1
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Pan SY, Tao-Min Huang T, Lin YC, Liu HT, Chou SC, Lee CY, Chen CC, Fu CH, Chao CC, Wu VC. The effects of double-filtration plasmapheresis on coagulation profiles and the risk of bleeding. J Formos Med Assoc 2024:S0929-6646(24)00106-2. [PMID: 38395630 DOI: 10.1016/j.jfma.2024.02.006] [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: 10/31/2023] [Revised: 02/02/2024] [Accepted: 02/16/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND/PURPOSE Double-filtration plasmapheresis (DFPP) can be used to remove circulating pathogenic molecules. By reclaiming filtered albumin, DFPP reduces the need for albumin and plasma replacement. Large proteins, such as fibrinogen, are removed. Our institution adopts a DFPP treatment protocol consisting of active surveillance of coagulation profiles and prophylactic supplementation of blood products containing fibrinogen. This study aims to investigate the effects of consecutive DFPP treatments on serial coagulation profiles and the risk of bleeding under this protocol. METHODS Serial laboratory data and bleeding events at a single tertiary medical center were prospectively collected. Prophylactic transfusion of cryoprecipitate or fresh frozen plasma (FFP) was instituted if significant coagulopathy or a clinically evident bleeding event was observed. RESULTS After the first treatment session, plasma fibrinogen levels decreased from 332 ± 106 mg/dL to 96 ± 44 mg/dL in the 37 study patients. In the following sessions, plasma fibrinogen levels were maintained at around 100 mg/dL under prophylactic transfusion. No major bleeding events were recorded, but five (14%) patients experienced minor bleeding. CONCLUSION DFPP treatment might be performed safely along with active monitoring of coagulation profiles and prophylactic transfusion of cryoprecipitate or FFP.
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Affiliation(s)
- Szu-Yu Pan
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan; Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei City, Taiwan
| | - Thomas Tao-Min Huang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan.
| | - Yi-Chan Lin
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Hui-Ting Liu
- Department of Nursing, National Taiwan University Hospital, Taipei City, Taiwan
| | - Sheng-Chieh Chou
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei City, Taiwan
| | - Chih-Yuan Lee
- Department of Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Chien-Chia Chen
- Department of Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Chuan-Hsiu Fu
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City, Taiwan
| | - Chi-Chao Chao
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City, Taiwan
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
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2
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Xu P, Zhao N, Wang J. Success rate and safety of living donor kidney transplantation in ABO blood group incompatible relatives: A systematic review and meta-analysis. Transpl Immunol 2023; 81:101921. [PMID: 37648033 DOI: 10.1016/j.trim.2023.101921] [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: 05/15/2023] [Revised: 08/15/2023] [Accepted: 08/27/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Kidney transplantation is considered an ideal treatment for end-stage renal disease (ESRD) because it provides a longer and better quality of life than dialysis. ABO-incompatible (ABO-I) kidney transplantation relies on two principles: (i) removal of antibodies from a blood group; and (ii) inhibition of reappearance of blood group antibodies by intensifying the induction and maintenance of immunosuppression. This systematic review aimed to analyze the success and safety of ABO-I live-donor kidney transplantation. METHODS Databases, including Google Scholar, PubMed, Embase, Web of Science, and Medline were searched. Search duration was from the database establishment to December 2022. A thorough search was performed for relevant studies investigating the success and safety of ABO-I live-donor kidney transplantation. Two investigators independently extracted literature information and assessed the quality of the included studies. Heterogeneity test was performed using Cochrane's Q and chi-squared tests. All statistical analyses were performed using R software (version 4.2.1). RESULTS The search for relevant literature in the five electronic databases yielded 1238 articles. Of the 1238 articles, only 15 were included. Meta-analysis of outcomes from five studies showed a survival rate of 0.93 (95% confidence interval [CI]: 0.88 to 0.97, P < 0.001) after ≥3 years, while outcomes from 12 studies revealed a short-term patient survival rate of 0.94 (95% CI: 0.92 to 0.96, P = 0.75). In contrast, long- and short-term graft survival rates were 0.89 (95% CI: 0.75 to 0.96, P < 0.001) and 0.94 (95% CI: 0.90 to 0.97, P < 0.001), respectively. Incidence rates of infectious, surgical, and medical complications were 0.31 (95% CI: 0.22 to 0.41, P < 0.001), 0.12 (95% CI: 0.05 to 0.25, P < 0.001), and 0.38 (95% CI: 0.17 to 0.66, P < 0.001), respectively. CONCLUSION Good long- and short-term patient outcomes and graft survival rates were observed after ABO-I kidney transplantation. Similarly, the safety of performing kidney transplantations from living donors with ABO-I blood groups was established by the results of the current meta-analysis. Therefore, ABO-I live-donor kidney transplantations should be encouraged to reduce the time recipients spend on waiting lists and supplement the existing paired-exchange donor program.
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Affiliation(s)
- Pengjie Xu
- Department of Nephrology, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang 315000, China.
| | - Nadan Zhao
- Department of Radiology, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang 315000, China
| | - Jiangdong Wang
- Department of Nephrology, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang 315000, China
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Ma Y, Man J, Gui H, Niu J, Yang L. Advancement in preoperative desensitization therapy for ABO incompatible kidney transplantation recipients. Transpl Immunol 2023; 80:101899. [PMID: 37433394 DOI: 10.1016/j.trim.2023.101899] [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: 05/20/2023] [Revised: 07/04/2023] [Accepted: 07/07/2023] [Indexed: 07/13/2023]
Abstract
ABO incompatibility has long been considered an absolute contraindication for kidney transplantation. However, with the increasing number of patients with ESRD in recent years, ABO-incompatible kidney transplantation (ABOi-KT) has expanded the types of donors by crossing the blood group barrier through preoperative desensitization therapy. At present, the desensitization protocols consist of removal of preexisting ABO blood group antibody titers and prevention of ABO blood group antibody return. Studies have suggested similar patient and graft survival among ABOi-KT and ABOc-KT recipients. In this review, we will summarize the effective desensitization regimens of ABOi-KT, aiming to explore effective ways to improve the success rate and the long-term survival rate of ABOi-KT recipients.
