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Smajdor J, Paczosa-Bator B, Piech R. Advances on Hormones and Steroids Determination: A Review of Voltammetric Methods since 2000. MEMBRANES 2022; 12:1225. [PMID: 36557132 PMCID: PMC9782681 DOI: 10.3390/membranes12121225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/18/2022] [Accepted: 11/22/2022] [Indexed: 06/17/2023]
Abstract
This article presents advances in the electrochemical determination of hormones and steroids since 2000. A wide spectrum of techniques and working electrodes have been involved in the reported measurements in order to obtain the lowest possible limits of detection. The voltammetric and polarographic techniques, due to their sensitivity and easiness, could be used as alternatives to other, more complicated, analytical assays. Still, growing interest in designing a new construction of the working electrodes enables us to prepare new measurement procedures and obtain lower limits of detection. A brief description of the measured compounds has been presented, along with a comparison of the obtained results.
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2
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Kizilbash SJ, Jensen CJ, Kouri AM, Balani SS, Chavers B. Steroid avoidance/withdrawal and maintenance immunosuppression in pediatric kidney transplantation. Pediatr Transplant 2022; 26:e14189. [PMID: 34786800 DOI: 10.1111/petr.14189] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/30/2021] [Accepted: 10/06/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Corticosteroids have been an integral part of maintenance immunosuppression for pediatric kidney transplantation. However, prolonged steroid therapy is associated with significant toxicities resulting in several SW/avoidance strategies in recent years. METHOD/OBJECTIVE This comprehensive review aims to discuss steroid-related toxicities and the safety, efficacy, and benefit of steroid avoidance/withdrawal immunosuppression in pediatric kidney transplant recipients. RESULTS Initial studies of SW/avoidance conducted in the setting of CSA and AZA showed an increased incidence of AR but no increase in graft loss or mortality with SW/avoidance maintenance immunosuppression. Studies performed under modern immunosuppression (induction therapy, Tac, and MMF) show no significant increase in AR or graft loss with SW/avoidance immunosuppression. Furthermore, SW/avoidance immunosuppression is associated with significant improvement in growth, BMI, BP control, and lipid profile in pediatric kidney transplant recipients. Despite these data, SW/avoidance remains controversial, and only 40% of pediatric kidney transplant recipients in the United States are currently on SW/avoidance maintenance immunosuppression. CONCLUSION SW/avoidance maintenance immunosuppression is safe and associated with fewer side effects compared with steroid-inclusive maintenance immunosuppression in pediatric kidney transplant recipients.
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Affiliation(s)
- Sarah J Kizilbash
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Chelsey J Jensen
- Solid Organ Transplant, University of Minnesota, Minneapolis, Minnesota, USA
| | - Anne M Kouri
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shanthi S Balani
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Blanche Chavers
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
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3
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Krall P, Yañez D, Rojo A, Delucchi Á, Córdova M, Morales J, Boza P, de la Rivera A, Espinoza N, Armijo N, Castañeda LE, Farfán MJ, Salas C. CYP3A5 and UGT1A9 Polymorphisms Influence Immunosuppressive Therapy in Pediatric Kidney Transplant Recipients. Front Pharmacol 2021; 12:653525. [PMID: 33967795 PMCID: PMC8100460 DOI: 10.3389/fphar.2021.653525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/23/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Tacrolimus (TAC) and mycophenolic acid (MPA) are the main immunosuppressive drugs used in pediatric kidney transplantation. Single nucleotide polymorphisms (SNPs) in metabolizing enzymes and transporters might influence plasma levels of these drugs. Herein, we sought to determine the influence of SNPs on CYP3A5, MRP2 and UGT1A9 genes in Chilean pediatric kidney recipients using TAC and MPA. Patients and Methods: A prospective study was performed on 104 pediatric kidney recipients that used TAC and MPA for immunosuppression. The median age at the time of transplantation was 8.1 years [Q1-Q3 4.5-11.6 years] and the main clinical diagnosis was a structural anomaly. In a subgroup of patients, a complete steroid withdrawal was made at day 7. The CYP3A5 polymorphism (ancestral allele *1; variant allele *3) was determined in the entire cohort, while MRP2 -24G > A, UGT1A9 -275T > A, and UGT1A9 -2152C > T polymorphisms were determined in 53 patients. Genotypes were associated with trough drug concentrations (C0), dose requirements normalized by weight (TAC-D mg/kg) or body surface (MPA-D mg/m2), trough levels normalized by dose requirements (C0/D), and area under the curve in 12 h normalized by dose requirements (AUC0-12h/D). Results: The frequencies of the variant alleles CYP3A5*3, MRP2-24A, UGT1A9-275A, and UGT1A9-2152T were 76.9, 22.1, 6.6, and 2.9%, respectively. AUC0-12h/TAC-D were 1.6-fold higher in CYP3A5*3/*3 patients than in CYP3A5*1 carriers (CYP3A5*1/*3 and CYP3A5*1/*1). When analyzing patients with steroid withdrawal, CYP3A5*3/*3 patients had 1.7-fold higher AUC0-12h/TAC-D than the other genotypes. Patients carrying the CYP3A5*3/*3 genotype had higher TAC-C0, lower TAC-D and higher TAC-C0/D, consistently in a 6-months follow-up. Creatinine clearance was stable during the follow-up, regardless of the genotype. No significant differences between MRP2 and UGT1A9 genotypes were observed in MPA-C0, MPA-D or MPA-C0/D. However, patients carrying the UGT1A9-275A allele had lower AUC0-12h/MPA-D than those carrying the UGT1A9-275T ancestral allele. Conclusions: These results support that CYP3A5 and UGT1A9 genotyping in pediatric recipients might be useful and advisable to guide TAC and MPA dosing and monitoring in children that undergo kidney transplantation.
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Affiliation(s)
- Paola Krall
- Departamento de Pediatría y Cirugía Infantil Oriente, Facultad de Medicina, Universidad de Chile, Santiago de Chile, Chile
| | - Dominique Yañez
- Laboratorio Clínico, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - Angélica Rojo
- Departamento de Pediatría y Cirugía Infantil Oriente, Facultad de Medicina, Universidad de Chile, Santiago de Chile, Chile
| | - Ángela Delucchi
- Departamento de Pediatría y Cirugía Infantil Oriente, Facultad de Medicina, Universidad de Chile, Santiago de Chile, Chile
| | - Miguel Córdova
- Laboratorio Clínico, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - Jorge Morales
- Servicio de Farmacia, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - Pía Boza
- Laboratorio Clínico, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | | | - Natalie Espinoza
- Laboratorio Clínico, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - Natalia Armijo
- Unidad de Nefrología, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - Luis E Castañeda
- Programa de Genética Humana, Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago de Chile, Chile
| | - Mauricio J Farfán
- Departamento de Pediatría y Cirugía Infantil Oriente, Facultad de Medicina, Universidad de Chile, Santiago de Chile, Chile.,Laboratorio Clínico, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - Carolina Salas
- Laboratorio Clínico, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
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4
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Puliyanda DP, Pizzo H, Rodig N, Somers MJG. Early outcomes comparing induction with antithymocyte globulin vs alemtuzumab in two steroid-avoidance protocols in pediatric renal transplantation. Pediatr Transplant 2020; 24:e13685. [PMID: 32112514 DOI: 10.1111/petr.13685] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/24/2020] [Accepted: 02/05/2020] [Indexed: 11/30/2022]
Abstract
Steroid avoidance in pediatric kidney transplants was found effective with extended daclizumab induction. Upon discontinuation of daclizumab, lymphocyte-depleting agents became used, with little comparative data. We assessed outcomes in children undergoing low immunologic-risk deceased donor (DD) kidney transplants using induction with antithymocyte globulin (ATG) compared to alemtuzumab. We reviewed consecutive DD kidney transplants from January 2015 to September 2017 at two pediatric centers that used different lymphocyte-depleting agents in steroid-avoidance protocols: ATG (Center A) and alemtuzumab (Center B), with tacrolimus and MMF as maintenance immunosuppression. Anti-infective prophylaxis was based on center protocol. Over the first year post-tx, there were similar rates of infections. EBV and BK viremia were comparable though Center A manifested more low-grade CMV viremia (A 46% vs B 0%; P = .0009) at median onset 1.8 months, followed by early seroconversion. Reduction of immunosuppression did not differ between groups. DSA at 1 year was similar (A 8% vs 13%) with low rates of BPAR. Need for steroid-based conversion was low. There were no graft losses and no differences in median eGFR at 30, 90, 180, and 365 days. (a) 1-year graft outcomes are excellent in steroid-avoidance regimens using ATG or alemtuzumab induction; (b) conversion to steroid-based therapy is low; (c) alemtuzumab/high-dose MMF is associated with lower WBC and more GCSF use; (d) alemtuzumab/higher dose MMF results in more diarrhea and azathioprine conversion than ATG/lower dose MMF; (e) CMV viremia is seen more often with ATG use with infection prophylaxis reduction; however, seroconversion occurs promptly.
