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Romine MM, Leeser DB, Kennamer K, Nguyen C, Jones H, McLawhorn K, Kendrick S, Irish W. Early outcomes associated with de novo once-daily extended-release versus twice-daily immediate-release tacrolimus in a predominantly African American kidney transplant population: A single-center observational study. Clin Transplant 2024; 38:e15268. [PMID: 38450751 DOI: 10.1111/ctr.15268] [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: 09/14/2023] [Revised: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 03/08/2024]
Abstract
INTRODUCTION The purpose of this study was to compare early outcomes of de novo LCPT (once-daily extended-release tacrolimus) to IR TAC (twice-daily immediate-release tacrolimus) in a predominantly African American (AA) adult kidney transplant population. METHODS This is a single center, retrospective cohort study. Patients were divided into two cohorts: IR TAC (administered between January 1, 2017, and January 31, 2019) and LCPT (administered between February 1, 2019, and May 31, 2020). Primary endpoints were changes in tacrolimus trough levels (ng/mL) and estimated glomerular filtration rate up to 12 months post-transplantation. Clinical endpoints included graft survival, delayed graft function, biopsy-proven rejection, CMV viremia, and BK. A propensity score weighted generalized linear mixed effects model was used for analysis. RESULTS The rate of change in tacrolimus levels was significantly higher in the LCPT cohort compared to the IR TAC cohort at 14 days post-discharge (.2455 ng/mL per day vs. .1073 ng/mL, respectively; p < .001). Subsequently, the LCPT cohort had a slightly higher rate of decline (-.015 ng/mL per day vs. -.010 ng/mL with IR TAC; p = .0894) up to 12 months post-discharge. Although eGFR was similar between the two cohorts at 12 months post-transplant, the rate of increase was slower in the LCPT cohort (.1371 mL/min per day vs. .1852 mL/min per day, p = .0314). No significant differences were found in graft survival, DGF, BPAR, CMV, or BK infection. CONCLUSION This study demonstrates that despite higher early trough levels with immediate post-transplant LCPT use, clinical outcomes are comparable to IR TAC at one-year post-transplant. Notably, LCPT use does not increase the incidence of DGF and that this formulation of CNI can be used as first line therapy post-transplant.
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Affiliation(s)
- Margaret M Romine
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - David B Leeser
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Karen Kennamer
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Catherine Nguyen
- East Carolina University Health System, Greenville, North Carolina, USA
| | - Heather Jones
- Eastern Nephrology Associates, Greenville, North Carolina, USA
| | | | - Scott Kendrick
- Eastern Nephrology Associates, Greenville, North Carolina, USA
| | - William Irish
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
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Roll GR, Cooper M, Verbesey J, Veale JL, Ronin M, Irish W, Waterman AD, Flechner SM, Leeser DB. Risk aversion in the use of complex kidneys in paired exchange programs: Opportunities for even more transplants? Am J Transplant 2022; 22:1893-1900. [PMID: 35181991 PMCID: PMC9543328 DOI: 10.1111/ajt.17008] [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: 10/21/2021] [Revised: 02/02/2022] [Accepted: 02/16/2022] [Indexed: 01/25/2023]
Abstract
This retrospective review of the largest United States kidney exchange reports characteristics, utilization, and recipient outcomes of kidneys with simple compared to complex anatomy and extrapolates reluctance to accept these kidneys. Of 3105 transplants performed, only 12.8% were right kidneys and 23.1% had multiple renal arteries. 59.3% of centers used fewer right kidneys than expected and 12.1% transplanted zero right kidneys or kidneys with more than 1 artery. Five centers transplanted a third of these kidneys (35.8% of right kidneys and 36.7% of kidneys with multiple renal arteries). 22.5% and 25.5% of centers currently will not entertain a match offer for a left or right kidney with more than one artery, respectively. There were no significant differences in all-cause graft failure or death-censored graft loss for kidneys with multiple arteries, and a very small increased risk of graft failure for right kidneys versus left of limited clinical relevance for most recipients. Kidneys with complex anatomy can be used with excellent outcomes at many centers. Variation in use (lack of demand) for these kidneys reduces the number of transplants, so systems to facilitate use could increase demand. We cannot know how many donors are turned away because perceived demand is limited.
