patient survival was 98.6%. Graft survival: Eighteen grafts were lost (16 from chronic rejection). Graft survival at 5 and 10 years was 92.3% and 61.3%, respectively. Rejection: Twenty-three (32.4%) patients were free from T-cell-mediated rejection (TCMR), 16 (22.5%) had >3 episodes. Sixteen (22.5%) were treated for antibody-mediated rejection (AMR). Infection: Twenty-three children developed Epstein-Barr virus (EBV), 5 developed cytomegalovirus (CMV), and 20 developed BK virus infection. Four (5.6%) developed PTLD. Twenty-two (31.0%) required treatment for neutropenia. Growth parameters: Mean height and weight increased by 0.56 and 0.69 SDS (standard deviation score), respectively. Body mass index increased by 5.1 kg/m2 at 10 years. Less than 40% required antihypertensive medications at all-time points. CONCLUSION Alemtuzumab, without corticosteroid maintenance, offers 98.6% patient survival at 14 years with five and 10-year graft survival of 92.3% and 61.3%, respectively. TCMR and AMR requiring treatment were 67.4% and 22.5%, respectively. CMV, EBV, and BK viremia rates were 7.0%, 32.4%, and 28.2%, respectively. Thirty-one percent were treated for neutropenia; 5.6% developed PTLD. There were improvements in growth parameters and blood pressure.
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Affiliation(s)
- Ashokkumar Jain
- Division of Transplantation, Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Deborah Daoud
- Division of Transplantation, Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Deborah Kees-Folts
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Michael A Freeman
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Fauzia Butt
- Division of Transplantation, Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Catherine S Abendroth
- Department of Pathology, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Hiroko Shike
- Department of Pathology, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Zakiyah Kadry
- Division of Transplantation, Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
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29
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Potluri VS, Bloom RD. Induction Therapy in Immunologically Well-Matched Recipients: Less May Be More. Clin J Am Soc Nephrol 2022; 17:173-175. [PMID: 35131923 PMCID: PMC8823936 DOI: 10.2215/cjn.16591221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Vishnu S. Potluri
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Roy D. Bloom
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, Philadelphia, Pennsylvania
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30
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Immunosuppression in the Age of Precision Medicine. Semin Nephrol 2022; 42:86-98. [DOI: 10.1016/j.semnephrol.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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31
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Chukwu CA, Spiers HV, Middleton R, Kalra PA, Asderakis A, Rao A, Augustine T. Alemtuzumab in renal transplantation. Reviews of literature and usage in the United Kingdom. Transplant Rev (Orlando) 2022; 36:100686. [DOI: 10.1016/j.trre.2022.100686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 11/24/2022]
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32
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Nikolova A, Patel JK. Induction Therapy and Therapeutic Antibodies. Handb Exp Pharmacol 2022; 272:85-116. [PMID: 35474024 DOI: 10.1007/164_2021_570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Prevention of allograft rejection is one of the crucial goals in solid organ transplantation to ensure durability of the graft and is chiefly mediated by cellular and humoral pathways targeting cell surface alloantigens. The risk of rejection is highest in the first post-transplant year and wanes with time albeit the risk always exists and varies with the type of organ transplanted. Induction therapies refer to the use of high-intensity immunosuppression in the immediate post-operative period to mitigate the highest risk of rejection. This term encompasses chiefly the use of antibody therapies directed against one of the key pathways in T-cell activation or abrogating effects of circulating alloantibodies. These antibodies carry more potent immunomodulatory effect than maintenance immunosuppressive therapy alone and many of them lead to durable immune cell depletion. A variety of monoclonal and polyclonal antibodies have been utilized for use not only for induction therapy, but also for treatment of allograft rejection when it occurs and as components of desensitization therapy before and after transplantation to modulate circulating alloantibodies.
