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Schold JD, Tambur AR, Mohan S, Kaplan B. Calibration of Priority Points for Sensitization Status of Kidney Transplant Candidates in the United States. Clin J Am Soc Nephrol 2024; 19:767-777. [PMID: 38509037 PMCID: PMC11168827 DOI: 10.2215/cjn.0000000000000449] [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: 09/28/2023] [Accepted: 03/14/2024] [Indexed: 03/22/2024]
Abstract
Key Points There are multiple factors associated with high sensitization levels among kidney transplant candidates, which differ by candidate sex. Since the initiation of the kidney allocation system, candidates with higher sensitization have higher rates of deceased donor transplantation. Priority points assigned to candidates associated with sensitization have led to inequities in access to deceased donor transplantation. Background A primary change to the national organ allocation system in 2014 for deceased donor kidney offers was to weight candidate priority on the basis of sensitization (i.e ., calculated panel reactive antibody percentage [cPRA%]) using a sliding scale. Increased priority for sensitized patients could improve equity in access to transplantation for disadvantaged candidates. We sought to evaluate the effect of these weights using a contemporary cohort of adult US kidney transplant candidates. Methods We used the national Scientific Registry of Transplant Recipients to evaluate factors associated with sensitization using multivariable logistic models and rates of deceased donor transplantation using cumulative incidence models accounting for competing risks and multivariable Cox models. Results We examined 270,912 adult candidates placed on the waiting list between January 2016 and September 2023. Six-year cumulative incidence of deceased donor transplantation for candidates with cPRA%=80–85 and 90–95 was 48% and 53%, respectively, as compared with 37% for candidates with cPRA%=0–20. In multivariable models, candidates with high cPRA% had the highest adjusted hazards for deceased donor transplantation. There was significant effect modification such that the association of high cPRA% with adjusted rates of deceased donor transplantation varied by region of the country, sex, race and ethnicity, prior dialysis time, and blood type. Conclusions The results indicate that the weighting algorithm for highly sensitized candidates may overinflate the need for prioritization and lead to higher rates of transplantation. Findings suggest recalibration of priority weights for allocation is needed to facilitate overall equity in access to transplantation for prospective kidney transplant candidates. However, priority points should also account for subgroups of candidates who are disadvantaged for access to donor offers.
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Affiliation(s)
- Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Anat R Tambur
- Department of Surgery, Northwestern University, Chicago, Illinois
| | - Sumit Mohan
- Department of Medicine, Columbia University, New York, New York
- Department of Epidemiology, Columbia University, New York, New York
| | - Bruce Kaplan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Jarmi T, Luo Y, Attieh RM, Qie Y, Gadd ME, Hundal T, Mao S, Murthy HS, Taner BC, Kharfan-Dabaja MA, Qin H. CAR T-cell therapy-paving the way for sensitized kidney transplant patients. Kidney Int 2024; 105:1124-1129. [PMID: 38573274 DOI: 10.1016/j.kint.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 01/18/2024] [Accepted: 02/02/2024] [Indexed: 04/05/2024]
Affiliation(s)
- Tambi Jarmi
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA.
| | - Yan Luo
- Regenerative Immunotherapy and CAR-T Translational Research Program, Mayo Clinic, Jacksonville, Florida, USA; Department of Cancer Biology, Mayo Clinic, Jacksonville, Florida, USA
| | - Rose Mary Attieh
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA
| | - Yaqing Qie
- Regenerative Immunotherapy and CAR-T Translational Research Program, Mayo Clinic, Jacksonville, Florida, USA
| | - Martha E Gadd
- Regenerative Immunotherapy and CAR-T Translational Research Program, Mayo Clinic, Jacksonville, Florida, USA
| | - Tanya Hundal
- Regenerative Immunotherapy and CAR-T Translational Research Program, Mayo Clinic, Jacksonville, Florida, USA
| | - Shennen Mao
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA
| | - Hemant S Murthy
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA; Blood and Marrow Transplantation and Cellular Therapy Program, Mayo Clinic, Jacksonville, Florida, USA
| | - Burcin C Taner
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA
| | - Mohamed A Kharfan-Dabaja
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA; Blood and Marrow Transplantation and Cellular Therapy Program, Mayo Clinic, Jacksonville, Florida, USA
| | - Hong Qin
- Regenerative Immunotherapy and CAR-T Translational Research Program, Mayo Clinic, Jacksonville, Florida, USA; Department of Cancer Biology, Mayo Clinic, Jacksonville, Florida, USA; Division of Hematology and Medical Oncology, Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA; Department of Immunology, Mayo Clinic, Rochester, Minnesota, USA.
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3
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Valentin MO, Crespo M, Fernandez C, Muro M, Vega R, Palou E, Ruiz JC, Diekman F, Padilla M, Mancebo E, Perez I, Andres A, Ontañon J, Dominguez-Gil B. Improving the Access of Highly Sensitized Patients to Kidney Transplantation From Deceased Donors: The Spanish PATHI Program With Allocation Based on the Virtual Crossmatch. Transplantation 2024; 108:787-801. [PMID: 37867239 DOI: 10.1097/tp.0000000000004824] [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: 10/24/2023]
Abstract
BACKGROUND In 2015, the Spanish National Transplant Organization developed a prioritization system (Program for Access to Transplantation for Highly Sensitized Patients [PATHI]) to increase transplant options for patients with calculated panel-reactive antibodies (cPRAs) ≥98%, based on virtual crossmatch. We describe the experience with the implementation of PATHI and assess its efficacy. METHODS PATHI registry was used to collect characteristics of donors and patients between June 15, 2015, and March 1, 2018. One-year graft and patient survival and acute rejection were also measured. A Cox model was used to identify factors related to patient death and graft loss and logistical regression for those associated with rejection. RESULTS One thousand eighty-nine patients were included, and 272 (25%) were transplanted. Transplant rate by cPRA was 54.9%, 40.5%, and 12.8% in patients with cPRA98%, cPRA99%, and cPRA100%, respectively. One-year patient survival was 92.5%. Recipient age ≥60, time under dialysis >7 y, and delayed graft function were mortality risk factors. One-year graft survival was 88.7%. The factor related to graft loss was delayed graft function. The rejection rate was 22%. Factors related to rejection were sex, older recipients, and posttransplant donor-specific antibodies. CONCLUSIONS A prioritization approach increases transplant options for highly sensitized patients with appropriate short-term postransplant outcomes. Along with other programs, PATHI may inspire other countries to adopt strategies to meet transplant needs of these patients.
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Affiliation(s)
- Maria O Valentin
- Nephrology Department, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Santander, Spain
| | - Marta Crespo
- Nephrology Department, Hospital De Mar, Barcelona, Spain
| | - Constantino Fernandez
- Nephrology Department, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Manuel Muro
- Immunology Department, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Rocio Vega
- Transplant Coordination Department, Organización Nacional de Trasplantes, Madrid, Spain
| | - Eduard Palou
- Immunology Department, Hospital Clinic, Barcelona, Spain
| | - Juan Carlos Ruiz
- Nephrology Department, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Santander, Spain
| | - Fritz Diekman
- Nephrology Department, Hospital Clinic, Barcelona, Spain
| | - Maria Padilla
- Immunology Department, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Esther Mancebo
- Immunology Department, Hospital 12 de Octubre, Madrid, Spain
| | - Isabel Perez
- Nephrology Department, Hospital Clinico San Carlos, Madrid, Spain
| | - Amado Andres
- Nephrology Department, Hospital 12 de Octubre, Madrid, Spain
| | - Jesus Ontañon
- Immunology Department, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Beatriz Dominguez-Gil
- Immunology Department, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
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4
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Ferrari K, Aarnink A, Ayav C, Frimat L, Couchoud C, Audry B, Antoine C, Girerd S. Evolution of HLA-sensitization according to immunosuppressive therapy management among kidney transplant patients returning to dialysis between 2008 and 2019: A French retrospective study. Clin Transplant 2024; 38:e15160. [PMID: 37823237 DOI: 10.1111/ctr.15160] [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: 08/22/2022] [Revised: 08/25/2023] [Accepted: 09/29/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND The optimal management of immunosuppressive therapy (IT) after kidney allograft failure (KAF) remains controversial. Although maintaining IT may reduce HLA-sensitization and improve access to retransplantation, it may also increase the rate of immunosuppression-related complications. The overall impact on patient mortality is unknown. The main objective of this study was to compare the evolution of HLA-sensitization 6 months after KAF according to IT management. METHODS Individual clinical and health care data were extracted from the French national end-stage kidney disease registry (Renal Epidemiology and Information Network [REIN]) and the French National Health Data system (SNDS), respectively. Patients aged > 18 years returning to dialysis after KAF between January 2008 and December 2019 in Lorraine were included. Patients were classified into two groups, IT continuation or IT discontinuation. HLA-sensitization was defined as an increase in incompatible graft rate (IGR) between KAF and 6 months post-KAF (change to a higher predefined category (0%-5%), (5%-20%), (20%-50%), (50%-85%), (85%-95%), (95%-98%), (98%-100%)). Secondary outcome was patient survival according to IT management. RESULTS A total of 121 patients were included, 35 (29%) of whom continued IT. HLA-sensitization after KAF tended to be higher in the "IT discontinuation" group (57% vs. 38% in the "IT continuation" group, p = .07). In multivariate analysis, IT continuation was associated with a lower increase in IGR (OR .37, 95% CI [.14; .93]). IT management was not associated with patient mortality. CONCLUSIONS Continuation of IT after KAF was associated with less change in IGR and was not associated with excess mortality.
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Affiliation(s)
- Kevin Ferrari
- Nephrology Department, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Alice Aarnink
- Histocompatibility Laboratory, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
- IMoPA6, UMR7365 CNRS, Université de Lorraine, Vandoeuvre-les-Nancy, France
| | - Carole Ayav
- Clinical Epidemiology, Inserm CIC-EC, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Luc Frimat
- Nephrology Department, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | | | | | | | - Sophie Girerd
- Nephrology Department, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
- Université de Lorraine, Inserm, Centre d'Investigation Clinique-1433, and Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT, Nancy, France
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5
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Tafulo S, Osório E, Mendes C, Liwski R. Complement-dependent cytotoxicity crossmatch in solid organ transplantation: The gold standard or golden history? Hum Immunol 2024; 85:110734. [PMID: 38030522 DOI: 10.1016/j.humimm.2023.110734] [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: 09/20/2023] [Revised: 11/19/2023] [Accepted: 11/20/2023] [Indexed: 12/01/2023]
Abstract
Complement-dependent cytotoxicity crossmatch (CDC-XM) has been considered for many years the standard of practice for determining compatibility in solid organ transplantation (SOT). However, as this method is laborious, time intensive and lacks sensitivity and specificity, it has been replaced in many laboratories worldwide by flow cytometry crossmatch (FCXM) and/or virtual crossmatch (vXM). With this study we intend to show the relevance of performing CDC-XM in the era of virtual crossmatching. We retrospectively analyzed 1,007 consecutive T and B cell deceased donor (DD) CDC-XMs performed in parallel using non-treated and dithiothreitol (DTT) treated sera between May 2022 and January 2023 in waitlisted patients with no donor specific antibodies (DSA) against HLA-A, B and/or DR antigens. Thirty five of 1,007 (3.5%) T cell crossmatches and 132 of 1,007 (13.1%) B cell crossmatches were positive with non-treated sera. Correlation with the vXM demonstrated no DSA in any of the positive T cell crossmatches. DSA were also absent in 126/132 positive B cell crossmatches, indicating a high rate of false positive CDC-XM. Indeed, only 4/35 T cell and 13/132 B cell CDC-XM remained positive after treatment with DTT, confirming that false positive reactivity with non-treated sera is high. Class I HLA DSA against C locus antigens were present in 17/1,007 T cell crossmatches and none were detected by CDC-XM (sensitivity = 0%). Similarly, only 6/77 B cell crossmatches with DSA targeting HLA-C, DQ and/or DP antigens were CDC-XM positive (sensitivity = 7.8%). Furthermore, only 4/6 positive B cell CDC-XM were confirmed to have complement binding potential using the C1q assay, suggesting additional false positive reactivity in 2/6 of the positive CDC-XM. Our study demonstrates that CDC-XM exhibits poor sensitivity, high false positive reactivity (especially without DTT treatment) and does not meaningfully contribute to pre-transplant compatibility testing in the context of vXM based allocation. Furthermore, the use of CDC-XM can unnecessarily delay or even prevent safe and appropriate transplant allocation.