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Affiliation(s)
- Garrett R. Roll
- Department of SurgeryDivision of TransplantUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Matthew Cooper
- Medstar Georgetown Transplant InstituteGeorgetown UniversityWashingtonDistrict of ColumbiaUSA
| | - Jennifer Verbesey
- Medstar Georgetown Transplant InstituteGeorgetown UniversityWashingtonDistrict of ColumbiaUSA
| | - Jeffrey L. Veale
- Department of UrologyUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | | | - William Irish
- Department of SurgeryEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Amy D. Waterman
- Department of SurgeryJ.C. Walter Transplant CenterHoustonTexasUSA,Terasaki Institute of Biomedical InnovationLos AngelesCaliforniaUSA
| | - Stuart M. Flechner
- Glickman Urological and Kidney InstituteCleveland ClinicClevelandOhioUSA
| | - David B. Leeser
- Department of SurgeryEast Carolina UniversityGreenvilleNorth CarolinaUSA
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Wong JH, Irish WD, DeMaria EJ, Vohra NA, Pories WJ, Brownstein MR, Altieri MS, Akram W, Haisch CE, Leeser DB, Tuttle JE. Development and Assessment of a Systematic Approach for Detecting Disparities in Surgical Access. JAMA Surg 2021; 156:239-245. [PMID: 33326009 DOI: 10.1001/jamasurg.2020.5668] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Although optimal access is accepted as the key to quality care, an accepted methodology to ascertain potential disparities in surgical access has not been defined. Objective To develop a systematic approach to detect surgical access disparities. Design, Setting, and Participants This cross-sectional study used publicly available data from the Health Cost and Utilization Project State Inpatient Database from 2016. Using the surgical rate observed in the 5 highest-ranked counties (HRCs), the expected surgical rate in the 5 lowest-ranked counties (LRCs) in North Carolina were calculated. Patients 18 years and older who underwent an inpatient general surgery procedure and patients who underwent emergency inpatient cholecystectomy, herniorrhaphy, or bariatric surgery in 2016 were included. Data were collected from January to December 2016, and data were analyzed from March to July 2020. Exposures Health outcome county rank as defined by the Robert Wood Johnson Foundation. Main Outcomes and Measures The primary outcome was the proportional surgical ratio (PSR), which was the disparity in surgical access defined as the observed number of surgical procedures in the 5 LRCs relative to the expected number of procedures using the 5 HRCs as the standardized reference population. Results In 2016, approximately 1.9 million adults lived in the 5 HRCs, while approximately 246 854 lived in the 5 LRCs. A total of 28 924 inpatient general surgical procedures were performed, with 4521 being performed in those living in the 5 LRCs and 24 403 in those living in the 5 HRCs. The rate of general surgery in the 5 HRCs was 13.09 procedures per 1000 population. Using the 5 HRCs as the reference, the PSR for the 5 LRCs was 1.40 (95% CI, 1.35-1.44). For emergent/urgent cholecystectomy, the PSR for the 5 LRCs was 2.26 (95% CI, 2.02-2.51), and the PSR for emergent/urgent herniorrhaphy was 1.83 (95% CI, 1.33-2.45). Age-adjusted rate of obesity (body mass index [calculated as weight in kilograms divided by height in meters squared] greater than 30), on average, was 36.6% (SD, 3.4) in the 5 LRCs vs 25.4% (SD, 4.6) in the 5 HRCs (P = .002). The rate of bariatric surgery in the 5 HRCs was 33.07 per 10 000 population with obesity. For the 5 LRCs, the PSR was 0.60 (95% CI, 0.51-0.69). Conclusions and Relevance The PSR is a systematic approach to define potential disparities in surgical access and should be useful for identifying, investigating, and monitoring interventions intended to mitigate disparities in surgical access that effects the health of vulnerable populations.
