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Lees JS, De La Mata NL, Sullivan MK, Wyld ML, Rosales BM, Cutting R, Hedley JA, Rutherford E, Mark PB, Webster AC. Sex differences in associations between creatinine and cystatin C-based kidney function measures with stroke and major bleeding. Eur Stroke J 2023; 8:756-768. [PMID: 37641551 PMCID: PMC10465308 DOI: 10.1177/23969873231173282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 04/14/2023] [Indexed: 08/31/2023] Open
Abstract
PURPOSE We sought to explore whether adding kidney function biomarkers based on creatinine (eGFRCr), cystatin C (eGFRCys) or a combination of the two (eGFRCr-Cys) could improve risk stratification for stroke and major bleeding, and whether there were sex differences in any additive value of kidney function biomarkers. METHOD We included participants from the UK Biobank who had not had a previous ischaemic or haemorrhagic stroke or major bleeding episode, and who had kidney function measures available at baseline. Cause-specific Cox proportional hazards models tested associations between eGFRCr, eGFRCys and eGFRCr-Cys (mL/min/1.73 m2) with ischaemic and haemorrhagic stroke, major bleeding (gastrointestinal or intracranial, including haemorrhagic stroke) and all-cause mortality. FINDINGS Among 452,879 eligible participants, 246,244 (54.4%) were women. Over 11.5 (IQR 10.8-12.2) years, there were 3706 ischaemic strokes, 795 haemorrhagic strokes, 26,025 major bleeding events and 28,851 deaths. eGFRCys was more strongly associated with ischaemic stroke than eGFRCr: an effect that was more pronounced in women (men - HR: 1.16, 95% CI: 1.12-1.19; female to male comparison - HR: 1.11, 95% CI: 1.05-1.16, per 10 mL/min/1.73 m2 decline in eGFRCys). This interaction effect was also demonstrated for eGFRCr-Cys, but not eGFRCr. eGFRCys and eGFRCr-Cys were more strongly associated with major bleeding and all-cause mortality than eGFRCr in both men and women. Event numbers were small for haemorrhagic stroke. DISCUSSION To a greater degree than is seen in men, eGFRCr underestimates risk of ischaemic stroke and major bleeding in women compared to eGFRCys. The difference between measures is likely explained by non-GFR biology of creatinine and cystatin C. CONCLUSION Enhanced measurement of cystatin C may improve risk stratification for ischaemic stroke and major bleeding and clinical treatment decisions in a general population setting, particularly for women.
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Affiliation(s)
- Jennifer Susan Lees
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Nicole L De La Mata
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Michael K Sullivan
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Melanie L Wyld
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Brenda M Rosales
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Rachel Cutting
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - James Alan Hedley
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Elaine Rutherford
- Renal Unit, Mountainhall Treatment Centre, NHS Dumfries and Galloway, Dumfries, UK
| | - Patrick Barry Mark
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Angela C Webster
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
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Hedley JA, Kelly PJ, Wyld M, Shah K, Morton RL, Byrnes J, Rosales BM, De La Mata NL, Wyburn K, Webster AC. Cost-effectiveness of Interventions to Increase Utilization of Kidneys From Deceased Donors With Primary Brain Malignancy in an Australian Setting. Transplant Direct 2023; 9:e1474. [PMID: 37090124 PMCID: PMC10118354 DOI: 10.1097/txd.0000000000001474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 01/26/2023] [Accepted: 01/28/2023] [Indexed: 04/25/2023] Open
Abstract
Kidneys from potential deceased donors with brain cancer are often foregone due to concerns of cancer transmission risk to recipients. There may be uncertainty around donors' medical history and their absolute transmission risk or risk-averse decision-making among clinicians. However, brain cancer transmissions are rare, and prolonging waiting time for recipients is harmful. Methods We assessed the cost-effectiveness of increasing utilization of potential deceased donors with brain cancer using a Markov model simulation of 1500 patients waitlisted for a kidney transplant, based on linked transplant registry data and with a payer perspective (Australian government). We estimated costs and quality-adjusted life-years (QALYs) for three interventions: decision support for clinicians in assessing donor risk, improved cancer classification accuracy with real-time data-linkage to hospital records and cancer registries, and increased risk tolerance to allow intermediate-risk donors (up to 6.4% potential transmission risk). Results Compared with current practice, decision support provided 0.3% more donors with an average transmission risk of 2%. Real-time data-linkage provided 0.6% more donors (1.1% average transmission risk) and increasing risk tolerance (accepting intermediate-risk 6.4%) provided 2.1% more donors (4.9% average transmission risk). Interventions were dominant (improved QALYs and saved costs) in 78%, 80%, and 87% of simulations, respectively. The largest benefit was from increasing risk tolerance (mean +18.6 QALYs and AU$2.2 million [US$1.6 million] cost-savings). Conclusions Despite the additional risk of cancer transmission, accepting intermediate-risk donors with brain cancer is likely to increase the number of donor kidneys available for transplant, improve patient outcomes, and reduce overall healthcare expenditure.
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Affiliation(s)
- James A. Hedley
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Patrick J. Kelly
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Melanie Wyld
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, New South Wales, Australia
| | - Karan Shah
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Rachael L. Morton
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Juliet Byrnes
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Brenda M. Rosales
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Nicole L. De La Mata
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Kate Wyburn
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
- Renal Unit, Royal Prince Alfred Hospital, New South Wales, Australia
| | - Angela C. Webster
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, New South Wales, Australia
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
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3
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Thomson IK, Hedley J, Rosales BM, Wyburn K, O'Leary MJ, Webster AC. Potential organ donors with primary brain tumours: missed opportunities for donation and transplantation identified in Australian cohort study 2010-2015. ANZ J Surg 2022; 92:2996-3003. [PMID: 36129448 PMCID: PMC9826272 DOI: 10.1111/ans.18037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 07/03/2022] [Accepted: 08/11/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Potential organ donors with primary brain tumours (PBT) frequently donate, however some may be declined due to uncertainty about tumour classification or transmission risk to transplant recipients. We sought to describe transmission risk and donation outcome of potential donors with PBT, including identifying missed opportunities for transplantation, and any PBT transmission events. METHODS We undertook a population-based cohort study in NSW of all potential donors 2010-2015. PBT potential donors were characterized according to tumour grade and transmission risk, and whether they donated organs. Data linkage was used to determine agreement of risk assessment of potential donors to that in the Biovigilance Register, and to identify any PBT transmissions. RESULTS Of 2957 potential donors, 76 (3%) had PBTs. There was agreement of risk assessment in 44 (58%) cases. PBT potential donors had fewer comorbidities (1.6 vs. 2.1, P = 0.006) than non-PBT potential donors. Forty-eight (63%) potential donors were declined for non-PBT reasons, 18 (24%) were declined because of perceived PBT transmission risk and 10 (13%) donated. All PBT donors had WHO-I or -II tumours, and none had a ventriculo-pertioneal shunt. No transmission events occurred. CONCLUSION Donors with WHO-I/II PBT appear to have minimal risk of tumour transmission in solid organ transplantation; it is reassuring that no PBT transmission occurred. There is evidence of risk aversion to referrals with WHO-III/IV tumours. There exists opportunity to improve potential donor risk assessment at the time of referral using integrated data sets, and to increase organ donation and transplantation rates through greater utilization of PBT referrals.