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Affiliation(s)
- Yuhua Ma
- Department of Urology, The Second Hospital of Lanzhou University, Lanzhou, China; Gansu Province Clinical Research Center for Urology, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China
| | - Jiangwei Man
- Department of Urology, The Second Hospital of Lanzhou University, Lanzhou, China; Gansu Province Clinical Research Center for Urology, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China
| | - Huiming Gui
- Department of Urology, The Second Hospital of Lanzhou University, Lanzhou, China; Gansu Province Clinical Research Center for Urology, Lanzhou, China
| | - Jiping Niu
- Department of Urology, The Second Hospital of Lanzhou University, Lanzhou, China; Gansu Province Clinical Research Center for Urology, Lanzhou, China
| | - Li Yang
- Department of Urology, The Second Hospital of Lanzhou University, Lanzhou, China; Gansu Province Clinical Research Center for Urology, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China.
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4
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Optimal Immunosuppression Strategy in the Sensitized Kidney Transplant Recipient. J Clin Med 2021; 10:jcm10163656. [PMID: 34441950 PMCID: PMC8396983 DOI: 10.3390/jcm10163656] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/09/2021] [Accepted: 08/15/2021] [Indexed: 01/10/2023] Open
Abstract
Patients with previous sensitization events against anti-human leukocyte antigens (HLA) often have circulating anti-HLA antibodies. Following organ transplantation, sensitized patients have higher rates of antibody-mediated rejection (AMR) compared to those who are non-sensitized. More stringent donor matching is required for these patients, which results in a reduced donor pool and increased time on the waitlist. Current approaches for sensitized patients focus on reducing preformed antibodies that preclude transplantation; however, this type of desensitization does not modulate the primed immune response in sensitized patients. Thus, an optimized maintenance immunosuppressive regimen is necessary for highly sensitized patients, which may be distinct from non-sensitized patients. In this review, we will discuss the currently available therapeutic options for induction, maintenance, and adjuvant immunosuppression for sensitized patients.
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5
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Ho QY, Teh SP, Thangaraju S, Teo SH, Tan HK, Abdul Rahman MB, Ng LC, Lim AEL, Choong LHL, Kee T, Kaushik M. Regional Citrate Anticoagulation during Double-Filtration Plasmapheresis in Kidney Transplant Recipients: A Single-Center Retrospective Cohort Study. Blood Purif 2021; 51:376-382. [PMID: 34198288 DOI: 10.1159/000517233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/12/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Double-filtration plasmapheresis (DFPP) may be used for immunomodulation in kidney transplant (KTx). While DFPP reduces plasma product exposure, risk of circuit clotting merits adequate anticoagulation. Regional citrate anticoagulation (RCA) avoids the risks of systemic anticoagulation, but a protocol for RCA-DFPP is not previously widely described. METHODS We conducted a single-center retrospective cohort study involving adult (≥21 years old) KTx recipients who underwent RCA-DFPP from 2018 to 2020 to investigate efficacy and safety for an RCA protocol during DFPP in KTx recipients. RESULTS Fifty-one (85%) of 60 RCA-DFPP sessions in 17 patients completed without circuit clotting. Circuit clotting was associated with high post-filter ionized calcium (28 vs. 3.7%, odds ratio 10.1, 95% CI 1.1-89.4, p = 0.037). Hypo- and hypercalcemia developed in 5 (8.3%) and 8 (13.3%) sessions, respectively, but no adverse effects were noted despite severe hypocalcemia in one. There was no significant change in pre- and post-RCA-DFPP sodium, bicarbonate, albumin, and platelet levels. With regards DFPP procedure, prolongation of prothrombin time (PT) and activated partial thromboplastin time (aPTT) was observed following 38 (64.4%) and 12 (20.3%) sessions, respectively. Severely prolonged (>1.5 × upper limit normal) PT and aPTT were recorded in 2 sessions each. Expectedly, hypofibrinogenemia developed after 31 (51.7%) sessions: including 4 (6.7%) severe hypofibrinogenemia (<0.5 g/L). Two patients developed bleeding requiring blood product transfusion. The median total volume of fluids administered per session was 1.495 (1.373-1.612) L; post-RCA-DFPP significant weight gain of 0.5 (0-1.25) kg was noted. Diuretic was commenced or dose increased following 20 (33.3%) sessions for fluid balance management. DISCUSSION/CONCLUSION Protocol-based RCA for DFPP is feasible and safe in KTx recipients. However, DFPP-related coagulopathy can develop consequent to treatment; caution should be exercised for patients with bleeding risk. Close monitoring and management of the patients' electrolytes, especially hypocalcemia and hypomagnesemia, and fluid status is recommended.
