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Sebti M, Petit-Hoang C, Chami B, Audureau É, Cordonnier-Jourdin C, Paul M, Pourcine F, Grimbert P, Ourghanlian C, Matignon M. ATG-Fresenius increases the risk of red blood cell transfusion after kidney transplantation. Front Immunol 2022; 13:1045580. [PMID: 36532030 PMCID: PMC9753326 DOI: 10.3389/fimmu.2022.1045580] [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: 09/15/2022] [Accepted: 11/08/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction In sensitized deceased donor kidney allograft recipients, the most frequent induction therapy is anti-thymocyte globulins (ATG), including Thymoglobulin® (Thymo) and ATG-Fresenius (ATG-F). Methods We conducted a 3-year monocentric observational study to compare the impact of ATGs on hematological parameters. We included adult kidney transplant recipients treated with ATG induction therapy, either Thymo or ATG-F, on a one-in-two basis. The primary endpoint was red blood cell (RBC) transfusions within 14 days after transplantation. Results Among 309 kidney allograft recipients, 177 (57.2%) received ATG induction, 90 (50.8 %) ATG-F, and 87 (49.2%) Thymo. The ATG-F group received significantly more RBC transfusions (63.3% vs. 46% p = 0.02) and in bigger volumes (p = 0.01). Platelet transfusion was similar in both groups. Within 14 and 30 days after transplantation, older age, ATG-F induction, and early surgical complication were independently associated with RBC transfusion. Patient survival rate was 95%, and the death-censored kidney allograft survival rate was 91.5% at 12 months post-transplantation. There was no difference in the incidence of acute rejection and infections or in the prevalence of anti-HLA donor-specific antibodies. Discussion In conclusion, after kidney transplantation, ATG-F is an independent risk factor for early RBC transfusion and early thrombocytopenia without clinical and biological consequences. These new data should be clinically considered, and alternatives to ATG should be further explored.
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Affiliation(s)
- Maria Sebti
- Pharmacy Department, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France
| | - Camille Petit-Hoang
- Nephrology and Renal Transplantation Department, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France
| | - Btissam Chami
- Etablissement Français du Sang (EFS) - Ile de France, Créteil, France
| | - Étienne Audureau
- Public Health Department, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France
| | - Catherine Cordonnier-Jourdin
- Pharmacy Department, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France
| | - Muriel Paul
- Pharmacy Department, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France
| | - Franck Pourcine
- Nephrology and Renal Transplantation Department, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France
| | - Philippe Grimbert
- Nephrology and Renal Transplantation Department, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France,AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, Fédération Hospitalo-Universitaire TRUE (InnovaTive theRapy for immUne disordErs), Créteil, France,Université Paris-Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France,AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, CIC biotherapy, Créteil, France
| | - Clément Ourghanlian
- Pharmacy Department, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France,Prevention, Diagnosis and Treatment of Infections Department, Unité Transversale de Traitement des Infections, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France
| | - Marie Matignon
- Nephrology and Renal Transplantation Department, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France,AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, Fédération Hospitalo-Universitaire TRUE (InnovaTive theRapy for immUne disordErs), Créteil, France,Université Paris-Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France,*Correspondence: Marie Matignon,
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Gupta A, Bhalla AK, Malik M, Gupta A, Bhargava V, Tiwari V, Gaur L, Gupta P, Jain M, Rana DS. Anti-T-Lymphocyte Immunoglobulin (Grafalon) as an Induction Agent for Renal Transplantation: A Real-World, Retrospective, Single-Center Experience. EXP CLIN TRANSPLANT 2022; 20:480-486. [PMID: 35620891 DOI: 10.6002/ect.2021.0432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Polyclonal antithymocyte globulins are widely used in the induction regimens of solid-organ transplant recipients; however, their doses and outcomes remain to be standardized in Indian patients. We report our clinical experience from the real-world use of Grafalon (an anti-T-lymphocyte globulin; ATG-Fresenius) as an induction agentin renal transplant recipients from India. MATERIALS AND METHODS In this retrospective, single- center, observational study, we analyzed the medical records of 177 consecutive, kidney-only transplant recipients who received induction therapy with Grafalon from September 2016 to March 2018 at our center. Incidences of biopsy-proven acute rejection and graft dysfunction, immunosuppression protocol, Grafalon dosage, 18-month post-transplant graft and patient survival, treatment-related adverse events, and infective complications were reported. RESULTS Mean age of patients was 41.46 years (range, 14-68 years), (85% were males). The average dose of Grafalon was 5.81 ± 1.95 mg/kg (range, 2.41 to 10.07 mg/kg). Graft dysfunction (ie, at least 20% increase in serum creatinine from baseline) was observed in 26 patients (14%): 11 patients (6.2%) had biopsy-proven acute rejections, 11 patients (6.2%) had acute tubular necrosis, and 4 patients (2.2%) had calcineurin inhibitor toxicity. Seven deaths were recorded: 2 each from fungal pneumonia, bacterial pneumonia, and acute coronary syndrome and 1 with urinary tract infection with septicemia. Death-censored graft survival was 100% at 12 months and 98% at 18-month follow-up; overall patient survival was 96%. Infective complications occurred in 40 patients (22.5%), with the most common being urinary tract infection in 32 patients (18%). No malignancies were reported. CONCLUSIONS Use of a potent induction therapy like anti-T-lymphocyte globulin (Grafalon) is often restricted by the risk of side effects and lack of local clinical evidence supporting its role in long-term graft survival. Real-world evidence support the safe and effective use of anti-T-lymphocyte globulin as an induction agent in renal transplant recipients with an individualized dosing approach.
