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Favi E, Cresseri D, Perego M, Ikehata M, Iesari S, Campise MR, Morello W, Testa S, Sioli V, Mattinzoli D, Longhi E, Del Gobbo A, Castellano G, Ferraresso M. Sequential administration of anti-complement component C5 eculizumab and type-2 anti-CD20 obinutuzumab for the treatment of early antibody-mediated rejection after kidney transplantation: A proof of concept. Clin Immunol 2024; 264:110240. [PMID: 38734036 DOI: 10.1016/j.clim.2024.110240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 04/02/2024] [Accepted: 05/08/2024] [Indexed: 05/13/2024]
Abstract
Kidney transplant (KT) candidates with donor-specific antibodies (DSA) exhibit exceedingly high antibody-mediated rejection (ABMR) and allograft loss rates. Currently, treatment of ABMR remains an unmet clinical need. We report the use of the anti-C5 eculizumab and the type-2 anti-CD20 obinutuzumab in two patients with early ABMR. Eculizumab (900 mg IV) led to complete inhibition of the terminal complement cascade (unremarkable AP50 and CH50 activity) and prompt stoppage of complement-dependent antibody-mediated allograft injury (clearance of intra-graft C4d and C5b-9 deposition). Despite complement inhibition, obinutuzumab (1000 mg IV) determined full and long-lasting peripheral B-cell depletion, with significant reduction in all DSA. Graft function improved, remaining stable up to three years of follow-up. No signs of active ABMR and rebound DSA were detected. Obinutuzumab B-cell depletion and inhibition of DSA production were not affected by complement blockage. Further studies are needed to confirm the potential benefit of obinutuzumab in association with complement inhibitors.
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Affiliation(s)
- Evaldo Favi
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy.
| | - Donata Cresseri
- Nephrology, Dialysis and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Marta Perego
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Masami Ikehata
- Renal Research Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Samuele Iesari
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Maria Rosaria Campise
- Nephrology, Dialysis and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - William Morello
- Pediatric Nephrology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Sara Testa
- Pediatric Nephrology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Viviana Sioli
- Laboratorio di Immunologia dei Trapianti, Trapianti Lombardia - NITp, 20122 Milan, Italy
| | - Deborah Mattinzoli
- Renal Research Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Elena Longhi
- Laboratorio di Immunologia dei Trapianti, Trapianti Lombardia - NITp, 20122 Milan, Italy
| | - Alessandro Del Gobbo
- Division of Pathology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Giuseppe Castellano
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy; Nephrology, Dialysis and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Mariano Ferraresso
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
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Li M, Hu X, Li Y, Chen G, Ding CG, Tian X, Tian P, Xiang H, Pan X, Ding X, Xue W, Zheng J, Ding C. Development and validation of a novel nomogram model for predicting delayed graft function in deceased donor kidney transplantation based on pre-transplant biopsies. BMC Nephrol 2024; 25:138. [PMID: 38641807 PMCID: PMC11031976 DOI: 10.1186/s12882-024-03557-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 03/21/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Delayed graft function (DGF) is an important complication after kidney transplantation surgery. The present study aimed to develop and validate a nomogram for preoperative prediction of DGF on the basis of clinical and histological risk factors. METHODS The prediction model was constructed in a development cohort comprising 492 kidney transplant recipients from May 2018 to December 2019. Data regarding donor and recipient characteristics, pre-transplantation biopsy results, and machine perfusion parameters were collected, and univariate analysis was performed. The least absolute shrinkage and selection operator regression model was used for variable selection. The prediction model was developed by multivariate logistic regression analysis and presented as a nomogram. An external validation cohort comprising 105 transplantation cases from January 2020 to April 2020 was included in the analysis. RESULTS 266 donors were included in the development cohort, 458 kidneys (93.1%) were preserved by hypothermic machine perfusion (HMP), 96 (19.51%) of 492 recipients developed DGF. Twenty-eight variables measured before transplantation surgery were included in the LASSO regression model. The nomogram consisted of 12 variables from donor characteristics, pre-transplantation biopsy results and machine perfusion parameters. Internal and external validation showed good discrimination and calibration of the nomogram, with Area Under Curve (AUC) 0.83 (95%CI, 0.78-0.88) and 0.87 (95%CI, 0.80-0.94). Decision curve analysis demonstrated that the nomogram was clinically useful. CONCLUSION A DGF predicting nomogram was developed that incorporated donor characteristics, pre-transplantation biopsy results, and machine perfusion parameters. This nomogram can be conveniently used for preoperative individualized prediction of DGF in kidney transplant recipients.
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Affiliation(s)
- Meihe Li
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, 710061, Xi'an, Shaanxi, China
| | - Xiaojun Hu
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, 710061, Xi'an, Shaanxi, China
| | - Yang Li
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, 710061, Xi'an, Shaanxi, China
| | - Guozhen Chen
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, 710061, Xi'an, Shaanxi, China
| | - Chen-Guang Ding
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, 710061, Xi'an, Shaanxi, China
| | - Xiaohui Tian
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, 710061, Xi'an, Shaanxi, China
| | - Puxun Tian
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, 710061, Xi'an, Shaanxi, China
| | - Heli Xiang
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, 710061, Xi'an, Shaanxi, China
| | - Xiaoming Pan
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, 710061, Xi'an, Shaanxi, China
| | - Xiaoming Ding
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, 710061, Xi'an, Shaanxi, China
| | - Wujun Xue
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, 710061, Xi'an, Shaanxi, China.
| | - Jin Zheng
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, 710061, Xi'an, Shaanxi, China.
| | - Chenguang Ding
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, 710061, Xi'an, Shaanxi, China
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Husain SA, Khanna S, Yu M, Adler JT, Cron DC, King KL, Schold JD, Mohan S. Cold Ischemia Time and Delayed Graft Function in Kidney Transplantation: A Paired Kidney Analysis. Transplantation 2024:00007890-990000000-00713. [PMID: 38557641 DOI: 10.1097/tp.0000000000005006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND We aimed to understand the association between cold ischemia time (CIT) and delayed graft function (DGF) after kidney transplantation and the impact of organ pumping on that association. METHODS Retrospective cohort study using US registry data. We identified kidney pairs from the same donor where both kidneys were transplanted but had a CIT difference >0 and ≤20 h. We determined the frequency of concordant (both kidneys with/without DGF) or discordant (only 1 kidney DGF) DGF outcomes. Among discordant pairs, we computed unadjusted and adjusted relative risk of DGF associated with longer-CIT status, when then repeated this analysis restricted to pairs where only the longer-CIT kidney was pumped. RESULTS Among 25 831 kidney pairs included, 71% had concordant DGF outcomes, 16% had only the longer-CIT kidney with DGF, and 13% had only the shorter-CIT kidney with DGF. Among discordant pairs, longer-CIT status was associated with a higher risk of DGF in unadjusted and adjusted models. Among pairs where only the longer-CIT kidney was pumped, longer-CIT kidneys that were pumped had a lower risk of DGF than their contralateral shorter-CIT kidneys that were not pumped regardless of the size of the CIT difference. CONCLUSIONS Most kidney pairs have concordant DGF outcomes regardless of CIT difference, but even small increases in CIT raise the risk of DGF. Organ pumping may mitigate and even overcome the adverse consequences of prolonged CIT on the risk of DGF, but prospective studies are needed to better understand this relationship.
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Affiliation(s)
- Syed Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology Group, New York, NY
| | - Sohil Khanna
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
| | - Miko Yu
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology Group, New York, NY
| | - Joel T Adler
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX
| | - David C Cron
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Kristen L King
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology Group, New York, NY
| | - Jesse D Schold
- Department of Surgery, University of Colorado-Anschutz Medical Campus, Aurora, CO
- Department of Epidemiology, School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora, CO
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology Group, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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Betjes MGH, Kho MML, Roodnat J, de Weerd AE. Transplant Candidates of 70+ Years Have Superior Survival If Receiving Pre-Emptively a Living Donor Kidney. J Clin Med 2024; 13:1853. [PMID: 38610618 PMCID: PMC11012907 DOI: 10.3390/jcm13071853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 03/13/2024] [Accepted: 03/21/2024] [Indexed: 04/14/2024] Open
Abstract
Background: The number of kidney transplant recipients over 70 years of age is increasing but detailed data on patient and graft survival in the modern era of immune suppression are few. Methods: A single-center cohort of patients of 70 years and older (n = 349) at time of kidney transplantation from 2010-2020 were followed until January 2023. Results: The median age was 73 years with a median follow-up of 4.3 years. Fifty percent of recipients of a living donor kidney (LDK, n = 143) received their graft pre-emptively. Cumulative death-censored graft survival was excellent in the LDK group and reached 98% at 5 years vs. 85% in the deceased donor kidney (DDK) group. Primary non-function (38%) and rejection (43%) were the major causes of graft loss in the first year after DDK transplantation. Rejection-related graft loss was 4.6% during follow-up. Median recipient survival was superior in the subgroup of pre-emptively transplanted LDK patients compared to non-pre-emptively LDK transplanted patients (11.1 versus 6.2 years). Non-pre-emptively transplanted patients had a significantly increased incidence of infection (HR 3.81, 1.46-9.96) and cardiovascular-related causes of death (HR 3.35, 1.16-9.71). Pre-emptive transplantation was also associated with a significantly improved graft survival in the DDK recipients but this result was confounded by significantly better HLA matching and younger donor age in this group. Conclusions: Pre-emptive LDK transplantation in patients of 70 years or older confers superior graft and recipient survival.
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Affiliation(s)
- Michiel G. H. Betjes
- Rotterdam Transplantation Institute, Department of Nephrology & Transplantation, Erasmus Medical Center, 3015GD Rotterdam, The Netherlands; (M.M.L.K.); (J.R.); (A.E.d.W.)
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Zhang Z, Shao K, Zhou C, Zhou P, Zhou Q, An H, Ji R. Using 1/2 Descending Time in CEUS to Identify Renal Allograft Rejection. Acad Radiol 2024:S1076-6332(24)00048-5. [PMID: 38418346 DOI: 10.1016/j.acra.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/14/2024] [Accepted: 01/22/2024] [Indexed: 03/01/2024]
Abstract
RATIONALE AND OBJECTIVES This study investigates the potential of quantitative Contrast-Enhanced Ultrasound (CEUS) parameters to distinguish between graft dysfunction due to rejection and non-rejection in kidney transplant recipients. METHODS In this retrospective study, 50 kidney transplant patients who presented elevated serum creatinine or proteinuria were analyzed. They were categorized as rejection or non-rejection based on biopsy outcomes. These classifications were applied in both derivation (n = 33) and validation cohorts (n = 17). Prior to the biopsy, all patients underwent a CEUS. Quantitative parameters derived from the CEUS were further analyzed for their consistency and reliability. Additionally, the relationship between the Banff scores, a standard for diagnosing transplant rejections, and these CEUS parameters was explored. RESULTS Significant differences between rejection and non-rejection groups were observed in the CEUS parameters of derivation cohorts. Specifically, Peak Intensity (PI), 1/2 Descending Time (DT/2), Area Under Curve (AUC), and Mean Transit Time (MTT) stood out. Sensitivity and specificity for these parameters were 76.5% and 87.5% for PI, 76.5% and 81.2% for DT/2, 76.5% and 87.5% for AUC, and 68.8% and 94.1% for MTT, respectively. DT/2 and MTT showed superior interobserver agreement compared to PI and AUC. When extrapolating the cutoff values from the derivation cohort to the validation group, DT/2 and AUC exhibited optimal diagnostic precision with positive and negative predictive values being 91.7% vs. 100% and 100% vs. 85.7%, respectively. Additionally, DT/2 effectively differentiated between mild and moderate to severe microvascular inflammation, pivotal in diagnosing antibody-mediated renal transplant rejection. CONCLUSION DT/2 from CEUS parameters presents as a reliable tool to differentiate rejection from non-rejection causes in renal transplant dysfunction. Yet, large-scale, multi-center studies are essential for further validation.
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Affiliation(s)
- Zhe Zhang
- Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kun Shao
- Department of Urology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chun Zhou
- Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Peijun Zhou
- Department of Urology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Quan Zhou
- Department of Urology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huimin An
- Department of Urology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ri Ji
- Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Alvarez A, Montgomery A, Galván NTN, Brewer ED, Rana A. Predicting wait time for pediatric kidney transplant: a novel index. Pediatr Nephrol 2024:10.1007/s00467-023-06232-1. [PMID: 38216782 DOI: 10.1007/s00467-023-06232-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Over one thousand pediatric kidney transplant candidates are added to the waitlist annually, yet the prospective time spent waiting is unknown for many. Our study fills this gap by identifying variables that impact waitlist time and by creating an index to predict the likelihood of a pediatric candidate receiving a transplant within 1 year of listing. This index could be used to guide patient management by giving clinicians a potential timeline for each candidate's listing based on a unique combination of risk factors. METHODS A retrospective analysis of 3757 pediatric kidney transplant candidates from the 2014 to 2020 OPTN/UNOS database was performed. The data was randomly divided into a training set, comprising two-thirds of the data, and a testing set, comprising one-third of the data. From the training set, univariable and multivariable logistic regressions were used to identify significant predictive factors affecting wait times. A predictive index was created using variables significant in the multivariable analysis. The index's ability to predict likelihood of transplantation within 1 year of listing was validated using ROC analysis on the training set. Validation of the index using ROC analysis was repeated on the testing set. RESULTS A total of 10 variables were found to be significant. The five most significant variables include the following: blood group, B (OR 0.65); dialysis status (OR 3.67); kidney disease etiology, SLE (OR 0.38); and OPTN region, 5 (OR 0.54) and 6 (OR 0.46). ROC analysis of the index on the training set yielded a c-statistic of 0.71. ROC analysis of the index on the testing set yielded a c-statistic of 0.68. CONCLUSIONS This index is a modest prognostic model to assess time to pediatric kidney transplantation. It is intended as a supplementary tool to guide patient management by providing clinicians with an individualized prospective timeline for each candidate. Early identification of candidates with potential for prolonged waiting times may help encourage more living donation including paired donation chains.
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Affiliation(s)
- Alexandra Alvarez
- Office of Student Affairs, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA.
| | - Ashley Montgomery
- Office of Student Affairs, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Nhu Thao Nguyen Galván
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Eileen D Brewer
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Abbas Rana
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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Guo P, Zhang R, Zhou J, Li P, Liu Y, Shi S. Intracellular tacrolimus concentration correlates with impaired renal function through regulation of the IS-AHR-ABC transporter in peripheral blood mononuclear cells. Int Immunopharmacol 2024; 126:111233. [PMID: 37979449 DOI: 10.1016/j.intimp.2023.111233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 11/11/2023] [Accepted: 11/12/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUNDS Tacrolimus (TAC) concentration in peripheral blood mononuclear cells (PBMCs) is regarded as a better predictor of its immunosuppressive effect than the TAC concentration in whole blood. However, whether the exposure of TAC in PBMCs or WB was altered in post-transplant recipients with renal impairment remains unclear. METHODS We investigated the relationship of trough TAC concentration in WB and PBMCs with renal functions in post-transplant recipients. The pharmacokinetic profiles of TAC in PBMCs and WB in the two chronic kidney disease (CKD) rat models were examined using UPLC-MS/MS. Western blotting and reverse transcription-quantitative polymerase chain reaction (RT-qPCR) were used to analyze the expression of proteins and mRNAs related to TAC metabolism and transport, respectively. In addition, the effects of uremic toxins on human PBMCs were investigated using whole-transcriptome sequencing (RNA sequencing [RNA-seq]). RESULTS We observed a decrease in the trough TAC concentration in PBMCs in the recipients with estimated glomerular filtration rate (eGFR) < 90 mL/min, compared with those of recipients with eGFR > 90 mL/min, but there was no difference in blood based on TAC concentrations (C0Blood). In a 150-patient post-transplant cohort, no significant relationship was observed between PBMCs and WB concentrations of TAC, and the eGFR value was correlated with TAC C0PBMCs but not with TAC C0Blood. In two CKD rat models, the TAC pharmacokinetic profile in the PBMCs was significantly lower than that in the control group; however, the blood TAC pharmacokinetic profiles in the two groups were similar. Transcriptome results showed that co-incubation of human PBMCs with uremic toxins upregulated the expression of AHR, ABCB1, and ABCC2. Compared to control rats, plasma IS increased by 1.93- and 2.26-fold and the expression of AHR, P-gp, and MRP2 in PBMCs was higher in AD and 5/6 nephrectomy (NX) rats, without modifying the expression of other proteins related to TAC exposure. CONCLUSION The pharmacokinetics of TAC in PBMCs changed with a decline in renal function. Uremic toxins accumulate during renal insufficiency, which activates AHR, upregulates the expression of P-gp and MRP2, and affects their intracellular concentrations. Our findings suggest that monitoring TAC concentrations in PBMCs is more important than monitoring WB concentrations in post-transplant recipients with renal impairment.