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Affiliation(s)
- Sandra Tafulo
- Centro de Sangue e da Transplantação do Porto, Instituto Português do Sangue e da Transplantação, Porto, Portugal; UMIB - Unit for Multidisciplinary Research in Biomedicine, ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal
| | - Ermelinda Osório
- Centro de Sangue e da Transplantação do Porto, Instituto Português do Sangue e da Transplantação, Porto, Portugal
| | - Cecília Mendes
- Centro de Sangue e da Transplantação do Porto, Instituto Português do Sangue e da Transplantação, Porto, Portugal
| | - Robert Liwski
- Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
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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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Noelle J, Mayet V, Lambert C, Couzi L, Chauveau B, Thierry A, Ecotière L, Bertrand D, Laurent C, Lemal R, Grèze C, Freist M, Heng AE, Rouzaire PO, Garrouste C. Impact of Calcineurin Inhibitor-Based Immunosuppression Maintenance During the Dialysis Period After Kidney Transplant Failure on the Next Kidney Graft Outcome: A Retrospective Multicenter Study With Propensity Score Analysis. Transpl Int 2023; 36:11775. [PMID: 37799669 PMCID: PMC10548547 DOI: 10.3389/ti.2023.11775] [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: 07/06/2023] [Accepted: 08/25/2023] [Indexed: 10/07/2023]
Abstract
The impact of immunosuppressive therapy (IS) strategies after kidney transplant failure (KTF) on potential future new grafts is poorly established. We assessed the potential benefit of calcineurin inhibitor (CNI)-based IS maintenance throughout the dialysis period on the outcome of the second kidney transplant (KT). We identified 407 patients who underwent a second KT between January 2008 and December 2018 at four French KT centers. Inverse probability of treatment weighting was used to control for potential confounding. We included 205 patients with similar baseline characteristics at KTF: a total of 53 received at least CNIs on the retransplant day (G-CNI), and 152 did not receive any IS (G-STOP). On the retransplant date, G-STOP patients experienced a longer pretransplant dialysis time, were more often hyperimmunized, and underwent more expanded-criteria donor KTs than G-CNI patients. During the second KT follow-up period, rejection episodes were similar in both groups. The 10-year survival rates without death and dialysis were 98.7% and 59.5% in G-CNI and G-STOP patients, respectively. In the multivariable analysis, CNI-based IS maintenance was associated with better survival (hazard ratio: 0.08; 95% confidence interval: 0.01-0.58, p = 0.01). CNI-based IS maintenance throughout the dialysis period after KTF may improve retransplantation outcomes.
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Affiliation(s)
- Juliette Noelle
- Service de Néphrologie Centre hospitalo-universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Valentin Mayet
- Service de Néphrologie Centre hospitalo-universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Céline Lambert
- Unité de Biostatistiques, Direction de la recherche clinique et d’ innovation, Centre hospitalo-universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Lionel Couzi
- Service de Néphrologie, Transplantation, Dialyse et Aphérèses, Centre hospitalo-universitaire Bordeaux, Bordeaux, France
| | - Bertrand Chauveau
- Service de Pathologie, Centre hospitalo-universitaire de Bordeaux, Bordeaux, France
| | - Antoine Thierry
- Service de Néphrologie-Hémodialyse-Transplantation Rénale, Centre hospitalo-universitaire Poitiers, Poitiers, France
| | - Laure Ecotière
- Service de Néphrologie-Hémodialyse-Transplantation Rénale, Centre hospitalo-universitaire Poitiers, Poitiers, France
| | - Dominique Bertrand
- Service de Néphrologie, Centre hospitalier régional universitaire rouen, Rouen, France
| | - Charlotte Laurent
- Service de Néphrologie, Centre hospitalier régional universitaire rouen, Rouen, France
| | - Richard Lemal
- Service d’Histocompatibilité et Immunogénétique, Centre hospitalo-universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Clarisse Grèze
- Service de Néphrologie Centre hospitalo-universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Marine Freist
- Service de Néphrologie Centre hospitalo-universitaire Clermont-Ferrand, Clermont-Ferrand, France
- Service de Néphrologie et Dialyse, Centre hospitalier Emile Roux, Le Puy-en-Velay, France
| | - Anne-Elisabeth Heng
- Service de Néphrologie Centre hospitalo-universitaire Clermont-Ferrand, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Paul-Olivier Rouzaire
- Service d’Histocompatibilité et Immunogénétique, Centre hospitalo-universitaire Clermont-Ferrand, Clermont-Ferrand, France
- EA 7453 CHELTER, Clermont-Ferrand, France
| | - Cyril Garrouste
- Service de Néphrologie Centre hospitalo-universitaire Clermont-Ferrand, Université Clermont Auvergne, Clermont-Ferrand, France
- EA 7453 CHELTER, Clermont-Ferrand, France
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8
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Motter JD, Massie AB, Garonzik-Wang JM, Pfeiffer RM, Yu KJ, Segev DL, Engels EA. Cancer Risk Following HLA-Incompatible Living Donor Kidney Transplantation. Transplant Direct 2023; 9:e1505. [PMID: 37492080 PMCID: PMC10365202 DOI: 10.1097/txd.0000000000001505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/05/2023] [Accepted: 05/06/2023] [Indexed: 07/27/2023] Open
Abstract
Incompatible living donor kidney transplant recipients (ILDKTr) require desensitization to facilitate transplantation, and this substantial upfront immunosuppression may result in serious complications, including cancer. Methods To characterize cancer risk in ILDKTr, we evaluated 858 ILDKTr and 12 239 compatible living donor kidney transplant recipients (CLDKTr) from a multicenter cohort with linkage to the US transplant registry and 33 cancer registries (1997-2016). Cancer incidence was compared using weighted Cox regression. Results Among ILDKTr, the median follow-up time was 6.7 y (maximum 16.1 y) for invasive cancers (ascertained via cancer registry linkage) and 5.0 y (maximum 16.1 y) for basal and squamous cell carcinomas (ascertained via the transplant registry and censored for transplant center loss to follow-up). Invasive cancers occurred in 53 ILDKTr (6.2%) and 811 CLDKTr (6.6%; weighted hazard ratio [wHR] 1.01; 95% confidence interval [CI], 0.76-1.35). Basal and squamous cell carcinomas occurred in 41 ILDKTr (4.8%) and 737 CLDKTr (6.0%) (wHR 0.99; 95% CI, 0.69-1.40). Cancer risk did not vary according to donor-specific antibody strength, and in an exploratory analysis, was similar between CLDKTr and ILDKTr for most cancer types and according to cancer stage, except ILDKTr had a suggestively increased risk of colorectal cancer (wHR 3.27; 95% CI, 1.23-8.71); however, this elevation was not significant after correction for multiple comparisons. Conclusions These findings indicate that the risk of cancer is not increased for ILDKTr compared with CLDKTr. The possible elevation in colorectal cancer risk is unexplained and might suggest a need for tailored screening or prevention.
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Affiliation(s)
- Jennifer D. Motter
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - Allan B. Massie
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
- Department of Population Health, New York University Grossman School of Medicine, New York, NY
| | | | - Ruth M. Pfeiffer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD
| | - Kelly J. Yu
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD
| | - Dorry L. Segev
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
- Department of Population Health, New York University Grossman School of Medicine, New York, NY
- Scientific Registry of Transplant Recipients, Minneapolis, MN
| | - Eric A. Engels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD
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Santos E, Spensley K, Gunby N, Clarke C, Anand A, Roufosse C, Willicombe M. Steroid Sparing Maintenance Immunosuppression in Highly Sensitised Patients Receiving Alemtuzumab Induction. Transpl Int 2023; 36:11056. [PMID: 37334011 PMCID: PMC10272412 DOI: 10.3389/ti.2023.11056] [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: 11/15/2022] [Accepted: 04/25/2023] [Indexed: 06/20/2023]
Abstract
This analysis reports on the outcomes of two different steroid sparing immunosuppression protocols used in the management of 120 highly sensitised patients (HSPs) with cRF>85% receiving Alemtuzumab induction, 53 maintained on tacrolimus (FK) monotherapy and 67 tacrolimus plus mycophenolate mofetil (FK + MMF). There was no difference in the median cRF or mode of sensitisation between the two groups, although the FK + MMF cohort received more poorly matched grafts. There was no difference in one-year patient or allograft survival, however rejection free survival was inferior with FK monotherapy compared with FK + MMF at 65.4% and 91.4% respectively, p < 0.01. DSA-free survival was comparable. Whilst there was no difference in rates of BK between the cohorts, CMV-free survival was inferior in the FK + MMF group at 86.0% compared with 98.1% in the FK group, p = 0.026. One-year post-transplant diabetes free survival was 89.6% and 100.0% in the FK and FK + MMF group respectively, p = 0.027, the difference attributed to the use of prednisolone to treat rejection in the FK cohort, p = 0.006. We report good outcomes in HSPs utilising a steroid sparing protocol with Alemtuzumab induction and FK + MMF maintenance and provide granular data on immunological and infectious complications to inform steroid avoidance in these patient groups.
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Affiliation(s)
- Eva Santos
- Histocompatibility and Immunogenetics Laboratory, Northwest London Pathology NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Katrina Spensley
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, United Kingdom
| | - Nicola Gunby
- Histocompatibility and Immunogenetics Laboratory, Northwest London Pathology NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Candice Clarke
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, United Kingdom
| | - Arthi Anand
- Histocompatibility and Immunogenetics Laboratory, Northwest London Pathology NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Candice Roufosse
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, United Kingdom
- Department of Histopathology, Northwest London Pathology NHS Trust, Charing Cross Hospital, London, United Kingdom
| | - Michelle Willicombe
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, United Kingdom
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10
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Sandal S, Ahn JB, Chen Y, Massie AB, Clark-Cutaia MN, Wu W, Cantarovich M, Segev DL, McAdams-DeMarco MA. Trends in the survival benefit of repeat kidney transplantation over the past 3 decades. Am J Transplant 2023; 23:666-672. [PMID: 36731783 PMCID: PMC10269548 DOI: 10.1016/j.ajt.2023.01.008] [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: 12/30/2022] [Accepted: 01/19/2023] [Indexed: 02/01/2023]
Abstract
Repeat kidney transplantation (re-KT) is the preferred treatment for patients with graft failure. Changing allocation policies, widening the risk profile of recipients, and improving dialysis care may have altered the survival benefit of a re-KT. We characterized trends in re-KT survival benefit over 3 decades and tested whether it differed by age, race/ethnicity, sex, and panel reactive assay (PRA). By using the Scientific Registry of Transplant Recipient data, we identified 25 419 patients who underwent a re-KT from 1990 to 2019 and 25 419 waitlisted counterfactuals from the same year with the same waitlisted time following graft failure. In the adjusted analysis, a re-KT was associated with a lower risk of death (adjusted hazard ratio [aHR] = 0.63; 95% confidence interval [CI], 0.61-0.65). By using the 1990-1994 era as a reference (aHR = 0.77; 95% CI, 0.69-0.85), incremental improvements in the survival benefit were noted (1995-1999: aHR = 0.72; 95% CI, 0.67-0.78: 2000-2004: aHR = 0.59; 95% CI, 0.55-0.63: 2005-2009: aHR = 0.59; 95% CI, 0.56-0.63: 2010-2014: aHR = 0.57; 95% CI, 0.53-0.62: 2015-2019: aHR = 0.64; 95% CI, 0.57-0.73). The survival benefit of a re-KT was noted in both younger (age = 18-64 years: aHR = 0.63; 95% CI, 0.61-0.65) and older patients (age ≥65 years: aHR = 0.66; 95% CI, 0.58-0.74; Pinteraction = .45). Patients of all races/ethnicities demonstrated similar benefits with a re-KT. However, it varied by the sex of the recipient (female patients: aHR = 0.60; 95% CI, 0.56-0.63: male patients: aHR = 0.66; 95% CI, 0.63-0.68; Pinteraction = .004) and PRA (0-20: aHR = 0.69; 95% CI, 0.65-0.74: 21-80: aHR = 0.61; 95% CI, 0.57-0.66; Pinteraction = .02; >80: aHR = 0.57; 95% CI, 0.53-0.61; Pinteraction< .001). Our findings support the continued practice of a re-KT and efforts to overcome the medical, immunologic, and surgical challenges of a re-KT.