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Affiliation(s)
- Quan Yao Ho
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore.,SingHealth-Duke NUS Transplant Centre, Singapore, Singapore
| | - Swee Ping Teh
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Sobhana Thangaraju
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore.,SingHealth-Duke NUS Transplant Centre, Singapore, Singapore
| | - Su Hooi Teo
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Han Khim Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Maslinna Binte Abdul Rahman
- SingHealth-Duke NUS Transplant Centre, Singapore, Singapore.,Nursing Division, Singapore General Hospital, Singapore, Singapore
| | - Li Choo Ng
- Nursing Division, Singapore General Hospital, Singapore, Singapore
| | - Amy Ee Lin Lim
- Nursing Division, Singapore General Hospital, Singapore, Singapore
| | - Lina Hui Lin Choong
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Terence Kee
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore.,SingHealth-Duke NUS Transplant Centre, Singapore, Singapore
| | - Manish Kaushik
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
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Choi AY, Manook M, Olaso D, Ezekian B, Park J, Freischlag K, Jackson A, Knechtle S, Kwun J. Emerging New Approaches in Desensitization: Targeted Therapies for HLA Sensitization. Front Immunol 2021; 12:694763. [PMID: 34177960 PMCID: PMC8226120 DOI: 10.3389/fimmu.2021.694763] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/24/2021] [Indexed: 01/11/2023] Open
Abstract
There is an urgent need for therapeutic interventions for desensitization and antibody-mediated rejection (AMR) in sensitized patients with preformed or de novo donor-specific HLA antibodies (DSA). The risk of AMR and allograft loss in sensitized patients is increased due to preformed DSA detected at time of transplant or the reactivation of HLA memory after transplantation, causing acute and chronic AMR. Alternatively, de novo DSA that develops post-transplant due to inadequate immunosuppression and again may lead to acute and chronic AMR or even allograft loss. Circulating antibody, the final product of the humoral immune response, has been the primary target of desensitization and AMR treatment. However, in many cases these protocols fail to achieve efficient removal of all DSA and long-term outcomes of patients with persistent DSA are far worse when compared to non-sensitized patients. We believe that targeting multiple components of humoral immunity will lead to improved outcomes for such patients. In this review, we will briefly discuss conventional desensitization methods targeting antibody or B cell removal and then present a mechanistically designed desensitization regimen targeting plasma cells and the humoral response.
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Affiliation(s)
| | | | | | | | | | | | | | - Stuart Knechtle
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Jean Kwun
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
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7
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May FNJ, Rees MT, Griffin S, Fildes JE. Understanding immunological response to desensitisation strategies in highly sensitised potential kidney transplant patients. Transplant Rev (Orlando) 2021; 35:100596. [DOI: 10.1016/j.trre.2021.100596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 01/18/2023]
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8
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Noble J, Metzger A, Naciri Bennani H, Daligault M, Masson D, Terrec F, Imerzoukene F, Bardy B, Fiard G, Marlu R, Chevallier E, Janbon B, Malvezzi P, Rostaing L, Jouve T. Apheresis Efficacy and Tolerance in the Setting of HLA-Incompatible Kidney Transplantation. J Clin Med 2021; 10:jcm10061316. [PMID: 33806743 PMCID: PMC8005077 DOI: 10.3390/jcm10061316] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/07/2021] [Accepted: 03/17/2021] [Indexed: 12/23/2022] Open
Abstract
Nearly 18% of patients on a waiting list for kidney transplantation (KT) are highly sensitized, which make access to KT more difficult. We assessed the efficacy and tolerance of different techniques (plasma exchanges [PE], double-filtration plasmapheresis [DFPP], and immunoadsorption [IA]) to remove donor specific antibodies (DSA) in the setting of HLA-incompatible (HLAi) KT. All patients that underwent apheresis for HLAi KT within a single center were included. Intra-session and inter-session Mean Fluorescence Intensity (MFI) decrease in DSA, clinical and biological tolerances were assessed. A total of 881 sessions were performed for 45 patients: 107 DFPP, 54 PE, 720 IA. The procedures led to HLAi KT in 39 patients (87%) after 29 (15–51) days. A higher volume of treated plasma was associated with a greater decrease of inter-session class I and II DSA (p = 0.04, p = 0.02). IA, PE, and a lower maximal DSA MFI were associated with a greater decrease in intra-session class II DSA (p < 0.01). Safety was good: severe adverse events occurred in 17 sessions (1.9%), more frequently with DFPP (6.5%) p < 0.01. Hypotension occurred in 154 sessions (17.5%), more frequently with DFPP (p < 0.01). Apheresis is well tolerated (IA and PE > DFPP) and effective at removing HLA antibodies and allows HLAi KT for sensitized patients.
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Affiliation(s)
- Johan Noble
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
- University Grenoble Alpes, 38000 Grenoble, France
| | - Antoine Metzger
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
| | - Hamza Naciri Bennani
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
| | - Melanie Daligault
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
| | - Dominique Masson
- HLA Laboratory—Établissement Français du Sang-EFS-, 38000 Grenoble, France; (D.M.); (B.B.)
| | - Florian Terrec
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
| | - Farida Imerzoukene
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
| | - Beatrice Bardy
- HLA Laboratory—Établissement Français du Sang-EFS-, 38000 Grenoble, France; (D.M.); (B.B.)
| | - Gaelle Fiard
- Urology Department, University Hospital Grenoble, 38000 Grenoble, France;
- TIMC-IMAG, Grenoble INP, CNRS, University Grenoble Alpes, F-38000 Grenoble, France
| | - Raphael Marlu
- Haemostasis Laboratory, University Hospital Grenoble, 38000 Grenoble, France;
| | - Eloi Chevallier
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
| | - Benedicte Janbon
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
| | - Paolo Malvezzi
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
| | - Lionel Rostaing
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
- University Grenoble Alpes, 38000 Grenoble, France
- Correspondence: ; Tel.: +33-476768945; Fax: +33-476765263
| | - Thomas Jouve
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
- University Grenoble Alpes, 38000 Grenoble, France
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9
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Noppakun K, Kittipanyaworakun T, Ruengorn C, Vongsanim S, Saikam A, Khamlueang N. Plasma volume treated with double filtration plasmapheresis and outcomes of acute antibody-mediated rejection in kidney transplant recipients: A retrospective cohort study. Ther Apher Dial 2020; 25:341-349. [PMID: 32666667 DOI: 10.1111/1744-9987.13560] [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: 04/25/2020] [Revised: 06/17/2020] [Accepted: 07/13/2020] [Indexed: 11/29/2022]
Abstract
A retrospective cohort study was conducted to evaluate the association between the plasma volume treated by double filtration plasmapheresis and allograft outcomes for the treatment of acute antibody-mediated rejection in kidney transplant recipients. Patients were divided into two groups: group 1, plasma volume treated between 1 and <1.3 total plasma volume and group 2, plasma volume treated ≥1.3 total plasma volume. Primary outcome was ≥50% reduction of serum creatinine rising from baseline value at 1 month. A total of 32 courses (146 sessions) of double filtration plasmapheresis were performed; 17 and 15 courses in group 1 and group 2, respectively. Primary outcome occurred in 41% of group 1 and 40% of group 2 (adjusted risk ratio 1.15 [95%CI, 0.48-2.76]). Graft loss at 1 year did not differ between the two groups (adjusted hazard ratio 0.65 [95%CI, 0.23-1.87]). Infection tendency seemed to be higher in group 2 (40% vs 18%, P = .243).