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Affiliation(s)
- Pengpeng Guo
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Rui Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Jinping Zhou
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Peixia Li
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Yani Liu
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China.
| | - Shaojun Shi
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China.
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Rizzolo K, Shen JI. Barriers to home dialysis and kidney transplantation for socially disadvantaged individuals. Curr Opin Nephrol Hypertens 2024; 33:26-33. [PMID: 38014998 DOI: 10.1097/mnh.0000000000000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
PURPOSE OF REVIEW People with kidney disease facing social disadvantage have multiple barriers to quality kidney care. The aim of this review is to summarize the patient, clinician, and system wide factors that impact access to quality kidney care and discuss potential solutions to improve outcomes for socially disadvantaged people with kidney disease. RECENT FINDINGS Patient level factors such as poverty, insurance, and employment affect access to care, and low health literacy and kidney disease awareness can affect engagement with care. Clinician level factors include lack of early nephrology referral, limited education of clinicians in home dialysis and transplantation, and poor patient-physician communication. System-level factors such as lack of predialysis care and adequate health insurance can affect timely access to care. Neighborhood level socioeconomic factors, and lack of inclusion of these factors into public policy payment models, can affect ability to access care. Moreover, the effects of structural racism and discrimination nay negatively affect the kidney care experience for racially and ethnically minoritized individuals. SUMMARY Patient, clinician, and system level factors affect access to and engagement in quality kidney care. Multilevel solutions are critical to achieving equitable care for all affected by kidney disease.
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Affiliation(s)
- Katherine Rizzolo
- Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Section of Nephrology
| | - Jenny I Shen
- The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California, USA
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9
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Yang S, Hou W, Liu L. Progress in preservation of intestinal grafts by oxygenated hypothermic machine perfusion. Transplant Rev (Orlando) 2024; 38:100802. [PMID: 37891046 DOI: 10.1016/j.trre.2023.100802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/03/2023] [Accepted: 10/07/2023] [Indexed: 10/29/2023]
Abstract
Intestine transplantation (IT) is a critical treatment strategy for irreversible intestinal failure. Among all abdominal solid organ transplants, the intestine was the most vulnerable to ischemia and reperfusion injury (IRI). The static cold storage (SCS) technique is currently the most commonly used graft preservation method, but its hypoxia condition causes metabolic disorders, resulting in the occurrence of IRI, limiting its application in marginal organs. It is especially important to improve preservation techniques in order to minimize damage to marginal donor organs, which draws more attention to machine perfusion (MP). There has been much debate about whether it is necessary to increase oxygen in these conditions to support low levels of metabolism since the use of machine perfusion to preserve organs. There is evidence that oxygenation helps to restore intracellular ATP levels in the intestine after thermal or cold ischemia damage. The goal of this review is to provide an overview of the role of oxygen in maintaining environmental stability in the gut under hypoxic conditions, as well as to investigate the possibilities and mechanisms of oxygen delivery during preservation in intestine transplantation studies and clinical models.
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Affiliation(s)
- Shuang Yang
- National Health Commission's Key Laboratory for Critical Care Medicine, Tianjin First Central Hospital, Nankai University, Tianjin, China
| | - Wen Hou
- Research Institute of Transplant Medicine, Tianjin First Central Hospital, Nankai University, Tianjin, China.
| | - Lei Liu
- Research Institute of Transplant Medicine, Tianjin First Central Hospital, Nankai University, Tianjin, China; Tianjin Key Laboratory for Organ Transplantation, Tianjin First Central Hospital, Nankai University, Tianjin, China; Organ Transplant Department, Tianjin First Central Hospital, Nankai University, Tianjin, China.
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Betjes MGH, Kal-van Gestel J, Roodnat JI, de Weerd AE. The Incidence of Antibody-Mediated Rejection Is Age-Related, Plateaus Late After Kidney Transplantation, and Contributes Little to Graft Loss in the Older Recipients. Transpl Int 2023; 36:11751. [PMID: 38188697 PMCID: PMC10768842 DOI: 10.3389/ti.2023.11751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 11/27/2023] [Indexed: 01/09/2024]
Abstract
It is not known whether antibody-mediated rejection (ABMR) is age-related, whether it plateaus late after transplantation, and to what extent it contributes to graft loss in older recipients. Patients transplanted between 2010 and 2015 (n = 1,054) in a single center had regular follow-up until January 2023. Recipients were divided into age groups at transplantation: 18-39 years ("young"), 40-55 years ("middle age"), and >55 years ("elderly"). Ten years after transplantation the cumulative % of recipients with ABMR was 17% in young, 15% in middle age, and 12% in elderly recipients (p < 0.001). The cumulative incidence of ABMR increased over time and plateaued 8-10 years after transplantation. In the elderly, with a median follow-up of 7.5 years, on average 30% of the recipients with ABMR died with a functional graft and ABMR contributed only 4% to overall graft loss in this group. These results were cross-validated in a cohort of recipients with >15 years follow-up. Multivariate cox-regression analysis showed that increasing recipient age was independently associated with decreasing risk for ABMR. In conclusion, the cumulative risk for ABMR is age-dependent, plateaus late after transplantation, and contributes little to overall graft loss in older recipients.
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Affiliation(s)
- Michiel G. H. Betjes
- Rotterdam Transplantation Institute, Department of Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, Netherlands
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11
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Obrișcă B, Leca N, Chou-Wu E, Sibulesky L, Bakthavatsalam R, Kling CE, Alawieh R, Smith KD, Ismail G, Gimferrer I. Anti-GSTT1 antibodies and Null genotype correlate with histological changes of antibody mediated rejection in kidney transplantation. Transpl Immunol 2023; 81:101943. [PMID: 37866670 DOI: 10.1016/j.trim.2023.101943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/10/2023] [Accepted: 10/19/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND The presence of anti-Glutathione S-transferase T1 (GSTT1) antibodies (abs) has been hypothesized as a pathogenic contributor in antibody-mediated rejection (AMR). METHODS We aimed to evaluate the relationship between genetic variants of GSTT1, anti-GSTT1 abs and AMR in a cohort of 87 kidney transplant (KTx) patients using Immucor's non-HLA Luminex assay. Patients were classified according to biopsy-proven AMR and HLA-DSA status: AMR with positive anti-HLA-DSAs (AMR/DSA+, n = 29), AMR but no detectable anti-HLA-DSAs (AMR/DSA-, n = 28) and control patients with stable allograft function and no evidence of rejection (n = 30). RESULTS At an MFI cut-off of 3000, the overall prevalence of anti-GSTT1 abs was 18.3%. The proportion of patients with anti-GSTT1 abs was higher in the AMR/DSA- group (25%), compared to the control (13.3%) and AMR/DSA+ group (3.4%) (p = 0.06). Among patients with anti-GSTT1 abs, the MFI was higher in AMR/DSA- and GSTT1-Null patients. Of 81 patients who underwent GSTT1 genotyping, 19.8% were homozygotes for the null allele (GSTT1-Null). GSTT1-Null status in the transplant recipients was associated with the development of anti-GSTT1 abs (OR, 4.49; 95%CI, 1.2-16.7). In addition, GSTT1-Null genotype (OR 26.01; 95%CI, 1.63-404) and anti-GSTT1 ab positivity (OR 14.8; 95%CI, 1.1-190) were associated with AMR. Within AMR/DSA- patients, the presence of anti-GSTT1 abs didn't confer a higher risk of failure within the study observation period. CONCLUSION The presence of anti-GSTT1 abs and GSTT1-Null genotype is associated with AMR, but do not appear to lead to accelerated graft injury in this cohort of early allograft injury changes, with a limited period of follow-up.
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Affiliation(s)
- Bogdan Obrișcă
- Fundeni Clinical Institute, Division of Nephrology, Bucharest, Romania
| | - Nicolae Leca
- University of Washington, Division of Nephrology, Seattle, WA, USA
| | - Elaine Chou-Wu
- Bloodworks Northwest, Immunogenetics/HLA Laboratory, Seattle, WA, USA
| | - Lena Sibulesky
- University of Washington, Division of Transplant Surgery, Seattle, WA, USA
| | | | - Catherine E Kling
- University of Washington, Division of Transplant Surgery, Seattle, WA, USA
| | - Rasha Alawieh
- Yale Waterbury Internal Medicine Residency Program, Waterbury, CT, USA
| | - Kelly D Smith
- University of Washington, Department of Laboratory Medicine and Pathology, Seattle, WA, USA
| | - Gener Ismail
- Fundeni Clinical Institute, Division of Nephrology, Bucharest, Romania
| | - Idoia Gimferrer
- Bloodworks Northwest, Immunogenetics/HLA Laboratory, Seattle, WA, USA.
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12
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Zou ZY, Dai LR, Hou YB, Yu CZ, Chen RJ, Chen YY, Liu B, Shi HB, Gong NQ, Chen ZS, Chen S, Chang S, Zhang WJ. Sirolimus in combination with low-dose extended-release tacrolimus in kidney transplant recipients. Front Med (Lausanne) 2023; 10:1281939. [PMID: 38105889 PMCID: PMC10722907 DOI: 10.3389/fmed.2023.1281939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/23/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction Many challenges remain for long-term survival of renal allografts. Once-daily sirolimus (SRL) combined with low-dose extended-release tacrolimus (LER-TAC) may improve medication adherence and reduce the potential nephrotoxicity of calcineurin inhibitors (CNI) compared with standard immunosuppression regimens, thus potentially improving long-term graft survival. Methods This retrospective, observational, single-center, propensity score matching (PSM) study compared conversion to SRL combined with low-dose ER-TAC and mycophenolic acid (MPA) combined with standard-dose TAC in kidney transplant recipients. After PSM, there were 56 patients in each group. Efficacy, safety, and medication adherence were evaluated over 12 months. Results There was no significant difference between the two groups in terms of graft and recipient survival and incidence of biopsy-proven acute rejection (p = 1.000), and none of the recipients developed dnDSA after conversion. The mean eGFR improved in SRL + LER-TAC group after conversion compared to before conversion (51.12 ± 20.1 ml/min/1.73 m2 vs. 56.97 ± 19.23 ml/min/1.73 m2, p < 0.05). The medication adherence at 12 months after conversion was superior to before conversion (p = 0.002). Discussion Our findings suggest that an immunosuppressive regimen of SRL combined with low-dose ER-TAC is no less effective and safe than standard immunosuppressive regimens for renal transplant recipients and may improve graft renal function and medication adherence.
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Affiliation(s)
- Zhi-yu Zou
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Lin-rui Dai
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Yi-bo Hou
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Chen-zhen Yu
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Ren-jie Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Yan-yan Chen
- Department of Information Management, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bin Liu
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Hui-bo Shi
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Nian-qiao Gong
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Zhi-shui Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Song Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Sheng Chang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Wei-jie Zhang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
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13
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Gonzalez Sepulveda JM, Mehrotra S, Yang JC, Schantz KJ, Becker Y, Formica R, Ladner DP, Kaufman D, Friedewald J. Physician Preferences when Selecting Candidates for Lower-Quality Kidney Offers. Clin J Am Soc Nephrol 2023; 18:1599-1609. [PMID: 37729938 PMCID: PMC10723918 DOI: 10.2215/cjn.0000000000000302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 09/14/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND In the United States, more than 50% of kidneys in the lowest 15% quality range (those with Kidney Donor Profile Index >85) are discarded. Studies suggest that using more of these kidneys could benefit patients waiting for a transplant. This study assesses the trade-offs physicians make when selecting recipients for lower-quality kidneys. METHODS A discrete choice experiment (DCE) was administered to surgeons and nephrologists in the United States who are involved in kidney acceptance decisions. The DCE presented kidneys that varied in terms of Kidney Donor Profile Index, expected cold ischemia time, donor age, pump parameters, serum creatinine levels, glomerulosclerosis, donor diabetes status, and whether donation was made after circulatory death. Candidate characteristics included recipients' age, diabetes history, time on dialysis, ejection fraction, HLA mismatch, calculated panel reactive antibody, and Karnofsky performance score. Regression analysis was used to estimate acceptability weights associated with kidney and recipient characteristics. RESULTS A total of 108 physicians completed the DCE. The likelihood of acceptance was significantly lower with deterioration of kidney quality, expected cold ischemia time at transplantation, and missing biopsy and pump information. Acceptance was prioritized for patients who were higher on the waiting list, younger recipients, those who have spent less time on dialysis, and those without a history of diabetes. Performance status (Karnofsky score) and calculated panel reactive antibody also had a statistically significant but smaller association. Finally, ejection fraction had a marginally significant association, and HLA match had no significant association with the acceptance of marginal kidneys. A group of respondents were found to be primarily concerned about cold ischemia time. CONCLUSIONS In this DCE, physicians considered the recipient characteristics that inform expected post-transplant survival score when they decided whether to accept a marginal kidney for a given recipient.
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Affiliation(s)
- Juan M. Gonzalez Sepulveda
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sanjay Mehrotra
- Industrial Engineering and Management Sciences, McCormick School of Engineering, Northwestern University, Evanston, Illinois
| | - Jui-Chen Yang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - Yolanda Becker
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Richard Formica
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Daniela P. Ladner
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Dixon Kaufman
- University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - John Friedewald
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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14
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Abinti M, Favi E, Alfieri CM, Zanoni F, Armelloni S, Ferraresso M, Cantaluppi V, Castellano G. Update on current and potential application of extracellular vesicles in kidney transplantation. Am J Transplant 2023; 23:1673-1693. [PMID: 37517555 DOI: 10.1016/j.ajt.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/28/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023]
Abstract
Kidney transplantation (KT) is the best treatment for end-stage kidney disease. However, early diagnosis of graft injury remains challenging, mainly because of the lack of accurate and noninvasive diagnostic techniques. Improving graft outcomes is equally demanding, as is the development of innovative therapies. Many research efforts are focusing on extracellular vesicles, cellular particles free in each body fluid that have shown promising results as precise markers of damage and potential therapeutic targets in many diseases, including the renal field. In fact, through their receptors and cargo, they act in damage response and immune modulation. In transplantation, they may be used to determine organ quality and aging, the presence of delayed graft function, rejection, and many other transplant-related pathologies. Moreover, their low immunogenicity and safe profile make them ideal for drug delivery and the development of therapies to improve KT outcomes. In this review, we summarize current evidence about extracellular vesicles in KT, starting with their characteristics and major laboratory techniques for isolation and characterization. Then, we discuss their use as potential markers of damage and as therapeutic targets, discussing their promising use in clinical practice as a form of liquid biopsy.