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Affiliation(s)
- Dechu P Puliyanda
- Pediatric Nephrology and Transplant Immunology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Helen Pizzo
- Pediatric Nephrology and Transplant Immunology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Nancy Rodig
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael J G Somers
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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5
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Dharnidharka VR. Scientometrics: Judging the impact of published articles in the field of pediatric kidney transplantation. Pediatr Transplant 2019; 23:e13533. [PMID: 31364235 DOI: 10.1111/petr.13533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 06/06/2019] [Accepted: 06/07/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Vikas R Dharnidharka
- Division of Pediatric Nephrology, Hypertension and Pheresis, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri, USA
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6
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De Lucena DD, Rangel ÉB. Glucocorticoids use in kidney transplant setting. Expert Opin Drug Metab Toxicol 2018; 14:1023-1041. [DOI: 10.1080/17425255.2018.1530214] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Débora Dias De Lucena
- Department of Medicine, Division of Nephrology, Federal University of São Paulo/Hospital do Rim e Hipertensão, São Paulo, Brazil
| | - Érika Bevilaqua Rangel
- Department of Medicine, Division of Nephrology, Federal University of São Paulo/Hospital do Rim e Hipertensão, São Paulo, Brazil
- Instituto Israelita de Ensino e Pesquisa, Hospital Israelita Albert Einstein, São Paulo, Brazil
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7
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Cho MH. Pediatric kidney transplantation is different from adult kidney transplantation. KOREAN JOURNAL OF PEDIATRICS 2018; 61:205-209. [PMID: 30032586 PMCID: PMC6106688 DOI: 10.3345/kjp.2018.61.7.205] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 05/02/2018] [Indexed: 12/19/2022]
Abstract
Kidney transplantation (KT) is the gold standard for renal replacement therapy in pediatric patients with end-stage renal disease. Recently, it has been observed that the outcome of pediatric KT is nearly identical to that in adults owing to the development and application of a variety of immunosuppressants and newer surgical techniques. However, owing to several differences in characteristics between children and adults, pediatric KT requires that additional information be learned and is associated with added concerns. These differences include post-KT complications, donor-recipient size mismatch, problems related to growth, and nonadherence to therapy, among others. This review was aimed at elucidating the clinical characteristics of pediatric KT that differ from those observed in adults.
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Affiliation(s)
- Min Hyun Cho
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
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8
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Haasova M, Snowsill T, Jones-Hughes T, Crathorne L, Cooper C, Varley-Campbell J, Mujica-Mota R, Coelho H, Huxley N, Lowe J, Dudley J, Marks S, Hyde C, Bond M, Anderson R. Immunosuppressive therapy for kidney transplantation in children and adolescents: systematic review and economic evaluation. Health Technol Assess 2018; 20:1-324. [PMID: 27557331 DOI: 10.3310/hta20610] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND End-stage renal disease is a long-term irreversible decline in kidney function requiring kidney transplantation, haemodialysis or peritoneal dialysis. The preferred option is kidney transplantation followed by induction and maintenance immunosuppressive therapy to reduce the risk of kidney rejection and prolong graft survival. OBJECTIVES To systematically review and update the evidence for the clinical effectiveness and cost-effectiveness of basiliximab (BAS) (Simulect,(®) Novartis Pharmaceuticals) and rabbit antihuman thymocyte immunoglobulin (Thymoglobuline,(®) Sanofi) as induction therapy and immediate-release tacrolimus [Adoport(®) (Sandoz); Capexion(®) (Mylan); Modigraf(®) (Astellas Pharma); Perixis(®) (Accord Healthcare); Prograf(®) (Astellas Pharma); Tacni(®) (Teva); Vivadex(®) (Dexcel Pharma)], prolonged-release tacrolimus (Advagraf,(®) Astellas Pharma); belatacept (BEL) (Nulojix,(®) Bristol-Myers Squibb), mycophenolate mofetil (MMF) [Arzip(®) (Zentiva), CellCept(®) (Roche Products), Myfenax(®) (Teva), generic MMF is manufactured by Accord Healthcare, Actavis, Arrow Pharmaceuticals, Dr Reddy's Laboratories, Mylan, Sandoz and Wockhardt], mycophenolate sodium, sirolimus (Rapamune,(®) Pfizer) and everolimus (Certican,(®) Novartis Pharmaceuticals) as maintenance therapy in children and adolescents undergoing renal transplantation. DATA SOURCES Clinical effectiveness searches were conducted to 7 January 2015 in MEDLINE (via Ovid), EMBASE (via Ovid), Cochrane Central Register of Controlled Trials (via Wiley Online Library) and Web of Science [via Institute for Scientific Information (ISI)], Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Health Technology Assessment (HTA) (The Cochrane Library via Wiley Online Library) and Health Management Information Consortium (via Ovid). Cost-effectiveness searches were conducted to 15 January 2015 using a costs or economic literature search filter in MEDLINE (via Ovid), EMBASE (via Ovid), NHS Economic Evaluation Databases (via Wiley Online Library), Web of Science (via ISI), Health Economic Evaluations Database (via Wiley Online Library) and EconLit (via EBSCOhost). REVIEW METHODS Titles and abstracts were screened according to predefined inclusion criteria, as were full texts of identified studies. Included studies were extracted and quality appraised. Data were meta-analysed when appropriate. A new discrete time state transition economic model (semi-Markov) was developed; graft function, and incidences of acute rejection and new-onset diabetes mellitus were used to extrapolate graft survival. Recipients were assumed to be in one of three health states: functioning graft, graft loss or death. RESULTS Three randomised controlled trials (RCTs) and four non-RCTs were included. The RCTs only evaluated BAS and tacrolimus (TAC). No statistically significant differences in key outcomes were found between BAS and placebo/no induction. Statistically significantly higher graft function (p < 0.01) and less biopsy-proven acute rejection (odds ratio 0.29, 95% confidence interval 0.15 to 0.57) was found between TAC and ciclosporin (CSA). Only one cost-effectiveness study was identified, which informed NICE guidance TA99. BAS [with TAC and azathioprine (AZA)] was predicted to be cost-effective at £20,000-30,000 per quality-adjusted life year (QALY) versus no induction (BAS was dominant). BAS (with CSA and MMF) was not predicted to be cost-effective at £20,000-30,000 per QALY versus no induction (BAS was dominated). TAC (with AZA) was predicted to be cost-effective at £20,000-30,000 per QALY versus CSA (TAC was dominant). A model based on adult evidence suggests that at a cost-effectiveness threshold of £20,000-30,000 per QALY, BAS and TAC are cost-effective in all considered combinations; MMF was also cost-effective with CSA but not TAC. LIMITATIONS The RCT evidence is very limited; analyses comparing all interventions need to rely on adult evidence. CONCLUSIONS TAC is likely to be cost-effective (vs. CSA, in combination with AZA) at £20,000-30,000 per QALY. Analysis based on one RCT found BAS to be dominant, but analysis based on another RCT found BAS to be dominated. BAS plus TAC and AZA was predicted to be cost-effective at £20,000-30,000 per QALY when all regimens were compared using extrapolated adult evidence. High-quality primary effectiveness research is needed. The UK Renal Registry could form the basis for a prospective primary study. STUDY REGISTRATION This study is registered as PROSPERO CRD42014013544. FUNDING The National Institute for Health Research HTA programme.
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Affiliation(s)
- Marcela Haasova
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Tristan Snowsill
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Tracey Jones-Hughes
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Louise Crathorne
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Chris Cooper
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Jo Varley-Campbell
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Ruben Mujica-Mota
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Helen Coelho
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Nicola Huxley
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Jenny Lowe
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Jan Dudley
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children (University Hospitals Bristol NHS Foundation Trust), Bristol, UK
| | - Stephen Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Chris Hyde
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Mary Bond
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
| | - Rob Anderson
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis & Modelling for Health Improvement, University of Exeter, Exeter, UK
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9
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Pediatric kidney transplantation: a historical review. Pediatr Res 2017; 81:259-264. [PMID: 27732587 DOI: 10.1038/pr.2016.207] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 09/30/2016] [Indexed: 01/10/2023]
Abstract
Successful renal transplantation is the optimal treatment for chronic kidney failure, but this was not always so for children. Beginning with the first kidney transplants in the 1950s, children experienced poorer patient and graft survival rates than adult patients. But over the last 6 decades, an improved understanding of the immune system which has steered pediatric multi-center clinical/pharmacokinetic and mechanistic studies that have sculpted our immunosuppression with markedly better patient and graft survivals. In addition, uniquely pediatric issues related to growth, development, neurocognitive maturation, increased complications from primary viral infections, and comorbid congenital/inherited disorders, are now diagnosed and effectively managed in these children. Refined pretransplant preparation (vaccinations for preventable diseases, attention to cognitive delays, effective dialysis and nutrition) improved donor selection, and more potent immunosuppression have all contributed to enhanced outcomes. Similarly, improvements in pediatric surgical techniques, postoperative care and better antiviral prophylaxis have all shortened hospitalizations and reduced morbidity. Today pediatric kidney transplant outcomes are markedly improved and younger children today experience better long-term graft survival than adults! While difficult problems remain, we have made tremendous progress and anticipate even more advances in the future of pediatric kidney transplantation.
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10
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Krause I, Davidovits M, Tamary H, Yutcis M, Dagan A. Anemia and markers of erythropoiesis in pediatric kidney transplant recipients compared to children with chronic renal failure. Pediatr Transplant 2016; 20:958-962. [PMID: 27620552 DOI: 10.1111/petr.12792] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2016] [Indexed: 12/29/2022]
Abstract
PTA and anemia of CKD share a similar pathogenesis. However, PTA may be disproportionate to the reduction in the GFR. Data relating to the mechanism of PTA are scarce. We evaluated the erythropoiesis parameters in pediatric kidney recipients compared to children with CKD. A total of 100 patients (54 post-kidney TX, 46 with CKD) were enrolled in the single-center cohort study. GFR was found to be significantly lower in the CKD group (49.7±22.4 vs 72.9±28.5 mL/min/1.73 m², P<.001); anemia was significantly more common in the TX patients (52% vs 41.3%, P<.001). Iron transferrin saturation and serum ferritin levels were lower in the CKD patients. In both groups, hemoglobin Z scores significantly correlated with GFR (R=.31, P=.07). This correlation was more prominent in the CKD group (R=.43, P=.008) compared to the TX group (R=.31, P=.04). Anemia was significantly more common in the TX patients than in the CKD patients despite a better GFR. The higher prevalence of anemia in the TX group could not be explained by an iron deficiency or reduced EPO production. We speculate that immunosuppressive therapy together with resistance to EPO may play a role in the pathogenesis of post-transplantation anemia.