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33
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Thymoglobulin versus Alemtuzumab versus Basiliximab Kidney Transplantation from Donors After Circulatory Death. Kidney Int Rep 2022; 7:732-740. [PMID: 35497810 PMCID: PMC9039467 DOI: 10.1016/j.ekir.2022.01.1042] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/03/2022] [Accepted: 01/03/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction The Campath, Calcineurin inhibitor (CNI) reduction, and Chronic allograft nephropathy (3C), a study comparing alemtuzumab versus basiliximab induction immunosuppression in kidney transplants, has found lower acute rejection rate with alemtuzumab but same graft survival. The aim of the current study is to evaluate the effect of induction immunosuppression (thymoglobulin, alemtuzumab, basiliximab) on the outcome of kidneys of donors after circulatory death (DCD). Methods Data of the 274 DCD patients of the 3C obtained from the sponsor were compounded with the 140 DCD patients who received thymoglobulin in a single center with the same entry criteria as the 3C, giving 414 patients on 3 induction regimes. Results There were more male donors (P < 0.05) and human leukocyte antigen and DR mismatched patients in the thymoglobulin group (P < 0.001). Death-censored graft survival at 6 months was 98.6% in the thymoglobulin, 95.5% in the alemtuzumab (P = 0.08), and 95.7% in the basiliximab group (P = 0.09) and at 2 years 97.9% versus 94.8% (P = 0.13, hazard ratio [HR] 2.8, 95% CI 0.7–10.9) versus 94.3% (P = 0.06, HR 3.5, 95% CI 0.9–13.6), respectively. The 2-year overall graft survival was 95% in the thymoglobulin versus 88% in the alemtuzumab (unadjusted P = 0.038, adjusted HR 2.4, 95% CI 0.99–5.9) and 91.4% in the basiliximab group (P = 0.21). The 2-year patient survival was numerically less in the alemtuzumab compared with the thymoglobulin group (91.8% vs. 97.1%, P = 0.052, HR 2.90, 95% CI 0.93–9.2). Acute rejection was 17% in the basiliximab, 4.3% in the thymoglobulin, and 6% in the alemtuzumab group (P < 0.001). Conclusion In DCD transplants, thymoglobulin induction may provide advantage over alemtuzumab in patient survival and the same advantage as alemtuzumab over basiliximab in terms of acute rejection. Differing maintenance immunosuppression may contribute to the difference found.
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34
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Abstract
Immunosuppression is complex, fraught with on-target and off-target adverse effects, and hard to get right but is the key to successful allotransplantation. Herein, we review the key immunosuppressive agent classes used for kidney transplant, highlighting mechanisms of action and typical clinical use.
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Affiliation(s)
- Jeanne Kamal
- Division of Nephrology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Alden Doyle
- Division of Nephrology, University of Virginia School of Medicine, Charlottesville, VA, USA.
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35
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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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36
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Wojciechowski D, Wiseman A. Long-Term Immunosuppression Management: Opportunities and Uncertainties. Clin J Am Soc Nephrol 2021; 16:1264-1271. [PMID: 33853841 PMCID: PMC8455033 DOI: 10.2215/cjn.15040920] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The long-term management of maintenance immunosuppression in kidney transplant recipients remains complex. The vast majority of patients are treated with the calcineurin inhibitor tacrolimus as the primary agent in combination with mycophenolate, with or without corticosteroids. A tacrolimus trough target 5-8 ng/ml seems to be optimal for rejection prophylaxis, but long-term tacrolimus-related side effects and nephrotoxicity support the ongoing evaluation of noncalcineurin inhibitor-based regimens. Current alternatives include belatacept or mammalian target of rapamycin inhibitors. For the former, superior kidney function at 7 years post-transplant compared with cyclosporin generated initial enthusiasm, but utilization has been hampered by high initial rejection rates. Mammalian target of rapamycin inhibitors have yielded mixed results as well, with improved kidney function tempered by higher risk of rejection, proteinuria, and adverse effects leading to higher discontinuation rates. Mammalian target of rapamycin inhibitors may play a role in the secondary prevention of squamous cell skin cancer as conversion from a calcineurin inhibitor to an mammalian target of rapamycin inhibitor resulted in a reduction of new lesion development. Early withdrawal of corticosteroids remains an attractive strategy but also is associated with a higher risk of rejection despite no difference in 5-year patient or graft survival. A major barrier to long-term graft survival is chronic alloimmunity, and regardless of agent used, managing the toxicities of immunosuppression against the risk of chronic antibody-mediated rejection remains a fragile balance.