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Affiliation(s)
- Matteo Abinti
- Nephrology, Dialysis and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Evaldo Favi
- Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Carlo Maria Alfieri
- Nephrology, Dialysis and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Francesca Zanoni
- Nephrology, Dialysis and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Silvia Armelloni
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Mariano Ferraresso
- Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplant Unit, Department of Translational Medicine (DIMET), University of Piemonte Orientale (UPO), "Maggiore della Carita" University Hospital, Novara, Italy
| | - Giuseppe Castellano
- Nephrology, Dialysis and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy.
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15
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Mortaja M, Demehri S. Skin cancer prevention - Recent advances and unmet challenges. Cancer Lett 2023; 575:216406. [PMID: 37734530 DOI: 10.1016/j.canlet.2023.216406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/01/2023] [Accepted: 09/18/2023] [Indexed: 09/23/2023]
Abstract
Cutaneous squamous cell carcinoma (cSCC) is the second most common malignancy in the world. Among many identified risk factors, immunosuppression is a major factor that contributes to cSCC development. Organ transplant recipients (OTRs) are at markedly increased risk of developing multiple cSCCs with a propensity for advanced metastatic disease, leading to significant morbidity and mortality. The severity of the cSCC phenotype in OTRs highlights the urgent need to identify effective preventive modalities in this population. Despite recent advances in skin cancer prevention (e.g., nicotinamide) and treatment (e.g., immune checkpoint blockade), these modalities have limited utility in OTRs due to the lack of efficacy or significant side effect. Topical treatments against precancerous skin lesions, actinic keratosis (AK), remain the primary strategy to prevent cSCC in OTRs, which also have significant deficiencies in this population. Herein, we review the epidemiology, risk factors, and current cSCC prevention strategies. We highlight the gaps and future clinical strategies to address cSCC risk in high-risk populations.
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Affiliation(s)
- Mahsa Mortaja
- Center for Cancer Immunology and Cutaneous Biology Research Center, Department of Dermatology and Center for Cancer Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - Shadmehr Demehri
- Center for Cancer Immunology and Cutaneous Biology Research Center, Department of Dermatology and Center for Cancer Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA.
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16
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Atiemo K, Baudier R, Craig-Schapiro R, Guo K, Mazumder N, Anderson A, Zhao L, Ladner D. Factors Underlying Racial Disparity in Utilization of Hepatitis C-Viremic Kidneys in the United States. J Racial Ethn Health Disparities 2023; 10:2185-2194. [PMID: 35997960 PMCID: PMC10348076 DOI: 10.1007/s40615-022-01398-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 11/30/2022]
Abstract
Utilization of hepatitis C (HCV) viremic kidneys is increasing in the United States. We examined racial disparity in this utilization using UNOS/OPTN data (2014-2020) and mixed effects models adjusting for donor/recipient/center factors. Included in the study were 58,786 adults receiving a deceased donor kidney transplant from 191 centers. Two thousand six hundred thirteen (4%) received kidneys from HCV-viremic donors. Of these, 1598 (61%) were HCV seronegative and 1015 (49%) were HCV seropositive. Among seronegative recipients, before adjusting for waiting time and education, Blacks (OR 0.69, 95%CI (0.60, 0.80)), Hispanics (OR 0.63, 95%CI (0.51, 0.79)), and Asians (OR 0.69, 95%CI (0.53, 0.90)) were less likely than Whites to receive HCV-viremic kidneys. In final models, effect of race was attenuated. Notably, shorter waiting time (OR 0.65, 95%CI (0.63, 0.67)) and increasing educational level (grade school less likely compared to high school OR 0.67, 95% CI (0.49, 0.92) and college more likely than high school (OR 1.16 95% CI (1.02, 1.31)) were associated with receipt of HCV-viremic kidneys. Among HCV-seropositive recipients, recipient race was not independently associated with receipt of HCV-viremic kidneys; however, centers with larger populations of Black waitlisted patients were more likely to utilize HCV-viremic kidneys (OR 1.71, 95%CI (1.20, 2.45)) compared to other centers. Our results suggest recipient race does not independently determine who receives HCV-viremic kidneys; however, other underlying factors including waiting time, education (among seronegative), and center racial mix (among seropositive) contribute to the current differential distribution of HCV-viremic kidneys among races.
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Affiliation(s)
- Kofi Atiemo
- Division of Transplant Surgery, Weill Cornell Medical Center, 525 East 68 thStreet, Box 98, New York, NY, 10065, USA.
| | - Robin Baudier
- Epidemiology Department, Tulane School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Rebecca Craig-Schapiro
- Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University Transplant Research Collaborative (NUTORC), Northwestern University, Chicago, IL, USA
| | - Kexin Guo
- Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University Transplant Research Collaborative (NUTORC), Northwestern University, Chicago, IL, USA
| | - Nikhilesh Mazumder
- Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University Transplant Research Collaborative (NUTORC), Northwestern University, Chicago, IL, USA
| | - Amanda Anderson
- Epidemiology Department, Tulane School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Lihui Zhao
- Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University Transplant Research Collaborative (NUTORC), Northwestern University, Chicago, IL, USA
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern Medicine, Chicago, IL, USA
| | - Daniela Ladner
- Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University Transplant Research Collaborative (NUTORC), Northwestern University, Chicago, IL, USA
- Division of Transplantation, Department of Surgery, Northwestern Medicine, Chicago, IL, USA
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern Medicine, Chicago, IL, USA
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Zeng S, Crichton ES, Ford ML, Badell IR. Memory T follicular helper cells drive donor-specific antibodies independent of memory B cells and primary germinal center and alloantibody formation. Am J Transplant 2023; 23:1511-1525. [PMID: 37302575 DOI: 10.1016/j.ajt.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 06/13/2023]
Abstract
Human leukocyte antigen antibodies are important immunologic mediators of renal allograft loss and are difficult to control. The inability to permanently eliminate donor-specific antibodies (DSA) is partly due to an incomplete understanding of the cellular mechanisms driving alloantibody formation, recurrence, and maintenance. Memory T follicular helper (mTfh) cells rapidly interact with memory B cells upon antigen re-exposure for anamnestic humoral responses, but little is known about Tfh memory in transplantation. We hypothesized that alloreactive mTfh cells form after transplantation and play a critical role in DSA formation following alloantigen re-encounter. To test this hypothesis, we utilized murine skin allograft models to identify and characterize Tfh memory and interrogate its ability to mediate alloantibody responses. We identified alloreactive Tfh memory as a mediator of accelerated humoral alloresponses independent of memory B cells and primary germinal center, or DSA, formation. Furthermore, we demonstrate that mTfh-driven alloantibody formation is susceptible to CD28 costimulation blockade. These findings provide novel insight into a pathologic role for memory Tfh in alloantibody responses and strongly support shifting therapeutic focus from the singular targeting of B cell lineage cells and alloantibodies themselves to multimodal strategies that include inhibition of mTfh cells to treat DSA.
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Affiliation(s)
- Shan Zeng
- Emory Transplant Center, Atlanta, Georgia, USA
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18
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Kohei N, Tanaka T, Miyairi S, Tsuda H, Abe T, Su CA, Kish DD, Tanabe K, Valujskikh A, Min B, Fairchild RL. Failure of Costimulatory Blockade-induced Regulatory T Cells to Sustain Long-term Survival of High Ischemic Allografts. Transplantation 2023; 107:1935-1944. [PMID: 36978228 PMCID: PMC10514235 DOI: 10.1097/tp.0000000000004570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
BACKGROUND Costimulatory blockade-induced allograft tolerance has been achieved in rodent models, but these strategies do not translate well to nonhuman primate and clinical transplants. One confounder that may underlie this discrepancy is the greater ischemic inflammation imposed on the transplants. In mice, cardiac allografts subjected to prolonged cold ischemic storage (CIS) before transplant have increased ischemia-reperfusion injury, which amplifies infiltrating endogenous memory CD8 T-cell activation within hours after transplantation to mediate acute graft inflammation and cytotoxic lymphocyte-associated molecule-4 immunoglobulin-resistant rejection. This study tested strategies inhibiting memory CD8 T-cell activation within such high ischemic allografts to achieve long-term survival. METHODS A/J (H-2 a ) hearts subjected to 0.5 or 8 h of CIS were transplanted to C57BL/6 (H-2 b ) recipients and treatment with peritransplant costimulatory blockade. At 60 d posttransplant, regulatory T cells (Treg) were depleted in recipients of high ischemic allografts with anti-CD25 monoclonal antibody (mAb) or diphtheria toxin. RESULTS Whereas peritransplant (days 0 and +1) anti-lymphocyte function-associated antigen-1 mAb and anti-CD154 mAb prolonged survival of >60% allografts subjected to minimal CIS for >100 d, only 20% of allografts subjected to prolonged CIS survived beyond day 80 posttransplant and rejection was accompanied by high titers of donor-specific antibody. Peritransplant anti-lymphocyte function-associated antigen-1, anti-tumor necrosis factor-α, and anti-CD154 mAb plus additional anti-CD154 mAb on days 14 and 16 obviated this donor-specific antibody and promoted Treg-mediated tolerance and survival of 60% of high ischemic allografts beyond day 100 posttransplant, but all allografts failed by day 120. CONCLUSIONS These studies indicate a strategy inducing prolonged high ischemic allograft survival through Treg-mediated tolerance that is not sustained indefinitely.
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Affiliation(s)
- Naoki Kohei
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Tokyo Women’s Medical University, Tokyo, Japan
| | - Toshiaki Tanaka
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Satoshi Miyairi
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Tokyo Women’s Medical University, Tokyo, Japan
| | - Hidetoshi Tsuda
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Department of Urology, Osaka University School of Medicine, Osaka, Japan
| | - Toyofumi Abe
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Department of Urology, Osaka University School of Medicine, Osaka, Japan
| | - Charles A. Su
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH
| | | | | | | | - Booki Min
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Robert L. Fairchild
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH
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19
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McDonald M. Allograft nephrectomy vs. no nephrectomy for failed renal transplants. FRONTIERS IN NEPHROLOGY 2023; 3:1169181. [PMID: 37675360 PMCID: PMC10479781 DOI: 10.3389/fneph.2023.1169181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 06/13/2023] [Indexed: 09/08/2023]
Abstract
The role of allograft nephrectomy (AN) in failed renal transplants is a topic of debate, owing to controversial results reported in the literature and the fact that most of the studies are limited by a retrospective design and small numbers of participants. Allograft nephrectomy is most likely of benefit in the patient with recurrent allograft intolerance syndrome (AIS) following pulse steroids. Immunosuppression weaning in the presence of clinical signs related to a chronic inflammatory state is also reasonable grounds to pursue AN. Studies are mainly inconclusive but suggest that AN has no overall benefit for allograft survival after retransplant. This topic is still of interest in the transplant field and is particularly relevant for patients who are likely to require retransplantation within their lifetime. Further assessment is needed in the form of randomized controlled trials that control for various AN indications and immunosuppression regimens, and have clearly defined survival outcomes.
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Affiliation(s)
- Michelle McDonald
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, United States
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20
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Betjes MGH, De Weerd A. Lowering maintenance immune suppression in elderly kidney transplant recipients; connecting the immunological and clinical dots. Front Med (Lausanne) 2023; 10:1215167. [PMID: 37502354 PMCID: PMC10368955 DOI: 10.3389/fmed.2023.1215167] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/09/2023] [Indexed: 07/29/2023] Open
Abstract
The management of long-term immune suppressive medication in kidney transplant recipients is a poorly explored field in the area of transplant medicine. In particular, older recipients are at an increased risk for side effects and have an exponentially increased risk of infection-related death. In contrast, an aged immune system decreases the risk of acute T-cell-mediated rejection in older recipients. Recent advances in alloimmunity research have shown a rapid and substantial decline in polyfunctional, high-risk CD4+ T cells post-transplantation. This lowers the direct alloreactivity responsible for T-cell-mediated rejection, also known as donor-specific hyporesponsiveness. Chronic antibody-mediated rejection (c-aABMR) is the most frequent cause of kidney graft loss in the long term. However, in older adults, c-aABMR as a cause of graft loss is outnumbered by death with a functioning graft. In addition, DSA development and a diagnosis of c-aABMR plateau ~10 years after transplantation, resulting in a very low risk for rejection thereafter. The intensity of immune suppression regimes could likely be reduced accordingly, but trials in this area are scarce. Tacrolimus monotherapy for 1 year after transplantation seems feasible in older kidney transplant recipients with standard immunological risk, showing the expected benefits of fewer infections and better vaccination responses.
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21
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Puliyanda D, Barday Z, Barday Z, Freedman A, Todo T, Chen AKC, Davidson B. Children Are Not Small Adults: Similarities and Differences in Renal Transplantation Between Adults and Pediatrics. Semin Nephrol 2023; 43:151442. [PMID: 37949683 DOI: 10.1016/j.semnephrol.2023.151442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Kidney transplantation is the treatment of choice for all patients with end-stage kidney disease, including pediatric patients. Graft survival in pediatrics was lagging behind adults, but now is comparable with the adult cohort. Although many of the protocols have been adopted from adults, there are issues unique to pediatrics that one should be aware of to take care of this population. These issues include recipient size consideration, increased incidence of viral infections, problems related to growth, common occurrence of underlying urological issues, and psychosocial issues. This article addresses the similarities and differences in renal transplantation, from preparing a patient for transplant, the transplant process, to post-transplant complications.
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Affiliation(s)
- Dechu Puliyanda
- Pediatric Nephrology and Comprehensive Transplant Program, Cedars Sinai Medical Center, Los Angeles, CA.
| | - Zibya Barday
- Department of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Zunaid Barday
- Department of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Andrew Freedman
- Pediatric Nephrology and Comprehensive Transplant Program, Cedars Sinai Medical Center, Los Angeles, CA
| | - Tsuyoshi Todo
- Pediatric Nephrology and Comprehensive Transplant Program, Cedars Sinai Medical Center, Los Angeles, CA
| | - Allen Kuang Chung Chen
- Pediatric Nephrology and Comprehensive Transplant Program, Cedars Sinai Medical Center, Los Angeles, CA
| | - Bianca Davidson
- Department of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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22
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Katz DA, Ten Eyck P, Binns G, Manay P, Sanders ML, Hornickel JL, Vu A, Swee M, Kalil R. Walking Ability and Brain Natriuretic Peptide Are Highly Predictive of Kidney Transplant Waiting List Removal. Transplant Direct 2023; 9:e1483. [PMID: 37197015 PMCID: PMC10184993 DOI: 10.1097/txd.0000000000001483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/15/2023] [Indexed: 05/19/2023] Open
Abstract
Kidney transplant waitlist management is complex because waiting time is long, and the patients have significant comorbidities. Identification of patients at highest risk for waiting list removal for death and medical complications could allow better outcomes and allocation of resources. Methods Demographics, functional and frailty assessment' and biochemical data were retrospectively analyzed on 313 consecutive patients listed for kidney transplant. Troponin, brain natriuretic peptide, components of the Fried frailty metrics, pedometer activity, and treadmill ability were measured at the time of transplant evaluation and at subsequent re-evaluations. Cox proportional hazards models were used to identify factors associated with death or waiting list removal for medical reasons. Multivariate models were created to identify significant predictor sets. Results Among 249 patients removed while waitlisted, 19 (6.1%) died and 51 (16.3%) were removed for medical reasons. Mean follow-up duration was 2.3 y (±1.5 y). 417 sets of measurements were collected. Significant (P < 0.05) non-time-dependent variables associated with the composite outcome identified on univariate analysis included N-terminal probrain natriuretic peptide (BNP), treadmill ability, pedometer activity, diagnosis of diabetes and the Center of Epidemiological Studies Depression Scale question asking how many days per week could you not get going. Significant time-dependent factors included BNP, treadmill ability, Up and Go, pedometer activity, handgrip, 30 s chair sit-stand test, and age. The optimal time-dependent predictor set included BNP, treadmill ability, and patient age. Conclusions Changes in functional and biochemical markers are predictive of kidney waitlist removal for death and medical reasons. BNP and measures of walking ability were of particular importance.
