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Usefulness of Delayed Introduction of Tacrolimus in Kidney Transplants Using Type-III Donors After Circulatory Death. Transplant Proc 2019; 51:337-340. [DOI: 10.1016/j.transproceed.2018.10.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 10/23/2018] [Indexed: 11/24/2022]
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Diyarbakir E, Kara A, Keleş S, Selli J, Bilen H, Eyerci N, Akdeniz N, Ateş O, Doğan H. Effects of immunosuppressive drugs on oral mucosa in patients with Behçet's disease: cytomorphological and cytopathological assessment. Turk J Med Sci 2016; 46:145-51. [PMID: 27511348 DOI: 10.3906/sag-1308-64] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 06/13/2015] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND/AIM The aim of this study was to investigate cytomorphological and cytopathological changes in oral exfoliated smears collected from immunosuppressed patients with Behçet's disease (BD) using stereological methods. MATERIALS AND METHODS For cytomorphometric analysis, mucosal cell smears were obtained from the buccal mucosa and the floor of the mouths of BD patients treated with immunosuppressive drugs and from healthy volunteers. All mucosal smears from the patients and the healthy volunteers were stained using the Papanicolaou method and examined cytopathologically under light microscopy and cytomorphologically via the stereological nucleator method. RESULTS The cytomorphological analysis revealed 3 types of mucosal cells, with numbers of particularly pink cells lower in the aphthous areas of the patients with BD compared to the healthy controls (P < 0.05). The nuclear volumes (NVs) and cytoplasmic volume (CVs) were significantly higher in the BD patients (P < 0.05), but the NV/CV ratio was higher only in the drug-use patient groups (P > 0.05). There was lower apoptotic activity in the nondrug-use patients with BD and in the immunosuppressive-taking BD patients. CONCLUSION The findings suggest that quantifiably morphological and morphometric changes in oral mucosa can be detected by stereological techniques. Changes in these parameters may indicate malignant transformation in the oral mucosa.
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Affiliation(s)
- Eda Diyarbakir
- Department of Medical Biology, Faculty of Medicine, Atatürk University, Erzurum, Turkey
| | - Adem Kara
- Department of Histology, Faculty of Veterinary Medicine, Atatürk University, Erzurum, Turkey
| | - Sadullah Keleş
- Department of Ophthalmology, Faculty of Medicine, Atatürk University, Erzurum, Turkey
| | - Jale Selli
- Department of Histology, Faculty of Medicine, Atatürk University, Erzurum, Turkey
| | - Handan Bilen
- Department of Dermatology, Faculty of Medicine, Atatürk University, Erzurum, Turkey
| | - Nilnur Eyerci
- Department of Medical Biology, Faculty of Medicine, Kafkas University, Kars, Turkey
| | - Necmettin Akdeniz
- Department of Dermatology, Faculty of Medicine, Atatürk University, Erzurum, Turkey
| | - Orhan Ateş
- Department of Ophthalmology, Faculty of Medicine, Atatürk University, Erzurum, Turkey
| | - Hasan Doğan
- Department of Medical Biology, Faculty of Medicine, Atatürk University, Erzurum, Turkey
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Mohty M, Bacigalupo A, Saliba F, Zuckermann A, Morelon E, Lebranchu Y. New directions for rabbit antithymocyte globulin (Thymoglobulin(®)) in solid organ transplants, stem cell transplants and autoimmunity. Drugs 2015; 74:1605-34. [PMID: 25164240 PMCID: PMC4180909 DOI: 10.1007/s40265-014-0277-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In the 30 years since the rabbit antithymocyte globulin (rATG) Thymoglobulin® was first licensed, its use in solid organ transplantation and hematology has expanded progressively. Although the evidence base is incomplete, specific roles for rATG in organ transplant recipients using contemporary dosing strategies are now relatively well-identified. The addition of rATG induction to a standard triple or dual regimen reduces acute cellular rejection, and possibly humoral rejection. It is an appropriate first choice in patients with moderate or high immunological risk, and may be used in low-risk patients receiving a calcineurin inhibitor (CNI)-sparing regimen from time of transplant, or if early steroid withdrawal is planned. Kidney transplant patients at risk of delayed graft function may also benefit from the use of rATG to facilitate delayed CNI introduction. In hematopoietic stem cell transplantation, rATG has become an important component of conventional myeloablative conditioning regimens, following demonstration of reduced acute and chronic graft-versus-host disease. More recently, a role for rATG has also been established in reduced-intensity conditioning regimens. In autoimmunity, rATG contributes to the treatment of severe aplastic anemia, and has been incorporated in autograft projects for the management of conditions such as multiple sclerosis, Crohn’s disease, and systemic sclerosis. Finally, research is underway for the induction of tolerance exploiting the ability of rATG to induce immunosuppresive cells such as regulatory T-cells. Despite its long history, rATG remains a key component of the immunosuppressive armamentarium, and its complex immunological properties indicate that its use will expand to a wider range of disease conditions in the future.