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Affiliation(s)
- Irit Krause
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikvah, Israel. .,Department of Pediatrics C, Schneider Children's Medical Center of Israel, Petach Tikvah, Israel. .,Sackler Faculty of Medicine Tel Aviv University, Ramat Aviv, Israel.
| | - Miriam Davidovits
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikvah, Israel.,Sackler Faculty of Medicine Tel Aviv University, Ramat Aviv, Israel
| | - Hannah Tamary
- Sackler Faculty of Medicine Tel Aviv University, Ramat Aviv, Israel.,Pediatric Hematology Unit, Schneider Children's Medical Center of Israel, Petach Tikvah, Israel
| | - Maria Yutcis
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikvah, Israel
| | - Amit Dagan
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikvah, Israel.,Sackler Faculty of Medicine Tel Aviv University, Ramat Aviv, Israel
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11
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Engberg H, Wehberg S, Bistrup C, Heaf J, Sørensen SS, Thiesson HC, Hansen JM, Svensson M, Green A, Marckmann P. Cancer risk and mortality after kidney transplantation: a population-based study on differences between Danish centres using standard immunosuppression with and without glucocorticoids. Nephrol Dial Transplant 2016; 31:2149-2156. [DOI: 10.1093/ndt/gfw304] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 07/03/2016] [Indexed: 12/14/2022] Open
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12
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The consequences of pediatric renal transplantation on bone metabolism and growth. Curr Opin Organ Transplant 2015; 18:555-62. [PMID: 23995376 DOI: 10.1097/mot.0b013e3283651b21] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW During childhood, growth retardation, decreased final height and renal osteodystrophy are common complications of chronic kidney disease (CKD). These problems remain present in patients undergoing renal transplantation, even though steroid-sparing strategies are more widely used. In this context, achieving normal height and growth in children after transplantation is a crucial issue for both quality of life and self-esteem. The aim of this review is to provide an overview of pathophysiology of CKD-mineral bone disorder (MBD) in children undergoing renal transplantation and to propose keypoints for its daily management. RECENT FINDINGS In adults, calcimimetics are effective for posttransplant hyperparathyroidism, but data are missing in the pediatric population. Fibroblast growth factor 23 levels are associated with increased risk of rejection, but the underlying mechanisms remain unclear. A recent meta-analysis also demonstrated the effectiveness of rhGH therapy in short transplanted children. SUMMARY In 2013, the daily clinical management of CKD-MBD in transplanted children should still focus on simple objectives: to optimize renal function, to develop and promote steroid-sparing strategies, to provide optimal nutritional support to maximize final height and avoid bone deformations, to equilibrate calcium/phosphate metabolism so as to provide acceptable bone quality and cardiovascular status, to correct all metabolic and clinical abnormalities that can worsen both bone and growth (mainly metabolic acidosis, anemia and malnutrition), promote good lifestyle habits (adequate calcium intake, regular physical activity, no sodas consumption, no tobacco exposure) and eventually to correct native vitamin D deficiency (target of 25-vitamin D >75 nmol/l).
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13
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Corticosteroid-free Kidney Transplantation Improves Growth: 2-Year Follow-up of the TWIST Randomized Controlled Trial. Transplantation 2015; 99:1178-85. [PMID: 25539467 DOI: 10.1097/tp.0000000000000498] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Corticosteroid withdrawal (CW) after pediatric kidney transplantation potentially improves growth while avoiding metabolic and other adverse events. We have recently reported the results of a 196 subject randomized controlled trial comparing early CW (tacrolimus, mycophenolate mofetil (MMF), daclizumab, and corticosteroids until day 4) with tacrolimus, MMF, and corticosteroid continuation (CC). At 6 months, CW subjects showed better growth with no adverse impact on acute rejection or graft survival (Am J Transplant 2010; 10: 828-836). This 2-year investigator-driven follow-up study aimed to determine whether improved growth persisted in the longer term. METHODS Data regarding growth, graft outcomes and adverse events were collected at 1 year (113 patients) and 2 years (106 patients) after transplantation. The primary endpoint, longitudinal growth calculated as delta height standard deviation score, was analyzed using a mixed model repeated measures model. RESULTS Corticosteroid withdrawal subjects grew better at 1 year (difference in adjusted mean change, 0.25; 95% confidence interval, 0.10, 0.40; P = 0.001). At 2 years, growth remained numerically better in CW subjects (0.20 (-0.01, 0.41); P = 0.06), and significantly better in prepubertal subjects (0.50 (0.16, 0.84); P = 0.004). Bacterial and viral infection was significantly more common in CW subjects at 1 year only. Corticosteroid withdrawal and CC subjects received similar exposure to both tacrolimus and MMF at 1 and 2 years. No significant difference in patient or graft survival, rejection, estimated glomerular filtration rate, or other adverse events was detected. CONCLUSION Early CW effectively and safely improves growth up to 2 years after transplantation, particularly in prepubertal children.
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Sharifian M, Arad B, Simfroosh N, Basiri A, Otukesh H, Esfandiar N. Effects of interleukin 2 receptor blockers on patient and graft survival in renal-transplanted children. Nephrourol Mon 2015; 6:e18641. [PMID: 25695021 PMCID: PMC4317716 DOI: 10.5812/numonthly.18641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 03/21/2014] [Accepted: 03/26/2014] [Indexed: 11/29/2022] Open
Abstract
Background: Monoclonal antibodies block interleukin-2 receptors on alloantigen-reactive T-Lymphocytes and induce selective immunosuppression. It is postulated that induction therapy with these agents in pediatric transplantation may decrease acute rejection and improve graft survival with no significant side effect or increase in the incidence of viral infections. Objectives: The aim of this study was to examine the effects of interleukin 2 receptor blockers on patient and graft survival in renal-transplanted children. Patients and Methods: One hundred and eighty six children aged 7-13 years who received renal transplantation in university-affiliated hospital between 2003 and 2012 were enrolled in the study. All patients received prednisolone, cyclosporine and mycophenolate mofetil or azathioprine as basic immunosuppressive therapy. Patients were divided into two groups according to receiving induction therapy with IL2-receptor blockers. We investigated for acute rejection episodes, Cytomegalovirus (CMV) and BK virus infection and one and three year’s survival of the patients and the grafts Results: From 186 renal-transplanted children included in this study, 36 patients were in treated group (group 1) and 150 patients in control group (group 2). The mean age of the patients was 10.4 ± 2 years and 55.6% were males. In first six months of transplantation, eight patients in group one had one episode of acute rejection and no one had two episodes. Early acute rejection rate was 8.36 (22%). In the control group, 37 patients had one episode and three patients had two episodes of acute rejection (rejection rate 28.6%). Therefore, early acute rejection rates were lower in group one. Late acute rejection rates did not show any difference in group 1 and group 2 (27.7% vs. 27.3% respectively). There was lower prevalence of steroid-resistance rejection in group 1 patients (5.5%) compared with 6.6% in group 2, but it did not reach statistical significance. None of the patients in IL2-R blocker group died at one year follow-up (patient survival 100%). However, in control group, four (2.6%) patients died toward the end of first year (patient survival 97.4%). When patients in group 1 and group 2 were age and sex matched with equal number the difference was significant (P < 0.05). Conclusions: Induction therapy with IL2-R blockers reduced the rate of early acute rejection, but had no effect on late acute rejections. Patient and graft survival were better in treated group, but did not reach statistical significance. A longer period of follow-up may be required to discern a clear advantage for induction therapy with these agents.
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Affiliation(s)
- Mostafa Sharifian
- Pediatric Infections Research Center, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Mostafa Sharifian, Pediatric Infections Research Center, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran. Tel: +98-9121485647, Fax: +98-2122220254, E-mail:
| | - Banafsheh Arad
- Pediatric Infections Research Center, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Naser Simfroosh
- Pediatric Infections Research Center, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Abbas Basiri
- Pediatric Infections Research Center, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | | | - Nasrin Esfandiar
- Pediatric Infections Research Center, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
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Cyclosporine A enhances gluconeogenesis while sirolimus impairs insulin signaling in peripheral tissues after 3 weeks of treatment. Biochem Pharmacol 2014; 91:61-73. [DOI: 10.1016/j.bcp.2014.06.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 06/16/2014] [Accepted: 06/16/2014] [Indexed: 02/07/2023]
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16
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Affiliation(s)
- Vikas R Dharnidharka
- From the Division of Pediatric Nephrology, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis (V.R.D.); the Division of Nephrology, Boston Children's Hospital and Harvard Medical School, Boston (P.F., W.E.H.); and the Division of Transplant Medicine, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milan (P.F.)
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Abstract
PURPOSE Mycophenolic acid (MPA) is an immunosuppressive agent that controls noninfectious uveitis. Intravitreal MPA delivery may be a potential adjuvant therapy in patients who have to discontinue steroid or immunosuppressive systemic therapy because of side effects. The aims of this study are to evaluate the in vitro effects of MPA over human retinal pigment epithelium (ARPE-19) and human Muller cells (MIO M-1). METHODS ARPE-19 cells and MIO M-1 cells were exposed to 25, 50, and 100 µg/mL of MPA (Roche Bioscience, Palo Alto, CA) for 24 hours. Toxicity was evaluated by trypan blue dye-exclusion cell viability assay, caspase-3/7 apoptosis-related assay, and JC-1 mitochondrial membrane potential assay. RESULTS The MPA (25 µg/mL and 50 µg/mL) did not cause reduction in cell viability or significant change in caspase-3/7 activity in both cell lines tested. Mycophenolic acid (100 µg/mL) caused a significant decrease in cell viability (P < 0.01) and higher caspase-3/7 activity (P < 0.05) in both cell lines compared with untreated cells. The JC-1 mitochondrial membrane potential did not show statistically significant differences for both cell lines and all concentration tested when compared with untreated controls (P > 0.05). CONCLUSION Intraocular delivery may be a potential alternative for the treatment of noninfectious uveitis, either by intravitreal injection or sustained-release drug-delivery systems, in doses of 50 µg/mL or lower.