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Affiliation(s)
- Daniel A. Katz
- Department of Surgery, Organ Transplant Center, University of Iowa Hospitals and Clinics, Iowa City, IA
- Transplant Department, Veterans Affairs Medical Center, Iowa City, IA
| | - Patrick Ten Eyck
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA
| | - Grace Binns
- Transplant Department, Veterans Affairs Medical Center, Iowa City, IA
| | - Priyadarshini Manay
- Department of Surgery, Organ Transplant Center, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - M. Lee Sanders
- Transplant Department, Veterans Affairs Medical Center, Iowa City, IA
- Division of Nephrology, Organ Transplant Center, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | | | - An Vu
- Transplant Department, Veterans Affairs Medical Center, Iowa City, IA
| | - Melissa Swee
- Transplant Department, Veterans Affairs Medical Center, Iowa City, IA
- Division of Nephrology, Organ Transplant Center, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Roberto Kalil
- Department of Medicine, University of Maryland Medical Center and Veterans Affairs Medical Center, Baltimore, MD
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23
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Bae S, Ahn JB, Joseph C, Whisler R, Schnitzler MA, Lentine KL, Kadosh BS, Segev DL, McAdams-DeMarco MA. Statins in Kidney Transplant Recipients: Usage, All-Cause Mortality, and Interactions with Maintenance Immunosuppressive Agents. J Am Soc Nephrol 2023; 34:1069-1077. [PMID: 36890643 PMCID: PMC10278772 DOI: 10.1681/asn.0000000000000112] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 01/17/2023] [Indexed: 03/10/2023] Open
Abstract
SIGNIFICANCE STATEMENT Cardiovascular diseases account for 32% of deaths among kidney transplant recipients. Statin therapy is common in this population. However, its effect on mortality prevention remains unclear among kidney transplant recipients, whose clinical risk profile might be unique because of concomitant immunosuppressive therapy. In this national study of 58,264 single-kidney transplant recipients, statin use was associated with a 5% decrease in mortality. More importantly, this protective association was stronger among those who used a mammalian target of rapamycin (mTOR) inhibitor for immunosuppression (27% decrease in mTOR inhibitor users versus 5% in nonusers). Our results suggest that statin therapy may reduce mortality in kidney transplant recipients and that the strength of this protective association may vary by immunosuppression regimen. BACKGROUND Cardiovascular diseases are the leading cause of mortality in kidney transplant (KT) recipients, accounting for 32% of deaths. Statins are widely used in KT recipients, but effectiveness for preventing mortality remains unclear in this population, especially because of interaction between statins and immunosuppressive agents. We analyzed a national cohort to assess the real-world effectiveness of statins for reducing all-cause mortality in KT recipients. METHODS We studied statin use and mortality among 58,264 adults (18 years or older) who received single kidneys between 2006 and 2016 and had Medicare part A/B/D. Statin use was ascertained from Medicare prescription drug claims and deaths from Center for Medicare and Medicaid Services records. We estimated the association of statin use with mortality using multivariable Cox models, with statin use as a time-varying exposure and immunosuppression regimen as effect modifiers. RESULTS Statin use increased from 45.5% at KT to 58.2% at 1-year post-KT to 70.9% at 5-year post-KT. We observed 9785 deaths over 236,944 person-years. Overall, statin use was significantly associated with lower mortality (adjusted hazard ratio [aHR], 0.95; 95% confidence interval [CI], 0.90 to 0.99). The strength of this protective association varied by calcineurin inhibitor use (among tacrolimus users, aHR, 0.97; 95% CI, 0.92 to 1.03 versus among calcineurin nonusers, aHR, 0.72; 95% CI, 0.60 to 0.87; interaction P =0.002), mammalian target of rapamycin (mTOR) inhibitor use (among mTOR inhibitor users, aHR, 0.73; 95% CI, 0.57 to 0.92 versus among nonusers, aHR, 0.95; 95% CI, 0.91 to 1.00; interaction P =0.03), and mycophenolate use (among mycophenolate users, aHR, 0.96; 95% CI, 0.91 to 1.02 versus among nonusers, aHR, 0.76; 95% CI, 0.64 to 0.89; interaction P =0.002). CONCLUSION Real-world evidence supports statin therapy for reducing all-cause mortality in KT recipients. Effectiveness might be greater when combined with mTOR inhibitor-based immunosuppression.
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Affiliation(s)
- Sunjae Bae
- Department of Surgery, NYU Grossman School of Medicine, New York, New York
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - JiYoon B. Ahn
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Corey Joseph
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Ryan Whisler
- Department of Pharmacy, Johns Hopkins Medicine, Baltimore, Maryland
| | | | - Krista L. Lentine
- Department of Internal Medicine, Saint Louis University, St. Louis, Missouri
| | - Bernard S. Kadosh
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Dorry L. Segev
- Department of Surgery, NYU Grossman School of Medicine, New York, New York
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Mara A. McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine, New York, New York
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
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24
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Wood P, Huang YS, Sanchez L, Kitt E, Abt PL, Bittermann T. The effectiveness and safety of antibody induction immunosuppression in a large cohort of United States pediatric liver transplant recipients. Am J Transplant 2023; 23:794-804. [PMID: 36933831 PMCID: PMC10247522 DOI: 10.1016/j.ajt.2023.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 01/31/2023] [Accepted: 03/06/2023] [Indexed: 03/18/2023]
Abstract
Data on the potential benefits and risks of induction therapy in pediatric liver transplantation (LT) are limited. This was a retrospective cohort study of 2748 pediatric LT recipients at 26 children's hospitals between January 1, 2006 to May 31, 2017 using data from the pediatric health information system linked to the United Network for Organ Sharing database. The induction regimen was obtained from the pediatric health information system day-by-day pharmacy resource utilization. Cox proportional hazards evaluated the association of induction regimen (none/corticosteroid-only, nondepleting, and depleting) on patient and graft survival. Additional outcomes, including opportunistic infections and posttransplant lymphoproliferative disorder, were studied using multivariable logistic regression. Overall, 64.9% received none/corticosteroid-only induction, whereas 28.1% received nondepleting, 8.3% received depleting, and 2.5% other antibody regimens. Differences in patient characteristics were small, but center practices were heterogeneous. Compared with none/corticosteroid-only induction, nondepleting induction was associated with reduced acute rejection (odd ratio [OR], 0.53; P <.001) but with the increased posttransplant lymphoproliferative disorder (OR, 1.75; P =.021). Depleting induction was associated with improved graft survival (hazard ratio [HR], 0.64; P =.028) but with increased noncytomegalovirus opportunistic infections (OR, 1.46; P =.046). Depleting induction is underused yet may offer long-term benefits in this large multicenter cohort. Greater consensus guidance in this aspect of pediatric LT care is warranted.
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Affiliation(s)
- Phoebe Wood
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yuan-Shung Huang
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lucia Sanchez
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Eimear Kitt
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Peter L Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Therese Bittermann
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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25
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Manook M, Olaso D, Anwar IJ, Yoon J, Delaura I, Bae Y, Moris D, Shaw B, Song M, Farris AB, Jackson A, Kwun J, Knechtle S. Desensitization and belatacept-based maintenance therapy in pregnancy-sensitized monkeys receiving a kidney transplant. SCIENCE ADVANCES 2023; 9:eadg1448. [PMID: 37205758 PMCID: PMC10198638 DOI: 10.1126/sciadv.adg1448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/14/2023] [Indexed: 05/21/2023]
Abstract
Among sensitized patients awaiting a transplant, females are disproportionately represented, partly because of pregnancy-induced sensitization. Using female NHPs sensitized by pregnancy alone, we examined the efficacy of costimulation blockade and proteasome inhibition for desensitization. Three animals received no desensitization (control), and seven animals received weekly carfilzomib (27 mg/m2) and belatacept (20 mg/kg) before kidney transplantation. All animals received renal allografts from crossmatch-positive/maximally MHC-mismatched donors. Controls and three desensitized animals received tacrolimus-based immunosuppression. Four desensitized animals received additional belatacept with tacrolimus-based immunosuppression. Multiparous females had less circulating donor-specific antibody when compared to skin-sensitized males before transplantation. While females receiving desensitization showed only a marginal survival benefit over control females (MST = 11 days versus 63 days), additional belatacept to posttransplant maintenance significantly prolonged graft survival (MST > 164 days) and suppressed posttransplant DSA and circulating follicular helper T-like cells. This combination of therapies demonstrates great potential to reduce antibody-mediated rejection in sensitized recipients.
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Affiliation(s)
- Miriam Manook
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Danae Olaso
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Imran J. Anwar
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Janghoon Yoon
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Isabel Delaura
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Yeeun Bae
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Dimitrios Moris
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Brian Shaw
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Mingqing Song
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Alton B. Farris
- Department of Pathology, Emory University School of Medicine, Atlanta, GA, USA
| | - Annette Jackson
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Jean Kwun
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Stuart Knechtle
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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26
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Kadatz MJ, Gill J, Gill J, Lan JH, McMichael LC, Chang DT, Gill JS. The Benefits of Preemptive Transplantation Using High-Kidney Donor Profile Index Kidneys. Clin J Am Soc Nephrol 2023; 18:01277230-990000000-00121. [PMID: 37027505 PMCID: PMC10278842 DOI: 10.2215/cjn.0000000000000134] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 02/16/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND The Kidney Donor Profile Index (KDPI) is a percentile score summarizing the likelihood of allograft failure: A KDPI ≥85% is associated with shorter allograft survival, and 50% of these donated kidneys are not currently used for transplantation. Preemptive transplantation (transplantation without prior maintenance dialysis) is associated with longer allograft survival than transplantation after dialysis; however, it is unknown whether this benefit extends to high-KDPI transplants. The objective of this analysis was to determine whether the benefit of preemptive transplantation extends to recipients of transplants with a KDPI ≥85%. METHODS This retrospective cohort study compared the post-transplant outcomes of preemptive and nonpreemptive deceased donor kidney transplants using data from the Scientific Registry of Transplant Recipients. 120,091 patients who received their first, kidney-only transplant between January 1, 2005, and December 31, 2017, were studied, including 23,211 with KDPI ≥85%. Of this cohort, 12,331 patients received a transplant preemptively. Time-to-event models for the outcomes of allograft loss from any cause, death-censored graft loss, and death with a functioning transplant were performed. RESULTS Compared with recipients of nonpreemptive transplants with a KDPI of 0%-20% as the reference group, the risk of allograft loss from any cause in recipients of a preemptive transplant with KDPI ≥85% (hazard ratio [HR], 1.51; 95% confidence interval [CI], 1.39 to 1.64) was lower than that in recipients of nonpreemptive transplant with a KDPI ≥85% (HR, 2.39; 95% CI, 2.21 to 2.58) and similar to that of recipients of a nonpreemptive transplant with a KDPI of 51%-84% (HR, 1.61; 95% CI, 1.52 to 1.70). CONCLUSIONS Preemptive transplantation is associated with a lower risk of allograft failure, irrespective of KDPI, and preemptive transplants with KDPI ≥85% have comparable outcomes with nonpreemptive transplants with KDPI 51%-84%.
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Affiliation(s)
- Matthew J. Kadatz
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Jagbir Gill
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
- Providence Health Research Institute, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcomes Sciences, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Justin Gill
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - James H. Lan
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lachlan C. McMichael
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Doris T. Chang
- Providence Health Research Institute, Vancouver, British Columbia, Canada
| | - John S. Gill
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
- Providence Health Research Institute, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcomes Sciences, Vancouver, British Columbia, Canada
- Tufts-New England Medical Center, Boston, Massachusetts
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27
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Friedewald JJ, Schantz K, Mehrotra S. Kidney organ allocation: reducing discards. Curr Opin Organ Transplant 2023; 28:145-148. [PMID: 36696090 DOI: 10.1097/mot.0000000000001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE OF REVIEW The donation and kidney transplant system in the United States is challenged with reducing the number of kidneys that are procured for transplant but ultimately discarded. That number can reach 20% of donated kidneys each year. RECENT FINDINGS The reasons for these discards, in the face of overwhelming demand, are multiple. SUMMARY The authors review the data supporting a number of potential causes for high discard rates as well as provide potential solutions to the problem.
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Affiliation(s)
| | - Karolina Schantz
- Northwestern University Industrial Engineering and Management Sciences, Evanston, Illinois, USA
| | - Sanjay Mehrotra
- Northwestern University Industrial Engineering and Management Sciences, Evanston, Illinois, USA
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28
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Spiers HVM, Stadler LKJ, Smith H, Kosmoliaptsis V. Extracellular Vesicles as Drug Delivery Systems in Organ Transplantation: The Next Frontier. Pharmaceutics 2023; 15:891. [PMID: 36986753 PMCID: PMC10052210 DOI: 10.3390/pharmaceutics15030891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/22/2023] [Accepted: 02/24/2023] [Indexed: 03/12/2023] Open
Abstract
Extracellular vesicles are lipid bilayer-delimited nanoparticles excreted into the extracellular space by all cells. They carry a cargo rich in proteins, lipids and DNA, as well as a full complement of RNA species, which they deliver to recipient cells to induce downstream signalling, and they play a key role in many physiological and pathological processes. There is evidence that native and hybrid EVs may be used as effective drug delivery systems, with their intrinsic ability to protect and deliver a functional cargo by utilising endogenous cellular mechanisms making them attractive as therapeutics. Organ transplantation is the gold standard for treatment for suitable patients with end-stage organ failure. However, significant challenges still remain in organ transplantation; prevention of graft rejection requires heavy immunosuppression and the lack of donor organs results in a failure to meet demand, as manifested by growing waiting lists. Pre-clinical studies have demonstrated the ability of EVs to prevent rejection in transplantation and mitigate ischemia reperfusion injury in several disease models. The findings of this work have made clinical translation of EVs possible, with several clinical trials actively recruiting patients. However, there is much to be uncovered, and it is essential to understand the mechanisms behind the therapeutic benefits of EVs. Machine perfusion of isolated organs provides an unparalleled platform for the investigation of EV biology and the testing of the pharmacokinetic and pharmacodynamic properties of EVs. This review classifies EVs and their biogenesis routes, and discusses the isolation and characterisation methods adopted by the international EV research community, before delving into what is known about EVs as drug delivery systems and why organ transplantation represents an ideal platform for their development as drug delivery systems.
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Affiliation(s)
- Harry V. M. Spiers
- Department of Surgery, University of Cambridge, Addenbrooke’s Hospital, Cambridge CB2 0QQ, UK; (H.V.M.S.)
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Lukas K. J. Stadler
- Department of Surgery, University of Cambridge, Addenbrooke’s Hospital, Cambridge CB2 0QQ, UK; (H.V.M.S.)
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Hugo Smith
- Department of Surgery, University of Cambridge, Addenbrooke’s Hospital, Cambridge CB2 0QQ, UK; (H.V.M.S.)
| | - Vasilis Kosmoliaptsis
- Department of Surgery, University of Cambridge, Addenbrooke’s Hospital, Cambridge CB2 0QQ, UK; (H.V.M.S.)