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Affiliation(s)
- Mohamad Mohty
- Department of Hematology and Cellular Therapy, CHU Hôpital Saint Antoine, 184, rue du Faubourg Saint Antoine, 75571, Paris Cedex 12, France,
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Grinyó JM, Cruzado JM, Bestard O, Vidal Castiñeira JR, Torras J. Immunosuppression in the era of biological agents. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 741:60-72. [PMID: 22457103 DOI: 10.1007/978-1-4614-2098-9_5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Immunosuppression is the mayor mechanism to prevent allograft rejection and to induce tolerance. Since the first solid organ transplant, the development of safe and effective immunosuppressive regimens was a constant over the last decades. A lot of immunosuppressants have been discovered, and today the immunosuppressive agents are classified in two broad groups: Xenobiotic immunosuppressants and biological immunosuppressants. Xenobiotics, like corticoids and calcineurin and mTOR inhibitors, mainly interfere with the intracellular molecular mechanisms of the various types of cells involved in the immune response and generally these immunosuppressants are used early on in the transplantation process to prevent rejection as well as in long-term maintenance therapy. On the other hand, target molecules of biological immunosuppressants are on the surface of these immunological cells and normally in clinical immunosuppressive protocols have been used as auxiliary agents of xenobiotics to prevent rejection as well as in the treatment of acute rejection. However, these xenobiotics and biological agents have multiple side effects; that is why there has been a search for new drugs to minimise these side effects and to improve patients' quality of life. In this way, new biological agents have been proposed as maintenance immunosuppressive agents. The majority of these new immunosuppressive agents are polyclonal or monoclonal antibodies and recently the so-called fusion proteins may be the start of a new era of biological immunosuppression for maintenance regimens.
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Affiliation(s)
- Josep M Grinyó
- Hospital Universitari de Bellvitge, Universidad de Barcelona, Spain.
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Gaber AO, Monaco AP, Russell JA, Lebranchu Y, Mohty M. Rabbit antithymocyte globulin (thymoglobulin): 25 years and new frontiers in solid organ transplantation and haematology. Drugs 2010; 70:691-732. [PMID: 20394456 DOI: 10.2165/11315940-000000000-00000] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The more than 25 years of clinical experience with rabbit antithymocyte globulin (rATG), specifically Thymoglobulin, has transformed immunosuppression in solid organ transplantation and haematology. The utility of rATG has evolved from the treatment of allograft rejection and graft-versus-host disease to the prevention of various complications that limit the success of solid organ and stem cell transplantation. Today, rATG is being successfully incorporated into novel therapeutic regimens that seek to reduce overall toxicity and improve long-term outcomes. Clinical trials have demonstrated the efficacy and safety of rATG in recipients of various types of solid organ allografts, recipients of allogeneic stem cell transplants who are conditioned with both conventional and nonconventional regimens, and patients with aplastic anaemia. Over time, clinicians have learnt how to better balance the benefits and risks associated with rATG. Advances in the understanding of the multifaceted mechanism of action will guide research into new therapeutic areas and future applications.
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Affiliation(s)
- A Osama Gaber
- Department of Surgery, The Methodist Hospital, Houston, Texas 77030, USA.