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Affiliation(s)
- David Wojciechowski
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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37
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Jorgenson MR, Descourouez JL, Brady BL, Chandran MM, Do V, Kim M, Laub MR, Lichvar A, Park JM, Szczepanik A, Alloway RR. A call for transplant stewardship: The need for expanded evidence-based evaluation of induction and biologic-based cost-saving strategies in kidney transplantation and beyond. Clin Transplant 2021; 35:e14372. [PMID: 34033140 DOI: 10.1111/ctr.14372] [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: 03/17/2021] [Revised: 05/15/2021] [Accepted: 05/19/2021] [Indexed: 12/14/2022]
Abstract
Rising expenditures threaten healthcare sustainability. While transplant programs are typically considered profitable, transplant medications are expensive and frequently targeted for cost savings. This review aims to summarize available literature supporting cost-containment strategies used in solid organ transplant. Despite widespread use of these tactics, we found the available evidence to be fairly low quality. Strategies mainly focus on induction, particularly rabbit antithymocyte globulin (rATG), given its significant cost and the lack of consensus surrounding dosing. While there is higher-quality evidence for high single-dose rATG, and dose-rounding protocols to reduce waste are likely low risk, more aggressive strategies, such as dosing rATG by CD3+ target-attainment or on ideal-body-weight, have less robust support and did not always attain similar efficacy outcomes. Extrapolation of induction dosing strategies to rejection treatment is not supported by any currently available literature. Cost-saving strategies for supportive therapies, such as IVIG and rituximab also have minimal literature support. Deferral of high-cost agents to the outpatient arena is associated with minimal risk and increases reimbursement, although may increase complexity and cost-burden for patients and infusion centers. The available evidence highlights the need for evaluation of unique patient-specific clinical scenarios and optimization of therapies, rather than simple blanket application of cost-saving initiatives in the transplant population.
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Affiliation(s)
- Margaret R Jorgenson
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Jillian L Descourouez
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Bethany L Brady
- Department of Pharmacy, Indiana University Health University Hospital, Indianapolis, IN, USA
| | - Mary M Chandran
- Department of Pharmacy, Children's Hospital of Colorado, Aurora, CO, USA
| | - Vincent Do
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Miae Kim
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Melissa R Laub
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | - Alicia Lichvar
- Department of Pharmacy Practice and Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Jeong M Park
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Amanda Szczepanik
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
| | - Rita R Alloway
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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38
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Franz BJ, Petraroia R, Faust CD, Crawford T, Smalls S, Vongsavanh C, Gibson K, Schmitz JL. Abrogating biologics interference in flow cytometric crossmatching. Hum Immunol 2021; 82:574-580. [PMID: 33934934 DOI: 10.1016/j.humimm.2021.01.016] [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: 10/01/2020] [Revised: 01/04/2021] [Accepted: 01/27/2021] [Indexed: 10/21/2022]
Abstract
The flow cytometric crossmatch is currently the gold standard for evaluating donor and recipient histocompatibility. The assay however does have limitations and is sensitive to false positive reactions resulting from the presence of non-HLA antibodies or therapy related immune biologics. Such false positive reactions can lead to the inappropriate decline of an acceptable donor organ or unnecessary therapeutic intervention. Here we describe the successful validation of anti-idiotype blocking antibodies in prevention of false positive flow crossmatch results caused by biologic therapy. Blocking antibodies specific for the Fab portion of Rituximab and/or Alemtuzumab were incubated with biologic containing patient serum prior to use in flow cytometric crossmatching. Biologic blocking successfully negated false positive crossmatch results with Rituximab (B cell ave. % change = -97%) or Alemtuzumab (T cell ave. % change = -99%, B cell ave. % change = -95%) infused sera respectively. Simultaneous blocking of these biologics was also successful. A complex case is presented to demonstrate the application of this procedure.
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Affiliation(s)
- Brian J Franz
- Histocompatibility Laboratory, McLendon Clinical Laboratories, UNC Hospitals, Chapel Hill, NC, USA
| | - Rosanne Petraroia
- Histocompatibility Laboratory, McLendon Clinical Laboratories, UNC Hospitals, Chapel Hill, NC, USA
| | - Cynthia D Faust
- Histocompatibility Laboratory, McLendon Clinical Laboratories, UNC Hospitals, Chapel Hill, NC, USA
| | - Tricia Crawford
- Histocompatibility Laboratory, McLendon Clinical Laboratories, UNC Hospitals, Chapel Hill, NC, USA
| | - Shari Smalls
- Histocompatibility Laboratory, McLendon Clinical Laboratories, UNC Hospitals, Chapel Hill, NC, USA
| | - Candy Vongsavanh
- Histocompatibility Laboratory, McLendon Clinical Laboratories, UNC Hospitals, Chapel Hill, NC, USA
| | - Keisha Gibson
- Division Pediatric Nephrology, Department of Pediatrics, UNC School of Medicine, Chapel Hill, NC, USA
| | - John L Schmitz
- Histocompatibility Laboratory, McLendon Clinical Laboratories, UNC Hospitals, Chapel Hill, NC, USA; Department of Pathology & Laboratory Medicine, UNC School of Medicine, Chapel Hill, NC, USA.