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, University of Cambridge, Cambridge CB2 0QQ, UK
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29
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Kim SH, Huh K, Lee KW, Park JB, Huh WS, Ko JH, Cho SY, Kang CI, Chung DR, Peck KR. Clinical effectiveness of zoster vaccine live in kidney transplant recipients immunized prior to transplantation: a retrospective single-centre cohort study. Clin Microbiol Infect 2023:S1198-743X(23)00084-8. [PMID: 36868356 DOI: 10.1016/j.cmi.2023.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/16/2023] [Accepted: 02/22/2023] [Indexed: 03/04/2023]
Abstract
OBJECTIVES Kidney transplant (KT) recipients have an increased risk of herpes zoster (HZ) and its complications. Although recombinant zoster vaccine is favoured over zoster vaccine live (ZVL), ZVL is also recommended to prevent HZ for KT candidates. We aimed to evaluate the clinical effectiveness of ZVL in KT recipients immunized before transplantation. METHODS Adult patients who received kidney transplantation from January 2014 to December 2018 were enrolled. Patients were observed until HZ occurrence, death, loss of allograft, loss to follow-up, or 5 years after transplantation. The inverse probability of the treatment-weighted Cox proportional hazard model was used to compare the incidence of HZ after transplantation between vaccinated and unvaccinated patients. RESULTS A total of 84 vaccinated and 340 unvaccinated patients were included. The median age was higher in the vaccinated group (57 vs. 54 years, p 0.003). Grafts from deceased donors were more frequently transplanted in the unvaccinated group (16.7% vs. 51.8%, p < 0.001). Five-year cumulative HZ incidence was 11.9%, which translated to 26.27 (95% CI, 19.33-34.95) per 1000 person-years. The incidence in the vaccinated and unvaccinated groups was 3.9% and 13.7%, respectively. After adjustment, vaccination showed significant protective effectiveness against HZ (adjusted hazard ratio, 0.18, 95% CI, 0.05-0.60). In addition, all four cases of disseminated zoster occurred in the unvaccinated group. DISCUSSION Our study, the first on the clinical effectiveness of zoster vaccines for KT recipients, suggests that ZVL before transplantation effectively prevents HZ.
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Affiliation(s)
- Si-Ho Kim
- Division of Infectious Diseases, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Kyungmin Huh
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Kyo Won Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Berm Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Woo Seong Huh
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae-Hoon Ko
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sun Young Cho
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Cheol-In Kang
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Doo Ryeon Chung
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyong Ran Peck
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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30
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Hwang CS, Kadakia Y, Sanchez-Vivaldi JA, Patel MS, Shah JA, DeGregorio L, Desai DM, Vagefi PA, MacConmara M. Delayed graft function in pediatric living donor kidney transplantation. Pediatr Transplant 2023; 27:e14432. [PMID: 36369617 DOI: 10.1111/petr.14432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/21/2022] [Accepted: 10/24/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Pediatric recipients of living donor kidneys have a low rate of delayed graft function (DGF). We examined the incidence, risk factors and outcomes of DGF in pediatric patients who received a living donor allograft. METHODS The STARfile was queried to examine all pediatric patients transplanted with a living donor kidney between 2000 and 2020. Donor and recipient demographic data were examined, as were survival and outcomes. Recipients were stratified into DGF and no DGF groups. DGF was defined as the need for dialysis within the first week after transplant. RESULTS 6480 pediatric patients received a living donor (LD) kidney transplant during the study period. 269 (4.2%) developed DGF post-transplant. Donors were similar in age, creatinine, and cold ischemia time. Recipients of kidneys with DGF were similar in age, sensitization status and HLA mismatch. Focal segmental glomerulosclerosis (FSGS) was the most common diagnosis in recipients with DGF, and allograft thrombosis was the most common cause of graft loss in this group. Small recipients (weight < 15 kg) were found to have a significantly higher rate of DGF. Length of stay doubled in recipients with DGF, and rejection rates were higher post-transplant. Recipients of LD kidneys who developed DGF had significantly worse 1 year allograft survival (67% vs. 98%, p < .0001). CONCLUSIONS Pediatric living donor kidney transplant recipients who experience DGF have significantly poorer allograft survival. Optimizing the donor and recipient matching to avoid compounding risks may allow for better outcomes.
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Affiliation(s)
- Christine S Hwang
- Division of Surgical Transplantation, Department of Surgery, University Of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Transplantation, Children's Medical Center, Dallas, TX, USA
| | - Yash Kadakia
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jorge A Sanchez-Vivaldi
- Division of Surgical Transplantation, Department of Surgery, University Of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Transplantation, Children's Medical Center, Dallas, TX, USA
| | - Madhukar S Patel
- Division of Surgical Transplantation, Department of Surgery, University Of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Transplantation, Children's Medical Center, Dallas, TX, USA
| | - Jigesh A Shah
- Division of Surgical Transplantation, Department of Surgery, University Of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Transplantation, Children's Medical Center, Dallas, TX, USA
| | - Lucia DeGregorio
- Division of Surgical Transplantation, Department of Surgery, University Of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Transplantation, Children's Medical Center, Dallas, TX, USA
| | - Dev M Desai
- Division of Surgical Transplantation, Department of Surgery, University Of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Transplantation, Children's Medical Center, Dallas, TX, USA
| | - Parsia A Vagefi
- Division of Surgical Transplantation, Department of Surgery, University Of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Transplantation, Children's Medical Center, Dallas, TX, USA
| | - Malcolm MacConmara
- Division of Surgical Transplantation, Department of Surgery, University Of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Transplantation, Children's Medical Center, Dallas, TX, USA
- TransMedics, Andover, MA, USA
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31
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De Nicola L, Serra R, Provenzano M, Minutolo R, Michael A, Ielapi N, Federico S, Carrano R, Bellizzi V, Garofalo C, Iodice C, Borrelli S, Grandaliano G, Stallone G, Gesualdo L, Chiodini P, Andreucci M. Risk of end-stage kidney disease in kidney transplant recipients versus patients with native chronic kidney disease: multicentre unmatched and propensity-score matched analyses. Nephrol Dial Transplant 2023; 38:507-516. [PMID: 35278077 DOI: 10.1093/ndt/gfac131] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In kidney transplant recipients (KTR), the end-stage kidney disease (ESKD) risk dependent on the risk factors acting in native chronic kidney disease (CKD) remains undefined. METHODS We compared risk and determinants of ESKD between 757 adult KTR and 1940 patients with native CKD before and after propensity-score (PS) analysis matched for unmodifiable risk factors [(age, sex, diabetes, cardiovascular disease and estimated glomerular filtration rate (eGFR)]. RESULTS In unmatched cohorts, eGFR was lower in CKD versus KTR (45.9 ± 11.3 versus 59.2 ± 13.4 mL/min/1.73 m2, P < 0.001). During a median follow-up of 5.4 years, the unadjusted cumulative incidence of ESKD was consistently lower in unmatched KTR versus CKD. Conversely, in PS-matched analysis, the risk of ESKD in KTR was 78% lower versus CKD at 1 year of follow-up while progressively increased over time resulting similar to that of native CKD patients after 5 years and 2.3-fold higher than that observed in CKD at 10 years. R2 analysis in unmatched patients showed that the proportion of the outcome variance explained by traditional ESKD determinants was smaller in KTR versus native CKD (31% versus 70%). After PS matching, the risk of ESKD [hazard ratio (HR), 95% confidence interval (95% CI)] was significantly associated with systolic blood pressure (1.02, 1.01-1.02), phosphorus (1.31, 1.05-1.64), 24-h proteinuria (1.11, 1.05-1.17) and haemoglobin (0.85, 0.78-0.93) irrespective of KTR status. Similar data were obtained after matching also for modifiable risk factors. CONCLUSIONS In KTR, when compared with matched native CKD patients, the risk of ESKD is lower in the first 5 years and higher later on. Traditional determinants of ESKD account for one-third of the variability of time-to-graft failure.
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Affiliation(s)
- Luca De Nicola
- Nephrology-Dialysis Unit, Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Raffaele Serra
- Interuniversity Center of Phlebolymphology (CIFL), Magna Graecia University of Catanzaro, Catanzaro, Italy.,Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Michele Provenzano
- Renal Unit, Department of Health Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Roberto Minutolo
- Nephrology-Dialysis Unit, Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Ashour Michael
- Renal Unit, Department of Health Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Nicola Ielapi
- Interuniversity Center of Phlebolymphology (CIFL), Magna Graecia University of Catanzaro, Catanzaro, Italy.,Department of Public Health and Infectious Disease, Sapienza University of Rome, Rome, Italy
| | - Stefano Federico
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Rosa Carrano
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Vincenzo Bellizzi
- Nephrology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Carlo Garofalo
- Nephrology-Dialysis Unit, Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Carmela Iodice
- Nephrology-Dialysis Unit, Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Silvio Borrelli
- Nephrology-Dialysis Unit, Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Giuseppe Grandaliano
- Nephrology Unit, Department of Translational Medicine and Surgery-Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore in Rome, Rome, Italy
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Paolo Chiodini
- Medical Statistics Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Michele Andreucci
- Renal Unit, Department of Health Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
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32
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Fallani G, Maroni L, Bonatti C, Comai G, Buzzi M, Cuna V, Vasuri F, Caputo F, Prosperi E, Pisani F, Pisillo B, Maurino L, Odaldi F, Bertuzzo VR, Tondolo F, Busutti M, Zanfi C, Del Gaudio M, La Manna G, Ravaioli M. Renal Vessel Extension With Cryopreserved Vascular Grafts: Overcoming Surgical Pitfalls in Living Donor Kidney Transplant. Transpl Int 2023; 36:11060. [PMID: 36846603 PMCID: PMC9950096 DOI: 10.3389/ti.2023.11060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/26/2023] [Indexed: 02/12/2023]
Abstract
In LDKT, right kidneys and kidneys with anomalous vascularization are often deferred because of concerns on complications and vascular reconstructions. To date, only few reports have examined renal vessel extension with cryopreserved vascular grafts in LDKT. The aim of this study is to investigate the effect of renal vessel extension on short-term outcomes and ischemia times in LDKT. From 2012 to 2020, recipients of LDKT with renal vessels extension were compared with standard LDKT recipients. Subset analysis of rights grafts and grafts with anomalous vascularization, with or without renal vessel extension, was performed. Recipients of LDKT with (n = 54) and without (n = 91) vascular extension experienced similar hospital stays, surgical complications and DGF rates. For grafts with multiple vessels, renal vessel extension granted a faster implantation time (44±5 vs. 72±14 min), which resulted comparable to that of standard anatomy grafts. Right kidney grafts with vascular extension had a faster implantation time compared to right kidney grafts without vascular lengthening (43±5 vs. 58±9 min), and a comparable implantation time to left kidney grafts. Renal vessel extension with cryopreserved vascular grafts allows faster implantation time in right kidney grafts or grafts with anomalous vascularization, maintaining similar surgical and functional outcomes.
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Affiliation(s)
- Guido Fallani
- Department of Hepatobiliary Surgery and Transplantation, Policlinico S. Orsola-Malpighi, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Lorenzo Maroni
- Department of Hepatobiliary Surgery and Transplantation, Policlinico S. Orsola-Malpighi, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Chiara Bonatti
- Department of Hepatobiliary Surgery and Transplantation, Policlinico S. Orsola-Malpighi, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giorgia Comai
- Department of Nephrology, Dialysis and Transplantation, Policlinico S. Orsola-Malpighi, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marina Buzzi
- Tissue Bank, Department of Immunohematology and Transfusion Medicine, Policlinico S. Orsola-Malpighi, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Vania Cuna
- Department of Nephrology, Dialysis and Transplantation, Policlinico S. Orsola-Malpighi, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Vasuri
- Department of Pathology, Policlinico S. Orsola-Malpighi, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesca Caputo
- Department of Hepatobiliary Surgery and Transplantation, Policlinico S. Orsola-Malpighi, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Enrico Prosperi
- Department of Hepatobiliary Surgery and Transplantation, Policlinico S. Orsola-Malpighi, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Federico Pisani
- Department of Hepatobiliary Surgery and Transplantation, Policlinico S. Orsola-Malpighi, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Beatrice Pisillo
- Department of Hepatobiliary Surgery and Transplantation, Policlinico S. Orsola-Malpighi, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Ludovica Maurino
- Department of Hepatobiliary Surgery and Transplantation, Policlinico S. Orsola-Malpighi, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Federica Odaldi
- Department of Hepatobiliary Surgery and Transplantation, Policlinico S. Orsola-Malpighi, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Valentina Rosa Bertuzzo
- Department of Hepatobiliary Surgery and Transplantation, Policlinico S. Orsola-Malpighi, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Tondolo
- Department of Nephrology, Dialysis and Transplantation, Policlinico S. Orsola-Malpighi, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Busutti
- Department of Nephrology, Dialysis and Transplantation, Policlinico S. Orsola-Malpighi, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Chiara Zanfi
- Department of Hepatobiliary Surgery and Transplantation, Policlinico S. Orsola-Malpighi, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Massimo Del Gaudio
- Department of Hepatobiliary Surgery and Transplantation, Policlinico S. Orsola-Malpighi, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gaetano La Manna
- Department of Nephrology, Dialysis and Transplantation, Policlinico S. Orsola-Malpighi, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Matteo Ravaioli
- Department of Hepatobiliary Surgery and Transplantation, Policlinico S. Orsola-Malpighi, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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33
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Hwang CS, MacConmara M, Dick AAS. Use of DCD organs: Expanding the donor pool to increase pediatric transplantation. Pediatr Transplant 2023; 27 Suppl 1:e14234. [PMID: 35098637 DOI: 10.1111/petr.14234] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/06/2021] [Accepted: 01/03/2022] [Indexed: 01/24/2023]
Abstract
The number of children being listed for transplant continues to be greater than the number of available organs. In fact, over the past decade, rates of liver and kidney transplants in pediatric transplantation are essentially unchanged (Am J Transplant. 2020;20:193 and Am J Transplant. 2020;20:20). The use of DCD donors offers a potential solution to organ scarcity; however, the use of DCD organs in pediatric transplantation remains a rare event. Pediatric transplants done using carefully chosen DCD donor organs have shown to have outcomes similar to those seen with the use of donation after brain death (DBD) donors. Herein, we review the literature to examine the utilization of DCD livers and kidneys, outcomes of these allografts, and assess if DCD organs are a viable method to increase organ availability in pediatric transplantation.
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Affiliation(s)
- Christine S Hwang
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Division of Pediatric Transplantation, Children's Medical Center, Dallas, Texas, USA
| | - Malcolm MacConmara
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Division of Pediatric Transplantation, Children's Medical Center, Dallas, Texas, USA
| | - André A S Dick
- Department of Surgery, University of Washington, Seattle, Washington, USA.,Department of Surgery, Seattle Children's Hospital, Seattle, Washington, USA
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34
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Rea KE, West KB, Dorste A, Christofferson ES, Lefkowitz D, Mudd E, Schneider L, Smith C, Triplett KN, McKenna K. A systematic review of social determinants of health in pediatric organ transplant outcomes. Pediatr Transplant 2023; 27:e14418. [PMID: 36321186 DOI: 10.1111/petr.14418] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/27/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Equitable access to pediatric organ transplantation is critical, although risk factors negatively impacting pre- and post-transplant outcomes remain. No synthesis of the literature on SDoH within the pediatric organ transplant population has been conducted; thus, the current systematic review summarizes findings to date assessing SDoH in the evaluation, listing, and post-transplant periods. METHODS Literature searches were conducted in Web of Science, Embase, PubMed, and Cumulative Index to Nursing and Allied Health Literature databases. RESULTS Ninety-three studies were included based on pre-established criteria and were reviewed for main findings and study quality. Findings consistently demonstrated disparities in key transplant outcomes based on racial or ethnic identity, including timing and likelihood of transplant, and rates of rejection, graft failure, and mortality. Although less frequently assessed, variations in outcomes based on geography were also noted, while findings related to insurance or SES were inconsistent. CONCLUSION This review underscores the persistence of SDoH and disparity in equitable transplant outcomes and discusses the importance of individual and systems-level change to reduce such disparities.