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Affiliation(s)
- Jan H Wong
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - William D Irish
- Division of Surgical Research, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina.,Department of Public Health, East Carolina University, Greenville, North Carolina
| | - Eric J DeMaria
- Division of General Minimal Invasive and Bariatric Surgery, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Nasreen A Vohra
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Walter J Pories
- Division of Surgical Research, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Michelle R Brownstein
- Division of Trauma and Critical Care, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Maria S Altieri
- Division of General Minimal Invasive and Bariatric Surgery, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Warqaa Akram
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Carl E Haisch
- Division of Surgical Immunology and Transplantation, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - David B Leeser
- Division of Surgical Immunology and Transplantation, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Janet E Tuttle
- Division of Surgical Immunology and Transplantation, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
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4
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Cooper M, Leeser DB, Flechner SM, Beaumont JL, Waterman AD, Shannon PW, Ronin M, Hil G, Veale JL. Ensuring the need is met: A 50-year simulation study of the National Kidney Registry's family voucher program. Am J Transplant 2021; 21:1128-1137. [PMID: 32506647 PMCID: PMC7984283 DOI: 10.1111/ajt.16101] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 09/08/2019] [Revised: 05/23/2020] [Accepted: 05/24/2020] [Indexed: 01/25/2023]
Abstract
The National Kidney Registry (NKR) Advanced Donation Program enables living donors the opportunity to donate altruistically, or in advance of a potential recipient's transplant, and to receive a voucher that can be redeemed for a future transplant facilitated by the NKR. Family vouchers allow a donor to identify multiple individuals within their immediate family, with the first person in that group in need of a transplant being prioritized to receive a kidney. An increase in vouchers introduces concerns that demand for future voucher redemptions could exceed the supply of available donors and kidneys. A Monte Carlo simulation model was constructed to estimate the annual number of voucher redemptions relative to the number of kidneys available over a 50-year time horizon under several projected scenarios for growth of the program. In all simulated scenarios, the number of available kidneys exceeded voucher redemptions every year. While not able to account for all real-life scenarios, this simulation study found that the NKR should be able to satisfy the likely redemption of increasing numbers of vouchers under a range of possible scenarios over a 50-year time horizon. This modeling exercise suggests that a donor family's future needs can be satisfied through the voucher program.
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Affiliation(s)
- Matthew Cooper
- Medstar Georgetown Transplant InstituteWashingtonDistrict of ColumbiaUSA
| | - David B. Leeser
- Department of SurgeryEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Stuart M. Flechner
- Glickman Urological and Kidney InstituteCleveland ClinicClevelandOhioUSA
| | | | - Amy D. Waterman
- Terasaki Research InstituteLos AngelesCaliforniaUSA,Department of NephrologyUniversity of CaliforniaLos AngelesCaliforniaUSA
| | | | | | - Garet Hil
- National Kidney RegistryBabylonNew YorkUSA
| | - Jeffrey L. Veale
- Department of UrologyUniversity of CaliforniaLos AngelesCaliforniaUSA
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5
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Leeser DB, Thomas AG, Shaffer AA, Veale JL, Massie AB, Cooper M, Kapur S, Turgeon N, Segev DL, Waterman AD, Flechner SM. Patient and Kidney Allograft Survival with National Kidney Paired Donation. Clin J Am Soc Nephrol 2020; 15:228-237. [PMID: 31992572 PMCID: PMC7015097 DOI: 10.2215/cjn.06660619] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [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: 06/07/2019] [Accepted: 11/14/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND OBJECTIVES In the United States, kidney paired donation networks have facilitated an increasing proportion of kidney transplants annually, but transplant outcome differences beyond 5 years between paired donation and other living donor kidney transplant recipients have not been well described. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using registry-linked data, we compared National Kidney Registry (n=2363) recipients to control kidney transplant recipients (n=54,497) (February 2008 to December 2017). We estimated the risk of death-censored graft failure and mortality using inverse probability of treatment weighted Cox regression. The parsimonious model adjusted for recipient factors (age, sex, black, race, body mass index ≥30 kg/m2, diabetes, previous transplant, preemptive transplant, public insurance, hepatitis C, eGFR, antibody depleting induction therapy, year of transplant), donor factors (age, sex, Hispanic ethnicity, body mass index ≥30 kg/m2), and transplant factors (zero HLA mismatch). RESULTS National Kidney Registry recipients were more likely to be women, black, older, on public insurance, have panel reactive antibodies >80%, spend longer on dialysis, and be previous transplant recipients. National Kidney Registry recipients were followed for a median 3.7 years (interquartile range, 2.1-5.6; maximum 10.9 years). National Kidney Registry recipients had similar graft failure (5% versus 6%; log-rank P=0.2) and mortality (9% versus 10%; log-rank P=0.4) incidence compared with controls during follow-up. After adjustment for donor, recipient, and transplant factors, there no detectable difference in graft failure (adjusted hazard ratio, 0.95; 95% confidence interval, 0.77 to 1.18; P=0.6) or mortality (adjusted hazard ratio, 0.86; 95% confidence interval, 0.70 to 1.07; P=0.2) between National Kidney Registry and control recipients. CONCLUSIONS Even after transplanting patients with greater risk factors for worse post-transplant outcomes, nationalized paired donation results in equivalent outcomes when compared with control living donor kidney transplant recipients.