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18
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Bruel A, Allain-Launay E, Humbert J, Ryckewaert A, Champion G, Moreau A, Renaudin K, Karam G, Roussey-Kesler G. Early protocol biopsies in pediatric renal transplantation: interest for the adaptation of immunosuppression. Pediatr Transplant 2014; 18:142-9. [PMID: 24341571 DOI: 10.1111/petr.12197] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2013] [Indexed: 12/21/2022]
Abstract
GPB are often performed in PRT to detect subclinical acute rejection or IF/TA. Reducing immunosuppression side effects without increasing rejection is a major concern in PRT. We report the results of GPB in children transplanted with a steroid-sparing protocol adapted to immunological risk. Children under 18 yr who received a renal transplantation between April 1, 2009 and May 31, 2012 were included. Immunosuppression consisted of an antibody induction therapy, tacrolimus, and MMF for all recipients. CSs were administered to children under five yr old, or receiving a second allograft. Twenty-eight children were included, 50% were CSs free. GPB were performed between three and six months. IF/TA was documented in seven biopsies; four of these seven children were CS free. One child, with CSs, presented a borderline rejection, and another child, steroid free, with significant inflammatory interstitial infiltrate, considered as a subclinical rejection, was treated with CSs pulses. The median eGFR was stable (74, 67.5, and 82 mL/min/1.73 m² at, respectively, seven days, three months, and one yr). Patient and graft survival were 100%. These results have to be confirmed in a larger cohort, with long-term follow-up.
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Affiliation(s)
- Alexandra Bruel
- Department of Pediatrics, Nantes University Hospital, Nantes, France
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19
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Pescovitz MD. Daclizumab: humanized monoclonal antibody to the interleukin-2 receptor. Expert Rev Clin Immunol 2014; 1:337-44. [DOI: 10.1586/1744666x.1.3.337] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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20
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Callanan DG. Novel intravitreal fluocinolone acetonide implant in the treatment of chronic noninfectious posterior uveitis. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/17469899.2.1.33] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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21
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Abstract
One of the ultimate goals of successful solid organ transplantation in pediatric recipients is attaining an optimal final adult height. This manuscript will discuss growth following transplantation in pediatric recipients of kidney, liver, heart, lung or small bowel transplants. Remarkably similar factors impact growth in all of these recipients. Age is a primary factor, with younger recipients exhibiting the greatest immediate catch-up growth. Graft function is a significant contributing factor, with a reduced glomerular filtration rate correlating with poor growth in kidney recipients and the need for re-transplantation with impaired growth in liver recipients. The known adverse impact of steroids on growth has led to modification of the steroid dose and even steroid withdrawal and avoidance. In kidney and liver recipients, this strategy has been associated with the development of acute rejection. In infant heart transplantation, avoiding maintenance corticosteroid immunosuppression is associated with normal growth velocity in the majority of patients. With marked improvements in patient and graft survival rates in pediatric organ recipients, quality of life issues, such as normal adult height, should now receive paramount attention. In general, normal growth following solid organ transplantation should be an achievable goal that results in normal adult height.
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Affiliation(s)
- Richard N Fine
- Division of Pediatric Nephrology, Department of Pediatrics, Stony Brook University, Stony Brook, NY, United States
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22
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Lopes P, Fuhrmann A, Sereno J, Pereira MJ, Nunes P, Pedro J, Melão A, Reis F, Carvalho E. Effects of cyclosporine and sirolimus on insulin-stimulated glucose transport and glucose tolerance in a rat model. Transplant Proc 2013; 45:1142-8. [PMID: 23622647 DOI: 10.1016/j.transproceed.2013.02.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Cyclosporine (CsA) and sirolimus (SRL) have been associated with undesirable side effects, including posttransplantation diabetes and hyperlipidemia, but the molecular mechanisms underlying these effects remain to be elucidated. Animal studies focusing on clinically relevant doses are advised. This study sought to compare the metabolic effects on isolated rat adipocytes treated with either CsA or SRL ex vivo and after long-term in vivo treatment in Wistar rats. We assessed the ex vivo effects of CsA (0.5-30 μmol/L) and SRL (1-250 μmol/L) on insulin-stimulated (14)C-glucose uptake in epididymal adipocytes (n = 6-9). In parallel, rats (n = 12) were treated with either vehicle, CsA (5 mg/kg/d) or SRL (1 mg/kg/d) for either 3 or 9 weeks. At the end of the treatment, glucose tolerance test (GTT) and insulin-stimulated (14)C-glucose uptake as well as biochemical parameters were analyzed. A significant reduction in the insulin-stimulated glucose uptake over basal was observed among isolated adipocytes, whether exposed ex vivo or in vivo to CsA or SRL treatment. Furthermore, the SRL group showed significantly lighter fat pads and smaller adipocytes at 3 weeks with a smaller gain in body weight throughout the study compared with either the vehicle or CsA cohorts. Glucose intolerance was observed after a GTT, at the end of the treatment with either drug. Additionally, at 9 weeks serum triglycerides were increased by CsA compared with vehicle or SRL treatment. Interestingly, although SRL-treated animals presented higher fed and fasted insulin levels compared with either group, suggesting insulin resistance, the CsA group presented lower fed and fasted insulin values, suggesting a defect in insulin secretion at 9 weeks. These results suggested that either ex vivo treatment of fat cells or in vivo treatment of rats with CsA or SRL impaired insulin-stimulated glucose uptake by adipocytes. Both drugs caused glucose intolerance, which altogether could be responsible for the development of posttransplantation diabetes.
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Affiliation(s)
- P Lopes
- Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal
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23
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Suszynski TM, Gillingham KJ, Rizzari MD, Dunn TB, Payne WD, Chinnakotla S, Finger EB, Sutherland DER, Najarian JS, Pruett TL, Matas AJ, Kandaswamy R. Prospective randomized trial of maintenance immunosuppression with rapid discontinuation of prednisone in adult kidney transplantation. Am J Transplant 2013; 13:961-970. [PMID: 23432755 PMCID: PMC3621067 DOI: 10.1111/ajt.12166] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 11/26/2012] [Accepted: 12/26/2012] [Indexed: 01/25/2023]
Abstract
Rapid discontinuation of prednisone (RDP) has minimized steroid-related complications following kidney transplant (KT). This trial compares long-term (10-year) outcomes with three different maintenance immunosuppressive protocols following RDP in adult KT. Recipients (n=440; 73% living donor) from March 2001 to April 2006 were randomized into one of three arms: cyclosporine (CSA) and mycophenolate mofetil (MMF) (CSA/MMF, n=151); high-level tacrolimus (TAC, 8-12 μg/L) and low-level sirolimus (SIR, 3-7 μg/L) (TACH/SIRL, n=149) or low-level TAC (3-7 μg/L) and high-level SIR (8-12 μg/L) (TACL/SIR(H) , n=140). Median follow-up was ∼7 years. There were no differences between arms in 10-year actuarial patient, graft and death-censored graft survival or in allograft function. There were no differences in the 10-year actuarial rates of biopsy-proven acute rejection (30%, 26% and 20% in CSA/MMF, TACH/SIRL and TACL/SIRH) and chronic rejection (38%, 35% and 31% in CSA/MMF, TACH/SIRL and TACL/SIRH). Rates of new-onset diabetes mellitus were higher with TACH/SIRL (p=0.04), and rates of anemia were higher with TACH/SIRL and TACL/SIRH (p=0.04). No differences were found in the overall rates of 16 other post-KT complications. These data indicate that RDP-based protocol yield acceptable 10-year outcomes, but side effects differ based on the maintenance regimen used and should be considered when optimizing immunosuppression following RDP.
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Affiliation(s)
- T M Suszynski
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - K J Gillingham
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - M D Rizzari
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - T B Dunn
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - W D Payne
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - S Chinnakotla
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - E B Finger
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | | | - J S Najarian
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - T L Pruett
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - A J Matas
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - R Kandaswamy
- Department of Surgery, University of Minnesota, Minneapolis, MN
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Chaudhuri A, Ozawa M, Everly MJ, Ettenger R, Dharnidharka V, Benfield M, Mathias R, Portale A, McDonald R, Harmon W, Kershaw D, Vehaskari VM, Kamil E, Baluarte HJ, Warady B, Li L, Sigdel TK, Hsieh SC, Dai H, Naesens M, Waskerwitz J, Salvatierra O, Terasaki PI, Sarwal MM. The clinical impact of humoral immunity in pediatric renal transplantation. J Am Soc Nephrol 2013; 24:655-64. [PMID: 23449533 DOI: 10.1681/asn.2012070663] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The development of anti-donor humoral responses after transplantation associates with higher risks for acute rejection and 1-year graft survival in adults, but the influence of humoral immunity on transplant outcomes in children is not well understood. Here, we studied the evolution of humoral immunity in low-risk pediatric patients during the first 2 years after renal transplantation. Using data from 130 pediatric renal transplant patients randomized to steroid-free (SF) or steroid-based (SB) immunosuppression in the NIH-SNSO1 trial, we correlated the presence of serum anti-HLA antibodies to donor HLA antigens (donor-specific antibodies) and serum MHC class 1-related chain A (MICA) antibody with both clinical outcomes and histology identified on protocol biopsies at 0, 6, 12, and 24 months. We detected de novo antibodies after transplant in 24% (23% of SF group and 25% of SB group), most often after the first year. Overall, 22% developed anti-HLA antibodies, of which 6% were donor-specific antibodies, and 6% developed anti-MICA antibody. Presence of these antibodies de novo associated with significantly higher risks for acute rejection (P=0.02), chronic graft injury (P=0.02), and decline in graft function (P=0.02). In summary, antibodies to HLA and MICA antigens appear in approximately 25% of unsensitized pediatric patients, placing them at greater risk for acute and chronic rejection with accelerated loss of graft function. Avoiding steroids does not seem to modify this incidence. Whether serial assessments of these antibodies after transplant could guide individual tailoring of immunosuppression requires additional study.