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Affiliation(s)
- Kajohnsak Noppakun
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Kidney Transplant and Research Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Thanapat Kittipanyaworakun
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chidchanok Ruengorn
- Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand.,Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Surachet Vongsanim
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Kidney Transplant and Research Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Anchalee Saikam
- Kidney Transplant and Research Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nikhom Khamlueang
- Kidney Transplant and Research Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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10
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Maurizi-Balzan J, Jouve T, Naciri-Bennani H, Noble J, Tanoukhi K, Motte L, Malvezzi P, Rostaing L. [How to implement a complete apheresis program within a hemodialysis unit]. Nephrol Ther 2019; 15:439-447. [PMID: 31585841 DOI: 10.1016/j.nephro.2019.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 01/07/2019] [Accepted: 01/14/2019] [Indexed: 12/13/2022]
Abstract
Many apheresis techniques can be performed in a blood-bank facility or a hemodialysis (HD) facility. However, it makes sense to perform apheresis in a hemodialysis facility as apheresis involves extra-corporeal circuits and because HD can be performed at the same time as apheresis (tandem procedure). Apheresis techniques comprise therapeutic plasma exchange, double-filtration plasmapheresis, and its derivative (rheopheresis and LDL-apheresis), and immunoadsorption (specific and semi-specific). We have setup an apheresis platform in our hospital that fulfills health recommendations. This process has involved financial investment and significant human resources, and has enabled us to network with different specialties (neurology, hematology, vascular medicine). We have setup protocols according to the type of pathology to be treated by apheresis, and to monitor clinical and biological data for each apheresis session. The main side effects of apheresis are a fall in blood pressure when a session is initiated, an increase in fluid overload, hypocalcemia, and the loss of some essential plasmatic factors. However, these side-effects are easily identified and can be properly managed in real time. Within two-years, we have performed 1845 apheresis sessions (134 patients). Of these, 66 received apheresis before and/or after kidney transplantation for ABO and/or HLA incompatibility (desensitization), for humoral rejection, or in the setting of relapsing focal-segmental glomerulosclerosis. Our patients' outcomes have been similar to those reported in the literature. The other 68 patients had various conditions. Because our program is now well-established, we are currently forming a specialist center to train physicians and nurses in the various apheresis techniques/procedures.
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Affiliation(s)
- Jocelyne Maurizi-Balzan
- Service de Néphrologie Hémodialyse Aphérèses et Transplantation rénale, CHU de Grenoble-Alpes, CS 10217, 38043 Grenoble cedex 09, France.
| | - Thomas Jouve
- Service de Néphrologie Hémodialyse Aphérèses et Transplantation rénale, CHU de Grenoble-Alpes, CS 10217, 38043 Grenoble cedex 09, France
| | - Hamza Naciri-Bennani
- Service de Néphrologie Hémodialyse Aphérèses et Transplantation rénale, CHU de Grenoble-Alpes, CS 10217, 38043 Grenoble cedex 09, France
| | - Johan Noble
- Service de Néphrologie Hémodialyse Aphérèses et Transplantation rénale, CHU de Grenoble-Alpes, CS 10217, 38043 Grenoble cedex 09, France
| | - Khadija Tanoukhi
- Service de Néphrologie Hémodialyse Aphérèses et Transplantation rénale, CHU de Grenoble-Alpes, CS 10217, 38043 Grenoble cedex 09, France
| | - Lionel Motte
- Service de Néphrologie Hémodialyse Aphérèses et Transplantation rénale, CHU de Grenoble-Alpes, CS 10217, 38043 Grenoble cedex 09, France
| | - Paolo Malvezzi
- Service de Néphrologie Hémodialyse Aphérèses et Transplantation rénale, CHU de Grenoble-Alpes, CS 10217, 38043 Grenoble cedex 09, France
| | - Lionel Rostaing
- Service de Néphrologie Hémodialyse Aphérèses et Transplantation rénale, CHU de Grenoble-Alpes, CS 10217, 38043 Grenoble cedex 09, France
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11
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Iwami D, Miura M, Chiba Y, Ota M, Matsumoto T, Hotta K, Sasaki H, Hirose T, Harada H, Shinohara N. Optimal Settings for Double Filtration Plasmapheresis With Targeted Removal Rate of Preexisting Antibody in Antibody-Incompatible Kidney Transplant. Transplant Proc 2018; 50:3478-3482. [DOI: 10.1016/j.transproceed.2018.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 05/23/2018] [Indexed: 11/24/2022]
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12
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Vatazin AV, Zulkarnaev AB. The impact of therapeutic plasma exchange and double filtration plasmapheresis on hemostasis in renal transplant recipients. TERAPEVT ARKH 2018; 90:22-27. [DOI: 10.26442/terarkh201890622-27] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aim. To investigate the impact of double filtration plasmapheresis (DFPP) and therapeutic plasma exchange (TPE) on hemostasis in renal transplant recipients. Materials and methods. 54 renal transplant patients with an acute humoral rejection were treated with therapeutic apheresis methods: 24 patients with DFPP and 30 patients with TPE. In all patients was performed 3-4 session. We analyzed international normalized ratio (INR), activated partial thromboplastin time (APTT), fibrinogen concentration and platelet count just before and after each session, and after the course of all procedures. After TPE plasma replacement was performed with an equivalent volume of a fresh frozen plasma. After DFPP was performed 10-20% albumin solution. Results and discussion. After each DFPP session was occurred an increased INR and aPTT. After course of all DFPP procedures fibrinogen level decreased by 46%. It was associated with increase of APTT and INR by 35% and 32% respectively. Mainly it was associated with dose of the procedures (volume of plasma perfusion), but not with the plasma separator type. One patient noted hemorrhagic complication. After each TPE session level of fibrinogen concentration, INR and aPPT remained in the normal range, but there was a moderate reduction in platelet count, more pronounced than during DFPP. Hemorrhagic complications were not. Conclusion. Double cascade plasmapheresis and therapeutic plasma exchange generate preconditions for hemorrhagic complications such as increased aPTT and INR, reduce fibrinogen concentration. However, bleeding complications are rare. At the same time, during high volume DFPP should be careful when initially level of fibrinogen is low. In this case fibrinogen concentration should be controlled after the procedure for timely replenishment of its deficit.