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Affiliation(s)
- Ashwani Gupta
- From the Department of Nephrology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India
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Kumar SSS, Veerappan I, Sethuraman R, Chakravarthy T, Siddharth V, Rajagopal A. Comparison of efficacy and safety between rabbit anti-thymocyte globulin and anti-T lymphocyte globulin in kidney only transplantation: A retrospective observational study. INDIAN JOURNAL OF TRANSPLANTATION 2022. [DOI: 10.4103/ijot.ijot_76_21] [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] Open
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Jha PK, Rana A, Kher A, Bansal SB, Sethi S, Nandwani A, Jain M, Bansal D, Yadav DK, Gadde A, Mahapatra AK, Sodhi P, Kher V. Grafalon® vs. Thymoglobulin® as an Induction Agent in Renal Transplantation - A Retrospective Study. Indian J Nephrol 2021; 31:336-340. [PMID: 34584347 PMCID: PMC8443089 DOI: 10.4103/ijn.ijn_205_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/16/2020] [Accepted: 07/28/2020] [Indexed: 11/04/2022] Open
Abstract
Introduction Antihuman thymocyte immunoglobulin, used as an induction agent in renal transplantation, is of two types - thymoglobulin and grafalon (formerly ATG-Fresenius). In this study, we compared outcomes with these two agents. Methods This was a single-center retrospective study of patients transplanted from January 2017 to October 2019, who received either grafalon or thymoglobulin induction. Grafalon or thymoglobulin was given at 6 and 3 mg/kg, respectively, followed by standard triple immunosuppression of tacrolimus, MMF, and prednisolone. Results Median follow up was 22 (3-36) months. Thymoglobulin was given to 255 patients, whereas 78 patients received grafalon. Baseline demographics were similar between the two groups although significantly more patients in the grafalon group received ABO incompatible transplant (15% vs. 4.3%; P = 0.002). Patient survival was similar between the two groups (99% in grafalon vs. 98.8% in thymoglobulin; P = 1.0). Death censored graft survival was also similar (99% in grafalon vs. 100% in thymoglobulin; P = 0.23). Biopsy proven acute rejection (BPAR) was significantly higher in the grafalon group (12.8% vs. 5.1%, P = 0.04). The significance persisted after multivariable regression analysis (P = 0.02). Other outcomes such as infection rate and estimated glomerular filtration rate on last follow up were comparable between the two groups. Conclusions Grafalon (6 mg/kg dose) when used as an induction agent was associated with significantly higher rate of BPARs as compared to thymoglobulin (3 mg/kg dose) although with comparable short-term patient and death censored graft survival, graft function, and infection rates.