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Thymoglobulin induction and sirolimus versus tacrolimus in kidney transplant recipients receiving mycophenolate mofetil and steroids. Transplantation 2010; 89:1511-7. [PMID: 20386144 DOI: 10.1097/tp.0b013e3181db09e4] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND To define the role of mammalian target of rapamycin inhibitors in kidney transplantation, we compared efficacy and safety of two immunosuppressive regimens-a calcineurin inhibitor-free regimen with depletive induction versus a calcineurin inhibitor-based regimen. METHODS De novo renal allograft recipients were randomized before transplantation to receive sirolimus (SRL; n=71, group A) or tacrolimus (n=70, group B). All patients received mycophenolate mofetil and corticosteroids. In group A, patients received rabbit antithymocyte globulin induction. In group B, antithymocyte globulin therapy could be given in case of delayed graft function. The estimated glomerular filtration rate (GFR) (Nankivell's formula) at month 12 was the primary endpoint. RESULTS GFR showed no significant difference at month 12, with 56.1 in group A versus 58.4 mL/min/1.73 m in group B. In functioning grafts, renal function was significantly better in the SRL group, with higher GFR values at months 1, 2, 3, 6, and 9 (P<0.05). At month 12, patient survival and incidence of biopsy-proven rejection were not different between groups (95.8% vs. 97.1%, and 16.9% vs. 12.9%, respectively). However, proportion of graft loss was higher with SRL at months 6 and 12 (11.3% vs. 0.0%, P=0.004; 14.1% vs. 4.3%, P=0.044, respectively). Adverse events and premature withdrawals were more frequent with SRL (P<0.001 and P<0.05, respectively), whereas cytomegalovirus infections were more frequent with tacrolimus (P<0.001). CONCLUSION Patients treated with induction plus SRL, mycophenolate mofetil, and corticosteroids may obtain good renal function but have a higher risk of adverse events, drug withdrawal, and graft loss.
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Diet C, Audard V, Roudot-Thoraval F, Matignon M, Lang P, Grimbert P. Immunological risk in recipients of kidney transplants from extended criteria donors. Nephrol Dial Transplant 2010; 25:2745-53. [PMID: 20220203 DOI: 10.1093/ndt/gfq114] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Determining if a kidney from a marginal donor is likely to elicit a strong and specific immune response, leading to an increased risk of acute rejection, is of importance in renal transplantation. METHODS In this study, we analysed the effect of extended criteria donor (ECD) on the incidence of biopsy-proven acute rejection (BPAR) and the effect of immunological risk factors on graft outcome in a large cohort of kidney transplant recipients (n = 2121 patients) grafted with ECD (n = 656 patients) or optimal donor (OD) (n = 1465 patients). RESULTS The incidence of BPAR was not statistically different between the ECD group recipients (105/656, 16%) and the OD group recipients (251/1465, 17%) (P = 0.52). These values remained similar after adjustment for immunological risk [defined as retransplantation and/or panel-reactive antibody (PRA) level >20%] (P = 0.92 for patients with immunological risk and P = 0.47 for patients without immunological risk). We next analysed the death-censored graft survival data for OD and ECD groups, as a function of immunological status, and found that the immunological risk factor did not affect graft survival in ECD transplant recipients (P = 0.64). CONCLUSION Although our groups were not homogenous, our study did not reveal an increased risk of acute rejection in recipients of ECD allograft.
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Affiliation(s)
- Carine Diet
- Nephrology and Renal Transplantation Department, Henri Mondor Hospital, AP-HP and Paris XII University, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil, France
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Guba M, Rentsch M, Wimmer CD, Uemueksuez A, Illner WD, Schönermarck U, Land WG, Jauch KW, Arbogast H. Calcineurin-inhibitor avoidance in elderly renal allograft recipients using ATG and basiliximab combined with mycophenolate mofetil. Transpl Int 2008; 21:637-45. [PMID: 18282242 DOI: 10.1111/j.1432-2277.2008.00658.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In old recipients of renal allografts from old donors, benefits of calcineurin-inhibitors (CNI) are curtailed by nephrotoxicity. Intending to improve the outcome of these recipients, we analyzed a CNI-free immunosuppressive regimen consisting of anti-thymocyte globulin (ATG), basiliximab, mycophenolate mofetil (MMF) and steroids. Kidney allograft recipients with low immunological risk (panel reactive antibodies <30%) were eligible for this study. Immunosuppression induction included ATG (4 mg/kg, day 0), basiliximab (20 mg, day 0 + 4) and steroids, followed by MMF (TL 2-6 microg/ml) and steroid maintenance treatment. Patient and graft survival rates respectively were 89.3% and 85.4% (12 months), and 86.6% and 76.8% (24 months). Delayed graft function occurred in 44.6%. S-creatinine at 12 months was 1.85 +/- 0.94 mg/dl. Thirty patients (53.6%) showed biopsy-proven rejections (6x Banff 3, 13x Banff 4I and 16x Banff 4II), 77% of which were steroid-sensitive, 23% required antibody treatment. After 12 months, 83% of the patients had an MMF-based immunosuppression, 43% were CNI-free. Cytomegalovirus (CMV) infections occurred in 28, tissue-invasive disease in three patients. Despite acceptable renal graft survival and function in some of patients with marginal organs, high incidences of rejections and CMV infections suggest the feasibility of CNI-avoidance using an MMF-based protocol only in carefully selected patients.