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Affiliation(s)
- Imogen K. Thomson
- Sydney School of Public Health, Faculty of Medicine and HealthUniversity of SydneyCamperdownNew South WalesAustralia
| | - James Hedley
- Sydney School of Public Health, Faculty of Medicine and HealthUniversity of SydneyCamperdownNew South WalesAustralia
| | - Brenda M. Rosales
- Sydney School of Public Health, Faculty of Medicine and HealthUniversity of SydneyCamperdownNew South WalesAustralia
| | - Kate Wyburn
- Sydney School of Public Health, Faculty of Medicine and HealthUniversity of SydneyCamperdownNew South WalesAustralia,Renal DepartmentRoyal Prince Alfred HospitalCamperdownNew South WalesAustralia
| | - Michael J. O'Leary
- Intensive Care UnitRoyal Prince Alfred HospitalCamperdownNew South WalesAustralia,New South Wales Organ and Tissue Donation ServiceKogarahNew South WalesAustralia
| | - Angela C. Webster
- Sydney School of Public Health, Faculty of Medicine and HealthUniversity of SydneyCamperdownNew South WalesAustralia,Centre for Transplant and Renal ResearchWestmead HospitalWestmeadNew South WalesAustralia
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Rosales BM, De La Mata N, Vajdic CM, Kelly PJ, Wyburn K, Webster AC. Cancer Mortality in People Receiving Dialysis for Kidney Failure: An Australian and New Zealand Cohort Study, 1980-2013. Am J Kidney Dis 2022; 80:449-461. [PMID: 35500725 DOI: 10.1053/j.ajkd.2022.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 03/11/2022] [Indexed: 02/07/2023]
Abstract
RATIONALE & OBJECTIVE Cancer is a significant cause of morbidity in the population with kidney failure; however, cancer mortality in people undergoing dialysis has not been well described. We sought to compare cancer mortality in people on dialysis for kidney failure with cancer mortality in the general population. STUDY DESIGN A retrospective cohort study using linked health-administrative and dialysis registry data. SETTING & PARTICIPANTS All people receiving dialysis represented in the Australian and New Zealand Dialysis and Transplantation Registry, 1980-2013. EXPOSURE Dialysis; hemodialysis (HD) and peritoneal dialysis (PD). OUTCOME Death and underlying cause of death ascertained using health administrative data and classified using International Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) codes. ANALYTICAL APPROACH Indirect standardization on age at death, sex, year, and country to estimate standardized mortality ratios (SMR). RESULTS Over 269,598 person years of observation, 34,100 deaths occurred among 59,648 people on dialysis, including 3,677 cancer deaths. The relative risk of all-site cancer death in dialysis was twice (SMR, 2.4 [95% CI, 2.33-2.49]) that of the general population and highest for oral and pharynx cancers (SMR, 24.3 [95% CI, 18.0-31.5]) and multiple myeloma (SMR, 22.5 [95% CI, 20.3-23.9]). Women on dialysis had a significantly higher risk of all-site cancer mortality (SMR, 2.7 [95% CI, 2.59-2.89]) compared with men (SMR, 2.3 [95% CI, 2.17-2.36]) (P < 0.001). People on HD (SMR, 2.2 [95% CI, 2.11-2.30]) experienced greater excess deaths from all-site cancer compared with people on PD (SMR, 1.3 [95% CI, 1.23-1.44]). Excess deaths have gradually decreased over time for all-site, multiple myeloma, and kidney cancers (P < 0.001) but have not kept up with improvements in the general population. By contrast, among people receiving dialysis, excess deaths increased for colorectal and lung cancers (P < 0.001). LIMITATIONS Confirmation of cancer diagnoses and population incidence data were not available; inability to exclude pre-existing cancers. CONCLUSIONS People on dialysis experience excess all-site and site-specific cancer mortality compared with the general population. Mortality differs by modality type, age, and sex. Understanding the role of kidney failure and other morbidities in the treatment of cancer is important for shared decision-making regarding cancer treatments and identifying potential approaches to improve outcomes.