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Affiliation(s)
- Pranaw Kumar Jha
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Abhyudaysingh Rana
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Ajay Kher
- Department of Nephrology, Max Super Specialty Hospital, Vaishali, Ghaziabad, Uttar Pradesh, India
| | - Shyam Bihari Bansal
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Sidharth Sethi
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Ashish Nandwani
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Manish Jain
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Dinesh Bansal
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Dinesh Kumar Yadav
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Ashwini Gadde
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Amit Kumar Mahapatra
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Puneet Sodhi
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Vijay Kher
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
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Chai YX, Ji JL, Li SJ, Cao YW, Sun XX, Wang QH, Huang T, Dong Z, Wang HY. Efficacy of anti-T-lymphocyte globulin-Fresenius as an induction agent in deceased-donor renal transplantation: A cohort study. Exp Ther Med 2020; 19:2384-2390. [PMID: 32104307 DOI: 10.3892/etm.2020.8451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 09/24/2019] [Indexed: 11/06/2022] Open
Abstract
Anti-T-lymphocyte globulin (ATG) is frequently used in the induction regimen of renal transplantation, but its dose has not been standardized. In the present study, the efficacy of different ATG-Fresenius (ATG-F) doses was assessed in recipients of renal transplantation. A total of 131 adult recipients of renal transplantation who received ATG-F induction between August 2015 and July 2018 were included. The incidence of biopsy-confirmed acute rejection, graft function, as well as graft and patient survival within 12 months post-transplant, was assessed, and adverse events, including hematologic and infection-associated side effects, were compared between patients receiving a cumulative ATG-F dose of <7 or ≥7 mg/kg. The incidence of biopsy-confirmed acute rejection was similar between patients receiving cumulative doses of <7 and ≥7 mg/kg (7.5 vs. 4.7%, P=0.766). The incidence of infection within 12 months was lower in the ATG-F <7 mg/kg group compared with that in the ≥7 mg/kg group (26.9 vs. 50.0%, P=0.006), but the incidence of pneumonia did not differ between the ATG-F <7 and ≥7 mg/kg groups (10.4 vs. 20.3%, P=0.117). The incidence of urinary infection was higher in the ≥7 mg/kg group than in the <7 mg/kg group (20.4 vs. 7.46%, P=0.033), while the extent and duration of anemia and lymphopenia was similar between groups. There was no difference in graft function, delayed graft function, as well as overall and graft survival between the groups. In conclusion, a moderate reduction in the cumulative ATG-F dose was not associated with an increased risk of acute rejection, while the risk of infection was reduced. Optimization of the ATG-F dose for induction may facilitate the reduction of the risk of infection without compromising the induction efficacy in renal transplant recipients.
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Affiliation(s)
- Yun-Xia Chai
- Department of Kidney Transplantation, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
| | - Jian-Lei Ji
- Department of Kidney Transplantation, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
| | - Shu-Juan Li
- Department of Kidney Transplantation, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
| | - Yan-Wei Cao
- Department of Kidney Transplantation, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
| | - Xiao-Xia Sun
- Department of Kidney Transplantation, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
| | - Qing-Hai Wang
- Department of Kidney Transplantation, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
| | - Tao Huang
- Department of Kidney Transplantation, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
| | - Zhen Dong
- Department of Kidney Transplantation, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
| | - Hong-Yang Wang
- Department of Kidney Transplantation, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
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Styrc B, Sobolewski M, Chudek J, Kolonko A, Więcek A. Effectiveness and safety of two different antithymocyte globulins used in induction therapy in kidney transplant recipients: A single‐center experience. Clin Transplant 2019; 33:e13680. [PMID: 31365162 DOI: 10.1111/ctr.13680] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 07/16/2019] [Accepted: 07/26/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Beata Styrc
- Department of Nephrology, Transplantation and Internal Medicine Medical University of Silesia Katowice Poland
| | - Michał Sobolewski
- Department of Nephrology, Transplantation and Internal Medicine Medical University of Silesia Katowice Poland
| | - Jerzy Chudek
- Department of Internal Medicine and Oncological Chemotherapy Medical University of Silesia Katowice Poland
| | - Aureliusz Kolonko
- Department of Nephrology, Transplantation and Internal Medicine Medical University of Silesia Katowice Poland
| | - Andrzej Więcek
- Department of Nephrology, Transplantation and Internal Medicine Medical University of Silesia Katowice Poland