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Affiliation(s)
- Abanti Chaudhuri
- Department of Pediatrics, Stanford University, Stanford, California, USA
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25
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Sarwal MM, Ettenger R, Dharnidharka V, Benfield M, Mathias R, Portale A, McDonald R, Harmon W, Kershaw D, Vehaskari VM, Kamil E, Baluarte HJ, Warady B, Tang L, Liu J, Li L, Naesens M, Sigdel T, Waskerwitz J, Salvatierra O. Complete steroid avoidance is effective and safe in children with renal transplants: a multicenter randomized trial with three-year follow-up. Am J Transplant 2012; 12:2719-29. [PMID: 22694755 PMCID: PMC3681527 DOI: 10.1111/j.1600-6143.2012.04145.x] [Citation(s) in RCA: 128] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To determine whether steroid avoidance in pediatric kidney transplantation is safe and efficacious, a randomized, multicenter trial was performed in 12 pediatric kidney transplant centers. One hundred thirty children receiving primary kidney transplants were randomized to steroid-free (SF) or steroid-based (SB) immunosuppression, with concomitant tacrolimus, mycophenolate and standard dose daclizumab (SB group) or extended dose daclizumab (SF group). Follow-up was 3 years posttransplant. Standardized height Z-score change after 3 years follow-up was -0.99 ± 2.20 in SF versus -0.93 ± 1.11 in SB; p = 0.825. In subgroup analysis, recipients under 5 years of age showed improved linear growth with SF compared to SB treatment (change in standardized height Z-score at 3 years -0.43 ± 1.15 vs. -1.07 ± 1.14; p = 0.019). There were no differences in the rates of biopsy-proven acute rejection at 3 years after transplantation (16.7% in SF vs. 17.1% in SB; p = 0.94). Patient survival was 100% in both arms; graft survival was 95% in the SF and 90% in the SB arms (p = 0.30) at 3 years follow-up. Over the 3 year follow-up period, the SF group showed lower systolic BP (p = 0.017) and lower cholesterol levels (p = 0.034). In conclusion, complete steroid avoidance is safe and effective in unsensitized children receiving primary kidney transplants.
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Affiliation(s)
- Minnie M. Sarwal
- California Pacific Medical Center, Sutter Health Care, San Francisco
- Stanford University Medical School, Stanford
| | | | | | | | | | | | - Ruth McDonald
- Children’s Hospital & Regional Medical Center Seattle
| | | | - David Kershaw
- C.S. Mott Children’s Hospital, University of Michigan
| | | | - Elaine Kamil
- Maxine Dunitz Children’s Health Center, Cedars-Sinai Medical Center
| | | | | | - Lily Tang
- Pharmaceutical Product Development (PPD)
| | - Jun Liu
- Pharmaceutical Product Development (PPD)
| | - Li Li
- California Pacific Medical Center, Sutter Health Care, San Francisco
- Stanford University Medical School, Stanford
| | - Maarten Naesens
- California Pacific Medical Center, Sutter Health Care, San Francisco
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium, EU
| | - Tara Sigdel
- California Pacific Medical Center, Sutter Health Care, San Francisco
- Stanford University Medical School, Stanford
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26
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Sigdel TK, Li L, Tran TQ, Khatri P, Naesens M, Sansanwal P, Dai H, Hsieh SC, Sarwal MM. Non-HLA antibodies to immunogenic epitopes predict the evolution of chronic renal allograft injury. J Am Soc Nephrol 2012; 23:750-63. [PMID: 22302197 DOI: 10.1681/asn.2011060596] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Chronic allograft injury (CAI) results from a humoral response to mismatches in immunogenic epitopes between the donor and recipient. Although alloantibodies against HLA antigens contribute to the pathogenesis of CAI, alloantibodies against non-HLA antigens likely contribute as well. Here, we used high-density protein arrays to identify non-HLA antibodies in CAI and subsequently validated a subset in a cohort of 172 serum samples collected serially post-transplantation. There were 38 de novo non-HLA antibodies that significantly associated with the development of CAI (P<0.01) on protocol post-transplant biopsies, with enrichment of their corresponding antigens in the renal cortex. Baseline levels of preformed antibodies to MIG (also called CXCL9), ITAC (also called CXCL11), IFN-γ, and glial-derived neurotrophic factor positively correlated with histologic injury at 24 months. Measuring levels of these four antibodies could help clinicians predict the development of CAI with >80% sensitivity and 100% specificity. In conclusion, pretransplant serum levels of a defined panel of alloantibodies targeting non-HLA immunogenic antigens associate with histologic CAI in the post-transplant period. Validation in a larger, prospective transplant cohort may lead to a noninvasive method to predict and monitor for CAI.
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Affiliation(s)
- Tara K Sigdel
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305-5208, USA
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27
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Sutherland SM, Chen G, Sequeira FA, Lou CD, Alexander SR, Tyan DB. Complement-fixing donor-specific antibodies identified by a novel C1q assay are associated with allograft loss. Pediatr Transplant 2012; 16:12-7. [PMID: 22093755 DOI: 10.1111/j.1399-3046.2011.01599.x] [Citation(s) in RCA: 148] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Long-term outcomes following renal transplantation remain disappointing. Recently, interest has focused on the antibody-mediated component of allograft injury and the deleterious effects of DSA. We applied a novel C1q solid-phase assay in parallel with the standard IgG SAB assay to identify DSA with the potential to activate complement by binding C1q. Among 193 consecutive renal transplants at our center, 19.2% developed de novo DSA following transplantation. Of the patients with DSA, 43% had antibodies that bound C1q in vitro [C1q+ DSA]. Patients with C1q+ DSA were more likely to develop allograft loss than patients with DSA that did not bind C1q (46.7% vs. 15%; p = 0.04); patients with C1q+ DSA were nearly six times more likely to lose their transplant than those with C1q- DSA. Additionally, patients with C1q+ DSA who underwent allograft biopsy were more likely to demonstrate C4d deposition (50% vs. 8%; p = 0.03) and meet criteria for acute rejection (60% vs. 17%; p = 0.02) when compared with patients with DSA that did not bind C1q. These data suggest that DSA with the ability to activate complement, as determined by this novel C1q assay, are associated with greater risk of acute rejection and allograft loss.
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Affiliation(s)
- Scott M Sutherland
- Division of Nephrology, Department of Pediatrics, Stanford University Medical Center, Stanford, CA 94305, USA.
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Abstract
PURPOSE OF REVIEW The recent surge in the use of steroid-avoidance protocols for pediatric renal transplant recipients has been fueled by the numerous adverse side effects of steroids and development of alternatives for successful immunosuppression. Steroid-avoidance protocols were first attempted in the adult population, and with positive outcomes, pediatrics soon followed. As more pediatric patients are placed on steroid-avoidance protocols, we must begin answering several important questions such as patient and graft outcome, safety profiles of various steroid-avoidance induction protocols, viral complications and incidence of transplant lymphoproliferative disease (PTLD), metabolic benefits, and the affect of steroid minimization on growth. RECENT FINDINGS Initial results from steroid-avoidance protocols show these protocols are safe and effective with improved graft survival, metabolic profiles, and linear growth without an increase in viremia or PTLD. SUMMARY Although initial results are promising, there is still a lack of long-term data from large, prospective randomized trials, and there is not enough data to determine the optimal steroid-avoidance protocol for pediatric renal transplant recipients.
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29
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Phenotypic evaluation of B-cell subsets after rituximab for treatment of acute renal allograft rejection in pediatric recipients. Transplantation 2011; 91:1010-8. [PMID: 21403590 DOI: 10.1097/tp.0b013e318213df29] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recently published pediatric trial of Rituximab for the treatment of CD20+ acute renal allograft rejection (AR) demonstrated transient depletion of circulating/intragraft B cells (Zarkhin et al., Am J Transplant 2008; 8: 2607). In this study, we have evaluated phenotypic definition of circulating B-cell subsets before and after standard of care and B-cell depletional AR therapies. METHODS We assessed peripheral B cells by flow cytometry at the time of AR and after AR treatment in 35 pediatric renal transplant recipients: 17 patients with AR who received Rituximab (R-AR; n=11) or steroid pulsing (S-AR; n=6), 18 stable patients with stable graft function with (iSTA; n=10) or without interval infection (hSTA; n=8), and 3 healthy volunteers. RESULTS Infections increased memory (P=0.02) and CD19+/CD27⁻/IgD⁻ double negative (DN) B cells (P=0.02) and decreased naive B cells (P=0.01) in iSTA group compared to hSTA patients. Decrease in naive/memory B cells ratio at AR was observed compared with hSTA patients (P=0.01). One year after AR treatment, S-AR patients had persistently lower naive/memory B-cell ratio (P=0.01) and higher DN B cells (P=0.0001) than hSTA patients, whereas after R-AR treatment naive/memory B-cell ratio (P=0.6) and DN B cells (P=0.13) recovered to levels of hSTA patients. R-AR patients with sustained AR resolution (n=8) had trend toward better graft survival (P=0.06) and higher naive B cells (P=0.004) than R-AR relapsers (n=3). CONCLUSIONS Increase in circulating memory B cells was seen in pediatric patients at AR. B cells persist as memory after S-AR treatment, whereas Rituximab resulted in repopulation of mostly naive B cells. The heterogeneity in B-cells reconstitution after rejection therapies deserves further investigation as a possible means to follow the clinical and immunologic outcomes of graft rejection.
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30
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Sigdel TK, Kaushal A, Gritsenko M, Norbeck AD, Qian WJ, Xiao W, Camp DG, Smith RD, Sarwal MM. Shotgun proteomics identifies proteins specific for acute renal transplant rejection. Proteomics Clin Appl 2011; 4:32-47. [PMID: 20543976 DOI: 10.1002/prca.200900124] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Acute rejection (AR) remains the primary risk factor for renal transplant outcome; development of non-invasive diagnostic biomarkers for AR is an unmet need. EXPERIMENTAL DESIGN We used shotgun proteomics applying LC-MS/MS and ELISA to analyze a set of 92 urine samples, from patients with AR, stable grafts (STA), proteinuria (NS), and healthy controls. RESULTS A total of 1446 urinary proteins (UP) were identified along with a number of nonspecific proteinuria-specific, renal transplantation specific and AR-specific proteins. Relative abundance of identified UP was measured by protein-level spectral counts adopting a weighted fold-change statistic, assigning increased weight for more frequently observed proteins. We have identified alterations in a number of specific UP in AR, primarily relating to MHC antigens, the complement cascade and extra-cellular matrix proteins. A subset of proteins (uromodulin, SERPINF1 and CD44), have been further cross-validated by ELISA in an independent set of urine samples, for significant differences in the abundance of these UP in AR. CONCLUSIONS AND CLINICAL RELEVANCE This label-free, semi-quantitative approach for sampling the urinary proteome in normal and disease states provides a robust and sensitive method for detection of UP for serial, non-invasive clinical monitoring for graft rejection after kidney transplantation.