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Affiliation(s)
| | | | - Claire M Vajdic
- Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | | | - Kate Wyburn
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Renal Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| | - Angela C Webster
- Sydney School of Public Health, Sydney, Australia; Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia
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5
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Waller KMJ, De La Mata NL, Wyburn KR, Hedley JA, Rosales BM, Kelly PJ, Ramachandran V, Shah KK, Morton RL, Rawlinson WD, Webster AC. Notifiable Infectious Diseases Among Organ Transplant Recipients: A Data-Linked Cohort Study, 2000–2015. Open Forum Infect Dis 2022; 9:ofac337. [PMID: 35937651 PMCID: PMC9348761 DOI: 10.1093/ofid/ofac337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Indexed: 11/12/2022] Open
Abstract
Background Infections, including common communicable infections such as influenza, frequently cause disease after organ transplantation, although the quantitative extent of infection and disease remains uncertain. Methods A cohort study was conducted to define the burden of notifiable infectious diseases among all solid organ recipients transplanted in New South Wales, Australia, 2000–2015. Data linkage was used to connect transplant registers to hospital admissions, notifiable diseases, and the death register. Standardized incidence ratios (SIRs) were calculated relative to general population notification rates, accounting for age, sex, and calendar year. Infection-related hospitalizations and deaths were identified. Results Among 4858 solid organ recipients followed for 39 183 person-years (PY), there were 792 notifications. Influenza was the most common infection (532 cases; incidence, 1358 [95% CI, 1247–1478] per 100 000 PY), highest within 3 months posttransplant. Next most common was salmonellosis (46 cases; incidence, 117 [95% CI, 87–156] per 100 000 PY), then pertussis (38 cases; incidence, 97 [95% CI, 71–133] per 100 000 PY). Influenza and invasive pneumococcal disease (IPD) showed significant excess cases compared with the general population (influenza SIR, 8.5 [95% CI, 7.8–9.2]; IPD SIR, 9.8 [95% CI, 6.9–13.9]), with high hospitalization rates (47% influenza cases, 68% IPD cases) and some mortality (4 influenza and 1 IPD deaths). By 10 years posttransplant, cumulative incidence of any vaccine-preventable disease was 12%, generally similar by transplanted organ, except higher among lung recipients. Gastrointestinal diseases, tuberculosis, and legionellosis had excess cases among transplant recipients, although there were few sexually transmitted infections and vector-borne diseases. Conclusions There is potential to avoid preventable infections among transplant recipients with improved vaccination programs, health education, and pretransplant donor and recipient screening.
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Affiliation(s)
- Karen M J Waller
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Health and Medicine, University of Sydney , Sydney , Australia
| | - Nicole L De La Mata
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Health and Medicine, University of Sydney , Sydney , Australia
| | - Kate R Wyburn
- Department of Renal Medicine, Royal Prince Alfred Hospital , Camperdown , Australia
- Sydney Medical School, Faculty of Health and Medicine, University of Sydney , Sydney , Australia
| | - James A Hedley
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Health and Medicine, University of Sydney , Sydney , Australia
| | - Brenda M Rosales
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Health and Medicine, University of Sydney , Sydney , Australia
| | - Patrick J Kelly
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Health and Medicine, University of Sydney , Sydney , Australia
| | - Vidiya Ramachandran
- Serology and Virology Division, New South Wales Health Pathology Randwick Prince of Wales Hospital , Randwick , Australia
| | - Karan K Shah
- Clinical Trials Centre, University of Sydney National Health and Medical Research Council , Camperdown , Australia
| | - Rachael L Morton
- Clinical Trials Centre, University of Sydney National Health and Medical Research Council , Camperdown , Australia
| | - William D Rawlinson
- Serology and Virology Division, New South Wales Health Pathology Randwick Prince of Wales Hospital , Randwick , Australia
- School of Medical Sciences, School of Biotechnology and Biomolecular Sciences, and School of Women’s and Children’s Health, University of New South Wales , Sydney , Australia
| | - Angela C Webster
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Health and Medicine, University of Sydney , Sydney , Australia
- Clinical Trials Centre, University of Sydney National Health and Medical Research Council , Camperdown , Australia
- Centre for Transplant and Renal Research, Westmead Hospital , Sydney , Australia
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6
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Waller KMJ, De La Mata NL, Rosales BM, Hedley JA, Kelly PJ, Thomson IK, O'Leary MJ, Cavazzoni E, Ramachandran V, Rawlinson WD, Wyburn KR, Webster AC. Characteristics and Donation Outcomes of Potential Organ Donors Perceived to Be at Increased Risk for Blood-borne Virus Transmission: An Australian Cohort Study 2010-2018. Transplantation 2022; 106:348-357. [PMID: 33988336 DOI: 10.1097/tp.0000000000003715] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Safely increasing organ donation to meet need is a priority. Potential donors may be declined because of perceived blood-borne virus (BBV) transmission risk. With hepatitis C (HCV) curative therapy, more potential donors may now be suitable. We sought to describe potential deceased donors with increased BBV transmission risk. METHODS We conducted a cohort study of all potential organ donors referred in NSW, Australia, 2010-2018. We compared baseline risk potential donors to potential donors with increased BBV transmission risk, due to history of HIV, HCV or hepatitis B, and/or behavioral risk factors. RESULTS There were 624 of 5749 potential donors (10.9%) perceived to have increased BBV transmission risk. This included 298 of 5749 (5.2%) with HCV (including HBV coinfections) and 239 of 5749 (4.2%) with increased risk behaviors (no known BBV). Potential donors with HCV and those with increased risk behaviors were younger and had fewer comorbidities than baseline risk potential donors (P < 0.001). Many potential donors (82 with HCV, 38 with risk behaviors) were declined for donation purely because of perceived BBV transmission risk. Most were excluded before BBV testing. When potential donors with HCV did donate, they donated fewer organs than baseline risk donors (median 1 versus 3, P < 0.01), especially kidneys (odds ratio 0.08, P < 0.001) and lungs (odds ratio 0.11, P = 0.006). CONCLUSIONS Many potential donors were not accepted because of perceived increased BBV transmission risk, without viral testing, and despite otherwise favorable characteristics. Transplantation could be increased from potential donors with HCV and/or increased risk behaviors.