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Affiliation(s)
- Markus Guba
- Department of Surgery, Klinikum Grosshadern, University of Munich, Munich, Germany.
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Audard V, Matignon M, Dahan K, Lang P, Grimbert P. Renal transplantation from extended criteria cadaveric donors: problems and perspectives overview. Transpl Int 2007; 21:11-7. [PMID: 17850235 DOI: 10.1111/j.1432-2277.2007.00543.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The critical shortage of organs available for renal transplantation has led to the consideration of alternative strategies for increasing the donor pool. Recently, the cadaveric kidney donor pool extended to donors who might have been deemed unsuitable in early times, leading to the concept of marginal donors and more recently to the notion of expanded criteria donors. Such organs are eligible for organ donation but, because of extreme age and other clinical characteristics, are expected to produce allograft at risk for diminished post-transplant function. Thus, the challenge is now to reduce the difference between graft outcome from patients grafted with marginal and 'optimal' donors. This implies appropriate transplantation strategies during pre-, peri- and post-transplantation phases including reduction of cold ischemia time, recipient selection, adaptation of immunosuppressive drug regimens, increase in nephron mass by dual kidney transplantation, and improvement in the graft selection process using histological criteria. This review summarizes current definition of a marginal donor and provides some guidance for clinical management of such transplant.
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Affiliation(s)
- Vincent Audard
- Service de Néphrologie et Transplantation Rénale, CHU Henri Mondor, et Institut Francilien de Recherche en Néphrologie et Transplantation, Université Paris XII, Créteil, France
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Segoloni GP, Messina M, Squiccimarro G, Mazzucco G, Torta E, Leonardi G, Fop F, Roggero S, Vigotti F, Piccoli GB. Preferential allocation of marginal kidney allografts to elderly recipients combined with modified immunosuppression gives good results. Transplantation 2006; 80:953-8. [PMID: 16249744 DOI: 10.1097/01.tp.0000174134.80947.0a] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND There is an increasing tendency to allocate kidneys from marginal donors in older recipients. This combination optimizes the uses of an expanded donor pool but demands attention for the higher nephrotoxic sensitivity of the kidney and the increased immunosuppression vulnerability of the elderly recipients. We aimed to reduce these hazards by means of a calcineurin-free induction therapy followed by a maintenance regimen targeted to minimize/withdraw steroid. METHODS Eighty-eight single (43%) or double (57%) transplant recipients (58.4+/-5.7 years) from 88 marginal donors (67+/-8.3 years) received monoclonal anti-IL-2 receptor antibodies, mycophenolate mofetil (MMF), and steroid. When serum creatinine was less than 2.6 mg/dL, tacrolimus was started and MMF was withdrawn when the tacrolimus trough level was above 15 ng/ml. Steroid was tapered to 5 mg at day 45 and then progressively reduced. RESULTS Overall patient and graft survival at the first and fourth year were respectively 100 and 96%, and 98 and 79%. Acute rejection rate was 13.6% (12/88), creatinine clearance remained stable (48.2 ml/min at the sixth month, 50.9 ml/min at 48th month). At the first, second, third, and fourth years, 23, 69, 80, and 100% of recipients were off steroids. For those on steroids, mean dose was respectively 2.6 mg/day from month 12. No recipient re-assumed steroids CONCLUSIONS In the "old-for-old" allocation, the calcineurin-inhibitor avoidance at induction and the steroid withdrawal/minimization during the tacrolimus-based maintenance regimen allow a low acute rejection rate, a stable renal function, and favorable recipient and graft outcomes.
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Affiliation(s)
- Giuseppe P Segoloni
- Renal Transplant Unit, Nephrology, Dialysis and Transplantation Department, S.Giovanni Battista Hospital, Turin, Italy.