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Barnes JC, Goodyear SJ, Imray CE, Lam FT, Kashi HS, Tan LC, Higgins R, Imray CH. Kidney retransplantation from HLA-incompatible living donors: A single-center study of 3rd/4th transplants. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.13104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2017] [Indexed: 12/15/2022]
Affiliation(s)
- James C.H. Barnes
- Department of Transplant Surgery; University Hospitals Coventry and Warwickshire NHS Trust; Coventry UK
- Nuffield Department of Surgical Sciences; University of Oxford; Oxford UK
| | - Stephen J. Goodyear
- Department of Vascular Surgery; Worcestershire Acute Hospitals NHS Trust; Worcester UK
| | | | - For Tai Lam
- Department of Transplant Surgery; University Hospitals Coventry and Warwickshire NHS Trust; Coventry UK
| | - Habib S. Kashi
- Department of Transplant Surgery; University Hospitals Coventry and Warwickshire NHS Trust; Coventry UK
| | - Lam Chin Tan
- Department of Transplant Surgery; University Hospitals Coventry and Warwickshire NHS Trust; Coventry UK
| | - Robert Higgins
- Department of Transplant Surgery; University Hospitals Coventry and Warwickshire NHS Trust; Coventry UK
| | - Christopher H.E. Imray
- Department of Transplant Surgery; University Hospitals Coventry and Warwickshire NHS Trust; Coventry UK
- Warwick Medical School; University of Warwick; Coventry UK
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14
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Lim E, Kim Y, Jeong JC, Park I, Kim H, Lee SH, Oh CK, Shin GT. Clinical analysis of single filtration plasmapheresis using continuous renal replacement therapy machines in kidney transplantation. Kidney Res Clin Pract 2017; 36:192-199. [PMID: 28680827 PMCID: PMC5491166 DOI: 10.23876/j.krcp.2017.36.2.192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 01/18/2017] [Accepted: 03/20/2017] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Plasmapheresis has become an essential element of kidney transplantation (KT). In the present study, we report clinical outcomes of filtration plasmapheresis using continuous renal replacement therapy machines with a single filter for the first time in Korea. METHODS We retrospectively analyzed six patients who underwent filtration plasmapheresis for KT in our center; plasmapheresis was performed using the Plasmaflex (Baxter®) with a TPE 2000 filter set (Baxter®) in our hemodialysis unit. Five percent albumin was used as the replacement fluid, and intravenous immunoglobulin G was administered after each plasmapheresis session. The target preoperative ABO isoagglutinin titer was less than 1:8. RESULTS Filtration plasmapheresis was performed in four patients for ABO-incompatible KT, one for antibody-mediated rejection after KT, and the last one for positive T cell crossmatch. Altogether, 46 sessions of plasmapheresis were performed. ABO isoagglutinin titers successfully declined to or below the target level in all patients, and all patients successfully received KT with no significant antibody titer rebound. Acute antibody-mediated rejection and positive T cell crossmatch were well treated with filtration plasmapheresis, and no patient required fresh frozen plasma infusion for coagulopathy. There were one episode of hypotension and three of hypocalcemia. No patients experienced bleeding, infection, or allergic reaction. CONCLUSION Filtration plasmapheresis was effective and safe. Although our result is from a single center, our protocol appears to be promising.
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Affiliation(s)
- Eunsoo Lim
- Department of Nephrology, Ajou University School of Medicine, Suwon, Korea
| | - Yujeong Kim
- Department of Nephrology, Ajou University School of Medicine, Suwon, Korea
| | - Jong Cheol Jeong
- Department of Nephrology, Ajou University School of Medicine, Suwon, Korea
| | - Inwhee Park
- Department of Nephrology, Ajou University School of Medicine, Suwon, Korea
| | - Heungsoo Kim
- Department of Nephrology, Ajou University School of Medicine, Suwon, Korea
| | - Su Hyung Lee
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Chang-Kwon Oh
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Gyu-Tae Shin
- Department of Nephrology, Ajou University School of Medicine, Suwon, Korea
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15
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Zhang Y, Briggs D, Lowe D, Mitchell D, Daga S, Krishnan N, Higgins R, Khovanova N. A new data-driven model for post-transplant antibody dynamics in high risk kidney transplantation. Math Biosci 2017; 284:3-11. [DOI: 10.1016/j.mbs.2016.04.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 04/01/2016] [Accepted: 04/25/2016] [Indexed: 11/28/2022]
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16
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Makroo R, Nayak S, Chowdhry M, Jasuja S, Sagar G, Rosamma N, Thakur U. Role of therapeutic plasma exchange in reducing ABO titers in patients undergoing ABO-incompatible renal transplant. APOLLO MEDICINE 2016. [DOI: 10.1016/j.apme.2016.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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17
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Walters G. Role of therapeutic plasmapheresis in ANCA-associated vasculitis. Pediatr Nephrol 2016; 31:217-25. [PMID: 25986911 DOI: 10.1007/s00467-014-3038-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 12/11/2014] [Accepted: 12/17/2014] [Indexed: 01/16/2023]
Abstract
Plasma exchange, or plasmapheresis, is a treatment method that developed over a period of two decades and involves the removal and replacement of a patient's circulating plasma. The aim of treatment is to remove disease-associated molecules and therefore interrupt disease progression. This article summarizes the developmental history of this treatment and then looks in more detail at data on the use of plasma exchange in treating antineutrophil antibody (ANCA)-associated vasculitis. The eight randomized trials and the Cochrane Systematic Review on treating renal vasculitis are summarized to show that plasma exchange may be effective in this disease, specifically in reducing the development of end-stage kidney disease (ESKD) by approximately 40%. The plasma exchange and glucocorticoid dosing in the treatment of anti-neutrophil cytoplasm antibody associated vasculitis (PEXIVAS) study is a currently enrolling study aiming to answer some of the outstanding questions relating to the use of this treatment in ANCA-associated vasculitis.