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Affiliation(s)
- Karen M J Waller
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Health and Medicine, The University of Sydney, Camperdown, NSW, Australia
| | - Nicole L De La Mata
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Health and Medicine, The University of Sydney, Camperdown, NSW, Australia
| | - Brenda M Rosales
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Health and Medicine, The University of Sydney, Camperdown, NSW, Australia
| | - James A Hedley
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Health and Medicine, The University of Sydney, Camperdown, NSW, Australia
| | - Patrick J Kelly
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Health and Medicine, The University of Sydney, Camperdown, NSW, Australia
| | - Imogen K Thomson
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Health and Medicine, The University of Sydney, Camperdown, NSW, Australia
| | - Michael J O'Leary
- NSW Organ and Tissue Donation Service, Kogarah, NSW, Australia
- Intensive Care Service, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Elena Cavazzoni
- NSW Organ and Tissue Donation Service, Kogarah, NSW, Australia
| | - Vidiya Ramachandran
- Serology and Virology Division, NSW Health Pathology, Prince of Wales Hospital, Randwick, NSW, Australia
| | - William D Rawlinson
- Serology and Virology Division, NSW Health Pathology, Prince of Wales Hospital, Randwick, NSW, Australia
- Schools of SOMS, BABS and Women's and Children's, University of NSW, Randwick, NSW, Australia
| | - Kate R Wyburn
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Angela C Webster
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Health and Medicine, The University of Sydney, Camperdown, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
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7
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Rosales BM, Langton-Lockton J, Hedley J, Cornall AM, Roberts JM, Garland SM, Kelly PJ, Hillman RJ, Webster AC. Prevalence of anal cytological abnormalities and high-risk human papillomavirus prevalence in kidney transplant recipients: A cross-sectional study. Clin Transplant 2021; 35:e14476. [PMID: 34498297 DOI: 10.1111/ctr.14476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/15/2021] [Accepted: 09/02/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Transplant recipients are at high-risk of anal squamous cell cancer. We aimed to estimate the prevalence of high-risk human papillomavirus (HPV) and high-grade squamous intraepithelial lesion (HSIL) and assess characteristics associated with results METHODS: We recruited kidney transplant recipients in a single-center, 2015-2018. Participants completed a clinical questionnaire and received an anal-swab sent for HPV-DNA and cytological testing RESULTS: A total of 97 (74%) of 125 recipients approached consented to participate. Participants were median 47 (IQR 40-55) years, 60% male and median 4.5 (IQR .9-13) months-since-transplant. Of 86 assessable samples, at least one HPV genotype was detected in 15 (17%) participants; 1 (1%) HPV16, 8 (9%) other high-risk HPV. Of 76 assessable cytology samples, 9 (12%) showed evidence of abnormality; 1 (1%) HSIL, 1 (1%) atypical-squamous-cells, cannot exclude HSIL. Both HSIL recipients had high-risk HPV and biopsy confirmed HSIL. High-risk HPV was detected in six (9%) recipients with normal cytology. History of sexually transmitted infection, and abnormal cervical pap smear in women, was associated with high-risk HPV and HSIL CONCLUSIONS: High-risk HPV and HSIL testing may identify kidney transplant recipients at higher risk of anal cancer. Longitudinal studies are needed to describe the natural history of anal cancer in transplant recipients.
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Affiliation(s)
- Brenda M Rosales
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Julian Langton-Lockton
- Sexual Health and HIV Service, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - James Hedley
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Alyssa M Cornall
- Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia.,Centre for Women's Infectious Diseases Research, The Royal Women's Hospital, Parkville, Australia
| | - Jennifer M Roberts
- Centre for Women's Infectious Diseases Research, The Royal Women's Hospital, Parkville, Australia.,Douglass Hanly Moir Pathology, Melbourne, Victoria, Australia
| | - Suzanne M Garland
- Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia.,Centre for Women's Infectious Diseases Research, The Royal Women's Hospital, Parkville, Australia
| | - Patrick J Kelly
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Richard J Hillman
- Women's Centre for Infectious Diseases, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Angela C Webster
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, New South Wales, Australia
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- Douglass Hanly Moir Pathology, Melbourne, Victoria, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, New South Wales, Australia
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8
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Hedley JA, Vajdic CM, Wyld M, Waller KMJ, Kelly PJ, De La Mata NL, Rosales BM, Wyburn K, Webster AC. Cancer transmissions and non-transmissions from solid organ transplantation in an Australian cohort of deceased and living organ donors. Transpl Int 2021; 34:1667-1679. [PMID: 34448264 DOI: 10.1111/tri.13989] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/14/2021] [Accepted: 07/15/2021] [Indexed: 01/21/2023]
Abstract
Evidence on cancer transmission from organ transplantation is poor. We sought to identify cases of cancer transmission or non-transmission from transplantation in an Australian cohort of donors and recipients. We included NSW solid organ deceased donors 2000-2012 and living donors 2004-2012 in a retrospective cohort using linked data from the NSW Biovigilance Register (SAFEBOD). Central Cancer Registry (CCR) data 1972-2013 provided a minimum one-year post-transplant follow-up. We identified cancers in donors and recipients. For each donor-recipient pair, the transmission was judged likely, possible, unlikely, or excluded using categorization from international guidelines. In our analysis, transmissions included those judged likely, while those judged possible, unlikely, or excluded were non-transmissions. In our cohort, there were 2502 recipients and 1431 donors (715 deceased, 716 living). There were 2544 transplant procedures, including 1828 (72%) deceased and 716 (28%) living donor transplants. Among 1431 donors, 38 (3%) had past or current cancer and they donated to 68 recipients (median 6.7-year follow-up). There were 64 (94%) non-transmissions, and 4 (6%) transmissions from two living and two deceased donors (all kidney cancers discovered during organ recovery). Donor transmitted cancers are rare, and selected donors with a past or current cancer may be safe for transplantation.
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Affiliation(s)
- James A Hedley
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Claire M Vajdic
- Cancer Epidemiology Research Unit, Centre for Big Data Research in Health, University of New South Wales, Kensington, NSW, Australia
| | - Melanie Wyld
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.,Renal Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Karen M J Waller
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Patrick J Kelly
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Nicole L De La Mata
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Brenda M Rosales
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Kate Wyburn
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.,Renal Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Angela C Webster
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia.,National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
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Waller KMJ, De La Mata NL, Hedley JA, Rosales BM, O’Leary MJ, Cavazzoni E, Ramachandran V, Rawlinson WD, Kelly PJ, Wyburn KR, Webster AC. New Blood Borne Virus Infections Among Organ Transplant Recipients: A Data-Linked Cohort Study Examining Transmissions and De Novo Infections. Int J Popul Data Sci 2020. [DOI: 10.23889/ijpds.v5i5.1642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
IntroductionSolid organ transplant recipients are at risk of infections, which may be either derived through transplantation or acquired later. Blood-borne viruses (BBV) are a particular concern for donor-derived transmissions. There is an increasing emphasis on biovigilance – monitoring the safety of donated organs. However, systematic surveillance to distinguish donor-transmitted infection from de novo post-transplant infection is challenging. Additional information can be obtained through linkage of administrative health data.