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Affiliation(s)
- Kelly E Rea
- Department of Psychology, University of Georgia, Athens, Georgia, USA
| | - Kara B West
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anna Dorste
- Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Debra Lefkowitz
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily Mudd
- Cleveland Clinic Children's, Center for Pediatric Behavioral Health, Wilmington, North Carolina, USA
| | - Lauren Schneider
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Courtney Smith
- Norton Children's, University of Louisville, Louisville, Kentucky, USA
| | - Kelli N Triplett
- Children's Health, Children's Medical Center Dallas, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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35
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Pasternak AL, Park JM, Pai MP. Predictive Capacity of Population Pharmacokinetic Models for the Tacrolimus Dose Requirements of Pediatric Solid Organ Transplant Recipients. Ther Drug Monit 2023; 45:95-101. [PMID: 36624576 PMCID: PMC9832243 DOI: 10.1097/ftd.0000000000001002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 04/01/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Transplant recipients require individualized tacrolimus doses to maximize graft survival. Multiple pediatric tacrolimus population pharmacokinetic (PopPK) models incorporating CYP3A5 genotype and other covariates have been developed. Identifying the optimal popPK model is necessary for clinical implementation in pediatric solid organ transplant. The primary objective was to compare the dose prediction capabilities of the developed models in pediatric kidney and heart transplant recipients. METHODS Pediatric kidney or heart transplant recipients treated with tacrolimus and available CYP3A5 genotype data were identified. The initial weight-based tacrolimus dose and first therapeutic tacrolimus dose were collected retrospectively. Three published popPK models were used to predict the tacrolimus dose required to achieve a tacrolimus trough concentration of 10 ng/mL. Model dose predictions were compared with the initial and first therapeutic doses using Friedman test. The first therapeutic dose was plotted against the model-predicted dose. RESULTS The median initial dose approximately 2-fold lower than the first therapeutic dose for CYP3A5 expressers. The Chen et al model provided the closest estimates to the first therapeutic dose for kidney transplant recipients; however, all 3 models tended to underpredict the observed therapeutic dose. For heart transplant recipients, Andrews et al model predicted doses that were higher than the initial dose but similar to the actual therapeutic dose. CONCLUSIONS Weight-based tacrolimus dosing appears to underestimate the tacrolimus dose requirements. The development of a separate popPK model is necessary for heart transplant recipients. A genotype-guided strategy based on the Chen et al model provided the best estimates for doses in kidney transplant recipients and should be prospectively evaluated.
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Affiliation(s)
- Amy L. Pasternak
- University of Michigan College of Pharmacy, Department of Clinical Pharmacy, 428 Church St. Ann Arbor, MI 48109
- University of Michigan Health, Michigan Medicine, Department of Pharmacy, 1500 East Medical Center Drive, UHB2D301 / 5008, Ann Arbor, MI 48109
| | - Jeong M. Park
- University of Michigan College of Pharmacy, Department of Clinical Pharmacy, 428 Church St. Ann Arbor, MI 48109
- University of Michigan Health, Michigan Medicine, Department of Pharmacy, 1500 East Medical Center Drive, UHB2D301 / 5008, Ann Arbor, MI 48109
| | - Manjunath P. Pai
- University of Michigan College of Pharmacy, Department of Clinical Pharmacy, 428 Church St. Ann Arbor, MI 48109
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36
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Lin X, Liu X, Wu X, Xie X, Liu G, Wu J, Peng W, Wang R, Chen J, Huang H. Wide-spectrum antibiotic prophylaxis guarantees optimal outcomes in drowned donor kidney transplantation. Expert Rev Anti Infect Ther 2023; 21:203-211. [PMID: 36573685 DOI: 10.1080/14787210.2023.2163237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Drowned victims possibly obtain various pathogens from drowning sites. Using drowned renal donors to expand the donor pool still lacks consensus due to the potential risk of disease transmission. RESEARCH DESIGN AND METHODS This retrospective study enrolled 38 drowned donor renal recipients in a large clinical center from August 2012 to February 2021. A 1:2 matched cohort was generated with donor demographics, including age, gender, BMI, and ICU durations. Donor microbiological results, recipient perioperative infections, and early post-transplant and first-year clinical outcomes were analyzed. RESULTS Compared to the control group, drowned donors had significantly increased positive fungal cultures (36.84% vs.13.15%, p = 0.039). Recipients in the drowned group had significantly higher rates of gram-negative bacteria (GNB) and multidrug-resistant GNB infections (23.68% vs.5.26%, 18.42% vs. 3.95%, both p < 0.05). Other colonization and infections were also numerically more frequent in the drowned group. Drowned donor recipients receiving inadequate antibiotic prophylaxis had more perioperative bloodstream infections, higher DGF incidences, and more first-year respiratory tract infections and recipient loss than those receiving adequate prophylaxis (all p < 0.05). Clinical outcomes were similar between the adequate group and the control group. CONCLUSIONS Drowned donors could be suitable options under wide-spectrum and adequate antimicrobial prophylaxis.
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Affiliation(s)
- Xiaoli Lin
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China.,Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China.,Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Zhejiang, China
| | - Xinyu Liu
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China.,Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China.,Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Zhejiang, China
| | - Xiaoying Wu
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China.,Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China.,Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Zhejiang, China
| | - Xishao Xie
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China.,Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China.,Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Zhejiang, China
| | - Guangjun Liu
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China.,Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China.,Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Zhejiang, China
| | - Jianyong Wu
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China.,Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China.,Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Zhejiang, China
| | - Wenhan Peng
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China.,Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China.,Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Zhejiang, China
| | - Rending Wang
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China.,Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China.,Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Zhejiang, China
| | - Jianghua Chen
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China.,Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China.,Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Zhejiang, China
| | - Hongfeng Huang
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China.,Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China.,Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Zhejiang, China
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37
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Zaphiros NH, Nie J, Chang S, Shah V, Kareem S, Zaaroura A, Kayler LK. Broad organ acceptance and equitable access to early kidney transplantation. Clin Transplant 2023; 37:e14916. [PMID: 36638138 DOI: 10.1111/ctr.14916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 12/23/2022] [Accepted: 01/10/2023] [Indexed: 01/14/2023]
Abstract
BACKGROUND Broad organ acceptance can increase early kidney transplantation (KTX) within <1-year of dialysis initiation while improving access inequity. METHODS Single-center data of adult isolated deceased-donor KTX recipients between 2013 and 2020 were stratified into three 2.5-year periods before-, early after-, and late after our center's deceased-donor organ acceptance practice change, excluding a 6-month implementation period. Outcomes were assessed within five recipient subgroups based on demographic and clinical characteristics. RESULTS Of 704 recipients, the frequency of early KTX was 22% pre-change, 36% early post-change, and 34% late post-change. Given similar post-change frequencies of early KTX, post-change eras were combined to improve analytic power of subgroup analyses. After the organ acceptance practice change (vs. pre-change), the likelihood of early KTX increased variably within historically underserved groups, including recipients who were older (37%-39%, p = .859), Black (10%-21%, p = .136), female (21%-37%, p = .034), diabetic (13%-32%, p = .010), and BMI≥35 kg/m2 (20%-34%, p = .007). Despite the practice change, Black recipients continued to experience less early KTX compared to non-Black recipients. The likelihood of delayed graft function was significantly increased (p < .001), and 1-year creatinine was significantly higher (p < .001) post-practice change, but between-era risk-adjusted death-censored graft survival was similar. CONCLUSIONS Transition to broader donor acceptance was associated with more early KTXs among historically underserved patient subgroups. However, the effect was non-significant among Black recipients, suggesting the need for additional strategies to impact early transplant access for this population. Studies of broad organ acceptance are needed to examine both access and outcomes.
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Affiliation(s)
- Nikolas H Zaphiros
- Department of Surgery, University at Buffalo, Buffalo, New York, USA.,Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, Buffalo, New York, USA
| | - Jing Nie
- Department of Epidemiology and Environmental Health, University at Buffalo School of Public Health and Health Professions, Buffalo, New York, USA
| | - Shirley Chang
- Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, Buffalo, New York, USA.,Department of Medicine, University at Buffalo, Buffalo, New York, USA
| | - Vaqar Shah
- Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, Buffalo, New York, USA.,Department of Medicine, University at Buffalo, Buffalo, New York, USA
| | - Samer Kareem
- Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, Buffalo, New York, USA.,Department of Medicine, University at Buffalo, Buffalo, New York, USA
| | - Ahmad Zaaroura
- Department of Surgery, University at Buffalo, Buffalo, New York, USA.,Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, Buffalo, New York, USA
| | - Liise K Kayler
- Department of Surgery, University at Buffalo, Buffalo, New York, USA.,Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, Buffalo, New York, USA.,Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, New York, USA
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Khairallah P, Robbins-Juarez S, Patel S, Shah V, Toma K, Fernandez H, Dube GK, King K, Mohan S, Husain SA, Morris H, Crew RJ. Tocilizumab for the treatment of chronic antibody mediated rejection in kidney transplant recipients. Clin Transplant 2023; 37:e14853. [PMID: 36398915 DOI: 10.1111/ctr.14853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 09/28/2022] [Accepted: 11/04/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic active antibody-mediated rejection (CAAMR) constitutes a dominant form of late allograft failure. Several treatment strategies directed at CAAMR have been attempted but proven ineffective at delaying kidney function decline or reducing donor-specific antibodies (DSA). We describe our single-center experience using tocilizumab in patients with CAAMR. METHODS This is a retrospective analysis using electronic medical records. 38 kidney transplant recipients at Columbia University Irving Medical Center who had been prescribed tocilizumab and followed for at least 3 months between August 2013 through December 2019 were included. RESULTS Tocilizumab use was associated with a decrease in the rate of estimated glomerular filtration rate (eGFR) decline in the 6 months following treatment initiation as compared to the 3 months before tocilizumab was initiated (difference between slopes before and after initiation of treatment = 2.6 mL/min/1.73 m2 (SE = .8, p = .002) per month for up to 6 months following Tocilizumab initiation). Allograft biopsies showed significant improvement in interstitial inflammation scores (score 1(0,1) to 0 (0,1), p = .03) while other histologic scores remained stable. There was no significant change in proteinuria or DSA titers post-treatment with tocilizumab. CONCLUSIONS Treatment of CAAMR with tocilizumab was associated with a decrease in the rate of eGFR decline and a reduction in interstitial inflammation scores in patients with CAAMR.
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Affiliation(s)
| | - Shelief Robbins-Juarez
- Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Shefali Patel
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Vaqar Shah
- Department of Medicine, SUNY University at Buffalo, Buffalo, New York, USA
| | - Katherine Toma
- Jersey Coast Nephrology and Hypertension Associates, Brick, New Jersey, USA
| | - Hilda Fernandez
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Geoffrey K Dube
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Kristen King
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Sumit Mohan
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Syed Ali Husain
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Heather Morris
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Russell John Crew
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
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Salinas T, Li C, Snopkowski C, Stryjniak G, Shankaranarayanan D, Albakry S, Ding R, Sharma VK, Salvatore SP, Seshan SV, Dadhania DM, Muthukumar T, Suthanthiran M. Urinary cell mRNA profiling of kidney allograft recipients: Development of a portable protocol for noninvasive diagnosis of T cell mediated rejection and BK virus nephropathy. J Immunol Methods 2023; 512:113402. [PMID: 36493873 DOI: 10.1016/j.jim.2022.113402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/22/2022] [Accepted: 12/03/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND We developed urinary cell mRNA profiling for noninvasive diagnosis of acute T cell mediated rejection (TCMR) and BK virus nephropathy (BKVN), two significant post-transplant complications. Our profiling protocol for the multicenter Clinical Trial of Transplantation-04 (CTOT-04) study consisted of centrifugation of urine to prepare cell pellets, washes, addition of an RNA preservative, storage at 800C and shipment in cold containers to our Gene Expression Monitoring (GEM) Core for RNA isolation and quantification of mRNA in RT-qPCR assays. To simplify profiling, we developed a filter-based protocol (ZFBP) that eliminated the need for centrifugation, RNA preservative, storage at 800C, and shipment in cold containers for mRNA profiling. Furthermore, we trained kidney allograft recipients to perform the filtration of urine at home using the filter and post the urinary cell lysate containing the RNA at ambient temperature to our GEM Core for profiling. Here, we report our refinement of ZFBP and investigation of its diagnostic performance characteristics. METHODS Total RNA was isolated from kidney allograft biopsy-matched urines using a filter-based protocol complemented by a silica-membrane-based cartridge for mRNA enrichment, the Weill Cornell Hybrid Protocol (WCHP). Absolute copy numbers of CD3ε mRNA, CXCL10 mRNA, and 18S rRNA, components of the CTOT-04 three-gene TCMR diagnostic signature, and urinary cell BKV VP 1 mRNA copy number were measured using RT-qPCR assays. Mann-Whitney test, Fischer exact test, and receiver operating characteristic (ROC) curve analysis were used for data analyses. RESULTS Urinary cell three-gene TCMR diagnostic signature scores in urines processed using the WCHP discriminated kidney allograft recipients with TCMR (12 TCMR biopsies from 11 patients) from those without TCMR or BKVN (29 No TCMR/No BKVN biopsies from 29 patients). The median (25th and 75th percentiles) score of the CTOT-04 three-gene TCMR diagnostic signature was -0.448 (-1.664, 0.204) in the TCMR group and - 2.542 (-3.267, -1.365) in the No TCMR/ No BKVN group (P = 0.0005, Mann-Whitney test). ROC curve analysis discriminated the TCMR group from the No TCMR/ No BKVN group; the area under the ROC curve (AUROC) was 0.84 (95% Confidence Intervals [CI], 0.69 to 0.98) (P < 0.001), and TCMR was diagnosed with a sensitivity of 67% (95% CI, 35 to 89) at a specificity of 86% (95% CI, 67 to 95) using the CTOT-04 validated cutpoint of -1.213 (P = 0.0016, Fisher exact test). BKV VP1 mRNA copy number in urines processed using the WCHP discriminated patients with BKVN (n = 7) from patients without TCMR or BKVN (n = 29) and the AUROC was 1.0 (95% CI, 1.00 to 1.00) (P < 0.0001) and BKVN was diagnosed with a sensitivity of 86% (95% CI, 42 to 99) at a specificity of 100% (95% CI, 85 to 100) with the previously validated cutpoint of 6.5 × 108 BKV-VP1 mRNA copies per microgram of RNA (P < 0.0001, Fisher exact test). CONCLUSION Urine processed using the WCHP predicted TCMR and BKVN in kidney allograft recipients. WCHP represents not only a significant advance toward the portability of urinary cell mRNA profiling but also improved patient management by minimizing their visits for urine collection.