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Affiliation(s)
- Shaifali Sandal
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada; Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.
| | - JiYoon B Ahn
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yusi Chen
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, New York, USA
| | - Allan B Massie
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, New York, USA
| | - Maya N Clark-Cutaia
- Department of Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
| | - Wenbo Wu
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Marcelo Cantarovich
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada; Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Dorry L Segev
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, New York, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, New York, USA; Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
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11
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Sapir-Pichhadze R, Oertelt-Prigione S. P3 2: a sex- and gender-sensitive model for evidence-based precision medicine: from knowledge generation to implementation in the field of kidney transplantation. Kidney Int 2023; 103:674-685. [PMID: 36731608 DOI: 10.1016/j.kint.2022.12.026] [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: 07/21/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 02/01/2023]
Abstract
Precision medicine emerged as a promising approach to identify suitable interventions for individual patients with a particular health concern and at various time points. Technology can enable the acquisition of increasing volumes of clinical and "omics" data at the individual and population levels and support advanced clinical decision making. However, to keep pace with evolving societal realities and developments, it is important to systematically include sex- and gender-specific considerations in the research process, from the acquisition of knowledge to implementation. Building on the foundations of evidence-based medicine and existing precision medicine frameworks, we propose a novel evidence-based precision medicine framework in the form of the P32model, which considers individual sex-related (predictive [P1], preventive [P2], and personalized [P3] medicine) and gender-related (participatory [P4], psychosocial [P5], and percipient [P6] medicine) domains and their intersection with ethnicity, geography, and other demographic and social variables, in addition to population, community, and public dimensions (population-informed [P7], partnered with community [P8], and public-engaging [P9] medicine, respectively). Through its ability to contextualize and reflect on societal realities and developments, our model is expected to promote consideration of diversity, equity, and inclusion principles and, thus, enrich science, increase reproducibility of research, and ensure its social impact.
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Affiliation(s)
- Ruth Sapir-Pichhadze
- Centre for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics, Occupational Health, McGill University, Montreal, Quebec, Canada; Division of Nephrology, Department of Medicine, McGill University, Montreal, Quebec, Canada.
| | - Sabine Oertelt-Prigione
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands; AG10 Sex- and Gender-Sensitive Medicine, Medical Faculty OWL, University of Bielefeld, Bielefeld, Germany.
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12
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Di Cocco P, Gaitonde S, Spaggiari M, Fratti A, Alvarez JA, Petrochenkov E, Valdenepas BT, Gupta P, Benedetti E, Tzvetanov I. Desensitizing With Temporary Donor Splenic Transplant: Hope for the Sensitized Patients on Pancreas and Kidney -Pancreas Transplant Waitlist. Transplant Proc 2023; 55:295-302. [PMID: 36801174 DOI: 10.1016/j.transproceed.2023.01.006] [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: 10/19/2022] [Revised: 12/20/2022] [Accepted: 01/24/2023] [Indexed: 02/21/2023]
Abstract
BACKGROUND Sensitized patients on a waitlist with donor specific antibodies (DSA) or positive flow cytometry cross match (FXM) to deceased donor organ have few pretransplant desensitization options due to increasing graft cold ischemia time. Herein, sensitized simultaneous kidney/pancreas recipients received temporary splenic transplant from the same donor under the hypothesis that spleen would function as a DSA graveyard and provide a safe immunologic window for transplant. METHODS We analyzed presplenic and postsplenic transplant FXM and DSA results of 8 sensitized patients who underwent simultaneous kidney and pancreas transplantation with temporary deceased donor spleen between November 2020 and January 2022. RESULTS Pre-splenic transplant, 4 sensitized patients were both T-cell and B-cell FXM positive; one was only B-cell FXM positive and 3 were DSA positive/FXM negative. Post-splenic transplant, all were FXM negative. Pre-splenic transplant class I and class II DSA were detected in 3 patients, only class I DSA in 4 patients, and only class II DSA in 1 patient. Postsplenic transplant, class I DSA was eliminated in all patients. Class II DSA persisted in 3 patients; all showed a marked decrease in DSA mean fluorescence index. Class II DSA was eliminated in one patient. CONCLUSION Donor spleen functions as a DSA graveyard and provides an immunologically safe window for kidney-pancreas transplantation.
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Affiliation(s)
| | - Sujata Gaitonde
- Department of Pathology, University of Illinois at Chicago, Illinois.
| | - Mario Spaggiari
- Department of Surgery, University of Illinois at Chicago, Illinois
| | - Alberto Fratti
- Department of Surgery, University of Illinois at Chicago, Illinois
| | | | | | - Bentio T Valdenepas
- Department of Pharmacy Practice, University of Illinois at Chicago, Illinois
| | - Priyanka Gupta
- Department of Pathology, University of Illinois at Chicago, Illinois
| | - Enrico Benedetti
- Department of Surgery, University of Illinois at Chicago, Illinois
| | - Ivo Tzvetanov
- Department of Surgery, University of Illinois at Chicago, Illinois
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13
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Abstract
Access to kidney transplantation is limited by HLA-specific sensitization. Desensitization strategies enable crossmatch-positive kidney transplantation. In this review, we describe clinical experience gained over the last 20 y using desensitization strategies before kidney transplantation and describe the different tools used (both drugs and apheresis options), including IVIg, rituximab, apheresis techniques, interleukin-6 interference, proteasome inhibition, enzymatic degradation of HLA antibodies, complement inhibition, and B cytokine interference. Although access to transplantation for highly sensitized kidney transplantation candidates has been vastly improved by desensitization strategies, it remains, however, limited by the recurrence of HLA antibodies after transplantation and the occurrence of antibody-mediated rejection.
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14
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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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15
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Gragert L, Kadatz M, Alcorn J, Stewart D, Chang D, Gill J, Liwski R, Gebel HM, Gill J, Lan JH. ABO-adjusted calculated panel reactive antibody (cPRA): A unified metric for immunologic compatibility in kidney transplantation. Am J Transplant 2022; 22:3093-3100. [PMID: 35975734 PMCID: PMC10087664 DOI: 10.1111/ajt.17175] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/17/2022] [Accepted: 08/13/2022] [Indexed: 01/25/2023]
Abstract
Implementation of the kidney allocation system in 2014 greatly reduced access disparity due to human leukocyte antigen (HLA) sensitization. To address persistent disparity related to candidate ABO blood groups, herein we propose a novel metric termed "ABO-adjusted cPRA," which simultaneously considers the impact of candidate HLA and ABO sensitization on the same scale. An ethnic-weighted ABO-adjusted cPRA value was computed for 190 467 candidates on the kidney waitlist by combining candidate's conventional HLA cPRA with the remaining fraction of HLA-compatible donors that are ABO-incompatible. Consideration of ABO sensitization resulted in higher ABO-adjusted cPRA relative to conventional cPRA by HLA alone, except for AB candidates since they are not ABO-sensitized. Within cPRA Point Group = 99%, 43% of the candidates moved up to ABO-adjusted cPRA Point Group = 100%, though this proportion varied substantially by candidate blood group. Nearly all O and most B candidates would have elevated ABO-adjusted cPRA values above this policy threshold for allocation priority, but relatively few A candidates displayed this shift. Overall, ABO-adjusted cPRA more accurately measures the proportion of immune-compatible donors compared with conventional HLA cPRA, especially for highly sensitized candidates. Implementation of this novel metric could enable the development of allocation policies permitting more ABO-compatible transplants without compromising equity.
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Affiliation(s)
- Loren Gragert
- Department of Pathology and Laboratory Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Matthew Kadatz
- Vancouver Coastal Health Research Institute, Vancouver, Canada.,Division of Nephrology, University of British Columbia, Vancouver, Canada
| | - James Alcorn
- United Network for Organ Sharing, Richmond, Virginia, USA
| | - Darren Stewart
- United Network for Organ Sharing, Richmond, Virginia, USA
| | - Doris Chang
- Providence Health Research Institute, Vancouver, Canada
| | - Jagbir Gill
- Division of Nephrology, University of British Columbia, Vancouver, Canada.,Providence Health Research Institute, Vancouver, Canada.,Centre for Health Evaluation and Outcomes Sciences, University of British Columbia, Vancouver, Canada
| | - Robert Liwski
- Department of Pathology, Dalhousie University, Halifax, Canada
| | - Howard M Gebel
- Department of Pathology, Emory University, Atlanta, Georgia, USA
| | - John Gill
- Division of Nephrology, University of British Columbia, Vancouver, Canada.,Providence Health Research Institute, Vancouver, Canada
| | - James H Lan
- Vancouver Coastal Health Research Institute, Vancouver, Canada.,Division of Nephrology, University of British Columbia, Vancouver, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
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16
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Schmitz R, Fitch ZW, Manook M, Schroder PM, Choi AY, Olaso D, Yoon J, Bae Y, Shaw BI, Song M, Kuchibhatla M, Farris AB, Kirk A, Kwun J, Knechtle SJ. Belatacept-Based Maintenance Immunosuppression Controls the Post-Transplant Humoral Immune Response in Highly Sensitized Nonhuman Primates. KIDNEY360 2022; 3:2116-2130. [PMID: 36591367 PMCID: PMC9802566 DOI: 10.34067/kid.0001732022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 09/12/2022] [Indexed: 11/06/2022]
Abstract
Preexisting donor-specific antibodies (DSA) to MHC antigens increase the risk of antibody-mediated rejection (AMR) in sensitized transplant recipients and reduces graft survival. Pretransplant desensitization with costimulation blockade and proteasome inhibition has facilitated transplantation in our preclinical nonhuman primate (NHP) model. However, long-term graft survival is limited by rebound of DSA after transplantation. In this study, we performed kidney transplants between highly sensitized, maximally MHC-mismatched NHPs (n=14). At kidney transplantation, primates received T cell depletion with rhesus-specific anti-thymocyte globulin (rhATG; n=10) or monoclonal anti-CD4 and anti-CD8 antibodies (n=4). Maintenance immunosuppression consisted of belatacept and tacrolimus (n=5) or belatacept and rapamycin (n=9) with steroids. Rebound of DSA post-kidney transplantation was significantly reduced compared with maintenance immunosuppression with tacrolimus, mycophenolate, and steroids. Protocol lymph node biopsy specimens showed a decrease in germinal center activity, with low frequencies of T follicular helper cells and class-switched B cells after kidney transplantation. Combined belatacept and rapamycin was superior in controlling viral reactivation, enabling weaning of ganciclovir prophylaxis. Tacrolimus was associated with increased morbidity that included cytomegalovirus and parvovirus viremia and post-transplant lymphoproliferative disorder. All primates in the tacrolimus/belatacept group failed discontinuation of antiviral therapy. Overall, belatacept-based immunosuppression increased AMR-free graft survival by controlling post-transplant humoral responses in highly sensitized NHP recipients and should be further investigated in a human clinical trial.
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Affiliation(s)
- Robin Schmitz
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Zachary W. Fitch
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Miriam Manook
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Paul M. Schroder
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Ashley Y. Choi
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Danae Olaso
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Janghoon Yoon
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Yeeun Bae
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Brian I. Shaw
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Mingqing Song
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Alton B. Farris
- Department of Pathology, Emory University School of Medicine, Atlanta, Georgia
| | - Allan Kirk
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Jean Kwun
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Stuart J. Knechtle
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
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17
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Ngamvichchukorn T, Ruengorn C, Noppakun K, Thavorn K, Hutton B, Sood MM, Knoll GA, Nochaiwong S. Association Between Pretransplant Dialysis Modality and Kidney Transplant Outcomes: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2237580. [PMID: 36264575 PMCID: PMC9585427 DOI: 10.1001/jamanetworkopen.2022.37580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
IMPORTANCE The benefits and disadvantages of different pretransplant dialysis modalities and their posttransplant outcomes remain unclear in contemporary kidney transplant care. OBJECTIVE To summarize the available evidence of the association of different pretransplant dialysis modalities, including hemodialysis and peritoneal dialysis (PD), with posttransplant outcomes. DATA SOURCES MEDLINE, Embase, PubMed, Cochrane Library, Scopus, CINAHL, and gray literature were searched from inception to March 18, 2022 (updated to April 1, 2022), for relevant studies and with no language restrictions. STUDY SELECTION Randomized clinical trials and nonrandomized observational (case-control and cohort) studies that investigated the association between pretransplant dialysis modality and posttransplant outcomes regardless of age or donor sources (living or deceased) were abstracted independently by 2 reviewers. DATA EXTRACTION AND SYNTHESIS Following Preferred Reporting Items for Systematic Reviews and Meta-analyses and Meta-analysis of Observational Studies in Epidemiology reporting guidelines, 2 reviewers independently extracted relevant information using a standardized approach. Random-effects meta-analysis was used to estimate pooled adjusted hazard ratio (HR) or odds ratio and 95% CI. MAIN OUTCOMES AND MEASURES Primary outcomes included all-cause mortality, overall graft failure, death-censored graft failure, and delayed graft function. Secondary outcomes included acute rejection, graft vessel thrombosis, oliguria, de novo heart failure, and new-onset diabetes after transplant. RESULTS The study analyzed 26 nonrandomized studies (1 case-control and 25 cohort), including 269 715 patients (mean recipient age range, 14.5-67.0 years; reported proportions of female individuals, 29.4%-66.9%) whose outcomes associated with pretransplant hemodialysis vs pretransplant PD were compared. No significant difference, with very low certainty of evidence, was observed between pretransplant PD and all-cause mortality (13 studies; n = 221 815; HR, 0.92 [95% CI, 0.84-1.01]; P = .08) as well as death-censored graft failure (5 studies; n = 96 439; HR, 0.98 [95% CI, 0.85-1.14]; P = .81). However, pretransplant PD was associated with a lower risk for overall graft failure (10 studies; n = 209 287; HR, 0.96 [95% CI, 0.92-0.99]; P = .02; very low certainty of evidence) and delayed graft function (6 studies; n = 47 118; odds ratio, 0.73 [95% CI, 0.70-0.76]; P < .001; low certainty of evidence). Secondary outcomes were inconclusive due to few studies with available data. CONCLUSIONS AND RELEVANCE Results of the study suggest that pretransplant PD is a preferred dialysis modality option during the transition to kidney transplant. Future studies are warranted to address shared decision-making between health care professionals, patients, and caregivers as well as patient preferences.