Objectives and ApproachWe aimed to identify donor-transmitted and de novo BBV infections among organ transplant recipients. We conducted a cohort study of all solid organ donor-recipient pairs in New South Wales, Australia, 2000-2015. Donor and recipient BBV infections were identified by linking transplant registries with administrative health data. Proven/probable donor-transmissions were identified among new recipient infections within 12 months of transplant, classified according to an international algorithm. All other new BBV infections were classified as de novo infections.
ResultsAmong 2,120 organ donors, 73 had a BBV infection (11/73 active, 62/73 past). Donors with BBV donated to 176 recipients, of whom 24/176 had the same BBV as their donor, and 152/176 did not; these 152 recipients were at risk of donor-transmission. Among those at risk, there were 3/152 proven/probable BBV transmissions (1 hepatitis C, 2 hepatitis B [HBV]) and 149/152 recipients with non-transmissions. All donor-transmissions were previously recognised by donation services, and were from donors with known BBV. There were no deaths from transmissions. There were 70 recipients with de novo BBV; 2/70 died from new HBV.
Conclusion / ImplicationsThis work confirms the safety of Australian organ donation, with no unrecognised BBV transmissions and many non-transmissions from donors with BBV. This may support increasing targeted donation from donors with BBV. However, de novo BBV infections were substantial and preventable. Data-linkage may be a useful adjunct to current biovigilance systems.
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Hedley JA, De La Mata N, Rosales BM, Waller KMJ, Thomson IK, Kelly PJ, O’Leary M, Cavazzoni E, Wyburn K, Webster AC. Perceived vs. Verified Cancer Transmission Risk from Deceased Organ Donors in New South Wales (NSW), Australia, 2010-2015. Int J Popul Data Sci 2020. [DOI: 10.23889/ijpds.v5i5.1495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
IntroductionDonor suitability assessment is often time-sensitive, with imperfect information available at referral. Opportunities for donation may be missed if donors are rejected based on inaccurate information.
Objectives and ApproachWe sought to compare assessment of cancer transmission risk based on information available at referral (perceived) versus subsequently obtained (verified) detailed medical history, and to identify any missed opportunities for donation. We used data from the NSW Biovigilance Register, a cohort study of deceased organ donor referrals in New South Wales (NSW) 2010-2015. Referrals from NSW who had consent and were otherwise suitable for donation (except for perceived or verified tumour) were analysed. Perceived tumour details were obtained from NSW Organ and Tissue Donation Service referral logs, while verified details were based on the Central Cancer Registry and Admitted Patient Data Collection. Cancer transmission risk was graded using Transplantation Society of Australia and New Zealand guidelines.
ResultsAmong 772 referrals otherwise suitable for donation, 601 (78%) had accurately classified cancer transmission risk (κ=0.59). Overall, 53 suitable referrals were rejected due to cancer transmission risk (missed opportunities), including 49 (92%) with overestimated risk (perceived high, verified low/none), and 4 (8%) due to excessive risk aversion (perceived and verified low risk). Missed opportunities had overestimated transmission risk for tumours including leukaemia (8, 16%), lung (8, 16%), melanoma (7, 14%), brain (6, 12%), and breast (6, 12%).
Conclusion / ImplicationsDespite time pressure and limited information availability, there is moderate agreement between perceived and verified cancer transmission risk. Nevertheless, improved information availability (e.g. via data linkage) could meaningfully increase the number of actual donors.
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11
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Waller KMJ, De La Mata NL, Hedley JA, Rosales BM, O'Leary MJ, Cavazzoni E, Ramachandran V, Rawlinson WD, Kelly PJ, Wyburn KR, Webster AC. New blood-borne virus infections among organ transplant recipients: An Australian data-linked cohort study examining donor transmissions and other HIV, hepatitis C and hepatitis B notifications, 2000-2015. Transpl Infect Dis 2020; 22:e13437. [PMID: 32767859 DOI: 10.1111/tid.13437] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Blood-borne viral infections can complicate organ transplantation. Systematic monitoring to distinguish donor-transmitted infections from other new infections post transplant is challenging. Administrative health data can be informative. We aimed to quantify post-transplant viral infections, specifically those transmitted by donors and those reactivating or arising new in recipients. METHODS We linked transplant registries with administrative health data for all solid organ donor-recipient pairs in New South Wales, Australia, 2000-2015. All new recipient notifications of hepatitis B (HBV), C (HCV), or human immunodeficiency virus (HIV) after transplant were identified. Proven/probable donor transmissions within 12 months of transplant were classified using an international algorithm. RESULTS Of 2120 organ donors, there were 72 with a viral infection (9/72 active, 63/72 past). These 72 donors donated to 173 recipients, of whom 24/173 already had the same infection as their donor, and 149/173 did not, so were at risk of donor transmission. Among those at risk, 3/149 recipients had proven/probable viral transmissions (1 HCV, 2 HBV); none were unrecognized by donation services. There were no deaths from transmissions. There were no donor transmissions from donors without known blood-borne viruses. An additional 68 recipients had new virus notifications, of whom 2/68 died, due to HBV infection. CONCLUSION This work confirms the safety of organ donation in an Australian cohort, with no unrecognized viral transmissions and most donors with viral infections not transmitting the virus. This may support targeted increases in donation from donors with viral infections. However, other new virus notifications post transplant were substantial and are preventable. Data linkage can enhance current biovigilance systems.