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39
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Risk factors for delayed graft function and their impact on graft outcomes in live donor kidney transplantation. Int Urol Nephrol 2021; 53:439-446. [PMID: 33394282 DOI: 10.1007/s11255-020-02687-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/14/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Delayed graft function (DGF) is a manifestation of acute kidney injury uniquely framed within the transplant process and a predictor of poor long-term graft function1. It is less common in the setting of living donor (LD) kidney transplantation. However, the detrimental impact of DGF on graft survival is more pronounced in LD2. PURPOSE To study the effects of DGF in the setting of LD kidney transplantation. METHODS We performed a retrospective analysis of LD kidney transplantations performed between 2010 and 2018 in the UNOS/OPTN database for DGF and its effect on graft survival. RESULTS A total of 42,736 LD recipients were identified, of whom 1115 (2.6%) developed DGF. Recipient dialysis status, male gender, diabetes, end-stage renal disease, donor age, right donor nephrectomy, panel reactive antibodies, HLA mismatch, and cold ischemia time were independent predictors of DGF. Three-year graft survival in patients with and without DGF was 89% and 95%, respectively. DGF was the greatest predictor of graft failure at three years (hazard ratio = 1.766, 95% CI: 1.514-2.059, P = 0.001) and was associated with higher rates of rejection (9% vs. 6.28%, P = 0.0003). Among patients with DGF, the graft survival rates with and without rejection were not different. CONCLUSION DGF is a major determinant of poor graft functional outcomes, independent of rejection.
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Pilch NA, Bowman LJ, Taber DJ. Immunosuppression trends in solid organ transplantation: The future of individualization, monitoring, and management. Pharmacotherapy 2020; 41:119-131. [PMID: 33131123 DOI: 10.1002/phar.2481] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/07/2020] [Accepted: 08/09/2020] [Indexed: 12/20/2022]
Abstract
Immunosuppression regimens used in solid organ transplant have evolved significantly over the past 70 years in the United States. Early immunosuppression and targets for allograft success were measured by incidence and severity of allograft rejection and 1-year patient survival. The limited number of agents, infancy of human leukocyte antigen (HLA) matching techniques and lack of understanding of immunoreactivity limited the early development of effective regimens. The 1980s and 1990s saw incredible advancements in these areas, with acute rejection rates halving in a short span of time. However, the constant struggle to achieve the optimal balance between under- and overimmunosuppression is weaved throughout the history of transplant immunosuppression. The aim of this paper is to discuss the different eras of immunosuppression and highlight the important milestones that were achieved while also discussing this in the context of rational agent selection and regimen design. This discussion sets the stage for how we can achieve optimal long-term outcomes during the next era of immunosuppression, which will move from universal protocols to patient-specific optimization.
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Affiliation(s)
- Nicole A Pilch
- Department of Pharmacy Practice and Outcomes Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lyndsey J Bowman
- Department of Pharmacy, Tampa General Hospital, Tampa, Florida, USA
| | - David J Taber
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.,Department of Pharmacy Services, Ralph H. Johnson VAMC, Charleston, South Carolina, USA
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Jalkh G, Abi Nahed R, Macaron G, Rensel M. Safety of Newer Disease Modifying Therapies in Multiple Sclerosis. Vaccines (Basel) 2020; 9:12. [PMID: 33375365 PMCID: PMC7823546 DOI: 10.3390/vaccines9010012] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 12/14/2022] Open
Abstract
In the past decade, the therapeutic arsenal for multiple sclerosis has expanded greatly. Newer more potent disease modifying therapies (DMTs) with varying mechanisms of actions are increasingly used early in the disease course. These newer DMTs include oral therapies (teriflunomide, dimethyl fumarate, fingolimod, siponimod, ozanimod, and cladribine) and infusion therapies (natalizumab, alemtuzumab, and ocrelizumab), and are associated with better control of disease activity and long-term outcomes in patients with MS compared to older injectable therapies (interferon beta and glatiramer acetate). However, they are associated with safety concerns and subsequent monitoring requirements. Adverse events are initially observed in phase 2 and 3 clinical trials, and further long-term data are collected in phase 3 extension studies, case series, and post-marketing reports, which highlight the need to periodically re-evaluate and adjust monitoring strategies to optimize treatment safety in an individualized approach.