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Affiliation(s)
- Giles Walters
- Department of Renal Medicine, Canberra Hospital, Garran, ACT, Australia. .,Australian National University Medical School, Canberra, ACT, Australia.
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18
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Koo TY, Yang J. Current progress in ABO-incompatible kidney transplantation. Kidney Res Clin Pract 2015; 34:170-9. [PMID: 26484043 PMCID: PMC4608875 DOI: 10.1016/j.krcp.2015.08.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 08/12/2015] [Accepted: 08/12/2015] [Indexed: 02/07/2023] Open
Abstract
ABO-incompatible kidney transplantation (ABOi KT) was introduced to expand the donor pool and minimize shortage of kidneys for transplantation. Because improved outcomes of ABOi KT were reported in Japan in the early 2000s, the number of ABOi KTs has been increasing worldwide. In addition, a better understanding of immune pathogenesis and subsequent aggressive immunosuppression has helped to make effective desensitization protocols. Current strategies of ABOi KT consist of pretransplant antibody removal using plasmapheresis or immunoadsorption to prevent hyperacute rejection and potent maintenance immunosuppression, such as tacrolimus and mycophenolate mofetil, to inhibit antibody-mediated rejection. Recent outcomes of ABOi KT are comparable with ABO-compatible KT. However, there are still many problems to be resolved. Very high anti-ABO antibody producers are difficult to desensitize. In addition, ABOi KT is associated with an increased risk of infection and possibly malignancy due to aggressive immunosuppression. Optimization of desensitization and patient-tailored immunosuppression protocols are needed to achieve better outcomes of ABOi KT. This review provides an overview of the history, immune mechanism, immunosuppressive protocol, outcomes, current obstacles, and future perspectives in ABOi KT.
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Affiliation(s)
- Tai Yeon Koo
- Transplantation Center, Seoul National University Hospital, Transplantation Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jaeseok Yang
- Transplantation Center, Seoul National University Hospital, Transplantation Research Institute, Seoul National University College of Medicine, Seoul, Korea
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19
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Higgins R, Lowe D, Daga S, Hathaway M, Williams C, Lam F, Kashi H, Tan LC, Imray C, Fletcher S, Krishnan N, Hart P, Zehnder D, Briggs D. Pregnancy-induced HLA antibodies respond more vigorously after renal transplantation than antibodies induced by prior transplantation. Hum Immunol 2015; 76:546-52. [DOI: 10.1016/j.humimm.2015.06.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 10/10/2014] [Accepted: 06/01/2015] [Indexed: 10/23/2022]
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20
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Higgins RM, Daga S, Mitchell DA. Antibody-incompatible kidney transplantation in 2015 and beyond. Nephrol Dial Transplant 2014; 30:1972-8. [PMID: 25500804 DOI: 10.1093/ndt/gfu375] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 11/11/2014] [Indexed: 01/18/2023] Open
Abstract
Rejection caused by donor-specific antibodies (principally ABO and HLA antibodies) has become one of the major barriers to successful long-term transplantation. This review focuses on clinical outcomes in antibody-incompatible transplantation, the current state of the science underpinning clinical observations, and how these may be translated into further novel therapies. The clinical outcomes for allografts facing donor-specific antibodies are at present determined largely by the use of agents developed in the 20th century for the treatment of T-lymphocyte-mediated cellular rejection, such as interleukin-2 agents and anti-thymocyte globulin. These treatments are partially effective, because acute antibody-mediated rejection is mediated to a considerable extent by T lymphocytes. However these treatments are essentially ineffective in chronic antibody-mediated rejection. Future therapies for the prevention and treatment of antibody-mediated rejection are likely to fall into the categories of those that reduce antibody production, extracorporeal antibody removal and disruption of the effector arms of antibody-mediated tissue damage.
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Affiliation(s)
- Rob M Higgins
- Renal Unit, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Sunil Daga
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Dan A Mitchell
- Warwick Medical School, University of Warwick, Coventry, UK
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21
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EXP CLIN TRANSPLANTExp Clin Transplant 2014; 12. [DOI: 10.6002/ect.2014.0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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22
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Innate functions of immunoglobulin M lessen liver gene transfer with helper-dependent adenovirus. PLoS One 2014; 9:e85432. [PMID: 24465560 PMCID: PMC3897443 DOI: 10.1371/journal.pone.0085432] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 11/26/2013] [Indexed: 12/24/2022] Open
Abstract
The immune system poses obstacles to viral vectors, even in the first administration to preimmunized hosts. We have observed that the livers of B cell-deficient mice were more effectively transduced by a helper-dependent adenovirus serotype-5 (HDA) vector than those of WT mice. This effect was T-cell independent as shown in athymic mice. Passive transfer of the serum from adenovirus-naïve WT to Rag1KO mice resulted in a reduction in gene transfer that was traced to IgM purified from serum of adenovirus-naïve mice. To ascribe the gene transfer inhibition activity to either adenoviral antigen-specific or antigen-unspecific functions of IgM, we used a monoclonal IgM antibody of unrelated specificity. Both the polyclonal and the irrelevant monoclonal IgM inhibited gene transfer by the HDA vector to either cultured hepatocellular carcinoma cells or to the liver of mice in vivo. Adsorption of polyclonal or monoclonal IgMs to viral capsids was revealed by ELISAs on adenovirus-coated plates. These observations indicate the existence of an inborn IgM mechanism deployed against a prevalent virus to reduce early post-infection viremia. In conclusion, innate IgM binding to adenovirus serotype-5 capsids restrains gene-transfer and offers a mechanism to be targeted for optimization of vector dosage in gene therapy with HDA vectors.