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Affiliation(s)
- Tanun Ngamvichchukorn
- Division of Nephrology, Department of Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Chidchanok Ruengorn
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Pharmacoepidemiology and Statistics Research Center, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Kajohnsak Noppakun
- Pharmacoepidemiology and Statistics Research Center, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kednapa Thavorn
- Pharmacoepidemiology and Statistics Research Center, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada
- ICES uOttawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Brian Hutton
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada
- ICES uOttawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Manish M. Sood
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Greg A. Knoll
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Surapon Nochaiwong
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Pharmacoepidemiology and Statistics Research Center, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
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18
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Recomendaciones para el trasplante renal de donante vivo. Nefrologia 2022. [DOI: 10.1016/j.nefro.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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19
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Impact of the Type of Dialysis on Time to Transplantation: Is It Just a Matter of Immunity? J Clin Med 2022; 11:jcm11041054. [PMID: 35207326 PMCID: PMC8874533 DOI: 10.3390/jcm11041054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/11/2022] [Accepted: 02/16/2022] [Indexed: 01/27/2023] Open
Abstract
Background: Renal transplantation represents the therapeutic gold standard in patients with end stage renal disease (ESRD). Still the role of pre-transplant dialysis in affecting time to transplantation has yet to be determined. We wanted to verify whether the type of renal replacement therapy (hemodialysis vs. peritoneal dialysis) affects time to transplantation and to identify clinical features related to the longer time to transplantation. Methods: We performed a retrospective single-center observational study on patients who had received a transplant in the Bologna Transplant Unit from 1991 to 2019, described through the analysis of digital transplant list documents for sex, age, body mass index (BMI), blood group, comorbidities, underlying disease, serology, type of dialysis, time to transplantation, Panel Reactive Antibodies (PRA) max, number of preformed anti Human Leukocyte Antigens (HLA) antibodies. A p-value < 0.05 was considered statistically significant. Results: In the 1619 patients analyzed, we observed a significant difference in time to transplant, PRA max and Preformed Antibodies Number between patients who received Hemodialysis (HD) and Peritoneal dialysis (PD). Then we performed a multiple regression analysis with all the considered factors in order to identify features that support these differences. The clinical variables that independently and directly correlate with longer time to transplantation are PRA max (p < 0.0001), Antibodies number (p < 0.0001) and HD (p < 0.0001); though AB blood group (p < 0.0001), age (p < 0.003) and PD (p < 0.0001) inversely correlate with time to transplantation. Conclusions: In our work, PD population received renal transplants in a shorter period of time compared to HD and turned out to be less immunized. Considering immunization, the type of dialysis impacts both on PRA max and on anti HLA antibodies.
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Siddiqui MU, Junarta J, Marhefka GD. Coronary Revascularization Versus Optimal Medical Therapy in Renal Transplant Candidates With Coronary Artery Disease: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2022; 11:e023548. [PMID: 35132876 PMCID: PMC9245820 DOI: 10.1161/jaha.121.023548] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background Coronary artery disease (CAD) is highly prevalent in patients with chronic kidney disease and is a common cause of mortality in end‐stage renal disease. Thus, patients with end‐stage renal disease are routinely screened for CAD before renal transplantation. The usefulness of revascularization before transplantation remains unclear. We hypothesize that there is no difference in all‐cause and cardiovascular mortality in waitlisted renal transplant candidates with CAD who underwent revascularization versus those treated with optimal medical therapy before transplantation. Methods and Results This meta‐analysis was reported according to the Preferred Reporting Items for Systematic Review and Meta‐Analyses guidelines. MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Risk of bias was assessed using the modified Newcastle‐Ottawa Scale and Cochrane risk of bias tool. The primary outcome of interest was all‐cause mortality. Eight studies comprising 945 patients were included (36% women, mean age 56 years). There was no difference in all‐cause mortality (risk ratio [RR], 1.16 [95% CI, 0.63–2.12), cardiovascular mortality (RR, 0.75 [95% CI, 0.29–1.89]), or major adverse cardiovascular events (RR, 0.78 [95% CI, 0.30–2.07]) when comparing renal transplant candidates with CAD who underwent revascularization versus those who were on optimal medical therapy before renal transplant. Conclusions This meta‐analysis demonstrates that revascularization is not superior to optimal medical therapy in reducing all‐cause mortality, cardiovascular mortality, or major adverse cardiovascular events in waitlisted kidney transplant candidates with CAD who eventually underwent kidney transplantation.
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Affiliation(s)
- Muhammad U Siddiqui
- Department of Medicine Thomas Jefferson University Hospitals Philadelphia PA
| | - Joey Junarta
- Department of Medicine Thomas Jefferson University Hospitals Philadelphia PA
| | - Gregary D Marhefka
- Jefferson Heart Institute Thomas Jefferson University Hospitals Philadelphia PA
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Bastos J, Machado DJDB, David-Neto E. Increasing transplantability in Brazil: time to discuss Kidney Paired Donation. J Bras Nefrol 2021; 44:417-422. [PMID: 35107119 PMCID: PMC9518625 DOI: 10.1590/2175-8239-jbn-2021-0141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 10/19/2021] [Indexed: 12/26/2022] Open
Abstract
Introduction: Kidney transplantation (KT) is the best treatment for chronic kidney disease. In Brazil, there are currently more than 26 thousand patients on the waitlist. Kidney Paired Donation (KPD) offers an incompatible donor-recipient pair the possibility to exchange with another pair in the same situation, it is a strategy to raise the number of KT. Discussion: KPD ceased being merely an idea over 20 years ago. It currently accounts for 16.2% of living donors KT (LDKT) in the USA and 8% in Europe. The results are similar to other LDKT. It is a promising alternative especially for highly sensitized recipients, who tend to accumulate on the waitlist. KPD is not limited to developed countries, as excellent results were already published in India in 2014. In Guatemala, the first LDKT through KPD was performed in 2011. However, the practice remains limited to isolated cases in Latin America. Conclusion: KPD programs with different dimensions, acceptance rules and allocation criteria are being developed and expanded worldwide to meet the demands of patients. The rise in transplantability brought about by KPD mostly meets the needs of highly sensitized patients. The Brazilian transplant program is mature enough to accept the challenge of starting its KPD program, intended primarily to benefit patients who have a low probability of receiving a transplant from a deceased donor.
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Affiliation(s)
- Juliana Bastos
- Santa Casa de Misericórdia de Juiz de Fora, Departamento de Transplante, Juiz de Fora, MG, Brasil
| | | | - Elias David-Neto
- Hospital das Clínicas da Universidade de São Paulo, Departamento de Transplante, São Paulo, SP, Brasil
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22
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Noble J, Metzger A, Daligault M, Chevallier E, Bugnazet M, Bardy B, Naciri Bennani H, Terrier N, Fiard G, Franquet Q, Janbon B, Masson D, Giovannini D, Malvezzi P, Jouve T, Rostaing L. Immortal Time-Bias-Corrected Survival of Highly Sensitized Patients and HLA-desensitized Kidney Transplant Recipients. Kidney Int Rep 2021; 6:2629-2638. [PMID: 34622102 PMCID: PMC8484495 DOI: 10.1016/j.ekir.2021.07.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/04/2021] [Accepted: 07/26/2021] [Indexed: 01/09/2023] Open
Abstract
Introduction In the setting of kidney transplantation (KT), we assessed the efficacy of desensitization and compared the survival of desensitized patients (HLA-incompatible KT) with similarly sensitized patients receiving HLA-compatible KT or sensitized patients still on a waiting list after adjusting for the usually unaccounted immortal time bias. Methods All patients in a French KT center on the waiting list between August 1994 and December 2019 with a high level of sensitization (panel-reactive antibodies [PRAs] ≥80%) were included. The primary outcome was all-cause mortality. A time-varying covariate Cox survival model was used to account for the immortal time bias. A landmark analysis was used as a sensitivity analysis. Results During the study period, 326 patients with high PRAs were followed, among which 147 (45%) remained on the waiting list at the time of last follow-up and 179 benefited from a KT. Thirty-six patients were desensitized, of which 30 received a kidney transplant, including eight deceased kidney donors. There were no differences in mortality rates between desensitized KT patients, nondesensitized KT patients, and waitlisted patients after adjusting for immortal time bias (hazard ratio [HR] = 0.48, P = 0.22). Death-censored graft survival was similar between desensitized and nondesensitized KT patients (HR = 0.92, P = 0.88 adjusting for donor age >65 years, donor status, and time on the waiting list). Mean estimated glomerular filtration rate at 1 year post-KT was similar for desensitized KT patients (53.3 ± 21 vs. 53.6 ± 21 ml/min per 1.73 m2 for nondesensitized patients; P = 0.95). Conclusions HLA-desensitization was effective for highly sensitized patients and gave access to KT without detrimental effects on patient or graft survival rates.
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Affiliation(s)
- Johan Noble
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
- University Grenoble Alpes, Grenoble, France
| | - Antoine Metzger
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
| | - Melanie Daligault
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
| | - Eloi Chevallier
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
| | - Mathilde Bugnazet
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
| | - Beatrice Bardy
- HLA Laboratory - Établissement Français du Sang (EFS), Grenoble, France
| | - Hamza Naciri Bennani
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
| | - Nicolas Terrier
- Urology Department, University Hospital Grenoble, Grenoble, France
| | - Gaelle Fiard
- Urology Department, University Hospital Grenoble, Grenoble, France
| | - Quentin Franquet
- Urology Department, University Hospital Grenoble, Grenoble, France
| | - Benedicte Janbon
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
| | - Dominique Masson
- HLA Laboratory - Établissement Français du Sang (EFS), Grenoble, France
| | - Diane Giovannini
- Pathology Department, University Hospital Grenoble, Grenoble, France
| | - Paolo Malvezzi
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
| | - Thomas Jouve
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
- University Grenoble Alpes, Grenoble, France
| | - Lionel Rostaing
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
- University Grenoble Alpes, Grenoble, France
- Correspondence: Lionel Rostaing, MD, PhD, Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Avenue Maquis du Grésivaudan, 38700 La Tronche, France.
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Farrington CA, Cutter G, Allon M. Arteriovenous Fistula Nonmaturation: What's the Immune System Got to Do with It? KIDNEY360 2021; 2:1743-1751. [PMID: 35373006 PMCID: PMC8785854 DOI: 10.34067/kid.0003112021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 09/14/2021] [Indexed: 02/04/2023]
Abstract
Background Arteriovenous fistula (AVF) nonmaturation is a persistent problem, particularly among female and Black patients. Increasingly, the immune system has been recognized as an important contributor to vascular disease, but few studies have examined immune factors relative to AVF maturation outcomes. This study evaluated the association of serum panel reactive antibodies (PRA), a measure of immune system reactivity assessed in patients undergoing kidney transplant evaluation, with AVF nonmaturation. Methods We identified 132 patients at our institution who underwent surgical AVF placement between 2010-2019 and had PRA testing within 1 year of AVF creation. Multivariable logistic regression was used to determine the association of patient demographic and clinical factors, class I and class II PRA levels, and preoperative arterial and venous diameters with AVF maturation outcomes. Results AVF nonmaturation was more likely in females than males (44% versus 20%, P=0.003) and in Black than white patients (40% versus 13%, P=0.001). Class II PRA was higher in females than males (12%±23% versus 4%±13%, P=0.02). In the multivariable model, AVF nonmaturation was associated with class II PRA (adjusted odds ratio [aOR], 1.34 per 10% increase; 95% confidence interval [95% CI], 1.04 to 1.82, P=0.02) and Black race (aOR, 3.34; 95% CI, 1.02 to 10.89, P=0.03), but not with patient sex or preoperative arterial or venous diameters. Conclusions The association of elevated class II PRA with AVF nonmaturation suggests the immune system may play a role in AVF maturation outcomes, especially among female patients.