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Affiliation(s)
- Tara K Sigdel
- Department of Pediatrics, Stanford University School of Medicine, CA 94304, USA
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Gajarski RJ, Blume ED, Urschel S, Schechtman K, Zheng J, West LJ, Altamirano L, Miyamoto S, Naftel DC, Kirklin JK, Zamberlan MC, Canter CE. Infection and malignancy after pediatric heart transplantation: The role of induction therapy. J Heart Lung Transplant 2011; 30:299-308. [DOI: 10.1016/j.healun.2010.09.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Revised: 09/04/2010] [Accepted: 09/22/2010] [Indexed: 01/24/2023] Open
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Abstract
Outcomes of pediatric kidney transplantation have improved significantly over the years, such that the majority of graft recipients survive to become adolescents and adults. In this article, the findings of some of the important trials that shaped the current therapeutic landscape of immunosuppression will be reviewed. As an evolving landscape, novel strategies are continuously being sought to address the significant challenges in pediatric transplantation. Among these challenges is the development of immunosuppressive strategies that not only minimize the risk of allograft rejection but also allow normal growth and developmental patterns in children. To that end, the growing clinical evidence that indicates that the use of steroid-sparing regimens is effective will be reviewed. Finally, a brief description of the TWIST study will be provided. This large-scale comparative study has been designed specifically to assess the effect of early steroid withdrawal on growth in pediatric renal transplant recipients. An overview of the preliminary analysis of the eagerly anticipated results of this landmark trial will also be provided.
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Affiliation(s)
- Ryszard Grenda
- Department of Nephrology, Kidney Transplantation and Hypertension, Children's Memorial Health Institute, Warsaw, Poland.
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Efficacy and safety of thymoglobulin induction as an alternative approach for steroid-free maintenance immunosuppression in pediatric renal transplantation. Transplantation 2011; 90:1516-20. [PMID: 20935596 DOI: 10.1097/tp.0b013e3181fc8937] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Given the recent withdrawal of daclizumab (DAC), the safety and efficacy of thymoglobulin (TMG) was tested as an alternative induction agent for steroid-free (SF) immunosuppression in pediatric kidney transplant recipients. METHODS Thirteen pediatric renal transplant recipients meeting defined high-risk criteria at transplantation were offered TMG induction and SF immunosuppression with maintenance mycophenolate mofetil and tacrolimus between October 2008 and January 2010. Patients were closely monitored at baseline, 3, 6, 9, and 12 months posttransplant for protocol biopsy and clinical outcomes. Outcomes were compared with 13 consecutively transplanted low-risk patients receiving an established DAC-based SF protocol (Sarwal et al., WA, American Transplant Congress 2003). RESULTS There was a significant trend for overall decrease in the absolute lymphocyte counts in TMG group (F=5.86, mixed model group effect P=0.02), predominately at 3 months compared with DAC group (0.7±0.6 vs. 2.1±1.0, P=0.0004); however, lymphocyte count was recovered and was back to reference range by 6 months in TMG. There was trend toward more subclinical cytomegalovirus (15% vs. 0%) and BK viremia (17% vs. 0%) in the TMG group, with no differences in the incidence of subclinical Epstein Barr virus viremia (23% vs. 31%) or clinical viral disease. Mean graft function was excellent, and with a minimum follow-up of 6 months, there were no episodes of acute rejection. CONCLUSION TMG seems to be a safe alternative induction strategy in patients for SF immunosuppression in pediatric renal transplantation. Extended follow-up and greater enrollment are necessary to fully explore the impact of TMG dosing on viral replication posttransplantation.
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Wesseling-Perry K, Bacchetta J. CKD-MBD after kidney transplantation. Pediatr Nephrol 2011; 26:2143-51. [PMID: 21394466 PMCID: PMC3203246 DOI: 10.1007/s00467-011-1829-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Revised: 02/11/2011] [Accepted: 02/12/2011] [Indexed: 01/01/2023]
Abstract
Successful kidney transplantation corrects many of the metabolic abnormalities associated with chronic kidney disease (CKD); however, skeletal and cardiovascular morbidity remain prevalent in pediatric kidney transplant recipients and current recommendations from the Kidney Disease Improving Global Outcomes (KDIGO) working group suggest that bone disease-including turnover, mineralization, volume, linear growth, and strength-as well as cardiovascular disease be evaluated in all patients with CKD. Although few studies have examined bone histology after renal transplantation, current data suggest that bone turnover and mineralization are altered in the majority of patients and that biochemical parameters are poor predictors of bone histology in this population. Dual energy X-ray absorptiometry (DXA) scanning, although widely performed, has significant limitations in the pediatric transplant population and values have not been shown to correlate with fracture risk; thus, DXA is not recommended as a tool for the assessment of bone density. Newer imaging techniques, including computed tomography (quantitative CT (QCT), peripheral QCT (pQCT), high resolution pQCT (HR-pQCT) and magnetic resonance imaging (MRI)), which provide volumetric assessments of bone density and are able to discriminate bone microarchitecture, show promise in the assessment of bone strength; however, future studies are needed to define the value of these techniques in the diagnosis and treatment of renal osteodystrophy in pediatric renal transplant recipients.
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Affiliation(s)
- Katherine Wesseling-Perry
- Department of Pediatrics, David Geffen School of Medicine at UCLA, A2-383 MDCC, 650 Charles Young Drive, Los Angeles, CA 90095, USA.
| | - Justine Bacchetta
- Department of Pediatrics, David Geffen School of Medicine at UCLA, A2-383 MDCC, 650 Charles Young Drive, Los Angeles, CA 90095 USA
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Differentially expressed RNA from public microarray data identifies serum protein biomarkers for cross-organ transplant rejection and other conditions. PLoS Comput Biol 2010; 6. [PMID: 20885780 PMCID: PMC2944782 DOI: 10.1371/journal.pcbi.1000940] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Accepted: 08/23/2010] [Indexed: 02/03/2023] Open
Abstract
Serum proteins are routinely used to diagnose diseases, but are hard to find due to low sensitivity in screening the serum proteome. Public repositories of microarray data, such as the Gene Expression Omnibus (GEO), contain RNA expression profiles for more than 16,000 biological conditions, covering more than 30% of United States mortality. We hypothesized that genes coding for serum- and urine-detectable proteins, and showing differential expression of RNA in disease-damaged tissues would make ideal diagnostic protein biomarkers for those diseases. We showed that predicted protein biomarkers are significantly enriched for known diagnostic protein biomarkers in 22 diseases, with enrichment significantly higher in diseases for which at least three datasets are available. We then used this strategy to search for new biomarkers indicating acute rejection (AR) across different types of transplanted solid organs. We integrated three biopsy-based microarray studies of AR from pediatric renal, adult renal and adult cardiac transplantation and identified 45 genes upregulated in all three. From this set, we chose 10 proteins for serum ELISA assays in 39 renal transplant patients, and discovered three that were significantly higher in AR. Interestingly, all three proteins were also significantly higher during AR in the 63 cardiac transplant recipients studied. Our best marker, serum PECAM1, identified renal AR with 89% sensitivity and 75% specificity, and also showed increased expression in AR by immunohistochemistry in renal, hepatic and cardiac transplant biopsies. Our results demonstrate that integrating gene expression microarray measurements from disease samples and even publicly-available data sets can be a powerful, fast, and cost-effective strategy for the discovery of new diagnostic serum protein biomarkers. Protein biomarkers in the blood are urgently needed for the diagnosis of a wide variety of diseases to improve health care. We aim to find a fast and cost-effective strategy to discover diagnostic protein biomarkers. Hundreds of diseases have already been investigated using microarray technology, measuring the mRNA expression of all genes in the disease-damaged tissues. We analyzed biopsy-based microarray data for 41 diseases in the public repository, identified genes with dysregulated mRNA expressions and detectable-protein abundance in the blood, and predicted them as candidate diagnostic protein biomarkers. We found that clinically and preclinically validated diagnostic protein biomarkers were significantly enriched in our predicted protein candidates for 22 diseases. We then measured the concentrations of ten predicted protein biomarkers in the serum samples from 39 renal transplant patients. Three of them were confirmed to be diagnostic of acute rejection after renal transplantation. All three proteins were further confirmed to be diagnostic of acute rejection in 63 cardiac transplant recipients. Our results show that publically available genome-wide gene expression data on disease-damaged tissues can be effectively translated into diagnostic protein biomarkers.
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Lau KK, Berg GM, Schjoneman YG, Perez RV, Butani L. Extended experience with a steroid minimization immunosuppression protocol in pediatric renal transplant recipients. Pediatr Transplant 2010; 14:488-95. [PMID: 19849807 DOI: 10.1111/j.1399-3046.2009.01254.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To determine the safety and efficacy of a novel steroid minimization protocol after renal transplantation at a single Northern California center. INTRODUCTION We have previously reported our experience on the short-term outcomes in eight children using our steroid minimization protocol. Herein, we present our ongoing experience in using this regimen in 20 children. METHODS Children receiving immunosuppression with a steroid minimization protocol at our center from 1/04-12/08 (Group 2) were retrospectively compared with 20 controls (Group 1). RESULTS At one-month follow-up, Group 2 was observed to have lower eGFR, hemoglobin, white cell count, and cholesterol. The incidence of adverse events during the first yr was comparable. Three patients in Group 1 displayed histological evidence of acute rejection, one patient in Group 2 developed humoral rejection; another patient in Group 2 had sub-clinical rejection. Surgical complications were observed in 20% of patients in both groups. While 10% of patients in Group 1 developed diabetes mellitus, none was observed in Group 2. Thirty and 40% of patients in Groups 1 and 2, respectively, suffered from infectious complications during the first yr. CONCLUSIONS Our novel steroid minimization immunosuppression is safe in children and associated with no increased risk of rejection and infection.