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23
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Eskandary F, Wahrmann M, Biesenbach P, Sandurkov C, Konig F, Schwaiger E, Perkmann T, Kunig S, Derfler K, Zlabinger GJ, Bohmig GA. ABO antibody and complement depletion by immunoadsorption combined with membrane filtration--a randomized, controlled, cross-over trial. Nephrol Dial Transplant 2013; 29:706-14. [DOI: 10.1093/ndt/gft502] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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24
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Ting SMS, Iqbal H, Hamborg T, Imray CHE, Hewins S, Banerjee P, Bland R, Higgins R, Zehnder D. Reduced functional measure of cardiovascular reserve predicts admission to critical care unit following kidney transplantation. PLoS One 2013; 8:e64335. [PMID: 23724043 PMCID: PMC3664577 DOI: 10.1371/journal.pone.0064335] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 04/13/2013] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND There is currently no effective preoperative assessment for patients undergoing kidney transplantation that is able to identify those at high perioperative risk requiring admission to critical care unit (CCU). We sought to determine if functional measures of cardiovascular reserve, in particular the anaerobic threshold (VO₂AT) could identify these patients. METHODS Adult patients were assessed within 4 weeks prior to kidney transplantation in a University hospital with a 37-bed CCU, between April 2010 and June 2012. Cardiopulmonary exercise testing (CPET), echocardiography and arterial applanation tonometry were performed. RESULTS There were 70 participants (age 41.7±14.5 years, 60% male, 91.4% living donor kidney recipients, 23.4% were desensitized). 14 patients (20%) required escalation of care from the ward to CCU following transplantation. Reduced anaerobic threshold (VO₂AT) was the most significant predictor, independently (OR = 0.43; 95% CI 0.27-0.68; p<0.001) and in the multivariate logistic regression analysis (adjusted OR = 0.26; 95% CI 0.12-0.59; p = 0.001). The area under the receiver-operating-characteristic curve was 0.93, based on a risk prediction model that incorporated VO₂AT, body mass index and desensitization status. Neither echocardiographic nor measures of aortic compliance were significantly associated with CCU admission. CONCLUSIONS To our knowledge, this is the first prospective observational study to demonstrate the usefulness of CPET as a preoperative risk stratification tool for patients undergoing kidney transplantation. The study suggests that VO₂AT has the potential to predict perioperative morbidity in kidney transplant recipients.
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Affiliation(s)
- Stephen M. S. Ting
- Department of Renal Medicine and Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Division of Metabolic and Vascular Health, Warwick Medical School, The University of Warwick, Coventry, United Kingdom
- * E-mail: (ST); (DZ)
| | - Hasan Iqbal
- Department of Cardiology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Thomas Hamborg
- Division of Health Sciences Statistics and Epidemiology, Warwick Medical School, The University of Warwick, Coventry, United Kingdom
| | - Chris H. E. Imray
- Department of Vascular and Renal Transplantation Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Division of Metabolic and Vascular Health, Warwick Medical School, The University of Warwick, Coventry, United Kingdom
| | - Susan Hewins
- Department of Renal Medicine and Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Prithwish Banerjee
- Department of Cardiology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Rosemary Bland
- Division of Metabolic and Vascular Health, Warwick Medical School, The University of Warwick, Coventry, United Kingdom
| | - Robert Higgins
- Department of Renal Medicine and Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Daniel Zehnder
- Department of Renal Medicine and Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Division of Metabolic and Vascular Health, Warwick Medical School, The University of Warwick, Coventry, United Kingdom
- * E-mail: (ST); (DZ)
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Abstract
PURPOSE OF REVIEW A dramatic shortage of available organs around the world encouraged attempts to cross previously forbidden immunological boundaries in kidney transplantation. This review focuses on the recent results of ABO-incompatible kidney transplantation. RECENT FINDINGS The outcome of ABO-incompatible kidney transplantation in terms of patient and graft survival is comparable to ABO-compatible transplantation for adult and pediatric recipients. Splenectomy has been replaced by the B-cell-depleting agent rituximab to avoid isoagglutinin titer rebound, prevent antibody-mediated rejection, and improve graft survival. However, the risk for infections may be increased and warrants caution. Corticosteroids remain a necessary component of any ABO-incompatible protocol; early as well as late steroid withdrawal may bear an enhanced risk for acute rejection and should only be performed with careful follow-up including protocol biopsies. The few studies that have long-term outcomes using protocol biopsies have characterized a state of accommodation by up-regulation of complement inhibitors, down-regulation of A/B antigens, and establishment of endothelial chimerism over time. SUMMARY The experience accumulated around the world indicates that ABO-incompatible kidney transplantation is well tolerated and effective in adults and in children, and it represents an important step forward in expanding the living donor pool. Further understanding of ABO-incompatible graft accommodation may have broader implication also for human leukocyte antigen-sensitized allograft recipients.
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26
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Sharif A, Alachkar N, Kraus E. Incompatible kidney transplantation: a brief overview of the past, present and future. QJM 2012; 105:1141-50. [PMID: 22908321 DOI: 10.1093/qjmed/hcs154] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Live kidney donor transplantation across immunological barriers, either blood group or positive crossmatch [ABO- and human leucocyte antigens (HLA)-incompatible kidney transplantation, respectively], is now practised widely across many transplant centres. This provides transplantation opportunities to patients that hitherto would have been deemed contra-indicated and would subsequently have waited indefinitely for a suitably matched kidney. Protocols have evolved with time as experience has grown and now a variety of desensitization strategies are currently practised to overcome such immunological barriers. In addition, desensitization protocols are complemented by kidney paired donation exchange schemes and therefore incompatible patients now have strategies to either confront or bypass immunological barriers, respectively. As the field expands it is clear that non-transplant clinicians will be exposed to incompatible kidney transplant recipients outside of experienced centres. It is therefore timely to review the evolution of practice that have led to current desensitization modalities, contrast protocols and outcomes of current regimens and speculate on future direction of incompatible kidney transplantation.