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Affiliation(s)
- Georges Jalkh
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
| | - Rachelle Abi Nahed
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
| | - Gabrielle Macaron
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Mary Rensel
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Uterine Transplantation: Evolving Data, Success, and Clinical Importance. J Minim Invasive Gynecol 2020; 28:502-512. [PMID: 33348011 DOI: 10.1016/j.jmig.2020.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 12/09/2020] [Accepted: 12/15/2020] [Indexed: 11/22/2022]
Abstract
Uterine transplantation is an evolving procedure to allow for childbearing in paitents with absolute uterine factor infertility. The objective of this study was to review the existing literature using a comprehensive PubMed literature search. A systematic medical subheadings search strategy was used with the terms "uterus transplant" and "uterine transplantation". Of the 75 full-text articles assessed for eligibility, 68 were included in the qualitative synthesis. Of these, 9 were included in the meta-analysis on living donor uterine transplant, 5 on deceased donor uterine transplant, and 6 case reports of single uterine transplants. In conclusion, uterus transplant is a nascent field undergoing a rapid rate of evolution as programs mature their data and increase the number of procedures performed. The most recent publications and advances are thus summarized in this article to capture the most up-to-date information.
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Mannon RB, Armstrong B, Stock PG, Mehta AK, Farris AB, Watson N, Morrison Y, Sarwal M, Sigdel T, Bridges N, Robien M, Newell KA, Larsen CP. Avoidance of CNI and steroids using belatacept-Results of the Clinical Trials in Organ Transplantation 16 trial. Am J Transplant 2020; 20:3599-3608. [PMID: 32558199 PMCID: PMC7710570 DOI: 10.1111/ajt.16152] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/09/2020] [Accepted: 06/11/2020] [Indexed: 01/25/2023]
Abstract
Immunosuppression devoid of corticosteroids has been investigated to avoid long-term comorbidities. Likewise, alternatives to calcineurin inhibitors have been investigated as a strategy to improve long-term kidney function following transplanion. Costimulatory blockade strategies that include corticosteroids have recently shown promise, despite their higher rates of early acute rejection. We designed a randomized clinical trial utilizing depletional induction therapy to mitigate early rejection risk while limiting calcineurin inhibitors and corticosteroids. This trial, Clinical Trials in Organ Transplantation 16 (CTOT-16), sought to evaluate novel belatacept-based strategies employing tacrolimus and corticosteroid avoidance. Sixty-nine kidney transplant recipients were randomized from 4 US transplant centers comparing a control group of with rabbit antithymocyte globulin (rATG) induction, rapid steroid taper, and maintenance mycophenolate and tacrolimus, to 2 arms using maintenance belatacept. There were no graft losses but there were 2 deaths in the control group. However, the trial was halted early because of rejection in the belatacept treatment groups. Serious adverse events were similar across groups. Although rejection was not uniform in the belatacept maintenance therapy groups, the frequency of rejection limits the practical implementation of this strategy to avoid both calcineurin inhibitors and corticosteroids at this time.
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Affiliation(s)
- Roslyn B. Mannon
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Peter G. Stock
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, CA
| | - Aneesh K. Mehta
- Emory Transplant Center, Emory University School of Medicine, Atlanta GA,Department of Medicine, Emory University School of Medicine, Atlanta GA
| | - Alton B. Farris
- Emory Transplant Center, Emory University School of Medicine, Atlanta GA
| | - Natasha Watson
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Yvonne Morrison
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Minnie Sarwal
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, CA
| | - Tara Sigdel
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, CA
| | - Nancy Bridges
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Mark Robien
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Kenneth A. Newell
- Emory Transplant Center, Emory University School of Medicine, Atlanta GA
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Long-Term Infectious and Noninfectious Outcomes of Monthly Alemtuzumab as a Calcineurin Inhibitor- and Steroid-Free Regimen for Pancreas Transplant Recipients. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2020; 2020:8883183. [PMID: 33101558 PMCID: PMC7569440 DOI: 10.1155/2020/8883183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/22/2020] [Accepted: 09/28/2020] [Indexed: 11/18/2022]
Abstract
Multiple doses of alemtuzumab for immunosuppressive therapy of patients with hematologic malignancies and hematopoietic stem cell transplant have been associated with a high rate of infection. In transplantation, limited alemtuzumab dosing has been successfully used as induction immunosuppression. The effect of multiple doses of alemtuzumab, used as maintenance therapy to minimize steroid and/or calcineurin inhibitor toxicity in solid organ transplant recipients, is unknown. We evaluated the infectious and noninfectious outcomes of 179 pancreas transplant recipients treated with alemtuzumab for induction and maintenance therapy (extended alemtuzumab exposure (EAE)) from 2/28/2003 through 8/31/2005, compared with 159 pancreas transplant recipients with standard induction and maintenance (SIM) therapy performed before (1/1/2002 until 12/31/2002) and after (1/1/2006 until 12/31/2006) the implementation of EAE. EAE was associated with higher risk of overall infections (hazard ratio (HR) 1.33 (1.06–1.66), P=0.01), bacterial infections (HR 1.33 (1.05–1.67), P=0.02), fungal infections (HR 1.86 (1.28–2.71), P < 0.01), and cytomegalovirus infections (HR 2.29 (1.39–3.77), P < 0.01). In addition, EAE was associated with higher risk of acute cellular rejection (HR 2.09 (1.46–2.99), P < 0.01). In conclusion, while a limited alemtuzumab dosing is safe and effective for induction therapy in pancreas transplantation, EAE combined with steroid and calcineurin minimization is associated with a high risk of infectious complications and acute cellular rejection.