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Affiliation(s)
- David B Leeser
- Department of Surgery, East Carolina University, Greenville, North Carolina;
| | - Alvin G Thomas
- Department of Surgery and.,Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Ashton A Shaffer
- Department of Surgery and.,Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | | | | | | | - Sandip Kapur
- Department of Surgery, Cornell University, New York, New York
| | - Nicole Turgeon
- Department of Surgery, Dell School of Medicine, University of Texas at Austin, Austin, Texas
| | - Dorry L Segev
- Department of Surgery and.,Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - Amy D Waterman
- Department of Nephrology, University of California, Los Angeles, Los Angeles, California.,Terasaki Research Institute, Los Angeles, California; and
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Rebellato LM, Veryser D, Ashby J, Ross BJ, Passwater M, Stanton J, Dy-Liacco M, Leeser DB. P184 Virtual crossmatches may improve efficiency in the HLA laboratory. Hum Immunol 2019. [DOI: 10.1016/j.humimm.2019.07.237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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7
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Flechner SM, Thomas AG, Ronin M, Veale JL, Leeser DB, Kapur S, Peipert JD, Segev D, Henderson ML, Shaffer AA, Cooper M, Hil G, Waterman AD. The first 9 years of kidney paired donation through the National Kidney Registry: Characteristics of donors and recipients compared with National Live Donor Transplant Registries. Am J Transplant 2018; 18:2730-2738. [PMID: 29603640 PMCID: PMC6165704 DOI: 10.1111/ajt.14744] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [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: 02/16/2018] [Revised: 03/18/2018] [Accepted: 03/20/2018] [Indexed: 01/25/2023]
Abstract
The practice of kidney paired donation (KPD) is expanding annually, offering the opportunity for live donor kidney transplant to more patients. We sought to identify if voluntary KPD networks such as the National Kidney Registry (NKR) were selecting or attracting a narrower group of donors or recipients compared with national registries. For this purpose, we merged data from the NKR database with the Scientific Registry of Transplant Recipients (SRTR) database, from February 14, 2008, to February 14, 2017, encompassing the first 9 years of the NKR. Compared with all United Network for Organ Sharing (UNOS) live donor transplant patients (49 610), all UNOS living unrelated transplant patients (23 319), and all other KPD transplant patients (4236), the demographic and clinical characteristics of NKR transplant patients (2037) appear similar to contemporary national trends. In particular, among the NKR patients, there were a significantly (P < .001) greater number of retransplants (25.6% vs 11.5%), hyperimmunized recipients (22.7% vs 4.3% were cPRA >80%), female recipients (45.9% vs 37.6%), black recipients (18.2% vs 13%), and those on public insurance (49.7% vs 41.8%) compared with controls. These results support the need for greater sharing and larger pool sizes, perhaps enhanced by the entry of compatible pairs and even chains initiated by deceased donors, to unlock more opportunities for those harder-to-match pairs.
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Affiliation(s)
| | | | | | | | | | | | - John D Peipert
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University
| | | | | | | | | | - Garet Hil
- National Kidney Registry, Babylon, NY
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Rosenberry PM, Niederhaus SV, Schweitzer EJ, Leeser DB. Decreasing dialysis catheter rates by creating a multidisciplinary dialysis access program. J Vasc Access 2018; 19:569-572. [PMID: 29575978 DOI: 10.1177/1129729818762977] [Citation(s) in RCA: 2] [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] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION: Centers for Medicare and Medicaid Services have determined that chronic dialysis units should have <12% of their patients utilizing central venous catheters for hemodialysis treatments. On the Eastern Shore of Maryland, the central venous catheter rates in the dialysis units averaged >45%. A multidisciplinary program was established with goals of decreasing catheter rates in order to decrease central line-associated bloodstream infections, decrease mortality associated with central line-associated bloodstream infection, decrease hospital days, and provide savings to the healthcare system. METHODS: We collected the catheter rates within three dialysis centers served over a 5-year period. Using published data surrounding the incidence and related costs of central line-associated bloodstream infection and mortality per catheter day, the number of central line-associated bloodstream infection events, the costs, and the related mortality could be determined prior to and after the initiation of the dialysis access program. RESULTS: An organized dialysis access program resulted in a 82% decrease in the number of central venous catheter days which lead to a concurrent reduction in central line-associated bloodstream infection and deaths. As a result of creating an access program, central venous catheter rates decreased from an average rate of 45% to 8%. The cost savings related to the program was calculated to be over US$5 million. The decrease in the number of mortalities is estimated to be between 13 and 27 patients. CONCLUSION: We conclude that a formalized access program decreases catheter rates, central line-associated bloodstream infection, and the resultant hospitalizations, mortality, and costs. Areas with high hemodialysis catheter rates should develop access programs to better serve their patient population.