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Affiliation(s)
- Keith K Lau
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
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Matas AJ, Granger D, Kaufman DB, Sarwal MM, Ferguson RM, Woodle ES, Gill JS. Steroid minimization for sirolimus-treated renal transplant recipients. Clin Transplant 2010; 25:457-67. [DOI: 10.1111/j.1399-0012.2010.01282.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Maduram A, John E, Hidalgo G, Bottke R, Fornell L, Oberholzer J, Benedetti E. Metabolic syndrome in pediatric renal transplant recipients: comparing early discontinuation of steroids vs. steroid group. Pediatr Transplant 2010; 14:351-7. [PMID: 19793225 DOI: 10.1111/j.1399-3046.2009.01243.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Steroids have played a valuable role in transplantation as a treatment option. The purpose of this study is to assess the prevalence of MS in pediatric RT patients receiving SG or early SWG; SG discontinued five days after transplantation. We retrospectively reviewed 58 pediatric RT patients between 2000 and 2007. MS criterion was defined as the presence of any three of five criteria: (i) BMI >97th percentile, (ii) hypertension (SBP/DBP > 95th percentile or on medications); (iii) triglycerides > 95thpercentile, (iv) HDL cholesterol < 5th percentile, (v) fasting glucose > 100 mg/dL. Twenty-five patients (43%) received SG and 33 patients (57%) received SWG. The prevalence of MS in SG was 68% compared to 15% in SWG. At six months and one yr after transplantation, mean serum glucose, total cholesterol, and triglycerides were significantly lower in the SWG. The prevalence of hypertension was significantly lower in the SWG, and patients in the SWG received significantly less lipid-lowering and anti-hypertensive medications than SG. Mean BMI percentile was significantly higher in SG one yr after transplantation but not after six months, although always significantly higher in patients with MS (p < 0.05). From this study, we conclude that for pediatric RT patients, cardiovascular risk factors are significantly lower in SG withdrawal groups.
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Affiliation(s)
- Amy Maduram
- Medical Scholars Program, University of Illinois, Urbana-Champaign, IL, USA
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Grenda R. Effects of steroid avoidance and novel protocols on growth in paediatric renal transplant patients. Pediatr Nephrol 2010; 25:747-52. [PMID: 19844746 DOI: 10.1007/s00467-009-1318-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 07/28/2009] [Accepted: 08/17/2009] [Indexed: 10/20/2022]
Abstract
The vast majority of kidney transplant recipients undergo triple maintenance immunosuppression that includes the use of steroids. Irrespective of their long history in organ transplantation and proven efficacy in preventing acute graft rejection, steroids exhibit an unfavourable toxicity profile, including growth retardation in children. Given these negative effects, therapeutic approaches that will substantially decrease patients' exposure to steroids have been considered. The planned approaches included alternate day administration, rapid or late steroid withdrawal at the pre-scheduled time after transplantation and complete steroid avoidance. All three of these strategies have been tested in single- or multicentre studies and shown to have distinct clinical advantages in terms of decreasing the incidence and severity of specific adverse events. However, the safety of these protocols could not be universally proven. The Stanford study showed that a complete steroid avoidance under the "cover" of tacrolimus, mycophenolate mofetil and extended daclizumab induction is a very effective regimen for obtaining an improvement in post-transplantation growth. The recently reported international randomized TWIST trial demonstrated growth improvement as early as 6 months post-transplantation. These protocols may potentially enable paediatric renal graft recipients to safely avoid steroid exposure.
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Affiliation(s)
- Ryszard Grenda
- Department of Nephrology, Kidney Transplantation and Hypertension, Children's Memorial Health Institute, Aleja Dzieci Polskich 20, 04-730 Warsaw, Poland.
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40
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Grenda R, Watson A, Trompeter R, Tönshoff B, Jaray J, Fitzpatrick M, Murer L, Vondrak K, Maxwell H, Van Damme-Lombaerts R, Loirat C, Mor E, Cochat P, Milford DV, Brown M, Webb NJA. A randomized trial to assess the impact of early steroid withdrawal on growth in pediatric renal transplantation: the TWIST study. Am J Transplant 2010; 10:828-836. [PMID: 20420639 DOI: 10.1111/j.1600-6143.2010.03047.x] [Citation(s) in RCA: 143] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Minimizing steroid exposure in pediatric renal transplant recipients can improve linear growth and reduce metabolic disorders. This randomized multicenter study investigated the impact of early steroid withdrawal on mean change in height standard deviation score (SDS) and the safety and efficacy of two immunosuppressive regimens during the first 6 months after transplantation. Children received tacrolimus, MMF, two doses of daclizumab and steroids until day 4 (TAC/MMF/DAC, n=98) or tacrolimus, MMF and standard-dose steroids (TAC/MMF/STR, n=98). Mean change in height SDS was 0.16 +/- 0.32 with TAC/MMF/DAC and 0.03 +/- 0.32 with TAC/MMF/STR. The mean treatment group difference was 0.13 (p < 0.005 [95% CI 0.04-0.22]), 0.21 in prepubertal (p = 0.009 [95% CI 0.05-0.36]) and 0.05 in pubertal children (p = ns). Frequency of biopsy-proven acute rejection was 10.2%, TAC/MMF/DAC, and 7.1%, TAC/MMF/STR. Patient and graft survival and renal function were similar. Significantly greater reductions in total cholesterol and triglycerides but significantly higher incidences of infection and anemia were found with TAC/MMF/DAC (p < 0.05 all comparisons). Early steroid withdrawal significantly aided growth at 6 months more so in prepubertal than pubertal children. This was accompanied by significantly better lipid and glucose metabolism profiles without increases in graft rejection or loss.
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Affiliation(s)
- R Grenda
- Children's Memorial Health Institute, Warsaw, Poland
| | - A Watson
- Nottingham University Hospitals, Nottingham, UK
| | - R Trompeter
- Great Ormond Street Hospital for Children, London, UK
| | - B Tönshoff
- University Children's Hospital, Heidelberg, Germany
| | - J Jaray
- Semmelweis University of Medicine, Budapest, Hungary
| | | | - L Murer
- Azienda Ospedaliera di Padova, Dipartimento de Pediatria, Padova, Italy
| | - K Vondrak
- University Hospital Motol, Prague, Czech Republic
| | - H Maxwell
- Royal Hospital for Sick Children, Yorkhill, Glasgow, UK
| | | | - C Loirat
- Hopital Robert Debre, Paris, France
| | - E Mor
- Rabin Medical Center, Petah Tikva, Israel
| | - P Cochat
- Hopital Femme Mère Enfant, Lyon, France
| | - D V Milford
- Birmingham Children's Hospital, Birmingham, UK
| | - M Brown
- Astellas Pharma Europe Ltd, Staines, UK
| | - N J A Webb
- Royal Manchester Children's Hospital, Manchester, UK
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Abstract
PURPOSE OF REVIEW Transplantation is the preferred method of treatment for end-stage renal disease in children. The rate of pediatric kidney transplantation has been steadily rising over the past decade. The use of increasingly potent immunosuppressive drugs has lessened the risk for acute rejection substantially and improved short-term outcomes; however, the long-term outcomes have remained inadequate. RECENT FINDINGS The follow-up of pediatric cohorts and the encouraging results from data registries prompt us to revisit our practices in transplantation so as to devise additional strategies to improve long-term outcomes. SUMMARY This review presents a comprehensive discussion of the major issues in pediatric renal transplantation, the newer immunosuppression approaches to limit toxicities of therapies in children and some critical issues that remain to be addressed, specific to the care of the transplanted child. The ultimate goal of designing optimum conditions for equating graft survival to patient survival still remains a major goal for pediatric organ transplantation.
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Gheith OA, Nematalla AH, Bakr MA, Refaie A, Shokeir AA, Ghoneim MA. Cost–benefit of steroid avoidance in renal transplant patients: A prospective randomized study. ACTA ACUST UNITED AC 2010; 44:175-82. [DOI: 10.3109/00365591003649219] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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HLA class I (ABC) upregulation on peripheral blood CD3+/CD8+ T lymphocyte surface is a potential predictor of acute rejection in renal transplantation. Transplantation 2010; 88:1393-7. [PMID: 20029336 DOI: 10.1097/tp.0b013e3181bc5c94] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Renal transplantation is currently the prevalent therapy for most patients with end-stage renal disease. No clinical markers for such rejection have been universally accepted. We aimed to investigate the possibility of use of human leukocyte antigen (HLA) class I (ABC) on peripheral blood CD3+/CD8+ T lymphocytes as a marker of acute rejection. METHODS For recipients undergoing renal transplantation from September 2007 to November 2008, peripheral blood samples were obtained pretransplantation and at days 3 and 7 posttransplantation when the patients were still hospitalized and at weeks 2 and 3 and months 1, 2, 3, and 6 posttransplantation. For patients with fever, lumbodynia, gross hematuria, or oliguria after transplantation, blood samples were collected immediately before and at days 3 and 7 after the administration of anti-inflammatory regents. The level of HLA class I (ABC) on peripheral-blood CD3+/CD8+ T lymphocytes was measured on flow cytometry. RESULTS For the 79 transplant recipients, the level of HLA class I (ABC) on peripheral-blood CD3+/CD8+ T lymphocytes was consistently elevated during the first 3 weeks after transplantation, declined gradually to pretransplantation levels, then tapered off and remained stable. Patients experiencing acute rejection (AR) or not after transplantation did not differ in level of HLA class I (ABC) up to 6-month follow-up, except at days 14 and 21 after transplantation, when the level was higher for patients experiencing AR (P<0.01). CONCLUSIONS Upregulation of HLA class I (ABC) on peripheral-blood CD3+/CD8+ T lymphocytes could be used as an accurate and reliable predictor of AR after renal transplantation.