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Korneffel K, Gehring B, Rospert D, Rees M, Ortiz J. BK Virus in Renal Transplant Patients Using Alemtuzumab for Induction Immunosuppression. EXP CLIN TRANSPLANT 2020; 18:557-563. [DOI: 10.6002/ect.2019.0041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Florescu DF, Seaman JA, Kalil AC, Qiu F, Bremers D, Westphal SG. Opportunistic Infections After Induction With Alemtuzumab or Basiliximab: A 3-Year Kidney Transplantation Experience. Transplant Proc 2020; 53:1058-1063. [PMID: 32921434 DOI: 10.1016/j.transproceed.2020.08.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 08/08/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Antibody induction immunosuppression is commonly used in kidney transplantation to decrease the risk of early acute rejection. However, infectious complications may arise in patients treated with higher intensity induction immunosuppression. In this study, we compared the rate of opportunistic infections during the 3 years after kidney transplantation in recipients who received either alemtuzumab or basiliximab for induction therapy. METHODS All renal transplant recipients from our center who received induction with alemtuzumab between 2011 and 2016 were included and matched 1:2 (by age and date of transplant) to renal transplant recipients who received basiliximab. The primary outcome was the rate of opportunistic infections. RESULTS Twenty-seven patients received alemtuzumab (mean age = 50.8 years; SD ±12), and 54 received basiliximab (mean age = 50.8 years; SD ±11.8). Infections within 3 years posttransplant were not different between groups: BK viremia (P = .99), BK nephritis (P = .48), cytomegalovirus infection (P = .13), varicella zoster virus (P = .22), and all infections (P = .87). Time to infection (P = .67), patient survival (P = .21), and time to rejection (P = .098) were similar in both groups. There were also no group differences in delayed graft function (P = .76), graft loss (P = .97), or rejection (P = .2). CONCLUSION The rate of infection was not significantly increased in recipients receiving lymphocyte-depleting alemtuzumab compared to recipients receiving basiliximab induction therapy, despite receiving similar maintenance immunosuppression. Although the immunologic risks differed between the 2 groups, there was no observable difference in clinical outcomes.
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Affiliation(s)
- Diana F Florescu
- Transplant Infectious Disease Division, University of Nebraska Medical Center, Omaha, Nebraska; Transplant Surgery Division, University of Nebraska Medical Center, Omaha, Nebraska.
| | - Jonathan A Seaman
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Andre C Kalil
- Transplant Infectious Disease Division, University of Nebraska Medical Center, Omaha, Nebraska
| | - Fang Qiu
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Scott G Westphal
- Department of Internal Medicine Nephrology Division, University of Nebraska Medical Center, Omaha, Nebraska
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Cai S, Chandraker A. Cell Therapy in Solid Organ Transplantation. Curr Gene Ther 2020; 19:71-80. [PMID: 31161989 DOI: 10.2174/1566523219666190603103840] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/30/2019] [Accepted: 05/23/2019] [Indexed: 12/28/2022]
Abstract
Transplantation is the only cure for end-stage organ failure. Current immunosuppressive drugs have two major limitations: 1) non antigen specificity, which increases the risk of cancer and infection diseases, and 2) chronic toxicity. Cell therapy appears to be an innovative and promising strategy to minimize the use of immunosuppression in transplantation and to improve long-term graft survival. Preclinical studies have shown efficacy and safety of using various suppressor cells, such as regulatory T cells, regulatory B cells and tolerogenic dendritic cells. Recent clinical trials using cellbased therapies in solid organ transplantation also hold out the promise of improving efficacy. In this review, we will briefly go over the rejection process, current immunosuppressive drugs, and the potential therapeutic use of regulatory cells in transplantation.