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Affiliation(s)
| | - Gary Cutter
- School of Public Health, University of Alabama, Birmingham, Alabama
| | - Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
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Perosa M, Ferreira GF, Modelli LG, Medeiros MP, Neto SR, Moreira F, Zampieri FG, de Marco R, Bortoluzzo AB, Venezuela MK. Disparity in the access to kidney transplantation for sensitized patients in the state of Sao Paulo-Brazil. Transpl Immunol 2021; 68:101441. [PMID: 34358637 DOI: 10.1016/j.trim.2021.101441] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 07/26/2021] [Accepted: 07/30/2021] [Indexed: 10/20/2022]
Abstract
Highly sensitized (HS) patients accumulate on deceased donor kidney transplantation (DDKT) waitlists worldwide due to matching difficulty and inequity of allocation policies. Current situation of HS patients on KT waitlist in Brazil has not been published. All patients enrolled on the KT waitlist of the State of São Paulo from 2002 to 2017 were retrospectively assessed. Patients were divided into eight groups according to their degree of sensitization, PRA of 0%, >0-40%, >40-80%, >80-85%, >85-90%, >90-95%, >95-98% and > 98%. Cumulative incidence curves for transplantation or mortality/removal from waitlist were estimated by competing risk. Among 50,249 waitlisted candidates, 1247 prioritized, 2467 with age < 18 or > 75 years and 4152 submitted to living-donor KT were excluded from the analysis, remaining 42,383 patients. There were 29,664(70%) PRA 0%, 5611(13.2%) PRA > 0-40%, 3442(8.2%) PRA > 40-80%, 507(1.2%) PRA > 80-85%, 564(1.3%) PRA > 85-90%, 825(1.9%) PRA >90-95%, 859(2%) PRA > 95-98% and 911(2.2%) PRA > 98%. There was a progressive increase in the need of prioritization, waiting time for KT or on waitlist and time on dialysis as PRA increased (p < 0.001). Probability of DDKT clearly increased as PRA decreased so that PRA 0% candidates were much more likely to be transplanted compared to PRA > 98% patients(HR:13.02, p < 0.001). Waiting list mortality/removal was higher among PRA > 0-40%(HR1.05,p = 0.03), PRA > 90-95%(HR:1.10,p = 0.05), PRA > 95-98%(HR:1.26,p < 0.001) and PRA > 98%(HR:1.09,p = 0.05) patients compared to PRA zero candidates. HS patients in Sao Paulo-Brazil required greater prioritization due to lack of venous access, longer dialysis and waitlist times, lower probability of DDKT and higher rates of waitlist mortality/removal. We confirmed the disparity of access to KT among HS patients in Sao Paulo-Brazil, indicating the need of new strategies that optimize transplantation for this subcategory of patients.
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Affiliation(s)
- Marcelo Perosa
- Kidney-Pancreas Transplantation Service of Leforte and Oswaldo Cruz Hospitals, Sao Paulo, Brazil.
| | - Gustavo F Ferreira
- Kidney Transplantation Service, Santa Casa Juiz de Fora, Minas Gerais, Brazil
| | - Luis G Modelli
- Kidney Transplantation Service, UNESP, Sao Paulo, Brazil
| | | | | | | | | | - Renato de Marco
- Immunogenetic Institute and Research Incentive Funding Association, Sao Paulo, Brazil
| | | | - Maria K Venezuela
- Insper Institute of Education and Research, Statistics and Data Science, Brazil
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25
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Sypek MP, Kausman JY, Watson N, Wyburn K, Holt SG, Hughes P, Clayton PA. The Introduction of cPRA and Its Impact on Access to Deceased Donor Kidney Transplantation for Highly Sensitized Patients in Australia. Transplantation 2021; 105:1317-1325. [PMID: 34019363 DOI: 10.1097/tp.0000000000003410] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In March 2016, Australia's deceased donor kidney allocation program introduced calculated panel reactive antibody (cPRA) based on antibody exclusions using multiplex assays to define sensitization for waitlisted candidates. We aimed to assess the impact of this change and review access to transplantation for highly sensitized patients under the current allocation rules. METHODS Registry data were used to reconstruct changes in panel reactive antibody (PRA)/cPRA for all patients active on the waiting list between 2013 and 2018. A multilevel, mixed-effects negative binomial regression model was used to determine the association between sensitization and transplantation rate in the cPRA era. RESULTS Following the introduction of cPRA, there was an increase in the percentage of the waiting list classified as highly sensitized (PRA/cPRA ≥80%) from 7.2% to 27.8% and very highly sensitized (PRA/cPRA ≥99%) from 2.7% to 15.3%. Any degree of sensitization was associated with a decreased rate of transplantation with a marked reduction for those with cPRA 95%-98% (adjusted incidence rate ratio, 0.36 [95% confidence interval, 0.28-0.47], P < 0.001) and cPRA ≥99% (adjusted incidence rate ratio, 0.09 [95% confidence interval, 0.07-0.12], P < 0.001). CONCLUSIONS The proportion of the waiting list classified as highly sensitized increased substantially following the introduction of cPRA, and despite current prioritization, very highly sensitized patients have markedly reduced access to deceased donor transplantation.
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Affiliation(s)
- Matthew P Sypek
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Australia
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Nephrology, Royal Children's Hospital, Melbourne, Australia
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Joshua Y Kausman
- Department of Nephrology, Royal Children's Hospital, Melbourne, Australia
- Clinical Paediatrics, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Narelle Watson
- Transplantation and Immunogenetics Services, Australian RedCross Lifeblood, Brisbane, Australia
| | - Kate Wyburn
- Royal Prince Alfred Hospital and Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Stephen G Holt
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Australia
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Australia
| | - Peter Hughes
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Australia
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Australia
| | - Philip A Clayton
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
- Central and Northern Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, Australia
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26
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Schinstock C, Tambur A, Stegall M. Current Approaches to Desensitization in Solid Organ Transplantation. Front Immunol 2021; 12:686271. [PMID: 34046044 PMCID: PMC8144637 DOI: 10.3389/fimmu.2021.686271] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/26/2021] [Indexed: 11/13/2022] Open
Abstract
Major advancements in the development of HLA antibody detection techniques and our understanding of the outcomes of solid organ transplant in the context of HLA antibody have occurred since the relevance of sensitization was first recognized nearly 50 years ago. Additionally, kidney paired donation programs (KPD) have become widespread, deceased donor allocation policies have changed, and several new therapeutic options have become available with promise to reduce HLA antibody. In this overview we aim to provide thoughtful guidance about when desensitization in kidney transplantation should be considered taking into account the outcomes of HLA incompatible transplantation. Novel therapeutics, desensitization endpoints, and strategies for future study will also be discussed. While most of our understanding about desensitization comes from studying kidney transplant candidates and recipients, many of the concepts discussed can be easily applied to desensitization in all of solid organ transplantation.
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Affiliation(s)
- Carrie Schinstock
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN, United States
| | - Anat Tambur
- Department of Surgery, Northwestern University, Chicago, IL, United States
| | - Mark Stegall
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN, United States
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27
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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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28
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Sahin GK, Usta S, Erdogmus S, Ors Sendogan D, Kutlay S, Erturk S, Keven K, Sengul S. Characteristics and Sensitization Risk Factors in Kidney Transplant Wait List Candidates: Panel Reactive Antibodies Status Is Crucial for Successful Kidney Allocation Systems in Turkey. EXP CLIN TRANSPLANT 2021; 21:229-235. [PMID: 33605201 DOI: 10.6002/ect.2020.0304] [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 Kidney transplant is the treatment of choice for end-stage renal disease. Because of the insufficient supply of donor organs for transplant, the number of patients on the transplant wait list is increasing. We analyzed demographic and clinical factors including sensitization status of patients on the kidney transplant wait list in our center. MATERIALS AND METHODS Patients on the kidney transplant wait list at Ankara University School of Medicine by July 2018 were evaluated. Data on demographics, comorbidities, treatment characteristics, and immunologic properties were collected. RESULTS The study included 528 kidney transplant candidates whose mean time on the deceased donor organ wait list was 57 ± 47 months. Enlisted patients were aged 53 ± 13 years, and 95% of them were on dialysis. Dialysis vintage was longer and percentage of patients who had anti-HLA antibodies was higher in women than men (P = .004 and P < .001, respectively). Levels for median fluorescence intensity were higher in women compared with men (class I, P < .001; and class II, P = .011). Transfusion (P < .001), pregnancy (P = .001), transplant (P < .001), longer dialysis vintage (P = .021), and longer time on wait list (P = .001) were associated with anti-HLA antibody positivity. Multiple regression analysis revealed that a history of transplant and blood transfusion were independent risk factors of a positive panel reactive antibodies. CONCLUSIONS In our kidney transplant candidates on the wait list, sensitization by transplant has a significant impact on development of anti-HLA antibodies. Updates of the organ allocation system to consider sensitized candidates and strategies to expand the deceased donor organ pool and donation rates are needed to increase the rate of deceased donor kidney transplant in Turkey.
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Affiliation(s)
- Gizem Kumru Sahin
- From the Ankara University Faculty of Medicine, Department of Nephrology, Ankara, Turkey
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KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation 2021; 104:S11-S103. [PMID: 32301874 DOI: 10.1097/tp.0000000000003136] [Citation(s) in RCA: 257] [Impact Index Per Article: 85.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, and immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence, and the strengths of recommendations are provided. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.
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Kransdorf EP, Pando MJ, Stewart D, Lindblad K, Bray R, Murphey C, Kaur N, Patel JK, Kim I, Zhang X, Maiers M, Kobashigawa JA, Gragert L. Stem cell donor HLA typing improves CPRA in kidney allocation. Am J Transplant 2021; 21:138-147. [PMID: 32558252 DOI: 10.1111/ajt.16156] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/19/2020] [Accepted: 06/13/2020] [Indexed: 01/25/2023]
Abstract
The Organ Procurement and Transplantation Network (OPTN) Kidney Allocation System provides a priority to sensitized candidates based on the calculated panel reactive antibody (CPRA) value. The human leukocyte antigen (HLA) haplotype reference panel used for calculation of the CPRA by the United Network for Organ Sharing (UNOS), the OPTN contractor, has limitations. We derived a novel panel from the National Marrow Donor Program HLA haplotype data set and compared the accuracy of CPRA values generated with this panel (NMDP-CPRA) to those generated from the UNOS panel (UNOS-CPRA), using predicted and actual deceased donor kidney offers for a cohort of 24 282 candidates. The overall accuracy for kidney offers was similar using NMDP-CPRA and UNOS-CPRA. Accuracy was slightly higher for NMDP-CPRA than UNOS-CPRA for candidates in several highly sensitized CPRA categories, with deviations in linkage disequilibrium for Caucasians and the smaller size of the UNOS panel as contributing factors. HLA data derived from stem cell donors yields CPRA values that are comparable to those derived from deceased kidney donors while improving upon several problems with the current reference panel. Consideration should be given to using stem cell donors as the reference panel for calculation of CPRA to improve equity in kidney transplant allocation.
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Affiliation(s)
- Evan P Kransdorf
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, California, USA
| | - Marcelo J Pando
- Transplant Immunology Laboratory, Scott & White Medical Center, Temple, Texas, USA
| | - Darren Stewart
- Research Department, United Network for Organ Sharing, Richmond, Virginia, USA
| | - Kelsi Lindblad
- Research Department, United Network for Organ Sharing, Richmond, Virginia, USA
| | - Robert Bray
- HLA Laboratory, Emory University Medical Center, Atlanta, Georgia, USA
| | - Cathi Murphey
- HLA Laboratory, Southwest Immunodiagnostics, San Antonio, Texas, USA
| | - Navchetan Kaur
- Department of Pathology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Jignesh K Patel
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, California, USA
| | - Irene Kim
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Xiaohai Zhang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Martin Maiers
- National Marrow Donor Program, Minneapolis, Minnesota, USA
| | - Jon A Kobashigawa
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, California, USA.,Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Loren Gragert
- Department of Pathology, Tulane University School of Medicine, New Orleans, Louisiana, USA.,National Marrow Donor Program, Minneapolis, Minnesota, USA
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31
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Abstract
INTRODUCTION Sensitization to human leukocyte antigens has long posed an obstacle to organ transplantation. With desensitization protocol refinement, new drug development, and organ allocation policy changes, access to transplant for sensitized patients has never been greater. Yet in spite of these advances the problem of donor-specific antibody remains incompletely solved, and many patients remain poorly served by the therapies that do exist. Area covered: Imlifidase is a new drug with a mechanism of action that enables it to transiently yet efficiently eliminate donor-specific antibody over a much more rapid time course than any heretofore existing therapy. This unique property suggests that imlifidase may have far-reaching potential for patients in whom donor-specific antibodies may preclude successful transplantation. Below follows a review of the clinical experience with imlifidase to date as well as a discussion of the transplant applications that eagerly await the availability of this novel agent. Expert opinion: Imlifidase is a first-in-class pharmaceutical agent that safely and efficiently cleaves IgG, and holds promise to be a game-changer for sensitized patients in need of lifesaving organ transplants.