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Montalbano M, Neff GW, Slapak-Green G, Berney T, Meyer D. Sirolimus therapy in orthotopic liver transplant (OLT) recipients with acute renal insufficiency. Dig Dis Sci 2004; 49:1986-9. [PMID: 15628739 DOI: 10.1007/s10620-004-9606-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Marzia Montalbano
- Department of Medicine, University of Miami, Miami, Florida 33136, USA
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Fulladosa X, Moreso F, Narváez JA, Grinyó JM, Serón D. Estimation of total glomerular number in stable renal transplants. J Am Soc Nephrol 2004; 14:2662-8. [PMID: 14514746 DOI: 10.1097/01.asn.0000088025.33462.b0] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Glomerular number (N(g)) is considered a major determinant of renal function and outcome. In the dog, it has been shown that Ng can be estimated with reasonable precision in vivo by means of a renal biopsy and magnetic resonance imaging (MRI). Thus, this method was applied to study anatomoclinical correlations in stable human renal transplants. Thirty-nine stable renal transplants were included. A protocol renal allograft biopsy was done at 4 mo. Biopsies were evaluated according to Banff criteria. Glomerular volume fraction (Vv(glom/cortex)) was measured by means of a point-counting method, and mean glomerular volume (V(g)) was estimated by means of Weibel and Gomez (V(g)-W&G) and maximal profile area (V(g)-MPA) methods. MRI was used to estimate renal cortical volume (V(cortex)). N(g) was calculated as (Vv(glom/cortex) x V(cortex))/V(g). GFR was estimated by the inulin clearance. Ten age-matched donor biopsies served as controls for V(g). Histologic diagnosis was as follows: normal (n = 20), borderline (n = 7), acute rejection (n = 1), and chronic allograft nephropathy (n = 11). Vv(glom/cortex) was 3.4 +/- 1.1%, V(cortex) was 167 +/- 46 cm(3), V(g)-W&G was 3.2 +/- 1.2 x 10(6) micro m(3), and V(g)-MPA was 3.3 +/- 1.0 x 10(6) micro m(3). V(g)-W&G in donor and recipient biopsies was not different (3.6 +/- 1.1 versus 3.2 +/- 1.2 x 10(6) micro m(3)). Total glomerular number estimated by means of V(g)-W&G (N(g)-W&G) was 0.73 +/- 0.33 x 10(6) and by V(g)-MPA (N(g)-MPA) was 0.74 +/- 0.31 x 10(6). A positive correlation between GFR and N(g)-W&G (r = 0.47, P = 0.002) was observed. Furthermore, the older the donor, the higher V(g)-W&G (r = 0.37, P = 0.01) and the lower N(g)-W&G (r = -0.40, P = 0.01). Total glomerular number can be estimated in stable renal allografts by means of a renal biopsy and MRI. Our data show that N(g) depends on donor age and positively correlates with GFR.
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Affiliation(s)
- Xavier Fulladosa
- Nephrology Department, Hospital Universitari de Bellvitge, Barcelona, Spain.
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Pascher A, Reutzel-Selke A, Jurisch A, Bachmann U, Heidenhain C, Nickel P, Reinke P, Brandt C, Pratschke J, Frei U, Neuhaus P, Volk HD, Tullius SG. Alterations of the immune response with increasing recipient age are associated with reduced long-term organ graft function of rat kidney allografts1. Transplantation 2003; 76:1560-8. [PMID: 14702524 DOI: 10.1097/01.tp.0000090161.79609.d3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Clinically, an increasing number of older recipients are listed for transplantation. We examined recipient age-associated alterations of the immune response and their effects on graft function. METHODS Three- and 18-month-old Lewis (LEW) rats received kidneys from 3- and 18-month-old Fischer 344 (F344) rats (1.5 mg/kg/d cyclosporine A for 10 days; n=6/group) and were observed for 180 days. In additional groups, double kidney transplantations were performed to determine the impact of nephron mass and recipient age on graft outcome. RESULTS All young recipients but only 66% of old recipients survived the observation period. Increasing recipient age resulted in a significant decrease in renal allograft function (P<0.001), more advanced morphologic evidence of chronic allograft damage (P<0.001), and greater cellular infiltration (P<0.05) and major histocompatibility complex expression (P<0.01) within grafts. Additional in vitro studies examined age-related changes in the cellular immune response by enzyme-linked immunosorbent assay, fluorescence-activated cell sorter analysis, and alloreactive enzyme-linked immunospot: splenocytes from old LEW rats produced significantly more interleukin (IL)-2 (P<0.0001), IL-4 (P<0.05), interferon (IFN)-gamma (P<0.0001), and tumor necrosis factor-alpha (P<0.05). IFN-gamma-producing memory-type T cells were significantly elevated in older rats (P<0.0001). Moreover, they revealed significantly more alloreactive T cells directed against F344 (146 +/- 64.2 and 512 +/- 277/10(6) T cells; P<0.05). Double renal allografts from young donors into old recipients confirmed an independent effect of recipient age on the acceleration of chronic graft deterioration. CONCLUSIONS The enhanced cellular immune responsiveness in elderly recipients was associated with advanced chronic graft injury. Clinically, older recipients may need a modified immunosuppression.