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Affiliation(s)
- Karen M J Waller
- Faculty of Health and Medicine, Sydney School of Public Health, Centre for Organ Donation Evidence, University of Sydney, Sydney, NSW, Australia
| | - Nicole L De La Mata
- Faculty of Health and Medicine, Sydney School of Public Health, Centre for Organ Donation Evidence, University of Sydney, Sydney, NSW, Australia
| | - James A Hedley
- Faculty of Health and Medicine, Sydney School of Public Health, Centre for Organ Donation Evidence, University of Sydney, Sydney, NSW, Australia
| | - Brenda M Rosales
- Faculty of Health and Medicine, Sydney School of Public Health, Centre for Organ Donation Evidence, University of Sydney, Sydney, NSW, Australia.,Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Michael J O'Leary
- New South Wales Organ and Tissue Donation Service, Sydney, NSW, Australia.,Department of Intensive Care Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Elena Cavazzoni
- New South Wales Organ and Tissue Donation Service, Sydney, NSW, Australia
| | - Vidiya Ramachandran
- Serology and Virology Division, NSW Health Pathology Randwick Prince of Wales Hospital, Randwick, NSW, Australia
| | - William D Rawlinson
- Serology and Virology Division, NSW Health Pathology Randwick Prince of Wales Hospital, Randwick, NSW, Australia.,Schools of SOMS, BABS and Women's and Children's, University of NSW, Kensington, NSW, Australia
| | - Patrick J Kelly
- Faculty of Health and Medicine, Sydney School of Public Health, Centre for Organ Donation Evidence, University of Sydney, Sydney, NSW, Australia
| | - Kate R Wyburn
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,Faculty of Health and Medicine, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Angela C Webster
- Faculty of Health and Medicine, Sydney School of Public Health, Centre for Organ Donation Evidence, University of Sydney, Sydney, NSW, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
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12
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Waller KMJ, Hedley JA, Rosales BM, De La Mata NL, Thomson IK, Walker J, Kelly PJ, O'Leary MJ, Cavazzoni E, Wyburn KR, Webster AC. Effect of language and country of birth on the consent process and medical suitability of potential organ donors; a linked-data cohort study 2010-2015. J Crit Care 2020; 57:23-29. [PMID: 32014644 DOI: 10.1016/j.jcrc.2020.01.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/02/2019] [Accepted: 01/20/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE Australia has unmet need for transplantation. We sought to assess the impact of cultural and linguistic diversity (CALD) on family consent and medical suitability for organ donation. METHOD Cohort study of New South Wales donor referrals, 2010-2015. Logistic regression estimated effects of primary language other than English and birthplace outside Australia (odds ratios OR, with 95% confidence intervals, 95%CI). Outcomes were whether families were asked for consent to donation, provided consent for donation, and whether the referral was medically suitable for donation. RESULTS Of 2977 organ donor referrals, a similar proportion of families had consent for donation was sought between non-English speakers and English speakers (p = .07), and between overseas-born compared to Australian-born referrals (p = .3). However, consent was less likely to be given for both non-English speakers than English speakers (OR 0.44, 95%CI:0.29-0.67), and those overseas-born than Australian-born (OR 0.54, 95%CI:0.41-0.72). For referrals both overseas-born and non-English speaking, families were both less likely to be asked for consent (OR 0.67; 95%CI:0.49-0.91) or give consent (OR 0.24; 95%CI0.16-0.37). There was no difference in medical suitability between English speakers and non-English speakers (p = .6), or between Australian-born and overseas-born referrals (p = .6). CONCLUSION Intervention to improve consent rates from CALD families may increase donation.
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Affiliation(s)
- Karen M J Waller
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - James A Hedley
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Brenda M Rosales
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Nicole L De La Mata
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Imogen K Thomson
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - John Walker
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; School of Economics, Faculty of Arts and Social Sciences, University of Sydney, Sydney, Australia.
| | - Patrick J Kelly
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Michael J O'Leary
- New South Wales Organ and Tissue Donation Service, Sydney, Australia.
| | - Elena Cavazzoni
- New South Wales Organ and Tissue Donation Service, Sydney, Australia.
| | - Kate R Wyburn
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Renal Department, Royal Prince Alfred Hospital, Sydney, Australia.
| | - Angela C Webster
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia.
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Rosales BM, De La Mata N, Vajdic CM, Kelly PJ, Wyburn K, Webster AC. Cancer mortality in kidney transplant recipients: An Australian and New Zealand population-based cohort study, 1980-2013. Int J Cancer 2019; 146:2703-2711. [PMID: 31340063 DOI: 10.1002/ijc.32585] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 07/04/2019] [Indexed: 01/03/2023]
Abstract
Cancer burden is increasing in kidney transplant recipients, but differences in mortality compared to the general population remain unclear. We sought to compare cancer mortality in paediatric and adult kidney transplant recipients with the general population and describe any differences, by site, age and sex, country and over time. We included kidney transplant recipients from the Australian and New Zealand Dialysis and Transplantation Registry, 1980-2013. Date of death and underlying cause of death were ascertained by data-linkage and classified using ICD10AM codes. Indirect standardisation was used to estimate standardised mortality ratios (SMR). There were 5,284 deaths in 17,628 kidney transplant recipients over 175,084 person-years of observation, including 1,061 (20%) cancer deaths. Relative cancer mortality was higher than the general population for all-site (SMR 2.9, 95% CI 2.7-3.1) cancer and highest for nonmelanoma skin cancer (SMR 50.9, 95% CI 43.5-59.6) and lymphoma (SMR 42.2, 95% CI 35.3-50.5). Relative cancer mortality decreased with increasing age in men (p < 0.001) and women (p = 0.001) but never reached parity with the general population. Relative mortality did not change with age for skin and lip, or colorectal cancers (p-value >0.1). Only relative colorectal cancer mortality increased over time (p = 0.002). Our study shows cancer mortality in kidney transplant recipients was higher than expected in the general population. The magnitude of excess mortality varied by cancer site, age and sex. Further evidence is needed to identify whether this variation is due to differences at diagnosis or access and effectiveness of cancer treatments in this population.
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Affiliation(s)
- Brenda M Rosales
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Nicole De La Mata
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Claire M Vajdic
- Centre for Big Data Research in Health, University of New South Wales, Kensington, NSW, Australia
| | - Patrick J Kelly
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Kate Wyburn
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia.,Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Angela C Webster
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Department of Renal Medicine and Transplantation, Westmead Hospital, Sydney, NSW, Australia
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Hedley JA, Chang N, Kelly PJ, Rosales BM, Wyburn K, O'Leary M, Cavazzoni E, Webster AC. Weekend effect: analysing temporal trends in solid organ donation. ANZ J Surg 2019; 89:1068-1074. [PMID: 30706681 DOI: 10.1111/ans.15015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/07/2018] [Accepted: 11/12/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Research suggests patients treated over weekends experience poorer outcomes. Only one US-based study explored this weekend effect in organ donation, specifically the kidney discard rate. In Australia potential donors are referred to a donation service, and donation proceeds if family consent is granted and the donor is deemed medically suitable to donate. Organ procurement occurs when utilization is almost certain hence discard rates are much lower than in the USA. We aimed to characterize the effect of weekend referral on organ donation in Australia. METHODS We retrospectively reviewed all New South Wales Organ and Tissue Donation Service logs from 2010 to 2016. Our primary outcome was progression to organ procurement, and secondary outcomes were family consent and meeting medical suitability thresholds. We used logistic regression with random effects adjusting for clustering of referral hospitals. RESULTS Of 3496 potential donors referred for consideration, 694 (20%) progressed to organ procurement. There were fewer referrals on weekends (average 415 versus 588 for weekdays). However, donation rates were no lower for weekend compared to weekday referrals (adjusted OR 1.17; 95% CI 0.95, 1.44). Family consent (adjusted OR 1.20; 95% CI 1.00, 1.44) and medical suitability (adjusted OR 1.15; 95% CI 0.96, 1.38) were not lower for weekend compared to weekday referrals. Similar results were found for all sensitivity analyses conducted. CONCLUSIONS In Australia, the donation pathway operates consistently throughout the week, with donation no less likely to proceed on weekends and holidays. This finding contrasts with findings in the USA.