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Affiliation(s)
- Bonnie E Lonze
- Vice Chair for Research, NYU Langone Health, Transplant Institute , New York, NY, USA
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Sylvestre R, Alencar de Pinho N, Massy ZA, Jacquelinet C, Prezelin-Reydit M, Galland R, Stengel B, Coscas R. Practice patterns of dialysis access and outcomes in patients wait-listed early for kidney transplantation. BMC Nephrol 2020; 21:422. [PMID: 33008322 PMCID: PMC7532567 DOI: 10.1186/s12882-020-02080-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Early kidney transplantation (KT) is the best option for patients with end-stage kidney disease, but little is known about dialysis access strategy in this context. We studied practice patterns of dialysis access and how they relate with outcomes in adults wait-listed early for KT according to the intended donor source. METHODS This study from the REIN registry (2002-2014) included 9331 incident dialysis patients (age 18-69) wait-listed for KT before or by 6 months after starting dialysis: 8342 candidates for deceased-donor KT and 989 for living-donor KT. Subdistribution hazard ratios (SHR) of KT and death associated with hemodialysis by catheter or peritoneal dialysis compared with arteriovenous (AV) access were estimated with Fine and Gray models. RESULTS Living-donor candidates used pretransplant peritoneal dialysis at rates similar to deceased-donor KT candidates, but had significantly more frequent catheter than AV access for hemodialysis (adjusted OR 1.25; 95%CI 1.09-1.43). Over a median follow-up of 43 (IQR: 23-67) months, 6063 patients received transplants and 305 died before KT. Median duration of pretransplant dialysis was 15 (7-27) months for deceased-donor recipients and 9 (5-15) for living-donor recipients. Catheter use in deceased-donor candidates was associated with a lower SHR for KT (0.88, 95%CI 0.82-0.94) and a higher SHR for death (1.53, 95%CI 1.14-2.04). Only five deaths occurred in living-donor candidates, three of them with catheter use. CONCLUSIONS Pretransplant dialysis duration may be quite long even when planned with a living donor. Advantages from protecting these patients from AV fistula creation must be carefully evaluated against catheter-related risks.
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Affiliation(s)
- Raphaëlle Sylvestre
- Clinical Epidemiology Team, Paris-Saclay University, Paris-Sud University, UVSQ, CESP, Inserm, Villejuif, France.,Division of Vascular Surgery, Ambroise Paré University Hospital, APHP, Boulogne-Billancourt, France
| | - Natalia Alencar de Pinho
- Clinical Epidemiology Team, Paris-Saclay University, Paris-Sud University, UVSQ, CESP, Inserm, Villejuif, France.
| | - Ziad A Massy
- Clinical Epidemiology Team, Paris-Saclay University, Paris-Sud University, UVSQ, CESP, Inserm, Villejuif, France.,Division of Nephrology, Ambroise Paré University Hospital, APHP, Boulogne-Billancourt, France
| | - Christian Jacquelinet
- Clinical Epidemiology Team, Paris-Saclay University, Paris-Sud University, UVSQ, CESP, Inserm, Villejuif, France.,Agence de la Biomédecine, Direction Médicale et Scientifique, Boulogne-Billancourt, France
| | - Mathilde Prezelin-Reydit
- Aurad-Aquitaine, Service Hémodialyse, Saint Denis La Plaine, France.,Bordeaux Population Health Research Center, Clinical Investigation Center-Clinical Epidemiology-CIC-1401, University of Bordeaux, INSERM, UMR1219, Bordeaux, France
| | | | - Bénédicte Stengel
- Clinical Epidemiology Team, Paris-Saclay University, Paris-Sud University, UVSQ, CESP, Inserm, Villejuif, France
| | - Raphael Coscas
- Clinical Epidemiology Team, Paris-Saclay University, Paris-Sud University, UVSQ, CESP, Inserm, Villejuif, France.,Division of Vascular Surgery, Ambroise Paré University Hospital, APHP, Boulogne-Billancourt, France
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Junarta J, Fernandez M, Chung I, Salha A, Klaud Francheska BD, Lowe-Jones R, Sharma R, Firoozi S, Banerjee D. Role of a cardio-renal multi-disciplinary team meeting in managing cardiovascular risk in patients on kidney transplant waitlists. Clin Transplant 2020; 34:e14061. [PMID: 32780546 DOI: 10.1111/ctr.14061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/26/2020] [Accepted: 08/03/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Waitlisted kidney transplant patients suffer from excess cardiovascular events. The benefits of regular cardiac investigations, potentially harmful and expensive, are unknown. We investigate the effectiveness of a cardio-renal MDT in managing high cardiovascular risk waitlisted transplant patients to prevent events and enable transplantation. METHODS Clinical outcomes in waitlisted transplant candidates managed by our cardio-renal MDT protocol were compared against our standard protocol. Data compared include the transplantation, event, and death rates, cost of cardiac investigations and procedures, and graft, patient survival, and re-hospitalization rates in transplanted patients. RESULTS 207 patients were studied (81 standard, 126 cardio-renal MDT). Over 2.7 years, the cardio-renal MDT protocol transplanted more patients than the standard group (35% vs 21%; P = .02). The managing cost per patient per year was higher in the standard group (£692 vs £610). This was driven by more echocardiograms and more tests per patient in the standard group (P < .01). There was no difference in adverse events or death. There was no difference in re-hospitalization, graft or patient survival rate in transplanted patients. CONCLUSIONS Our cardio-renal MDT was effective in managing high-risk kidney transplant candidates with greater rates of transplantation and low rates of events at a lower cost.
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Affiliation(s)
- Joey Junarta
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, London, UK.,Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Maria Fernandez
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Isaac Chung
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Ahmad Salha
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Racquel Lowe-Jones
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Rajan Sharma
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Sami Firoozi
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Debasish Banerjee
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, London, UK.,Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Malfait T, Emonds MP, Daniëls L, Nagler EV, Van Biesen W, Van Laecke S. HLA Class II Antibodies at the Time of Kidney Transplantation and Cardiovascular Outcome: A Retrospective Cohort Study. Transplantation 2020; 104:823-834. [DOI: 10.1097/tp.0000000000002889] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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35
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Stranavova L, Hruba P, Slatinska J, Sawitzki B, Reinke P, Volk HD, Viklicky O. Dialysis therapy is associated with peripheral marginal zone B-cell augmentation. Transpl Immunol 2020; 60:101289. [PMID: 32229239 DOI: 10.1016/j.trim.2020.101289] [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: 02/27/2020] [Revised: 03/24/2020] [Accepted: 03/25/2020] [Indexed: 11/17/2022]
Abstract
Chronic kidney disease stage 5 (CKD5) dialysis patients who stay long term in uremic environment often exhibit several, poorly defined, immune impairments. In this study, we assessed peripheral virus-specific effector/memory cells and subpopulations of T, B and DC cells using ELISPOT and FACS methods in 74 low-risk kidney transplant candidates without anti-HLA antibodies, prior to transplantation in pre-emptive (never experienced dialysis) and dialysis cohorts. There was difference in circulating marginal zone B cells (MZB) (IgDhighCD27high) between dialysis patients and those receiving kidney grafts pre-emptively (P = .002). Patients treated on dialysis >12 months had also 4.2-fold greater risk of increased absolute numbers of MZB (95%CI:1.6-11.2; P = .004). There were no other differences in B-, T- and DC-cell subsets. Numbers of effector/memory T cells reactive to major opportunistic virus-specific antigens (CMV, BKV and EBV) were not affected by dialysis. Non-sensitised dialysis-treated patients displayed significantly more circulating MZB compared to those CKD5 patients that had never undergone dialysis therapy.
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Affiliation(s)
- Lucia Stranavova
- Transplant Laboratory, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Petra Hruba
- Transplant Laboratory, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Janka Slatinska
- Department of Nephrology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Birgit Sawitzki
- BIH Centre for Regenerative Therapies, Berlin Centre for Advanced Therapies, Charité University Medicine Berlin, Berlin, Germany
| | - Petra Reinke
- BIH Centre for Regenerative Therapies, Berlin Centre for Advanced Therapies, Charité University Medicine Berlin, Berlin, Germany
| | - Hans-Dieter Volk
- BIH Centre for Regenerative Therapies, Berlin Centre for Advanced Therapies, Charité University Medicine Berlin, Berlin, Germany
| | - Ondrej Viklicky
- Transplant Laboratory, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic; Department of Nephrology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic.
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36
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Kulkarni S, Ladin K, Haakinson D, Greene E, Li L, Deng Y. Association of Racial Disparities With Access to Kidney Transplant After the Implementation of the New Kidney Allocation System. JAMA Surg 2020; 154:618-625. [PMID: 30942882 DOI: 10.1001/jamasurg.2019.0512] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Inactive patients on the kidney transplant wait-list have a higher mortality. The implications of this status change on transplant outcomes between racial/ethnic groups are unknown. Objectives To determine if activity status changes differ among races/ethnicities and levels of sensitization, and if these differences are associated with transplant probability after implementation of the Kidney Allocation System. Design, Setting, and Participants A multistate model was constructed from the Organ Procurement and Transplantation Network kidney transplant database (December 4, 2014, to September 8, 2016). The time interval followed Kidney Allocation System implementation and provided at least 1-year follow-up for all patients. The model calculated probabilities between active and inactive status and the following competing risk outcomes: living donor transplant, deceased donor transplant, and death/other. This retrospective cohort study included 42 558 patients on the Organ Procurement and Transplantation Network kidney transplant wait-list following Kidney Allocation System implementation. To rule out time-varying confounding from relisting, analysis was limited to first-time registrants. Owing to variations in listing practices, primary center listing data were used for dually listed patients. Individuals listed for another organ or pancreatic islets were excluded. Analysis began July 2017. Main Outcome and Measures Probabilities were determined for transitions between active and inactive status and the following outcome states: active to living donor transplant, active to deceased donor transplant, active to death/other, inactive to living donor transplant, inactive to deceased donor transplant, and inactive to death/other. Results The median (interquartile range) age at listing was 55.0 (18.0-89.0) years, and 26 535 of 42 558 (62.4%) were men. White individuals were 43.3% (n = 18 417) of wait-listed patients, while black and Hispanic individuals made up 27.8% (n = 11 837) and 19.5% (n = 8296), respectively. Patients in the calculated plasma reactive antibody categories of 0% or 1% to 79% showed no statistically significant difference in transplant probability among races/ethnicities. White individuals had an advantage in transplant probability over black individuals in calculated plasma reactive antibody categories of 80% to 89% (hazard ratio [HR], 1.8 [95% CI, 1.4-2.2]) and 90% or higher (HR, 2.4 [95% CI, 2.1-2.6]), while Hispanic individuals had an advantage over black individuals in the calculated plasma reactive antibody group of 90% or higher (HR, 2.5 [95% CI, 2.1-2.8]). Once on the inactive list, white individuals were more likely than Hispanic individuals (HR, 1.2 [95% CI, 1.17-1.3]) or black individuals (HR, 1.4 [95% CI, 1.3-1.4]) to resolve issues for inactivity resulting in activation. Conclusions and Relevance For patients who are highly sensitized, there continues to be less access to kidney transplant in the black population after the implementation of the Kidney Allocation System. Health disparities continue after listing where individuals from minority groups have greater difficulty in resolving issues of inactivity.
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Affiliation(s)
- Sanjay Kulkarni
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Keren Ladin
- Department of Community Medicine and Public Health, Tufts University, Boston, Massachusetts
| | | | - Erich Greene
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Luhang Li
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut
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37
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Van Laecke S, Abramowicz D. Cardiovascular disease in kidney transplant recipients: leave no stone unturned. Nephrol Dial Transplant 2020; 34:727-730. [PMID: 31062030 DOI: 10.1093/ndt/gfz084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Indexed: 12/25/2022] Open
Affiliation(s)
- Steven Van Laecke
- Department of Internal Medicine, Renal Division, University Hospital Ghent, Ghent, Belgium
| | - Daniel Abramowicz
- Department of Nephrology and Hypertension, University Hospital Antwerp, Edegem, Belgium
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38
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Holscher CM, Jackson KR, Segev DL. Transplanting the Untransplantable. Am J Kidney Dis 2020; 75:114-123. [DOI: 10.1053/j.ajkd.2019.04.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 04/22/2019] [Indexed: 12/27/2022]
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Abstract
Antibody-mediated rejection is a major clinical challenge that limits graft survival. Various modalities of treatment have been reported in small studies in paediatric heart recipients. A novel approach is to use complement-inhibiting agents, such as eculizumab, which inhibits cleavage of C5 to C5a thereby limiting the formation of membrane attack complex and terminal complement-mediated injury of tissue-bound antibodies. This medical modality of treatment has theoretical advantages but the collective experience in its use in the solid organ transplant community remains small. We add to this experience by combining 14 cases from 6 paediatric heart centres in this descriptive study.