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Affiliation(s)
- Andreas Pascher
- Department of General Surgery, Charité-Campus Virchow, Berlin, Germany
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Grinyó JM, Gil-Vernet S, Cruzado JM, Caldés A, Riera L, Serón D, Rama I, Torras J. Calcineurin inhibitor-free immunosuppression based on antithymocyte globulin and mycophenolate mofetil in cadaveric kidney transplantation: results after 5 years. Transpl Int 2003. [PMID: 12879230 DOI: 10.1111/j.1432-2277.2003.tb00247.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Kidney grafts from suboptimal donors are more likely to suffer the nephrotoxic side-effects of cyclosporine than kidneys from standard donors. In an attempt to avoid the use of cyclosporine, we carried out a prospective study in low-immunological risk recipients of suboptimal kidneys, using an immunosuppressive protocol combining Thymoglobuline in induction with a bi-therapy of mycophenolate mofetil (MMF) and steroids. Patients with panel reactive antibodies (PRA) <50% receiving a first renal transplant from a suboptimal donor (age >or=50, non heart beating, arterial hypertension, or acute renal failure) or a kidney at risk of delayed graft function (DGF) because of a prolonged cold ischaemia time (CIT) of 24 h or more, were eligible for this trial. Between September 1996 and December 1999, 30 patients were enrolled for the trial and treated with MMF 2 g orally, pre-operatively, and 3 g daily, post-operatively; Thymoglobuline 2 mg/kg IV pre-operatively, 1.5 mg/kg IV the next day, and for doses of 1 mg/kg IV given on alternate days; and prednisolone 0.25 mg/kg per day, reduced progressively from the end of the first month to 0.1 mg/kg per day by 3 months post-transplant. Cyclosporine was added only if rejection grade II or higher, or a reduction in MMF below 1 g daily, occurred. Ten patients (30%) suffered from DGF, and one kidney suffered primary non function. Seven patients (24%) suffered acute rejection (six were biopsy proven, 3 grade I and 3 grade II). MMF dosage was reduced in 28 patients because of adverse events, and calcineurin inhibitors were introduced in 16 patients. There were 14 episodes of opportunistic infection (cytomegalovirus (CMV 10), Herpes zoster 2, Listeria monocytogenes 1, Pseudomonas aeuruginosa 1), and 7 malignancies (skin 2, thyroid 1, lung 1, Kaposi's sarcoma 2, post-transplantation lymphoproliferative disorder 1). Mean serum creatinine was 178, 199, 213, and 218 micromol/l at 1, 2, 3 and 5 years after transplantation, respectively. Actuarial patient and graft (after censoring for death) survival was 94% and 83% after 1 year and 79% and 65% after 5 years, respectively. These results show that with the combination of MMF, Thymoglobuline and steroids the use of cyclosporine can be delayed, and in a few cases completely avoided, with good efficacy in terms of prevention of rejection and recovery of renal function. Regardless of acceptable patient and graft survival, side-effects of MMF at the doses used in this protocol were common and led to overimmunosuppression in the long-term. Starting MMF at low dose, MPA monitoring and probably CMV prophylaxis may improve the results of this regimen.
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Affiliation(s)
- Josep M Grinyó
- Nephrology Department, Hospital of Bellvitge, CSUB, Feixa Llarga s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.