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Singh TP, Faber C, Blume ED, Worley S, Almond CS, Smoot LB, Dillis S, Nasman C, Boyle GJ. Safety and early outcomes using a corticosteroid-avoidance immunosuppression protocol in pediatric heart transplant recipients. J Heart Lung Transplant 2010; 29:517-22. [PMID: 20061164 DOI: 10.1016/j.healun.2009.11.601] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Revised: 11/18/2009] [Accepted: 11/20/2009] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Long-term oral corticosteroids have been a mainstay of maintenance immunosuppression in pediatric heart transplantation. In this study, we report early clinical outcomes in a cohort of pediatric heart transplant recipients managed using a steroid-avoidance protocol. METHODS Of the 70 patients who underwent heart transplantation during the study period, 55 eligible recipients, including 49 non-sensitized and 6 sensitized (all 55 with negative crossmatch) patients, entered a steroid-avoidance immunosuppression protocol consisting of thymoglobin induction followed by a 2-drug, tacrolimus-based, corticosteroid-free regimen. The primary outcome variable was freedom from moderate rejection (International Society for Heart and Lung Transplantation [ISHLT] Grade 2R/3A or antibody-mediated rejection). RESULTS The median age at transplant was 7.1 years (range 2 weeks to 22 years) and median follow-up was 19 months (range 2 to 46 months). Fifty patients survived to discharge after transplantation. Of these patients, 2 (4%) were discharged on steroids and 8 (16%) started on maintenance steroids at follow-up. Rejection was diagnosed in 8 patients (Grade 2R cellular rejection in 3 and antibody-mediated rejection in 5). Freedom from rejection was 92% at 6 months (95% confidence interval [CI] 80% to 97%) and 87% at 1 year (CI 73% to 94%). Post-transplant survival was 91% at 6 months (CI 79% to 96%) and 88% at 12 and 24 months (CI 75% to 95%). There was 1 death due to rejection (antibody-mediated) 8 months after transplantation. CONCLUSIONS An immunosuppression protocol consisting of induction followed by corticosteroid avoidance appears to achieve acceptable rejection rates during the first year post-transplant in pediatric heart transplant recipients.
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Affiliation(s)
- Tajinder P Singh
- Department of Cardiology, Children's Hospital Boston, Boston, Massachusetts 02115, USA.
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45
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Benfield MR, Bartosh S, Ikle D, Warshaw B, Bridges N, Morrison Y, Harmon W. A randomized double-blind, placebo controlled trial of steroid withdrawal after pediatric renal transplantation. Am J Transplant 2010; 10:81-8. [PMID: 19663893 DOI: 10.1111/j.1600-6143.2009.02767.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In an effort to reduce rejection, extend allograft survival and minimize complications, we hypothesized that robust immunosuppression during the first 6 months after transplantation would allow for the safe withdrawal of steroids. A total of 274 pediatric subjects were enrolled and received an anti-CD25 antibody, sirolimus, calcineurin inhibitor and steroids. At 6 months after transplantation, subjects were randomized to steroid withdrawal (n=73) versus continued low-dose steroids (n=59). This study was stopped prior to target enrollment because of the incidence of post-transplant lymphoproliferative disorder. At the time of study termination, 132 subjects had been randomized and were available for analysis. At 18 months after transplantation, there was no difference in the standardized height z score; however, the standardized height velocity was greater in the steroid withdrawal group compared to the control group (p=0.033). There were no differences in acute rejection episodes between treatment groups. The 3-year allograft survival rate was 84.5% in the control group and 98.6% in the steroid withdrawal group (p=0.002). The immunosuppressive protocol utilized in this study allowed for the withdrawal of steroids without an increased risk of rejection or allograft loss. However, the complications associated with the use of this immunosuppressive protocol were too high to recommend its routine use in pediatric patients.
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Affiliation(s)
- M R Benfield
- Division of Pediatric Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA.
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The new face of transplant surgery: a survey on cosmetic surgery in transplant recipients. Aesthetic Plast Surg 2009; 33:819-26; discussion 827. [PMID: 19787392 DOI: 10.1007/s00266-009-9417-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Accepted: 09/05/2009] [Indexed: 12/28/2022]
Abstract
BACKGROUND Transplant surgery has undergone tremendous advances within the last decade. Improvements in surgical techniques, availability of potent immunosuppressive medications, and utilization of more sophisticated post-transplant immunosuppression protocols have revolutionized the field. These developments have resulted in increased allograft survival, prolonged longevity, and improved quality of life in transplant organ recipients. Elimination of steroids in many postoperative immunosuppressive regimens has tremendously impacted the quality of life and physical appearance of these patients. They are living longer and more normal lives than previously considered possible. As a testament to the success of transplantation surgery, many transplant patients are now seeking aesthetic surgery. METHODS A survey was sent to ASPS members asking about their experience with transplant patients undergoing aesthetic procedures. RESULTS Of the 789 (18%) plastic surgeons who responded, 201 (25%) have performed aesthetic surgery on transplant recipients. A total of 278 patients underwent 292 surgical aesthetic procedures and 64 patients underwent 94 nonsurgical aesthetic procedures. The incidence of reported perioperative complications was 3.4%. There were very few additional precautions taken with these patients relative to the general population. With the exception of obtaining medical clearance, these additional precautions were inconsistent among plastic surgeons. CONCLUSION Cosmetic surgery in transplant recipients is being successfully practiced in the USA. Surgical and nonsurgical aesthetic procedures are being performed safely in organ transplant recipients without a significant increase in the incidence or degree of complications. If certain precautions are undertaken, these patients may expect a degree of success comparable to that of the rest of the population.
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Chaudhuri A, Salvatierra O, Sarwal MM. Extended daclizumab monotherapy for rejection-free survival in non-adherent adolescent recipients of renal allografts. Pediatr Transplant 2009; 13:927-32. [PMID: 19017291 DOI: 10.1111/j.1399-3046.2008.01081.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Acute rejection episodes are almost inevitable in the face of immunosuppression non-adherence and a known risk factor for developing chronic allograft nephropathy and accelerated graft loss. Daclizumab, a humanized monoclonal antibody directed against the alpha chain of the IL-2 receptor, is an important advance for induction therapy in renal transplant immunosuppression, reducing early acute graft rejection without affecting the tolerability of standard immunosuppression, for both steroid-based and steroid-free immunosuppressive protocols, in children and adults. In the absence of depot immunosuppression for maintenance therapy, we explored extended daclizumab therapy as temporary maintenance immunosuppression for acute rejection prophylaxis in two patients with recalcitrant immunosuppression non-adherence. Both patients had prior episodes of aggressive acute rejection associated with their non-adherence but achieved stable and rejection-free renal allograft function with daclizumab monotherapy in the presence of documented non-adherence thus providing an effective bridge for up to 12 months until immunosuppression adherence was re-established with ongoing psychosocial support. This report suggests that daclizumab monotherapy over an extended period of time during the period of non-adherence in the post transplant period could be a rescue modality to avoid immune activation and thereby prevent acute rejection in the face of erratic maintenance immunosuppression.
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Affiliation(s)
- Abanti Chaudhuri
- Department of Pediatrics and Surgery, Stanford University School of Medicine, CA, USA
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48
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Abstract
The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially on the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.
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Sigdel TK, Klassen RB, Sarwal MM. Interpreting the proteome and peptidome in transplantation. Adv Clin Chem 2009; 47:139-69. [PMID: 19634780 DOI: 10.1016/s0065-2423(09)47006-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Publication of the human proteome has prompted efforts to develop high-throughput techniques that can catalogue and quantify proteins and peptides present in different tissue types. The field of proteomics aims to identify, quantify, analyze, and functionally define a large number of proteins in cellular processes in different disease states on a global scale. Peptidomics, a newer name in the -omics world, measures and identifies naturally occurring low molecular weight peptides, also providing an insight into enzymatic processes and molecular events occurring in the system of interest. One area of major interest is the use of proteomics to identify diagnostic and prognostic biomarkers for different diseases as well as for various clinical phenotypes in organ transplantation that can advance targeted therapy for various forms of graft injury. Outcomes in organ transplantation can be potentially improved by identifying noninvasive biomarkers that will serve as triggers that predate graft injury, and can offer a means to customize patient treatment by differentiating among causes of acute and chronic graft injury. Proteomic and peptidomic strategies can be harnessed for frequent noninvasive measurements in tissue fluids, allowing for serial monitoring of organ disease. In this review, we describe the basic techniques used in proteomic and peptidomic approaches, point out special considerations in using these methods, and discuss their applications in recently published studies in organ transplantation.
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Affiliation(s)
- Tara K Sigdel
- Department of Pediatrics-Nephrology, Stanford University Medical School, Stanford University, Stanford, California 94305, USA
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Barletta GM, Kirk E, Gardner JJ, Rodriguez JF, Bursach SM, Bunchman TE. Rapid discontinuation of corticosteroids in pediatric renal transplantation. Pediatr Transplant 2009; 13:571-8. [PMID: 19413717 DOI: 10.1111/j.1399-3046.2009.01178.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Corticosteroid immunosuppression has permitted the development of successful allotransplantation; however, corticosteroids are associated significant post-transplant complications. To circumvent these problems, we implemented a protocol of rapid discontinuation of corticosteroids in 19 consecutive pediatric primary kidney transplant recipients. Mean age at time of transplant was 13.4 (+/-4.5) yr, 52.6% were male, 63.2% underwent living donor transplantation. All patients were administered Thymoglobulin [anti-thymocyte globulin (rabbit)] as induction immunosuppression with a rapid tapering dose of corticosteroids (total of five daily doses), and maintained on mycophenolate mofetil and tacrolimus. Two patients had immediate recurrence of primary disease (FSGS), requiring further corticosteroid therapy. Otherwise, remaining 17 patients were maintained off corticosteroids, with excellent graft function; mean baseline eGFR of 112 mL/min/1.73 m(2) (+/-19) at 28 months (+/-14) post-transplantation. There was 100% patient and rejection-free graft survival at 27 months (range 5-58 months) post-transplantation; 47% underwent renal transplant biopsy secondary to acute rise in serum creatinine with or without worsening hypertension. All biopsies had no evidence of acute rejection; 62.5% had findings consistent with tacrolimus toxicity. Renal transplantation utilizing a rapid discontinuation of corticosteroid protocol in pediatric patients appears to be safe and effective, without increasing the risk of acute rejection or graft loss.
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Affiliation(s)
- Gina-Marie Barletta
- Pediatric Nephrology, Dialysis and Transplantation, Helen DeVos Children's Hospital, Grand Rapids, MI 49503, USA.
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