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Affiliation(s)
- Songjie Cai
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, United States
| | - Anil Chandraker
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, United States
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van der Zwan M, Clahsen-Van Groningen MC, van den Hoogen MWF, Kho MML, Roodnat JI, Mauff KAL, Roelen DL, van Agteren M, Baan CC, Hesselink DA. Comparison of Alemtuzumab and Anti-thymocyte Globulin Treatment for Acute Kidney Allograft Rejection. Front Immunol 2020; 11:1332. [PMID: 32719676 PMCID: PMC7350932 DOI: 10.3389/fimmu.2020.01332] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 05/26/2020] [Indexed: 12/15/2022] Open
Abstract
Rabbit anti-thymocyte globulin (rATG) is currently the treatment of choice for glucocorticoid-resistant, recurrent, or severe acute allograft rejection (AR). However, rATG is associated with severe infusion-related side effects. Alemtuzumab is incidentally given to kidney transplant recipients as treatment for AR. In the current study, the outcomes of patients treated with alemtuzumab for AR were compared with that of patients treated with rATG for AR. The patient-, allograft-, and infection-free survival and adverse events of 116 alemtuzumab-treated patients were compared with those of 108 patients treated with rATG for AR. Propensity scores were used to control for differences between the two groups. Patient- and allograft survival of patients treated with either alemtuzumab or rATG were not different [hazard ratio (HR) 1.14, 95%-confidence interval (CI) 0.48–2.69, p = 0.77, and HR 0.82, 95%-CI 0.45–1.5, p = 0.52, respectively). Infection-free survival after alemtuzumab treatment was superior compared with that of rATG-treated patients (HR 0.41, 95%-CI 0.25–0.68, p < 0.002). Infusion-related adverse events occurred less frequently after alemtuzumab treatment. Alemtuzumab therapy may therefore be an alternative therapy for glucocorticoid-resistant, recurrent, or severe acute kidney transplant rejection.
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Affiliation(s)
- Marieke van der Zwan
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands.,Rotterdam Transplant Group, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Marian C Clahsen-Van Groningen
- Rotterdam Transplant Group, Erasmus MC, University Medical Center, Rotterdam, Netherlands.,Department of Pathology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Martijn W F van den Hoogen
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands.,Rotterdam Transplant Group, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Marcia M L Kho
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands.,Rotterdam Transplant Group, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Joke I Roodnat
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands.,Rotterdam Transplant Group, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Katya A L Mauff
- Department of Biostatistics, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Dave L Roelen
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, Netherlands
| | - Madelon van Agteren
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands.,Rotterdam Transplant Group, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Carla C Baan
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands.,Rotterdam Transplant Group, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Dennis A Hesselink
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands.,Rotterdam Transplant Group, Erasmus MC, University Medical Center, Rotterdam, Netherlands
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Interventions to Prevent Nonmelanoma Skin Cancers in Recipients of a Solid Organ Transplant: Systematic Review of Randomized Controlled Trials. Transplantation 2020; 103:1206-1215. [PMID: 31246934 DOI: 10.1097/tp.0000000000002641] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Organ transplant recipients are at high risk of developing skin cancer. The benefits and harms of interventions to prevent nonmelanoma skin cancer in solid organ transplant recipients have not been summarized. METHODS We searched MEDLINE, Embase, and CENTRAL through April 2018. Risk of bias was assessed using the Cochrane tool, and evidence certainty was evaluated using the Grades of Recommendation, Assessment, Development, and Evaluation process. Prespecified outcomes were nonmelanoma skin cancer, clearance and prevention of keratotic skin lesions, and intervention-specific adverse events. RESULTS Ninety-two trials (20 012 participants) were included. The evaluated treatments were cancer-specific interventions (acitretin, imiquimod, photodynamic therapy, nicotinamide, topical diclofenac, and selenium) and immunosuppression regimes (azathioprine, mycophenolate mofetil, calcineurin inhibitors, mammalian target of rapamycin [mTOR] inhibitors, belatacept, induction agents, and withdrawal of calcineurin inhibitors or corticosteroids). Effects on nonmelanoma skin cancer were uncertain for photodynamic therapy (3 trials, 93 participants, risk ratio [RR] 1.42 [95% confidence interval (CI), 0.65-3.11]; low certainty evidence), nicotinamide (2 trials, 60 participants), acitretin (2 trials, 61 participants), and imiquimod (1 trial, 20 participants) compared to control. mTOR inhibitors probably reduced skin cancer compared to calcineurin inhibitors (12 trials, 2225 participants, RR 0.62 [95% CI, 0.45-0.85]; moderate certainty evidence). Photodynamic therapy may cause pain at the treatment site (4 trials, 95 patients, RR 17.09 [95% CI, 4.22-69.26]; low certainty evidence). CONCLUSIONS There is limited evidence for the efficacy and safety of specific treatments to prevent nonmelanoma skin cancers among solid organ transplant recipients.