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40
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Jackson KR, Zhou S, Ruck J, Massie AB, Holscher C, Kernodle A, Glorioso J, Motter J, Neu A, Desai N, Segev DL, Garonzik-Wang J. Pediatric deceased donor kidney transplant outcomes under the Kidney Allocation System. Am J Transplant 2019; 19:3079-3086. [PMID: 31062464 PMCID: PMC6834871 DOI: 10.1111/ajt.15419] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 04/08/2019] [Accepted: 04/26/2019] [Indexed: 01/25/2023]
Abstract
The Kidney Allocation System (KAS) has resulted in fewer pediatric kidneys being allocated to pediatric deceased donor kidney transplant (pDDKT) recipients. This had prompted concerns that post-pDDKT outcomes may worsen. To study this, we used SRTR data to compare the outcomes of 953 pre-KAS pDDKT (age <18 years) recipients (December 4, 2012-December 3, 2014) with the outcomes of 934 post-KAS pDDKT recipients (December 4, 2014-December 3, 2016). We analyzed mortality and graft loss by using Cox regression, delayed graft function (DGF) by using logistic regression, and length of stay (LOS) by using negative binomial regression. Post-KAS recipients had longer pretransplant dialysis times (median 1.26 vs 1.07 years, P = .02) and were more often cPRA 100% (2.0% vs 0.1%, P = .001). Post-KAS recipients had less graft loss than pre-KAS recipients (hazard ratio [HR]: 0.35 0.540.83 , P = .005) but no statistically significant differences in mortality (HR: 0.29 0.721.83 , P = .5), DGF (odds ratio: 0.93 1.321.93 , P = .2), and LOS (LOS ratio: 0.96 1.061.19 , P = .4). After adjusting for donor-recipient characteristics, there were no statistically significant post-KAS differences in mortality (adjusted HR: 0.37 1.042.92 , P = .9), DGF (adjusted odds ratio: 0.94 1.412.13 , P = .1), or LOS (adjusted LOS ratio: 0.93 1.041.16 , P = .5). However, post-KAS pDDKT recipients still had less graft loss (adjusted HR: 0.38 0.590.91 , P = .02). KAS has had a mixed effect on short-term posttransplant outcomes for pDDKT recipients, although our results are limited by only 2 years of posttransplant follow-up.
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Affiliation(s)
- Kyle R. Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sheng Zhou
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jessica Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Courtenay Holscher
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amber Kernodle
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jaime Glorioso
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer Motter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alicia Neu
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Niraj Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland,Scientific Registry of Transplant Recipients, Minneapolis, Minnesota
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41
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Vatazin AV, Zulkarnaev AB, Stepanov VA. Survival analysis of patients in the waiting list for kidney transplantation in terms of competing risks. RUSSIAN JOURNAL OF TRANSPLANTOLOGY AND ARTIFICIAL ORGANS 2019. [DOI: 10.15825/1995-1191-2019-1-35-45] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Aim: to analyze the survival of patients on the waiting list for kidney transplantation and the results of transplantation depending on the duration of waiting.Materials and methods. We performed a retrospective observational analysis that included 1,197 patients on the waiting list. The end point was exclusion from the waiting list (WL). The causes for exclusion (death, exclusion due to deterioration of the comorbid background or transplantation) were considered in terms of competing risks.Results. In total, 72.5% of patients reached the end point: 21.1% of them died, 11% were excluded, and 40.4% underwent transplantation. Kaplan–Meier estimate showed that cumulative risk of death was 80.4% [95% CI 77.9; 88.6], of exclusion was 77.9% [95% CI 65.4; 88.2], of transplantation was 63.6% [95% CI 58.3; 69] after 10 years on the waiting list. However, such an assessment cannot be directly interpreted as a prediction of the relevant event risk of occurrence for the patient in the WL, because it does not take into account competing events. According to a balanced assessment of the competing risks (Fine and Gray estimate), cumulative incidence was 30.9% (95% CI 27.7; 34.2) for death, 18.2% [95% CI 15.5; 21.1] for exclusion and 49.4% [95% CI 46; 52.6%] for transplantation after 10 years on WL. The probability of transplantation was significantly higher than the risk of death up to and including 5 years of waiting (incidence rate ratio – IRR 1.769 [95% CI 1.098; 2.897]). When waiting 7 to 8 years, the probability of transplantation was less than the risk of death: IRR 0.25 (95% CI 0.093; 0.588; p = 0.0009). Of the 483 recipients, 61 died and 119 returned to dialysis. The risk of graft loss after 10 years was 68.5% [95% CI 57.5; 79.1] and the risk of death of a recipient with a functioning graft was 48.3% [95% CI 34.7; 63] according to Kaplan–Meier estimate. The cumulative incidence of the method was 30.8% [95% CI 23.3; 38.5%] and 55.7% [95% CI 46.6; 63.5%] according to Fine and Gray estimate, respectively. The risk of death after transplantation increases significantly when waiting for more than 6 years – IRR 4.325 [95% CI 1.649; 10.47], p = 0.0045 relative to a shorter waiting period. With an increase in the waiting period, the comorbid background (CIRS scale) deteriorates significantly, even adjusted for the initial patient condition: the partial correlation r = 0.735; p < 0.0001.Conclusion. 1. In the context of competing risks, the Fine and Gray estimate gives a more balanced risk assessment compared to the Kaplan–Meier method. 2. Increasing the waiting time for transplantation significantly increases the risk of death of the candidate on the waiting list and reduces the probability of transplantation, as well as increases the risk of death of the recipient after transplantation. Apparently, this is mainly due to the deterioration of the comorbid background.
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Affiliation(s)
- A. V. Vatazin
- M.F. Vladimirsky Moscow Regional Research Clinical Institute
| | | | - V. A. Stepanov
- M.F. Vladimirsky Moscow Regional Research Clinical Institute
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Lucisano G, Brookes P, Santos-Nunez E, Firmin N, Gunby N, Hassan S, Gueret-Wardle A, Herbert P, Papalois V, Willicombe M, Taube D. Allosensitization after transplant failure: the role of graft nephrectomy and immunosuppression - a retrospective study. Transpl Int 2019; 32:949-959. [PMID: 30980556 DOI: 10.1111/tri.13442] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/07/2019] [Accepted: 04/09/2019] [Indexed: 01/30/2023]
Abstract
There are conflicting data about the role of transplant nephrectomy and immunosuppression withdrawal on the development of allosensitization and the impact on re-transplantation. We divided 109 first graft recipients into two groups according to whether they underwent nephrectomy (NX+, n = 61) or their graft was left in situ (NX-, n = 48). Sera were assessed for HLA-A/B/Cw/DR/DQ antibodies at the time of NX/transplant failure and after 3, 6, 12, 24 months. The NX+ group showed a higher rate of donor specific antibody (DSA) and non-DSA human leukocyte antigen (HLA) antibody production at all the time points. Multivariable analysis showed that nephrectomy was a strong, independent risk factor for the development of DSAs after 12 and 24 months (P = 0.005 and 0.008). In the NX- group, low tacrolimus levels correlated with DSA formation (AUC 0.817, P = 0.002; best cut-off level 2.9 ng/ml). Analysis with a standardized pool of UK donors showed a more difficult grade of HLA matchability following nephrectomy compared with the NX- group. Nephrectomy is followed by the long-term production of DSA and non-DSA HLA antibodies and negatively impacts on the chances of finding a HLA-compatible kidney. Tacrolimus levels ≥3 ng/ml are protective against the development of allosensitization and could facilitate re-transplantation in the NX- group.
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Affiliation(s)
- Gaetano Lucisano
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Paul Brookes
- Histocompatibility and Immunogenetics, Imperial College Healthcare NHS Trust, London, UK
| | - Eva Santos-Nunez
- Histocompatibility and Immunogenetics, Imperial College Healthcare NHS Trust, London, UK
| | - Nicola Firmin
- Histocompatibility and Immunogenetics, Imperial College Healthcare NHS Trust, London, UK
| | - Nicola Gunby
- Histocompatibility and Immunogenetics, Imperial College Healthcare NHS Trust, London, UK
| | - Sevda Hassan
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Alexander Gueret-Wardle
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Paul Herbert
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Vassilios Papalois
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Michelle Willicombe
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - David Taube
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
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Jackson KR, Covarrubias K, Holscher CM, Luo X, Chen J, Massie AB, Desai N, Brennan DC, Segev DL, Garonzik-Wang J. The national landscape of deceased donor kidney transplantation for the highly sensitized: Transplant rates, waitlist mortality, and posttransplant survival under KAS. Am J Transplant 2019; 19:1129-1138. [PMID: 30372592 PMCID: PMC6433516 DOI: 10.1111/ajt.15149] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 10/11/2018] [Accepted: 10/14/2018] [Indexed: 02/07/2023]
Abstract
Deceased donor kidney transplantation (DDKT) rates for highly sensitized (HS) candidates increased early after implementation of the Kidney Allocation System (KAS) in 2014. However, this may represent a bolus effect, and a granular investigation of the current state of DDKT for HS candidates remains lacking. We studied 270 722 DDKT candidates from the SRTR from 12/4/2011 to 12/3/2014 ("pre-KAS") and 12/4/2014 to 12/3/2017 ("post-KAS"), analyzing DDKT rates for HS candidates using adjusted negative binomial regression. Post-KAS, candidates with the highest levels of sensitization had an increased DDKT rate compared with pre-KAS (cPRA 98% adjusted incidence rate ratio [aIRR]:1.27 1.772.46 P = .001, cPRA 99% aIRR:3.18 4.365.98 P < .001, cPRA 99.5-99.9% aIRR:16.91 24.2934.89 P < .001, and cPRA 99.9%+ aIRR:8.79 11.5815.26 P < .001). To determine whether these changes produced more equitable access to DDKT, we compared DDKT rates of HS to non-HS candidates (cPRA 0-79%). Post-KAS, cPRA, 98% candidates had an equivalent DDKT rate (aIRR:0.65 0.941.36 , P = .8) to non-HS candidates, whereas 99% candidates had a higher DDKT rate (aIRR:1.19 1.682.38 , P = .02). Although cPRA 99.5-99.9% candidates had an increased DDKT rate (aIRR:2.46 3.504.98 , P < .001) compared to non-HS candidates, cPRA 99.9%+ candidates had a significantly lower DDKT rate (aIRR:0.29 0.400.56 , P < .001). KAS has improved access to DDKT for HS candidates, although substantial imbalance exists between cPRA 99.5-99.9% and 99.9%+ candidates.
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Affiliation(s)
- Kyle R Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Karina Covarrubias
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Courtenay M Holscher
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Xun Luo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Niraj Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel C Brennan
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
- Scientific Registry of Transplant Recipients, Minneapolis, Minnesota
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Tan VS, Garg AX, McArthur E, Patzer RE, Gander J, Roshanov P, Kim SJ, Knoll GA, Yohanna S, McCallum MK, Naylor KL. Predicting 3-Year Survival in Patients Receiving Maintenance Dialysis: An External Validation of iChoose Kidney in Ontario, Canada. Can J Kidney Health Dis 2018; 5:2054358118799693. [PMID: 30302267 PMCID: PMC6172940 DOI: 10.1177/2054358118799693] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 07/27/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Many patients with end-stage kidney disease (ESKD) do not appreciate how their survival may differ if treated with a kidney transplant compared with dialysis. A risk calculator (iChoose Kidney) developed and validated in the United States provides individualized mortality estimates for different treatment options (dialysis vs living or deceased donor kidney transplantation). The calculator can be used with patients and families to help patients make more educated treatment decisions. OBJECTIVE To validate the iChoose Kidney risk calculator in Ontario, Canada. DESIGN External validation study. SETTING We used several linked administrative health care databases from Ontario, Canada. PATIENTS We included 22 520 maintenance dialysis patients and 4505 kidney transplant recipients. Patients entered the cohort between 2004 and 2014. MEASUREMENTS Three-year all-cause mortality. METHODS We assessed model discrimination using the C-statistic. We assessed model calibration by comparing the observed versus predicted mortality risk and by using smoothed calibration plots. We used multivariable logistic regression modeling to recalibrate model intercepts using a correction factor, when appropriate. RESULTS In our final version of the iChoose Kidney model, we included the following variables: age (18-80 years), sex (male, female), race (white, black, other), time on dialysis (<6 months, 6-12 months, >12 months), and patient comorbidities (hypertension, diabetes, and/or cardiovascular disease). Over the 3-year follow-up period, 33.3% of dialysis patients and 6.2% of kidney transplant recipients died. The discriminatory ability was moderate (C-statistic for dialysis: 0.70, 95% confidence interval [CI]: 0.69-0.70, and C-statistic for transplant: 0.72, 95% CI: 0.69-0.75). The 3-year observed and predicted mortality estimates were comparable and even more so after we recalibrated the intercepts in 2 of our models (dialysis and deceased donor kidney transplantation). As done in the United States, we developed a Canadian Web site and an iOS application called Dialysis vs. Kidney Transplant- Estimated Survival in Ontario. LIMITATIONS Missing data in our databases precluded the inclusion of all variables that were in the original iChoose Kidney (ie, patient ethnicity and low albumin). We were unable to perform all preplanned analyses due to the limited sample size. CONCLUSIONS The original iChoose Kidney risk calculator was able to adequately predict mortality in this Canadian (Ontario) cohort of ESKD patients. After minor modifications, the predictive accuracy improved. The Dialysis vs. Kidney Transplant- Estimated Survival in Ontario risk calculator may be a valuable resource to help ESKD patients make an informed decision on pursuing kidney transplantation.