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Grimbert P, Baron C, Fruchaud G, Hemery F, Desvaux D, Buisson C, Chopin D, Dahmane D, Remy P, Pastural M, Abbou C, Weil B, Lang P. Long-term results of a prospective randomized study comparing two immunosuppressive regimens, one with and one without CsA, in low-risk renal transplant recipients. Transpl Int 2002. [DOI: 10.1111/j.1432-2277.2002.tb00106.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kiehl MG, Schäfer-Eckart K, Kröger M, Bornhäuser M, Basara N, Blau IW, Kienast J, Fauser AA, Ehninger G, Armstrong VW, Shipkova M. Mycophenolate mofetil for the prophylaxis of acute graft-versus-host disease in stem cell transplant recipients. Transplant Proc 2002; 34:2922-4. [PMID: 12431658 DOI: 10.1016/s0041-1345(02)03489-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- M G Kiehl
- Department of Hematology/Oncology, BMT Unit, Idar-Oberstein, Germany.
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19
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Vathsala A. Tailoring immunosuppressive therapy in renal transplantation. Transplant Proc 2002; 34:2478-9. [PMID: 12270484 DOI: 10.1016/s0041-1345(02)03182-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- A Vathsala
- Department of Renal Medicine, Singapore General Hospital, Singapore
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20
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Donati D, Ambrosini A, Marconi A, Mazzola E. Calcineurin inhibitor-free immunosuppressive regimen for marginal donors/recipients of kidney transplantation. Transplant Proc 2002; 34:1678-80. [PMID: 12176532 DOI: 10.1016/s0041-1345(02)02977-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- D Donati
- Renal Transplant Unit, Azienda Ospedaliera Ospedale di Circolo, Viale Borri 57, 21100 Varese, Italy
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21
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Abstract
In parallel with increased clinical demand, less than optimal or so-called marginal kidney grafts are being used for transplantation. In addition to donor age, it appears that several factors may impact negatively on the quality of the graft. Most importantly, a more precise definition of the term 'marginal graft' is needed. The present review analyzes potential risk factors, suggests scoring systems for a more precise definition, and discusses potential treatment options to improve the quality of marginal grafts.
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Affiliation(s)
- Stefan G Tullius
- Department of Surgery, Charité--Campus Virchow Clinic, Berlin, Germany.
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22
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Young M, Plosker GL. Mycophenolate mofetil: a pharmacoeconomic review of its use in solid organ transplantation. PHARMACOECONOMICS 2002; 20:675-713. [PMID: 12162756 DOI: 10.2165/00019053-200220100-00004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
UNLABELLED Most pharmacoeconomic studies of mycophenolate mofetil have focused on its use as part of maintenance immunosuppression for renal transplantation, involving short-term (3 to 12 months) time frames. In general, mycophenolate mofetil reduced the treatment costs for rejection episodes and graft failure which offset its higher drug acquisition cost compared with azathioprine. Several cost analyses have been modelled on the large multicentre trials of adult renal transplant recipients. The use of mycophenolate mofetil was associated with either cost savings or no additional costs after 6 or 12 months in French, US and Canadian analyses of triple or quadruple immunosuppressant therapy. A further cost analysis utilising a registry database of renal transplant recipients in the US found mycophenolate mofetil to be cost saving compared with azathioprine after 6.4 years when evaluating costs due to graft loss only. Of the limited cost-effectiveness analyses with the drug, one US study modelled the 1- and 10-year cost effectiveness of mycophenolate mofetil and various other immunosuppressants used in combined regimens. Long-term use of mycophenolate mofetil was less cost effective than other regimens, but the use of long-term mycophenolate mofetil in high-risk patients was shown to be a relatively cost-effective strategy. In another US analysis comparing mycophenolate mofetil with azathioprine as part of quadruple therapy, mycophenolate mofetil was associated with slightly lower costs during the first year after renal transplantation as well as improved clinical outcomes. CONCLUSION Pharmacoeconomic studies support the use of mycophenolate mofetil as part of immunosuppressant therapy in renal transplantation, at least in the short term. Although the cost effectiveness of mycophenolate mofetil in the long term is less clear, limited pharmacoeconomic data available appear promising. Among issues to be examined in future economic analyses in renal transplantation are the calcineurin-sparing potential of mycophenolate mofetil and the feasibility of using more efficient mycophenolate mofetil dosage regimens when using the drug on a long-term basis. Additional pharmacoeconomic analyses of mycophenolate mofetil are also needed in other types of solid organ transplantation.