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Affiliation(s)
| | | | | | - David B Leeser
- 3 Brody School of Medicine, East Carolina University, Greenville, NC, USA
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9
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LaMattina JC, Powell JM, Costa NA, Leeser DB, Niederhaus SV, Bromberg JS, Alvarez-Casas J, Phelan MS, Barth RN. Surgical complications of laparoendoscopic single-site donor nephrectomy: a retrospective study. Transpl Int 2017; 30:1132-1139. [PMID: 28672056 DOI: 10.1111/tri.13005] [Citation(s) in RCA: 7] [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: 05/24/2017] [Revised: 06/13/2017] [Accepted: 06/26/2017] [Indexed: 01/29/2023]
Abstract
The single-port approach has been associated with an unacceptably high rate of umbilical port hernias in large series of patients undergoing single-port cholecystectomy and colectomy and with additional surgical risks thought secondary to technical and ergonomic limitations. A retrospective review of 378 consecutive laparoendoscopic single-site(LESS) donor nephrectomies performed between 04/15/2009 and 04/09/2014 was conducted. Twelve patients (3%) developed an umbilical hernia. Eleven (92%) were female and eight (73%) of these patients had a prior pregnancy. Hernias were reported 13.5 ± 6.9 months after donation, and the mean size was 5.1 ± 3.7 cm. Seven additional cases (1.9%) required a return to the operating room for internal hernia (2), evisceration (1), bleeding (1), enterotomy (1), and wound infection (2). The original incision was utilized for reexploration. One patient required emergent conversion to an open procedure for bleeding during the initial donation. There were no mortalities. Recipient patient and graft survival were 99% and 99% at 1 year, respectively. Although reports associated with earlier experiences with single-site procedures suggested an unacceptably high rate of hernias at the surgical site, this does not seem to be the case at our center. This technique is a reliable surgical technique for left donor nephrectomy at this institution.
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Affiliation(s)
- John C LaMattina
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jessica M Powell
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nadiesda A Costa
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - David B Leeser
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Silke V Niederhaus
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jonathan S Bromberg
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Josue Alvarez-Casas
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael S Phelan
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rolf N Barth
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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Yi SY, Shaw K, Costa N, Leeser DB. Pancreas Transplant at the University of Maryland. Clin Transpl 2015; 31:113-119. [PMID: 28514573] [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] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The characteristic of our diabetic population has been ever changing. No longer are our Type 1 diabetics young and thin; they too suffer from the obesity epidemic and now present later with the complications of diabetes (renal dysfunction, hypoglycemic unawareness, vision loss, neuropathy, etc.). Even with all of our medical and technological advances to combat diabetes, there are many who are not very well controlled. We evaluated the pancreas transplant recipients in the last three years at the University of Maryland to study the outcomes of these older and higher body mass index (BMI) recipients, as well as the impact of using older and higher BMI donors. We saw no difference in the survival of the patient or the allograft of recipients who were older or had higher BMIs. We also saw no difference in morbidity for these patients. There also was no difference when using older or higher BMI donor organs, longer cold ischemic times, different types of donors (donation after cardiac death versus brain dead donors), or different types of organs (simultaneous pancreas kidney, pancreas transplant alone, or pancreas after kidney). In reviewing our waitlist, our patients range widely in age and BMI. As long as they are fit for surgery, we will continue to transplant our ever growing population of older and obese diabetics without any more adverse outcomes than occur in our normal weight and younger patients.