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Xuan D, Chen G, Wang C, Yao X, Yin H, Zhang L, Xuan J, Chen L. A Cost-effectiveness Analysis of Rabbit Antithymocyte Globulin Versus Antithymocyte Globulin-fresenius as Induction Therapy for Patients With Kidney Transplantation From Donation After Cardiac Death in China. Clin Ther 2018; 40:1741-1751. [PMID: 30243768 DOI: 10.1016/j.clinthera.2018.08.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 07/06/2018] [Accepted: 08/13/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE Induction immunosuppression therapy is used to support optimal outcomes in kidney transplantation. This study was to assess the cost-effectiveness of rabbit antithymocyte globulin (r-ATG) versus ATG-Fresenius (ATG-F) in kidney transplantation in the Chinese setting from the perspective of the health care payer. METHODS A 2-part survival model was developed, consisting of a short-term part and a long-term part. The short-term part analyzed the first year, using the decision tree, and consisted of the functioning transplant, acute rejection (AR), delayed graft function (DGF), dialysis, and death health states. The long-term part analyzed 2 to 5 years, using Markov model, and consisted of the functioning transplant, chronic dysfunction, recurring primary disease, dialysis, and death health states, with capture of the association between DGF and graft loss. Costs, including drug acquisition and other direct medical costs, were derived from China IQVIA database (formerly known as IMS) hospitaldatabase, chart review, and physician interviews. Clinical outcomes and utility were retrieved from published literature. The model calculated quality-adjusted life-years (QALYs) and total costs per patient. Costs and QALYs were discounted at an annual rate of 3.5%. Univariate sensitivity analysis and probability sensitivity analysis (PSA) were conducted to assess the impact of uncertainty of the variables on the results. FINDINGS Patients who received r-ATG had more clinical effectiveness than patients who received ATG-F mainly because of less AR, DGF, and dialysis. The incremental QALY was 0.01 over a 1-year time horizon and 0.0496 over a 5-year time horizon. R-ATG and ATG-F drug costs were ¥10,783 and ¥8409, respectively. However, the total treatment costs of the r-ATG arm were lower than the ATG-F arm because of lower costs related to DGF, AR, dialysis, and adverse events. In total, r-ATG saved ¥5423 over the 1-year and ¥7042 over the 5-year time horizon. R-ATG was dominant with lower total direct medical costs and higher QALYs compared with ATG-F. Both univariate sensitivity analysis and PSA found the robustness of the model results. PSA results indicated that r-ATG was cost-effective compared with ATG-F in 86.81% of the simulations, considering <3 times the gross domestic product per capita as the threshold. IMPLICATIONS From the perspective of the health care payer, r-ATG should be considered as the preferred treatment agent for induction therapy for Chinese patients undergoing kidney transplantation because of its lower overall medical costs and greater QALYs gained compared with ATG-F. The study was limited by lack of long-term efficacy data among the Chinese population and lack of comprehensive real-world higher quality costs data.
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Affiliation(s)
- Dennis Xuan
- Department of Health Policy and Management, University of North Carolina Gillings School of Public Health; Chapel Hill, North Carolina
| | - Guodong Chen
- Organ Transplant Center, the First Affiliated Hospital of Sun Yat-sen University; Guangzhou, China
| | - Changxi Wang
- Organ Transplant Center, the First Affiliated Hospital of Sun Yat-sen University; Guangzhou, China
| | | | | | - Lei Zhang
- Centennial Scientific Ltd., Shanghai, China
| | - Jianwei Xuan
- Health Economic Research Institute, Sun Yat-sen University, Guangzhou, China
| | - Lizhong Chen
- Organ Transplant Center, the First Affiliated Hospital of Sun Yat-sen University; Guangzhou, China.
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Bomfim GF, Cau SBA, Bruno AS, Fedoce AG, Carneiro FS. Hypertension: a new treatment for an old disease? Targeting the immune system. Br J Pharmacol 2018; 176:2028-2048. [PMID: 29969833 DOI: 10.1111/bph.14436] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/14/2018] [Accepted: 06/24/2018] [Indexed: 12/22/2022] Open
Abstract
Arterial hypertension represents a serious public health problem, being a major cause of morbidity and mortality worldwide. The availability of many antihypertensive therapeutic strategies still fails to adequately treat around 20% of hypertensive patients, who are considered resistant to conventional treatment. In the pathogenesis of hypertension, immune system mechanisms are activated and both the innate and adaptive immune responses play a crucial role. However, what, when and how the immune system is triggered during hypertension development is still largely undefined. In this context, this review highlights scientific advances in the manipulation of the immune system in order to attenuate hypertension and end-organ damage. Here, we discuss the potential use of immunosuppressants and immunomodulators as pharmacological tools to control the activation of the immune system, by non-specific and specific mechanisms, to treat hypertension and improve end-organ damage. Nevertheless, more clinical trials should be performed with these drugs to establish their therapeutic efficacy, safety and risk-benefit ratio in hypertensive conditions. LINKED ARTICLES: This article is part of a themed section on Immune Targets in Hypertension. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v176.12/issuetoc.
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Affiliation(s)
| | - Stefany Bruno Assis Cau
- Department of Pharmacology, Institute of Biological Science, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Alexandre Santos Bruno
- Department of Pharmacology, Institute of Biological Science, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Aline Garcia Fedoce
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Fernando S Carneiro
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
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Daloul R, Gupta S, Brennan DC. Biologics in Transplantation (Anti-thymocyte Globulin, Belatacept, Alemtuzumab): How Should We Use Them? CURRENT TRANSPLANTATION REPORTS 2017. [DOI: 10.1007/s40472-017-0147-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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