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Affiliation(s)
- Thalia Salinas
- Division of Nephrology and Hypertension, Department of Medicine, NewYork-Presbyterian-Weill Cornell Medicine, New York, NY, USA; Department of Transplantation Medicine, NewYork-Presbyterian Hospital-Weill Cornell Medicine, New York, NY, USA.
| | - Carol Li
- Division of Nephrology and Hypertension, Department of Medicine, NewYork-Presbyterian-Weill Cornell Medicine, New York, NY, USA
| | - Catherine Snopkowski
- Division of Nephrology and Hypertension, Department of Medicine, NewYork-Presbyterian-Weill Cornell Medicine, New York, NY, USA
| | - Gabriel Stryjniak
- Division of Nephrology and Hypertension, Department of Medicine, NewYork-Presbyterian-Weill Cornell Medicine, New York, NY, USA
| | - Divya Shankaranarayanan
- Division of Nephrology and Hypertension, Department of Medicine, NewYork-Presbyterian-Weill Cornell Medicine, New York, NY, USA
| | - Shady Albakry
- Division of Nephrology and Hypertension, Department of Medicine, NewYork-Presbyterian-Weill Cornell Medicine, New York, NY, USA
| | - Ruchuang Ding
- Division of Nephrology and Hypertension, Department of Medicine, NewYork-Presbyterian-Weill Cornell Medicine, New York, NY, USA
| | - Vijay K Sharma
- Division of Nephrology and Hypertension, Department of Medicine, NewYork-Presbyterian-Weill Cornell Medicine, New York, NY, USA
| | - Steven P Salvatore
- Division of Renal Pathology, Department of Pathology, NewYork-Presbyterian Hospital-Weill Cornell Medicine, New York, NY, USA
| | - Surya V Seshan
- Division of Renal Pathology, Department of Pathology, NewYork-Presbyterian Hospital-Weill Cornell Medicine, New York, NY, USA
| | - Darshana M Dadhania
- Division of Nephrology and Hypertension, Department of Medicine, NewYork-Presbyterian-Weill Cornell Medicine, New York, NY, USA; Department of Transplantation Medicine, NewYork-Presbyterian Hospital-Weill Cornell Medicine, New York, NY, USA
| | - Thangamani Muthukumar
- Division of Nephrology and Hypertension, Department of Medicine, NewYork-Presbyterian-Weill Cornell Medicine, New York, NY, USA; Department of Transplantation Medicine, NewYork-Presbyterian Hospital-Weill Cornell Medicine, New York, NY, USA
| | - Manikkam Suthanthiran
- Division of Nephrology and Hypertension, Department of Medicine, NewYork-Presbyterian-Weill Cornell Medicine, New York, NY, USA; Department of Transplantation Medicine, NewYork-Presbyterian Hospital-Weill Cornell Medicine, New York, NY, USA
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Al Jurdi A, Liu EC, Salinas T, Aull MJ, Lubetzky M, Drelick AL, Small CB, Kapur S, Hartono C, Muthukumar T. Complications of rabbit anti-thymocyte globulin induction immunosuppression in HIV-infected kidney transplant recipients. FRONTIERS IN NEPHROLOGY 2022; 2:1047170. [PMID: 37675034 PMCID: PMC10479633 DOI: 10.3389/fneph.2022.1047170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 11/29/2022] [Indexed: 09/08/2023]
Abstract
Background Kidney transplantation in HIV-infected individuals with end-stage kidney disease is associated with improved survival compared to dialysis. Rabbit anti-thymocyte globulin (rATG) induction in HIV-infected kidney transplant recipients has been associated with a lower risk of acute rejection, but data on the rates of de novo malignancy and BK viremia in these patients is lacking. Methods We performed a single-center retrospective cohort study of adult HIV-infected individuals who underwent kidney transplantation with rATG induction between January 2006 and December 2016. The primary outcome was the development of de novo malignancy. Secondary outcomes included the development of BK viremia, infections requiring hospitalization, HIV progression, biopsy-proven acute rejection, and patient and allograft survival. Results Twenty-seven HIV-infected individuals with end-stage kidney disease received deceased (n=23) or living (n=4) donor kidney transplants. The cumulative rate of malignancy at five years was 29%, of whom 29% died because of advanced malignancy. BK viremia was detected in six participants (22%), of whom one had biopsy-proven BK virus-associated nephropathy and all of whom cleared the BK viremia. Five-year acute rejection rates, patient survival and death-censored allograft survival were 17%, 85% and 80% respectively. Conclusion rATG induction in HIV-infected kidney transplant recipients was associated with a low risk of acute rejection, but a potentially higher risk of de novo malignancies and BK viremia in this cohort. Screening strategies to closely monitor for BK virus infection and malignancy post-transplantation may improve outcomes in HIV-infected kidney transplant recipients receiving rATG induction.
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Affiliation(s)
- Ayman Al Jurdi
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, United States
| | - Esther C. Liu
- Department of Pharmacy, NewYork Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
| | - Thalia Salinas
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- Department of Transplantation Medicine, NewYork Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
| | - Meredith J. Aull
- Division of Transplant Surgery, Department of Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Michelle Lubetzky
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- Department of Transplantation Medicine, NewYork Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
| | - Alexander L. Drelick
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Catherine B. Small
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Sandip Kapur
- Division of Transplant Surgery, Department of Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Choli Hartono
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- Department of Transplantation Medicine, NewYork Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
- The Rogosin Institute, New York, NY, United States
| | - Thangamani Muthukumar
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- Department of Transplantation Medicine, NewYork Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
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Woods C, Owens G, Shelton BA, MacLennan PA, Sawinski D, Jacobson J, Locke JE. Efficacy of hope: Analysis of organ quality and availability among deceased HIV-positive donors. Transpl Infect Dis 2022; 24:e13916. [PMID: 35904220 PMCID: PMC9780158 DOI: 10.1111/tid.13916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/21/2022] [Accepted: 04/16/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Improved survival among people with human immunodeficiency virus (HIV) (PWH) has led to increased organ failure, necessitating transplantation. In 2013, the HIV Organ Policy Equity (HOPE) Act was passed, allowing PWH to donate organs to other PWH. No study has assessed organ quality and quantity among a national pool of PWH. METHODS CFAR Network of Integrated Clinical Systems (CNICS), a multicenter study capturing data on PWH, was used to identify 6504 deaths from 1999 to 2018. Exclusions included cause of death, chronic kidney disease, fibrosis-4 score ≥ 3.25, and opportunistic infection at the time of death. Donor quality was defined by HIV viremia and the kidney donor profile index (KDPI). The CDC Wonder database, which contains national death data, permitted the estimation of deaths among PWH nationally from 1999 to 2018. Assuming CNICS was representative of PWH nationally, percentages of potential donors were applied to the CDC Wonder cohort. RESULTS Within CNICS, there were 3241 (65.9%) potential kidney donors and 3536 (71.9%) potential liver donors from 1999 to 2018. Based on viremia and KDPI, 821 were lower-risk kidney donors (16.7%) and 1206 (24.5%) were lower-risk liver donors. Within CDC Wonder, we identified 12 048 potential donors from 1999 to 2018. Extrapolating from CNICS to the national cohort suggested 396 kidney donors (792 kidneys) and 433 liver donors annually, with 100 kidney donors (200 kidneys) and 147 livers being lower-risk. CONCLUSION A substantial number of PWH meet donation criteria, a valuable source of organs for PWH in need of transplants. Our estimates suggest there may be more available organs from PWH than current transplant numbers indicate.
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Affiliation(s)
| | - Grace Owens
- University of Alabama at Birmingham Heersink School of Medicine
- University of Virginia
| | | | | | | | | | - Jayme E. Locke
- University of Alabama at Birmingham Heersink School of Medicine
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Li H, Shao G, Zhao Y, Zhong H. The value of inflow inversion recovery MRI for the diagnosis of transplant renal artery stenosis: comparison with digital subtraction angiography. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2022. [DOI: 10.1186/s43055-021-00682-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
To date, few data on the assessment of transplant renal artery stenosis (TRAS) by using inflow inversion recovery (IFIR) are available. The aims of this study was to evaluate the feasibility of IFIR in the assessment of TRAS using Digital Subtraction Angiography (DSA) as the reference.
Results
We retrospectively assessed the IFIR of 195 transplant renal arteries. The IFIR images for 194/195 arteries were judged to be of excellent, good, or moderate quality, and 1/195 was not diagnostic. There were 100 arteries with TRAS, of which 27 were subjected to DSA. The stenosis percentages were divided into five grades. Using DSA images, the TRAS in 27 patients were estimated as grade 1 (2, 7.4%), grade 2 (8, 29.6%), grade 3 (10, 37.0%), grade 4 (7, 25.9%) and grade 5 (0, 0%). In comparison, the TRAS was shown to be grade 1 (1, 3.7%), grade 2 (8, 29.6%), grade 3 (9, 33.3%), grade 4 (9, 33%) and grade 5 (0, 0%) in the IFIR images. The nonparametric Wilcoxon signed-rank test was used to compare IFIR with DSA. In addition, a Bland–Altman plot was used to estimate the agreement between IFIR and DSA measurements. There was no significant difference between IFIR and DSA measurements (p < 0.05).
Conclusions
Relative to the reference DSA, IFIR was shown to be noninvasive, accurate for the diagnosis and evaluation of TRAS.
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Chancay J, Liu C, Chauhan K, Andersen L, Harris C, Coca S, Delaney V, Tedla F, De Boccardo G, Sehgal V, Moledina D, Formica R, Reghuvaran A, Banu K, Florman S, Akalin E, Shapiro R, Salem F, Menon MC. Role of time from transplantation to biopsy in histologic ABMR: A single center report. Clin Transplant 2022; 36:e14802. [PMID: 36069577 PMCID: PMC10211409 DOI: 10.1111/ctr.14802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 06/24/2022] [Accepted: 08/19/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Allograft biopsies with lesions of Antibody-Mediated Rejection (ABMR) with Microvascular Inflammation (MVI) have shown heterogeneous etiologies and outcomes. METHODS To examine factors associated with outcomes in biopsies that meet histologic ABMR criteria, we retrospectively evaluated for-cause biopsies at our center between 2011 and 2017. We included biopsies that met the diagnosis of ABMR by histology, along with simultaneous evaluation for anti-Human Leukocyte Antigen (HLA) donor-specific antibodies (DSA). We evaluated death-censored graft loss (DCGL) and used a principal component analysis (PCA) approach to identify key predictors of outcomes. RESULTS Out of the histologic ABMR cohort (n = 118), 70 were DSA-positive ABMR, while 48 had no DSA. DSA(+)ABMR were younger and more often female recipients. DSA(+)ABMR occurred significantly later post-transplant than DSA(-)ABMR suggesting time-dependence. DSA(+)ABMR had higher inflammatory scores (i,t), chronicity scores (ci, ct) and tended to have higher MVI scores. Immunodominance of DQ-DSA in DSA(+)ABMR was associated with higher i+t scores. Clinical/histologic factors significantly associated with DCGL after biopsy were inputted into the PCA. Principal component-1 (PC-1), which contributed 34.8% of the variance, significantly correlated with time from transplantation to biopsy, ci/ct scores and DCGL. In the PCA analyses, i, t scores, DQ-DSA, and creatinine at biopsy retained significant correlations with GL-associated PCs. CONCLUSIONS Time from transplantation to biopsy plays a major role in the prognosis of biopsies with histologic ABMR and MVI, likely due to ongoing chronic allograft injury over time.
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Affiliation(s)
- Jorge Chancay
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Caroline Liu
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Kinsuk Chauhan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Lisa Andersen
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Cynthia Harris
- Transplant Center at Massachusetts General Hospital, Harvard Medical School, Cambridge, MA, United States
| | - Steven Coca
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Veronica Delaney
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Fasika Tedla
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Graciela De Boccardo
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Vinita Sehgal
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Dennis Moledina
- Yale New Haven Transplantation Center, Yale School of Medicine, New Haven, CT, United States
| | - Richard Formica
- Yale New Haven Transplantation Center, Yale School of Medicine, New Haven, CT, United States
| | - Anand Reghuvaran
- Yale New Haven Transplantation Center, Yale School of Medicine, New Haven, CT, United States
| | - Khadija Banu
- Yale New Haven Transplantation Center, Yale School of Medicine, New Haven, CT, United States
| | - Sander Florman
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Enver Akalin
- Montefiore Einstein Center for Transplantation, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Ron Shapiro
- Transplant Center at Massachusetts General Hospital, Harvard Medical School, Cambridge, MA, United States
| | - Fadi Salem
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Madhav C Menon
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Yale New Haven Transplantation Center, Yale School of Medicine, New Haven, CT, United States
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Frutos MÁ, Crespo M, Valentín MDLO, Alonso-Melgar Á, Alonso J, Fernández C, García-Erauzkin G, González E, González-Rinne AM, Guirado L, Gutiérrez-Dalmau A, Huguet J, Moral JLLD, Musquera M, Paredes D, Redondo D, Revuelta I, Hofstadt CJVD, Alcaraz A, Alonso-Hernández Á, Alonso M, Bernabeu P, Bernal G, Breda A, Cabello M, Caro-Oleas JL, Cid J, Diekmann F, Espinosa L, Facundo C, García M, Gil-Vernet S, Lozano M, Mahillo B, Martínez MJ, Miranda B, Oppenheimer F, Palou E, Pérez-Saez MJ, Peri L, Rodríguez O, Santiago C, Tabernero G, Hernández D, Domínguez-Gil B, Pascual J. Recommendations for living donor kidney transplantation. Nefrologia 2022; 42 Suppl 2:5-132. [PMID: 36503720 DOI: 10.1016/j.nefroe.2022.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/26/2021] [Indexed: 06/17/2023] Open
Abstract
This Guide for Living Donor Kidney Transplantation (LDKT) has been prepared with the sponsorship of the Spanish Society of Nephrology (SEN), the Spanish Transplant Society (SET), and the Spanish National Transplant Organization (ONT). It updates evidence to offer the best chronic renal failure treatment when a potential living donor is available. The core aim of this Guide is to supply clinicians who evaluate living donors and transplant recipients with the best decision-making tools, to optimise their outcomes. Moreover, the role of living donors in the current KT context should recover the level of importance it had until recently. To this end the new forms of incompatible HLA and/or ABO donation, as well as the paired donation which is possible in several hospitals with experience in LDKT, offer additional ways to treat renal patients with an incompatible donor. Good results in terms of patient and graft survival have expanded the range of circumstances under which living renal donors are accepted. Older donors are now accepted, as are others with factors that affect the decision, such as a borderline clinical history or alterations, which when evaluated may lead to an additional number of transplantations. This Guide does not forget that LDKT may lead to risk for the donor. Pre-donation evaluation has to centre on the problems which may arise over the short or long-term, and these have to be described to the potential donor so that they are able take them into account. Experience over recent years has led to progress in risk analysis, to protect donors' health. This aspect always has to be taken into account by LDKT programmes when evaluating potential donors. Finally, this Guide has been designed to aid decision-making, with recommendations and suggestions when uncertainties arise in pre-donation studies. Its overarching aim is to ensure that informed consent is based on high quality studies and information supplied to donors and recipients, offering the strongest possible guarantees.
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Affiliation(s)
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | | | | | - Juana Alonso
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | | | - Esther González
- Nephrology Department, Hospital Universitario 12 Octubre, Spain
| | | | - Lluis Guirado
- Nephrology Department, Fundacio Puigvert, Barcelona, Spain
| | | | - Jorge Huguet
- RT Surgical Team, Fundació Puigvert, Barcelona, Spain
| | | | - Mireia Musquera
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | - David Paredes
- Donation and Transplantation Coordination Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Ignacio Revuelta
- Nephrology and RT Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Antonio Alcaraz
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Manuel Alonso
- Regional Transplantation Coordination, Seville, Spain
| | | | - Gabriel Bernal
- Nephrology Department, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Alberto Breda
- RT Surgical Team, Fundació Puigvert, Barcelona, Spain
| | - Mercedes Cabello
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | - Joan Cid
- Apheresis and Cell Therapy Unit, Haemotherapy and Haemostasis Department, Hospital Clinic Universitari, Barcelona, Spain
| | - Fritz Diekmann
- Nephrology and RT Department, Hospital Clinic Universitari, Barcelona, Spain
| | - Laura Espinosa
- Paediatric Nephrology Department, Hospital La Paz, Madrid, Spain
| | - Carme Facundo
- Nephrology Department, Fundacio Puigvert, Barcelona, Spain
| | | | | | - Miquel Lozano
- Apheresis and Cell Therapy Unit, Haemotherapy and Haemostasis Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | | | | | | | - Eduard Palou
- Immunology Department, Hospital Clinic i Universitari, Barcelona, Spain
| | | | - Lluis Peri
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | | | | | - Domingo Hernández
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | - Julio Pascual
- Nephrology Department, Hospital del Mar, Barcelona, Spain.