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Affiliation(s)
- A Sharif
- Renal Institute of Birmingham, Queen Elizabeth Hospital, Edgbaston, Mindelsohn Way, Birmingham, B15 2WB, UK.
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27
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Muscroft L, Zehnder D, Fletcher S, Krishnan N, Watson D, Murthy B, Higgins R. Rapid resolution of severe sustained low blood pressure in haemodialysis patients after successful renal transplantation. Nephrol Dial Transplant 2012; 27:4223-7. [PMID: 22859790 DOI: 10.1093/ndt/gfs338] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Low blood pressure occurring in the absence of volume depletion, anti-hypertensive medication, heart failure or cortisol deficiency occurs in ~5-10% of haemodialysis patients, and can result in serious complications. The pathophysiology of this syndrome is poorly understood. METHODS We describe eight cases with dialysis-associated hypotension who underwent renal transplantation. Four patients were severely hypotensive with a systolic blood pressure (SBP) <100 mmHg before and during dialysis, and four had a SBP usually <100 mmHg during dialysis, but usually >100 mmHg between sessions. All had donor-specific human leukocyte antigen antibodies. Six patients underwent pre-transplant plasmapheresis, which was curtailed in two because of further falls in blood pressure. Two patients experienced clotting of their arteriovenous fistula. In one patient cryofiltration was used, which was tolerated without severe falls in the BP. The remaining patient, who had hypotension-associated retinal vein thrombosis before transplant, was supported with an epinephrine infusion and did not receive plasmapheresis. RESULTS Post-transplant, the first patient did not receive pressor therapy and died from bowel ischaemia. The other seven patients were supported with inotropes on critical care. The administration of steroids did not reverse hypotension. The mean pre-treatment SBP was 96 mmHg (range 71-110, SEM 5.0). After inotropes were withdrawn and graft function was established, the mean SBP was 127 mmHg (range 113-149, SEM 4.9) (P < 0.01). CONCLUSIONS Renal transplantation was performed successfully and safely in patients when pressor therapy was used to treat severe dialysis-associated hypotension and, moreover, the blood pressure normalized rapidly after graft function was established.
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28
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Human Leukocyte Antigen-Specific Antibodies and Gamma-Interferon Stimulate Human Microvascular and Glomerular Endothelial Cells to Produce Complement Factor C4. Transplantation 2012; 93:867-73. [DOI: 10.1097/tp.0b013e31824b3762] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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29
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ABO Incompatible Kidney Transplantation-Current Status and Uncertainties. J Transplant 2011; 2011:970421. [PMID: 22174989 PMCID: PMC3235893 DOI: 10.1155/2011/970421] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Accepted: 10/23/2011] [Indexed: 12/17/2022] Open
Abstract
In the past, ABO blood group incompatibility was considered an absolute contraindication for kidney transplantation. Progress in defined desensitization practice and immunologic understanding has allowed increasingly successful ABO incompatible transplantation during recent years. This paper focused on the history, disserted outcomes, desensitization modalities and protocols, posttransplant immunologic surveillance, and antibody-mediated rejection in transplantation with an ABO incompatible kidney allograft. The mechanism underlying accommodation and antibody-mediated injury was also described.
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30
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Human leukocyte antigen antibody-incompatible renal transplantation: excellent medium-term outcomes with negative cytotoxic crossmatch. Transplantation 2011; 92:900-6. [PMID: 21968524 DOI: 10.1097/tp.0b013e31822dc38d] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Human leukocyte antigen (HLA) antibody-incompatible renal transplantation has been increasingly performed since 2000 but with few data on the medium-term outcomes. METHODS Between 2003 and 2011, 84 patients received renal transplants with a pretreatment donor-specific antibody (DSA) level of more than 500 in a microbead assay. Seventeen patients had positive complement-dependent cytotoxic (CDC) crossmatch (XM), 44 had negative CDC XM and positive flow cytometric XM, and 23 had DSA detectable by microbead only. We also reviewed 28 patients with HLA antibodies but no DSA at transplant. DSAs were removed with plasmapheresis pretransplant, and patients did not routinely receive antithymocyte globulin posttransplant. RESULTS Mean follow-up posttransplantation was 39.6 (range 2-91) months. Patient survival after the first year was 93.8%. Death-censored graft survival at 1, 3, and 5 years was 97.5%, 94.2%, and 80.4%, respectively, in all DSA+ve patients, worse at 5 years in the CDC+ve than in the CDC-ve/DSA+ve group at 45.6% and 88.6%, respectively (P<0.03). Five-year graft survival in the DSA-ve group was 82.1%. Rejection occurred in 53.1% of DSA+ve patients in the first year compared with 22% in the DSA-ve patients (P<0.003). CONCLUSIONS HLA antibody-incompatible renal transplantation had a high success rate if the CDC XM was negative. Further work is required to predict which CDC+ve XM grafts will be successful and to treat slowly progressive graft damage because of DSA in the first few years after transplantation.
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Sinha D, Lambie M, Krishnan N, McSorley K, Hamer R, Lowe D, Briggs D, Fletcher S, Zehnder D, Higgins RM. Cryofiltration in the Treatment of Cryoglobulinemia and HLA Antibody-Incompatible Transplantation. Ther Apher Dial 2011; 16:91-6. [DOI: 10.1111/j.1744-9987.2011.01004.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Plasma exchange in the treatment of Wegener's granulomatosis, microscopic polyangiitis, Churg–Strauss syndrome and renal limited vasculitis. Curr Opin Rheumatol 2011; 23:12-7. [DOI: 10.1097/bor.0b013e32834120c1] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Current world literature. Curr Opin Rheumatol 2010; 23:125-30. [PMID: 21124095 DOI: 10.1097/bor.0b013e3283422cce] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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