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23
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Affiliation(s)
- S G Tullius
- Department of Surgery, Charité-Virchow Clinic, Humboldt University, Augustenburger Platz 1, 13353 Berlin, Germany
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24
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Charpentier B. An induction versus no-induction protocol in anticalcineurin-based immunosuppression using very low-dose steroids. Transplant Proc 2001; 33:3S-10S. [PMID: 11406262 DOI: 10.1016/s0041-1345(01)02111-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- B Charpentier
- University Hospital of Bicêtre, Le Kremlin-Bicêtre, France
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25
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Basara N, Günzelmann S, Willenbacher W, Fauser AA, Kiehl MG. New immunosuppressants in BMT/GVHD. Transplant Proc 2001; 33:2220-2. [PMID: 11377507 DOI: 10.1016/s0041-1345(01)01946-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- N Basara
- Department of Hematology/Oncology, BMT Unit, Oberstein, Germany
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26
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Affiliation(s)
- J M Grinyó
- Hospital de Bellvitge, University of Barcelona, Barcelona, Spain.
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27
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Calcineurin inhibitor sparing and weaning in immunosuppression: a step forward in transplant recipient care. Curr Opin Organ Transplant 2000. [DOI: 10.1097/00075200-200009000-00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Immunosuppression advancing in the new millennium: lessons learned from recent multicenter and single center clinical trials. Curr Opin Organ Transplant 2000. [DOI: 10.1097/00075200-200009000-00015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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29
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Affiliation(s)
- J M Grinyó
- Hospital de Bellvitge, University of Barcelona, Barcelona, Spain
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30
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Serón D, Moreso F, Ramón JM, Hueso M, Condom E, Fulladosa X, Bover J, Gil-Vernet S, Castelao AM, Alsina J, Grinyó JM. Protocol renal allograft biopsies and the design of clinical trials aimed to prevent or treat chronic allograft nephropathy. Transplantation 2000; 69:1849-55. [PMID: 10830221 DOI: 10.1097/00007890-200005150-00019] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The minimum sample size to perform a clinical trial aimed to modify the natural history of chronic allograft nephropathy (CAN) is very large. Since the presence of chronic tubulointerstitial damage in renal protocol biopsy specimens is an independent predictor of late outcome, we evaluated whether protocol biopsies could facilitate the design of trials aimed to prevent or treat CAN. METHODS Two hundred eighty-two protocol biopsy specimens were obtained 3 months after transplantation in 280 patients with serum creatinine levels <300 micromol/L, proteinuria <1000 mg/day, and stable function. The specimens were evaluated according to the Banff criteria. RESULTS Graft survival depended on the presence of CAN and renal transplant vasculopathy (RTV). Thus, biopsy specimens were classified as: (a) no CAN (n=174); (b) CAN without RTV (n=87); and (c) CAN with RTV (n=21). Graft survival at 10 years was 95%, 82%, and 41%, respectively (P=0.001). Total serum cholesterol before transplantation was 4.5+/-1.1, 4.6+/-1.1, and 5.3+/-1.6 mmol/L, respectively (P=0.009) and it was the only predictor of RTV. Power analysis (beta=20%, alpha=5%) was done to evaluate whether protocol biopsies can facilitate the design of clinical trials aimed either to prevent or treat CAN. We showed that the most feasible approach would be to use the presence of CAN as the primary efficacy end point in a prevention trial. To demonstrate a 50% reduction in the incidence of CAN at 3 months, 570 patients would be required. CONCLUSIONS Protocol biopsies may allow a reduction of sample size and especially the time of follow-up in a trial aimed to prevent CAN.
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Affiliation(s)
- D Serón
- Department of Nephrology, Ciutat Sanitària i Universitària de Bellvitge, Barcelona, Spain
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31
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Abramowicz D, Wissing KM, Broeders N. Nephrotoxicity of calcineurin inhibitors: new therapeutic approaches. Transplant Proc 2000; 32:3S-5S. [PMID: 10686309 DOI: 10.1016/s0041-1345(00)00807-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- D Abramowicz
- Nephrology Department, Hôpital Erasme, Brussels, Belgium
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