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Guthoff M, Berger K, Althaus K, Mühlbacher T, Bakchoul T, Steurer W, Nadalin S, Königsrainer A, Heyne N. Low-dose alemtuzumab induction in a tailored immunosuppression protocol for sensitized kidney transplant recipients. BMC Nephrol 2020; 21:178. [PMID: 32404066 PMCID: PMC7218828 DOI: 10.1186/s12882-020-01767-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 03/16/2020] [Indexed: 01/08/2023] Open
Abstract
Background Induction therapy is crucial in kidney transplantation and constitutes an important cornerstone for long-term allograft survival. Alemtuzumab is a depleting CD52-specific antibody with T- and B-cell activity, leading to prolonged lymphocyte depletion for up to 12 months, with profound immunosuppression and an associated risk of serious infections. Current concepts aim to optimize dosing strategies to reduce side effects. Here we present data from an ongoing centre protocol consisting of low-dose alemtuzumab induction and tailored immunosuppression in sensitized patients undergoing kidney transplantation. Methods 10-year results of the protocol were analysed. Low-dose alemtuzumab induction consisted of a single dose of 20 mg intraoperatively, followed by tacrolimus and corticosteroids for initial immunosuppression, with mycophenolate mofetil suspended until a total lymphocyte count (TLC) >5% or 200/μl was reached. Results Between 01/2007 and 04/2017, 46 patients were treated in accordance with the protocol in 48 kidney transplantations. Median PRAmax was 43 [22-76; IQR] %; all patients had negative CDC-crossmatch prior to transplantation. Low-dose alemtuzumab was well tolerated. Median time to TLC recovery was 77 [62-127; IQR] d. Within a median follow-up of 3.3 [1.5-5.6; IQR] years, 12 (25%) patients developed BPAR, 10 of which were antibody-mediated (3 acute, 7 chronic ABMR). Death-censored 5-year allograft survival was 79.2%, with an excellent allograft function at the end of follow-up. There was no increased rate of infections, in particular viral infections. Conclusions Our protocol, comprising low-dose alemtuzumab induction, initial suspension of mycophenolate mofetil and triple maintenance immunosuppression, provides excellent patient and allograft outcome in sensitized renal allograft recipients.
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Affiliation(s)
- Martina Guthoff
- Department of Diabetology, Endocrinology, Nephrology, Section of Nephrology and Hypertension, University of Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Germany.,Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Otfried-Müller-Str. 47, 72076, Tübingen, Germany.,German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany
| | - Kilian Berger
- Department of Diabetology, Endocrinology, Nephrology, Section of Nephrology and Hypertension, University of Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Germany
| | - Karina Althaus
- Center for Clinical Transfusion Medicine, Otfried-Müller-Str. 4/1, 72076, Tübingen, Germany
| | - Thomas Mühlbacher
- Department of Diabetology, Endocrinology, Nephrology, Section of Nephrology and Hypertension, University of Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Germany.,Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Otfried-Müller-Str. 47, 72076, Tübingen, Germany.,German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany
| | - Tamam Bakchoul
- Center for Clinical Transfusion Medicine, Otfried-Müller-Str. 4/1, 72076, Tübingen, Germany
| | - Wolfgang Steurer
- Department of General- and Visceral Surgery, Leonberg Hospital, Rutesheimer Str. 50, 71229, Leonberg, Germany
| | - Silvio Nadalin
- Department of General-, Visceral- and Transplant Surgery, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Alfred Königsrainer
- Department of General-, Visceral- and Transplant Surgery, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Nils Heyne
- Department of Diabetology, Endocrinology, Nephrology, Section of Nephrology and Hypertension, University of Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Germany. .,Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Otfried-Müller-Str. 47, 72076, Tübingen, Germany. .,German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany.
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