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Affiliation(s)
- James A Hedley
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas Chang
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Patrick J Kelly
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Brenda M Rosales
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kate Wyburn
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Renal Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | | | | | - Angela C Webster
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, New South Wales, Australia
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Shaw JA, Page K, Fernandez-Garcia D, Hills A, Boydell AR, Primrose L, Toghill B, Hastings RK, Gleeson K, Rosales BM, Goddard K, Guttery DS, Ali S, Coombes RC. Abstract LB-224: Circulating tumor DNA for early detection and intervention in breast cancer: ctDNA profiles discriminate between healthy women in a true cancer screening setting and disease-free women on follow up. Cancer Res 2018. [DOI: 10.1158/1538-7445.am2018-lb-224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Successful early detection and intervention in cancer is key if we are to drastically improve cancer survivorship. Previous research by us and others has shown that copy number and mutational profiling of circulating cell-free DNA (cfDNA) can detect minimal residual disease and predict who will relapse after early stage breast cancer (Shaw et al. Genome Res 2012, doi: 10.1101, Garcia-Murillas et al. Sci Transl Med. 2015 doi: 10.1126). Here we used massively parallel sequencing with the Ion CHEF -S5 and Oncomine™ Breast cfDNA Assay (Thermofisher) for ultrasensitive detection of circulating tumour derived DNA (ctDNA) in 26 asymptomatic early stage breast cancer patients with no scan evidence of distant metastases on follow up after surgery, (all of whom were receiving adjuvant AI (PAI) at the time of blood sampling). We compared these early stage breast cancers with cfDNA isolated from 40 patients with metastatic breast cancer (MBC) and 92 healthy age matched female controls (HC) attending for a routine breast screening mammogram. The Oncomine™ Breast cfDNA Assay targets >150 hotspot mutations in 10 breast cancer genes and uses tag sequencing technology to achieve a limit of detection (LOD) down to 0.1%. One or more driver mutations were detected in cfDNA of 19 (73%) PAIs and 29 (72.5 %) MBCs, whereas just 15 HCs (16%) were positive. Applying this threshold of 1 or more driver mutations for detection of ctDNA (Cohen et al. Science. 2018 doi: 10.1126) there was a significant difference between ctDNA positive cancers and healthy controls, which also remained significant for 2 or more driver mutations (P < 0.0001 and P < 0.001 respectively, Fisher's exact test) (Abbosh et al. Nature 2017, doi: 10.1038). It is notable that >72% of breast cancers were positive with this test, both disease-free women on follow up and patients with MBC, suggesting a role for the test in routine monitoring. A second finding of clinical significance was that variant allele fraction of ESR1 mutant ctDNA was significantly higher in cancers than controls (PAIs than HCs (P = 0.034) and MBCs than HCs (P = 0.002); adjusted P value, Dunn's multiple comparison test) suggesting that ESR1 mutations distinguish disease-free breast cancer survivors receiving adjuvant aromatase inhibitors from normal women. Importantly, we are the first to report ultrasensitive evaluation of ctDNA alterations in a large number of healthy women in a true cancer screening setting. The 15 healthy women that were “positive” for ctDNA may be harbouring an early stage cancer not detectable by imaging. Research is ongoing to validate these results in a larger study, but our results suggest that the approach may have utility for early disease detection and monitoring to enable appropriate intervention at earlier stages.
Citation Format: Jacqui A. Shaw, Karen Page, Daniel Fernandez-Garcia, Allison Hills, Anna R. Boydell, Lindsay Primrose, Bradley Toghill, Robert K. Hastings, Kelly Gleeson, Brenda M. Rosales, Kate Goddard, David S. Guttery, Simak Ali, Raoul C. Coombes. Circulating tumor DNA for early detection and intervention in breast cancer: ctDNA profiles discriminate between healthy women in a true cancer screening setting and disease-free women on follow up [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr LB-224.
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Affiliation(s)
| | - Karen Page
- 1University of Leicester, Leicester, United Kingdom
| | | | | | | | | | | | | | | | | | - Kate Goddard
- 2Imperial College London, London, United Kingdom
| | | | - Simak Ali
- 2Imperial College London, London, United Kingdom
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Page K, Guttery DS, Fernandez-Garcia D, Hills A, Hastings RK, Luo J, Goddard K, Shahin V, Woodley-Barker L, Rosales BM, Coombes RC, Stebbing J, Shaw JA. Next Generation Sequencing of Circulating Cell-Free DNA for Evaluating Mutations and Gene Amplification in Metastatic Breast Cancer. Clin Chem 2017; 63:532-541. [PMID: 27940449 PMCID: PMC6241835 DOI: 10.1373/clinchem.2016.261834] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/19/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Breast cancer tissues are heterogeneous and show diverse somatic mutations and somatic copy number alterations (CNAs). We used a novel targeted next generation sequencing (NGS) panel to examine cell-free DNA (cfDNA) to detect somatic mutations and gene amplification in women with metastatic breast cancer (MBC). METHODS cfDNA from pretreated patients (n = 42) and 9 healthy controls were compared with matched lymphocyte DNA by NGS, using a custom 158 amplicon panel covering hot-spot mutations and CNAs in 16 genes, with further validation of results by droplet digital PCR. RESULTS No mutations were identified in cfDNA of healthy controls, whereas exactly half the patients with metastatic breast cancer had at least one mutation or amplification in cfDNA (mean 2, range 1-6) across a total of 13 genes. Longitudinal follow up showed dynamic changes to mutations and gene amplification in cfDNA indicating clonal and subclonal response to treatment that was more dynamic than cancer antigen 15-3 (CA15-3). Interestingly, at the time of blood sampling disease progression was occurring in 7 patients with erb-b2 receptor tyrosine kinase 2 (ERBB2) gene amplification in their cfDNA and 3 of these patients were human epidermal growth factor receptor 2 (HER2) negative at diagnosis, suggesting clonal evolution to a more aggressive phenotype. Lastly, 6 patients harbored estrogen receptor 1 (ESR1) mutations in cfDNA, suggesting resistance to endocrine therapy. Overall 9 of 42 patients (21%) had alterations in cfDNA that could herald a change in treatment. CONCLUSIONS Targeted NGS of cfDNA has potential for monitoring response to targeted therapies through both mutations and gene amplification, for analysis of dynamic tumor heterogeneity and stratification to targeted therapy.