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Bae S, Alejo JL, Chiang TP, Werbel WA, Tobian AA, Moore LW, Guha A, Huang HJ, Knight RJ, Gaber AO, Ghobrial RM, McAdams-DeMarco MA, Segev DL. mTOR inhibitors, mycophenolates, and other immunosuppression regimens on antibody response to SARS-CoV-2 mRNA vaccines in solid organ transplant recipients. Am J Transplant 2022; 22:3137-3142. [PMID: 35869809 PMCID: PMC9350033 DOI: 10.1111/ajt.17158] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/24/2022] [Accepted: 07/16/2022] [Indexed: 01/25/2023]
Abstract
A recent study concluded that SARS-CoV-2 mRNA vaccine responses were improved among transplant patients taking mTOR inhibitors (mTORi). This could have profound implications for vaccine strategies in transplant patients; however, limitations in the study design raise concerns about the conclusions. To address this issue more robustly, in a large cohort with appropriate adjustment for confounders, we conducted various regression- and machine learning-based analyses to compare antibody responses by immunosuppressive agents in a national cohort (n = 1037). MMF was associated with significantly lower odds of positive antibody response (aOR = 0.09 0.130.18 ). Consistent with the recent mTORi study, the odds tended to be higher with mTORi (aOR = 1.00 1.452.13 ); however, importantly, this seemingly protective tendency disappeared (aOR = 0.47 0.731.12 ) after adjusting for MMF. We repeated this comparison by combinations of immunosuppression agents. Compared to MMF + tacrolimus, MMF-free regimens were associated with higher odds of positive antibody response (aOR = 2.39 4.267.92 for mTORi+tacrolimus; 2.34 5.5415.32 for mTORi-only; and 6.78 10.2515.93 for tacrolimus-only), whereas MMF-including regimens were not, regardless of mTORi use (aOR = 0.81 1.542.98 for MMF + mTORi; and 0.81 1.512.87 for MMF-only). We repeated these analyses in an independent cohort (n = 512) and found similar results. Our study demonstrates that the recently reported findings were confounded by MMF, and that mTORi is not independently associated with improved vaccine responses.
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Affiliation(s)
- Sunjae Bae
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Jennifer L. Alejo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Teresa P.Y. Chiang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - William A. Werbel
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron A.R. Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Linda W. Moore
- Department of Surgery, Houston Methodist Hospital, Houston, Texas, USA
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Ashrith Guha
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, Texas, USA
- Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Howard J. Huang
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, Texas, USA
- Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
| | - Richard J. Knight
- Department of Surgery, Houston Methodist Hospital, Houston, Texas, USA
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, Texas, USA
| | - A. Osama Gaber
- Department of Surgery, Houston Methodist Hospital, Houston, Texas, USA
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, Texas, USA
| | - R. Mark Ghobrial
- Department of Surgery, Houston Methodist Hospital, Houston, Texas, USA
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Mara A. McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Dorry L. Segev
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
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Characteristics of Potential and Actual Living Kidney Donors: A Single-center Experience. Transplantation 2022; 107:941-951. [PMID: 36476994 DOI: 10.1097/tp.0000000000004357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND There are limited data and no national capture of barriers associated with initiating and completing the donation process for potential living kidney donors (LKDs). METHODS We performed a retrospective analysis of 3001 intake forms completed by prospective LKDs from 2016 to 2019 at a single transplant center. We analyzed data from all potential donors who completed the intake until they became ineligible or withdrew or donation was complete. We used univariate and multivariate models to evaluate independent factors associated with donation at various stages in the donation process. RESULTS The donation process was deconstructed into 5 steps: intake form, immunologic compatibility testing, clinic evaluation, selection committee review, and donation. The highest percentage of potential donors dropped out after completing the intake form, primarily because of not responding to the follow-up phone call (22.6%). Of 455 potential LKDs that completed immunologic compatibility testing, 36% were ABO or crossmatch incompatible. One-hundred eighty-eight (7.5%) of all LKD applicants reached donation, the majority of whom were White (91.0%) and female (63.8%). CONCLUSIONS A minority of LKD applicants make it to donation. Our ability to track all potential LKDs from the initial touch point to the transplant center will help us develop interventions to address barriers to a successful donation.
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Bharadwaj P, Shrestha S, Pongracz T, Concetta C, Sharma S, Le Moine A, de Haan N, Murakami N, Riella LV, Holovska V, Wuhrer M, Marchant A, Ackerman ME. Afucosylation of HLA-specific IgG1 as a potential predictor of antibody pathogenicity in kidney transplantation. Cell Rep Med 2022; 3:100818. [PMID: 36384101 PMCID: PMC9729883 DOI: 10.1016/j.xcrm.2022.100818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/23/2022] [Accepted: 10/17/2022] [Indexed: 11/17/2022]
Abstract
Antibody-mediated rejection (AMR) is the leading cause of graft failure. While donor-specific antibodies (DSAs) are associated with a higher risk of AMR, not all patients with DSAs develop rejection, suggesting that the characteristics of alloantibodies determining their pathogenicity remain undefined. Using human leukocyte antigen (HLA)-A2-specific antibodies as a model, we apply systems serology tools to investigate qualitative features of immunoglobulin G (IgG) alloantibodies including Fc-glycosylation patterns and FcγR-binding properties. Levels of afucosylated anti-A2 antibodies are elevated in seropositive patients, especially those with AMR, suggesting potential cytotoxicity via FcγRIII-mediated mechanisms. Afucosylation of both glycoengineered monoclonal and naturally glycovariant polyclonal serum IgG specific to HLA-A2 drives potentiated binding to, slower dissociation from, and enhanced signaling through FcγRIII, a receptor widely expressed on innate effector cells, and greater cytotoxicity against HLA-A2+ cells mediated by natural killer (NK) cells. Collectively, these results suggest that afucosylated DSA may be a biomarker of AMR and contribute to pathogenesis.
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Affiliation(s)
- Pranay Bharadwaj
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH 03755, USA
| | - Sweta Shrestha
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH 03755, USA
| | - Tamas Pongracz
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Leiden, the Netherlands
| | - Catalano Concetta
- Institute for Medical Immunology, Université Libre de Bruxelles, Charleroi, Belgium,Department of Nephrology, Dialysis and Renal Transplantation, Hôpital Erasme, Université libre de Bruxelles, Bruxelles, Belgium
| | - Shilpee Sharma
- Institute for Medical Immunology, Université Libre de Bruxelles, Charleroi, Belgium
| | - Alain Le Moine
- Department of Nephrology, Dialysis and Renal Transplantation, Hôpital Erasme, Université libre de Bruxelles, Bruxelles, Belgium
| | - Noortje de Haan
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Leiden, the Netherlands
| | - Naoka Murakami
- Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Leonardo V. Riella
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA,Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Vanda Holovska
- HLA Laboratory, Laboratoire Hospitalier Universitaire de Bruxelles (LHUB), Hôpital Erasme ULB, Brussels, Belgium
| | - Manfred Wuhrer
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Leiden, the Netherlands
| | - Arnaud Marchant
- Institute for Medical Immunology, Université Libre de Bruxelles, Charleroi, Belgium
| | - Margaret E. Ackerman
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH 03755, USA,Thayer School of Engineering, Dartmouth College, Hanover, NH 03755, USA,Corresponding author
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Predictors of Length of Stay and Mortality During Simultaneous Liver-Kidney Transplant Index Admission: Results From the US-Multicenter SLKT Consortium. Transplant Direct 2022; 8:e1408. [PMID: 36398193 PMCID: PMC9666195 DOI: 10.1097/txd.0000000000001408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/13/2022] [Accepted: 09/28/2022] [Indexed: 11/15/2022] Open
Abstract
Length of stay (LOS) during index solid organ transplant impacts morbidity and healthcare costs. To date, there are no studies evaluating characteristics and outcomes of simultaneous liver-kidney transplant (SLKT) index hospitalization. We examined factors associated with LOS and mortality during index SLKT admission. Methods Adult SLKT recipients between 2002 and 2017 at 6 transplant centers across 6 UNOS regions were retrospectively enrolled in the US-Multicenter SLKT Consortium. Multivariable regression analyses assessed predictors of SLKT LOS and death during index admission. Results Median age of cohort (N = 570) was 58 y (interquartile range: 51-64); 63% male, 75% White, 32.3% hepatitis C, 23.3% alcohol-related, 20.1% nonalcoholic steatohepatitis with median MELD-Na at SLKT 28 (23-34). Seventy-one percent were hospitalized at the time of SLKT with median LOS pretransplant of 10 d. Majority of patients were discharged alive (N = 549; 96%)' and 36% were discharged to subacute rehab facility. LOS for index SLKT was 19 d (Q1: 10, Q3: 34 d). Female sex (P = 0.003), Black race (P = 0.02), advanced age (P = 0.007), ICU admission at time of SLKT (P = 0.03), high MELD-Na (P = 0.003), on cyclosporine during index hospitalization (P = 0.03), pre-SLKT dialysis (P < 0.001), and kidney delayed graft function (P < 0.001) were the recipient factors associated with prolonged LOS during index SLKT hospitalization. Prolonged LOS also contributed to overall mortality (HR = 1.007; P = 0.03). Conclusions Despite excellent survival, index SLKT admission was associated with high-resource utilization with more than half the patients with LOS >2 wk and affected overall patient survival. Further investigation is needed to optimize healthcare resources for these patients in a financially strained healthcare landscape.
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Sharma P, Xie J, Wang L, Zhang M, Magee J, Answine A, Barman P, Jo J, Sinha J, Schluger A, Perreault GJ, Walters KE, Cullaro G, Wong R, Filipek N, Biggins SW, Lai JC, VanWagner LB, Verna EC, Patel YA. Burden of early hospitalization after simultaneous liver-kidney transplantation: Results from the US Multicenter SLKT Consortium. Liver Transpl 2022; 28:1756-1765. [PMID: 35665591 PMCID: PMC11068063 DOI: 10.1002/lt.26523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 04/26/2022] [Accepted: 05/18/2022] [Indexed: 01/13/2023]
Abstract
The burden of early hospitalization (within 6 months) following simultaneous liver-kidney transplant (SLKT) is not known. We examined risk factors associated with early hospitalization after SLKT and their impact on patient mortality conditional on 6-month survival. We used data from the US Multicenter SLKT Consortium cohort study of all adult SLKT recipients between 2002 and 2017 who were discharged alive following SLKT. We used Poisson regression to model rates of early hospitalizations after SLKT. Cox regression was used to identify risk factors associated with mortality conditional on survival at 6 months after SLKT. Median age (N = 549) was 57.7 years (interquartile range [IQR], 50.6-63.9) with 63% males and 76% Whites; 33% had hepatitis C virus, 20% had non-alcohol-associated fatty liver disease, 23% alcohol-associated liver disease, and 24% other etiologies. Median body mass index (BMI) and Model for End-Stage Liver Disease-sodium scores were 27.2 kg/m2 (IQR, 23.6-32.2 kg/m2 ) and 28 (IQR, 23-34), respectively. Two-thirds of the cohort had at least one hospitalization within the first 6 months of SLKT. Age, race, hospitalization at SLKT, diabetes mellitus, BMI, and discharge to subacute rehabilitation (SAR) facility after SLKT were independently associated with a high incidence rate ratio of early hospitalization. Number of hospitalizations within the first 6 months did not affect conditional survival. Early hospitalizations after SLKT were very common but did not affect conditional survival. Although most of the risk factors for early hospitalization were nonmodifiable, discharge to SAR after initial SLKT was associated with a significantly higher incidence rate of early hospitalization. Efforts and resources should be focused on identifying SLKT recipients at high risk for early hospitalization to optimize their predischarge care, discharge planning, and long-term follow-up.
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Affiliation(s)
- Pratima Sharma
- Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jiaheng Xie
- Department of Biostatistics, University of Michigan School of Public Health, Anna Arbor, Michigan, USA
| | - Leyi Wang
- Department of Biostatistics, University of Michigan School of Public Health, Anna Arbor, Michigan, USA
| | - Min Zhang
- Department of Biostatistics, University of Michigan School of Public Health, Anna Arbor, Michigan, USA
| | - John Magee
- Department of Surgery, Michigan Medicine, University of Michigan, Anna Arbor, Michigan, USA
| | - Adeline Answine
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Pranab Barman
- Division of Gastroenterology and Hepatology, University of California, San Diego, California, USA
| | - Jennifer Jo
- Department of Internal Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jasmine Sinha
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Aaron Schluger
- Department of Internal Medicine, Westchester Medical Center, Westchester, New York, USA
| | - Gabriel J. Perreault
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York, USA
| | - Kara E. Walters
- Division of Gastroenterology, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Giuseppe Cullaro
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| | - Randi Wong
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| | - Natalia Filipek
- Department of Internal Medicine, University of Washington, Seattle, Washington, USA
| | - Scott W. Biggins
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, USA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| | - Lisa B. VanWagner
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Elizabeth C. Verna
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York, USA
| | - Yuval A. Patel
- Division of Gastroenterology and Hepatology, Duke University, Durham, North Carolina, USA
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50
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Wei Y, Wu D, Chen Y, Dong C, Qi J, Wu Y, Cai R, Zhou S, Li C, Niu L, Wu T, Xiao Y, Liu T. Population pharmacokinetics of mycophenolate mofetil in pediatric patients early after liver transplantation. Front Pharmacol 2022; 13:1002628. [PMID: 36313303 PMCID: PMC9608800 DOI: 10.3389/fphar.2022.1002628] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: To investigate the factors influencing the pharmacokinetics of mycophenolate mofetil (MMF) in pediatric patients after liver transplantation, and to establish a population pharmacokinetics model, which can provide a reference for clinical dosage adjustment. Methods: A prospective study in a single center was performed on pediatric patients who were administrated with mycophenolate mofetil dispersible tablets (MMFdt) for at least 4 days after liver transplantation continuously. Blood samples were collected in ethylene diamine tetraacetic acid anticoagulant tubes before dosing and 0.5, 1, 2, 4, 8, and 12 h after the morning intake of MMFdt. The concentrations of mycophenolic acid (MPA) in plasma were assayed with a validated reverse-phase high-performance liquid chromatography method. UGT1A8 518C > G, UGT1A9 -275T > A, UGT1A9 -2152C > T, UGT2B7 211G > T, SLC O 1B1 521T > C polymorphism were determined by Sanger sequencing. Nonlinear mixed effects modeling was used to establish the population pharmacokinetics (PPK) model. The predictability and stability of the model were internally evaluated by the goodness of fit plots, visual prediction check, normalized prediction errors, and bootstraps. Results: A two-compartment model with first-order absorption and first-order elimination was established with 115 MPA concentrations from 20 pediatric patients. The final model were: CL/F (L/h) = 14.8×(WT/7.5)0.75×(DOSE/11.16)0.452×е0.06, Ka (h−1) = 2.02×(WT/7.5)−0.25, Vc/F (L) = 6.01×(WT/7.5), Vp/F (L) = 269 (fixed), Q/F (L/h) = 15.4×(WT/7.5)0.75×е1.39. Where CL/F was the apparent clearance rate, Ka was the absorption rate constant, Vc/F was the apparent distribution volume of the central compartment, Vp/F was the apparent distribution volume of the peripheral compartment, Q/F was the atrioventricular clearance rate, WT was the body weight of the subject, and DOSE was the MMFdt administered dose. The model indicated there was large inter-individual variability in CL/F and Q/F after multiple dosing of MMFdt. Internal evaluation results showed that the final model had good stability and prediction performance. Conclusion: A stable and predictive population pharmacokinetic model of MMFdt in pediatric patients after the early stage of liver transplantation was established. The pediatric patient’s weight and the dose of MMFdt can be a reference to adjust the MMFdt dose.
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Affiliation(s)
- Yinyi Wei
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Dongni Wu
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yiyu Chen
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- *Correspondence: Taotao Liu, ; Yiyu Chen,
| | - Chunqiang Dong
- Department of Organ Transplant, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jianying Qi
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yun Wu
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Rongda Cai
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Siru Zhou
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Chengxin Li
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lulu Niu
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Tingqing Wu
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yang Xiao
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Taotao Liu
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- *Correspondence: Taotao Liu, ; Yiyu Chen,
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