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Affiliation(s)
- Vivian S. Tan
- Division of Nephrology, Western University, London, ON, Canada
| | - Amit X. Garg
- Division of Nephrology, Western University, London, ON, Canada
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
| | - Eric McArthur
- Institute for Clinical Evaluative Sciences, London, ON, Canada
| | | | | | - Pavel Roshanov
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - S. Joseph Kim
- University Health Network, University of Toronto, ON, Canada
| | - Greg A. Knoll
- Division of Nephrology, Department of Medicine, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | | | | | - Kyla L. Naylor
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, ON, Canada
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Heidt S, Claas FHJ. Transplantation in highly sensitized patients: challenges and recommendations. Expert Rev Clin Immunol 2018; 14:673-679. [PMID: 30004800 DOI: 10.1080/1744666x.2018.1498335] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Highly sensitized patients awaiting a kidney transplant accrue on the transplant waiting list. The breadth of HLA antibodies in this subpopulation of patients precludes receiving a compatible organ offer through regular allocation within an acceptable time-frame. Areas covered: Several alternative options to receive a transplant exist for these patients, including additional priority in regular allocation, special programs based on allocation through acceptable antigens, kidney paired donation programs, desensitization protocols, or a combination of the latter two. In this review, these options and their outcomes are discussed as well as some possibilities to further enhance transplantation of this disadvantaged group of patients. Expert commentary: For highly sensitized patients, special attention is required, for which several strategies may apply. A step-wise approach may be the optimal strategy to facilitate successful transplantation of highly sensitized patients.
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Affiliation(s)
- Sebastiaan Heidt
- a Department of Immunohematology and Blood Transfusion , Leiden University Medical Center , Leiden , the Netherlands
| | - Frans H J Claas
- a Department of Immunohematology and Blood Transfusion , Leiden University Medical Center , Leiden , the Netherlands
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Van Laecke S, Malfait T, Schepers E, Van Biesen W. Cardiovascular disease after transplantation: an emerging role of the immune system. Transpl Int 2018; 31:689-699. [PMID: 29611220 DOI: 10.1111/tri.13160] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 02/12/2018] [Accepted: 03/22/2018] [Indexed: 02/06/2023]
Abstract
Cardiovascular disease (CVD) after transplantation remains a major concern. Little is known about what drives the increased cardiovascular risk in transplant recipients apart from traditional risk factors. The immune system is involved in the pathogenesis of hypertension, atherosclerosis, and coronary artery disease in the general population. Recently, inhibition of interleukin 1 - β by canakinumab versus placebo decreased the incidence of cardiovascular events. Emerging evidence points to a role of adaptive cellular immunity in the development of CVD. Especially, expansion of pro-inflammatory and antiapoptotic cytotoxic CD4+ CD28null T cells is closely associated with incident CVD in various study populations including transplant recipients. The association of cytomegalovirus exposure with increased cardiovascular mortality might be explained by its capacity to upregulate these cytotoxic cells. Also, humoral immunity seems to be relevant for cardiovascular outcome in transplant recipients. Panel-reactive antibodies at baseline and donor-specific antibodies are independently associated with poor cardiovascular outcome after kidney transplantation. Cardiovascular effects of immunosuppressive drugs and statins do not only imply indirect positive or negative effects on traditional cardiovascular risk factors but also intrinsic immunological effects. How immunosuppressive drugs modify atherosclerosis largely remains elusive.
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Affiliation(s)
| | - Thomas Malfait
- Renal Division, Ghent University Hospital, Ghent, Belgium
| | - Eva Schepers
- Renal Division, Ghent University Hospital, Ghent, Belgium
| | - Wim Van Biesen
- Renal Division, Ghent University Hospital, Ghent, Belgium
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Hernández D, Muriel A, Castro de la Nuez P, Alonso-Titos J, Ruiz-Esteban P, Duarte A, Gonzalez-Molina M, Palma E, Alonso M, Torres A. Survival in Southern European patients waitlisted for kidney transplant after graft failure: A competing risk analysis. PLoS One 2018. [PMID: 29513701 PMCID: PMC5841738 DOI: 10.1371/journal.pone.0193091] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background Whether patients waitlisted for a second transplant after failure of a previous kidney graft have higher mortality than transplant-näive waitlisted patients is uncertain. Methods We assessed the relationship between a failed transplant and mortality in 3851 adult KT candidates, listed between 1984–2012, using a competing risk analysis in the total population and in a propensity score-matched cohort. Mortality was also modeled by inverse probability weighting (IPTW) competing risk regression. Results At waitlist entry 225 (5.8%) patients had experienced transplant failure. All-cause mortality was higher in the post-graft failure group (16% vs. 11%; P = 0.033). Most deaths occurred within three years after listing. Cardiovascular disease was the leading cause of death (25.3%), followed by infections (19.3%). Multivariate competing risk regression showed that prior transplant failure was associated with a 1.5-fold increased risk of mortality (95% confidence interval [CI], 1.01–2.2). After propensity score matching (1:5), the competing risk regression model revealed a subhazard ratio (SHR) of 1.6 (95% CI, 1.01–2.5). A similar mortality risk was observed after the IPTW analysis (SHR, 1.7; 95% CI, 1.1–2.6). Conclusions Previous transplant failure is associated with increased mortality among KT candidates after relisting. This information is important in daily clinical practice when assessing relisted patients for a retransplant.
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Affiliation(s)
- Domingo Hernández
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
- * E-mail:
| | - Alfonso Muriel
- Clinic Biostatistic Unit, Hospital Ramón y Cajal IRYCIS, CIBERESP, Universidad Autónoma, Madrid, Spain
| | | | - Juana Alonso-Titos
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Pedro Ruiz-Esteban
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Ana Duarte
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Miguel Gonzalez-Molina
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Eulalia Palma
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Manuel Alonso
- Transplant Coordination Center and Andalusian Health Service, Seville, Spain
| | - Armando Torres
- Nephrology Department, Hospital Universitario de Canarias, CIBICAN, University of La Laguna, REDinREN (RD16/0009/0031) and Instituto Reina Sofía de Investigación Renal (IRSIN), Tenerife, Spain
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Kulkarni S, Hall I, Formica R, Thiessen C, Stewart D, Gan G, Greene E, Deng Y. Transition probabilities between changing sensitization levels, waitlist activity status and competing-risk kidney transplant outcomes using multi-state modeling. PLoS One 2017; 12:e0190277. [PMID: 29287087 PMCID: PMC5747475 DOI: 10.1371/journal.pone.0190277] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 12/11/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Sensitization and activity status are associated with kidney transplant waitlist mortality. Unknown is how changes in these covariates after listing impact transplant outcomes. METHODS Two cohorts were created from the OPTN (Organ Procurement and Transplantation Network) database, one pre-KAS (new kidney allocation system) (10/01/2009-12/04/2013, n = 97,793) and one post-KAS (12/04/2014-06/17/2015, n = 13,113). Multi-state modeling provides transition probabilities between intermediate states (CPRA category/activity status combinations) and competing-risk outcomes: transplant (living), transplant (deceased), death, or other/well. RESULTS Transition probabilities show chances of converting between intermediate states prior to a competing-risk outcome. One year transplant probabilities for post-KAS candidates with a CPRA of 0%(P, 0.123[95% CI, 0.117,0.129]), 1-79%(P, 0.125 [95% CI, 0.112,0.139]), 95-98%(P, 0.242[95% CI, 0.188, 0.295]) and 99-100%(P, 0.252 [95% CI, 0.195, 0.308]) were significantly higher than the pre-KAS cohort; they were lower for CPRA 80-89%(P, 0.152 [95% CI, 0.116,0.189]) and not statistically different for CPRA 90-94%(P, 0.180 [95% CI, 0.137,0.223]) candidates. Post-KAS, Whites had a statistically higher transplant probability only at a CPRA of 99-100%. CONCLUSION Multi-state modeling provides transition probabilities between CPRA/activity status combinations, giving estimates on how changing patient characteristic's after listing impact outcomes. Preliminarily, across most CPRA categories, there was no statistical difference in transplant probabilities between Whites, Blacks and Hispanics following KAS implementation, however, this finding requires longer follow-up for validation.
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Affiliation(s)
- Sanjay Kulkarni
- Department of Surgery, Section of Organ Transplantation & Immunology, Yale School of Medicine, New Haven, CT, United States of America
- Department of Medicine, Section of Nephrology, Yale School of Medicine, New Haven, CT, United States of America
| | - Isaac Hall
- Department of Medicine, Section of Nephrology, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Richard Formica
- Department of Surgery, Section of Organ Transplantation & Immunology, Yale School of Medicine, New Haven, CT, United States of America
- Department of Medicine, Section of Nephrology, Yale School of Medicine, New Haven, CT, United States of America
| | - Carrie Thiessen
- Department of Surgery, Section of Organ Transplantation & Immunology, Yale School of Medicine, New Haven, CT, United States of America
| | - Darren Stewart
- United Network for Organ Sharing, Richmond, VA, United States of America
| | - Geliang Gan
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, United States of America
| | - Erich Greene
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, United States of America
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, United States of America
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Abstract
HLAs are fundamental to the adaptive immune response and play critical roles in the cellular and humoral response in solid organ transplantation. The genes encoding HLA proteins are the most polymorphic within the human genome, with thousands of different allelic variants known within the population. Application of the principles of population genetics to the HLA genes has resulted in the development of a numeric metric, the calculated panel-reactive antibody (CPRA) that predicts the likelihood of a positive crossmatch as a function of a transplant candidate's unacceptable HLA antigens. The CPRA is an indispensible measure of access to transplantation for sensitized candidates and is used as the official measure of sensitization for allocation of points in the US Kidney Allocation System and Eurotransplant. Here, we review HLA population genetics and detail the mathematical basis of the CPRA. An understanding of these principles by transplant clinicians will lay the foundation for continued innovation in the care of sensitized patients.
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Sypek MP, Hughes P, Kausman JY. HLA epitope matching in pediatric renal transplantation. Pediatr Nephrol 2017; 32:1861-1869. [PMID: 27995324 DOI: 10.1007/s00467-016-3557-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 11/30/2016] [Accepted: 12/01/2016] [Indexed: 10/20/2022]
Abstract
Chronic graft loss due to antibody-mediated rejection (AMR) and the difficulty of re-transplanting highly sensitized patients are two of the major long-term challenges in pediatric renal transplantation. Treatments for AMR are often ineffective and desensitization protocols can be a high risk, making prevention a highly appealing strategy. Insights into the structural determinants of humoral alloantigenicity present an exciting opportunity to reassess our current paradigm of tissue matching and potentially preventing these complications. We review the theory behind human leukocyte antigen (HLA) B cell epitopes and the various systems that have been proposed to define them, including eplets. There is a growing body of clinical evidence suggesting that epitope-based tissue matching may be superior to traditional HLA antigen matching at predicting a range of clinical outcomes. However, additional studies are required to better understand the biological relevance of these systems of defining epitopes and their role in pediatric transplantation.
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Affiliation(s)
- Matthew P Sypek
- Department of Nephrology, Royal Children's Hospital, Melbourne, Australia. .,Department of Nephrology, Royal Melbourne Hospital, Melbourne, Australia. .,University of Melbourne, Melbourne, Australia.
| | - Peter Hughes
- Department of Nephrology, Royal Children's Hospital, Melbourne, Australia.,Department of Nephrology, Royal Melbourne Hospital, Melbourne, Australia.,University of Melbourne, Melbourne, Australia
| | - Joshua Y Kausman
- Department of Nephrology, Royal Children's Hospital, Melbourne, Australia.,Department of Nephrology, Royal Melbourne Hospital, Melbourne, Australia.,University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Australia
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