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Affiliation(s)
- Karen Page
- Department of Cancer Studies and Cancer Research UK Leicester Centre, University of Leicester, Leicester, UK
| | - David S Guttery
- Department of Cancer Studies and Cancer Research UK Leicester Centre, University of Leicester, Leicester, UK
| | - Daniel Fernandez-Garcia
- Department of Cancer Studies and Cancer Research UK Leicester Centre, University of Leicester, Leicester, UK
| | - Allison Hills
- Department of Surgery and Cancer, Division of Cancer, and
| | - Robert K Hastings
- Department of Cancer Studies and Cancer Research UK Leicester Centre, University of Leicester, Leicester, UK
| | - Jinli Luo
- Department of Cancer Studies and Cancer Research UK Leicester Centre, University of Leicester, Leicester, UK
| | - Kate Goddard
- Department of Medical Oncology, Imperial College London, Charing Cross Hospital, London, UK
| | - Vedia Shahin
- Department of Medical Oncology, Imperial College London, Charing Cross Hospital, London, UK
| | - Laura Woodley-Barker
- Department of Medical Oncology, Imperial College London, Charing Cross Hospital, London, UK
| | | | | | | | - Jacqueline A Shaw
- Department of Cancer Studies and Cancer Research UK Leicester Centre, University of Leicester, Leicester, UK;
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Shaw JA, Guttery DS, Hills A, Fernandez-Garcia D, Page K, Rosales BM, Goddard KS, Hastings RK, Luo J, Ogle O, Woodley L, Ali S, Stebbing J, Coombes RC. Mutation Analysis of Cell-Free DNA and Single Circulating Tumor Cells in Metastatic Breast Cancer Patients with High Circulating Tumor Cell Counts. Clin Cancer Res 2017; 23:88-96. [PMID: 27334837 PMCID: PMC6241844 DOI: 10.1158/1078-0432.ccr-16-0825] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 05/13/2016] [Accepted: 06/12/2016] [Indexed: 12/21/2022]
Abstract
PURPOSE The purpose of this study was to directly compare mutation profiles in multiple single circulating tumor cells (CTC) and cell-free DNA (cfDNA) isolated from the same blood samples taken from patients with metastatic breast cancer (MBC). We aimed to determine whether cfDNA would reflect the heterogeneity observed in 40 single CTCs. EXPERIMENTAL DESIGN CTCs were enumerated by CELLSEARCH. CTC count was compared with the quantity of matched cfDNA and serum CA15-3 and alkaline phosphatase (ALP) in 112 patients with MBC. In 5 patients with ≥100 CTCs, multiple individual EpCAM-positive CTCs were isolated by DEPArray and compared with matched cfDNA and primary tumor tissue by targeted next-generation sequencing (NGS) of about 2,200 mutations in 50 cancer genes. RESULTS In the whole cohort, total cfDNA levels and cell counts (≥5 CTCs) were both significantly associated with overall survival, unlike CA15-3 and ALP. NGS analysis of 40 individual EpCAM-positive CTCs from 5 patients with MBC revealed mutational heterogeneity in PIK3CA, TP53, ESR1, and KRAS genes between individual CTCs. In all 5 patients, cfDNA profiles provided an accurate reflection of mutations seen in individual CTCs. ESR1 and KRAS gene mutations were absent from primary tumor tissue and therefore likely either reflect a minor subclonal mutation or were acquired with disease progression. CONCLUSIONS Our results demonstrate that cfDNA reflects persisting EpCAM-positive CTCs in patients with high CTC counts and therefore may enable monitoring of the metastatic burden for clinical decision-making. Clin Cancer Res; 23(1); 88-96. ©2016 AACR.
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Affiliation(s)
- Jacqueline A Shaw
- Department of Cancer Studies, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, United Kingdom.
| | - David S Guttery
- Department of Cancer Studies, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, United Kingdom
| | - Allison Hills
- Department of Surgery and Cancer, Imperial College London, Hammersmith, United Kingdom
| | - Daniel Fernandez-Garcia
- Department of Cancer Studies, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, United Kingdom
| | - Karen Page
- Department of Cancer Studies, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, United Kingdom
| | - Brenda M Rosales
- Department of Surgery and Cancer, Imperial College London, Hammersmith, United Kingdom
| | - Kate S Goddard
- Department of Surgery and Cancer, Imperial College London, Hammersmith, United Kingdom
| | - Robert K Hastings
- Cancer Research UK Leicester Centre, University of Leicester, Leicester, London, United Kingdom
| | - Jinli Luo
- Cancer Research UK Leicester Centre, University of Leicester, Leicester, London, United Kingdom
| | - Olivia Ogle
- Department of Surgery and Cancer, Imperial College London, Hammersmith, United Kingdom
| | - Laura Woodley
- Department of Surgery and Cancer, Imperial College London, Hammersmith, United Kingdom
| | - Simak Ali
- Department of Surgery and Cancer, Imperial College London, Hammersmith, United Kingdom
| | - Justin Stebbing
- Department of Surgery and Cancer, Imperial College London, Hammersmith, United Kingdom
| | - R Charles Coombes
- Department of Surgery and Cancer, Imperial College London, Hammersmith, United Kingdom.
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