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Affiliation(s)
- Soo Y Yi
- University of Maryland, Baltimore, MD
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11
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Afaneh C, Cheng E, Aull MJ, Watkins AC, Kim J, Leeser DB, Kapur S. Renal allograft outcomes following early corticosteroid withdrawal in Hispanic transplant recipients. Clin Transplant 2013; 27:E611-8. [PMID: 24033380 DOI: 10.1111/ctr.12218] [Citation(s) in RCA: 2] [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] [Accepted: 08/01/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Renal transplant outcomes in Hispanics have been conflicting regarding acute rejection (AR) and allograft survival. Additionally, the feasibility of early corticosteroid withdrawal (ECW) regimens among Hispanics has not been adequately addressed. The purpose of this study is to report outcomes following ECW among Hispanic renal transplant recipients. METHODS We retrospectively reviewed 498 consecutive renal transplants performed at our institution between July 2005 and October 2007, including 73 Hispanic and 146 white recipients who had ECW (median follow-up 49 months). Demographics, transplant data, and outcomes of Hispanic and white recipients (WR) were analyzed. RESULTS Hispanics had a higher incidence of diabetes mellitus and hypertension (p = 0.007), a higher proportion of blood type O (p = 0.006), and a higher serum panel reactive antibody at the time of transplantation (p = 0.02) compared with WR. Additionally, Hispanics were on dialysis longer than WR prior to transplantation (p = 0.03). Nevertheless, the incidence of AR, patient, and graft survival rates was similar (p > 0.05) between Hispanics and WR. Ethnicity was not an independent predictor of inferior patient and graft outcomes in multivariate analyses. CONCLUSION Our single-center experience indicates that ECW can be performed in Hispanic renal transplant recipients, with patient and allograft outcomes comparable with those observed in WR.
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Affiliation(s)
- Cheguevara Afaneh
- Division of Transplantation, Department of Surgery, New York-Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA
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12
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Abstract
IMPORTANCE Despite the potential for altruistic nondirected donors (NDDs) to trigger multiple transplants through nonsimultaneous transplant chains, concerns exist that these chains siphon NDDs from the deceased donor wait list and that donors within chains might not donate after their partner receives a transplant. OBJECTIVE To determine the number of transplantations NDDs trigger through chains. DESIGN Retrospective review of large, multicenter living donor-recipient database. SETTING Fifty-seven US transplant centers contributing donor-recipient pairs to the database. PARTICIPANTS The NDDs initiating chain transplantation. MAIN OUTCOMES MEASURE Number of transplants per NDD. RESULTS Seventy-seven NDDs enabled 373 transplantations during 46 months starting February 2008. Mean chain length initiated by NDDs was 4.8 transplants (median, 3; range, 1-30). The 40 blood type O NDDs triggered a mean chain length of 6.0 (median, 4; range, 2-30). During the interval, 66 of 77 chains were closed to the wait list, 4 of 77 were ongoing, and 7 of 77 were broken because bridge donors became unavailable. No chains were broken in the last 15 months, and every recipient whose incompatible donor donated received a kidney. One hundred thirty-three blood type O recipients were transplanted. CONCLUSION AND RELEVANCE This large series demonstrates that NDDs trigger almost 5 transplants on average, more if the NDD is blood type O. There were more blood type O recipients than blood type O NDDs participating. The benefits of transplanting 373 patients and enabling others without living donors to advance outweigh the risk of broken chains that is decreasing with experience. Even 66 patients on the wait list without living donors underwent transplantation with living-donor grafts at the end of these chains.
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Affiliation(s)
- Marc L Melcher
- Department of Surgery, Stanford University, 750 Welch Rd, Ste 200, Palo Alto, CA 94025, USA.
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Melcher ML, Leeser DB, Gritsch HA, Milner J, Kapur S, Busque S, Roberts JP, Katznelson S, Bry W, Yang H, Lu A, Mulgaonkar S, Danovitch GM, Hil G, Veale JL. Chain transplantation: initial experience of a large multicenter program. Am J Transplant 2012; 12:2429-36. [PMID: 22812922 DOI: 10.1111/j.1600-6143.2012.04156.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We report the results of a large series of chain transplantations that were facilitated by a multicenter US database in which 57 centers pooled incompatible donor/recipient pairs. Chains, initiated by nondirected donors, were identified using a computer algorithm incorporating virtual cross-matches and potential to extend chains. The first 54 chains facilitated 272 kidney transplants (mean chain length = 5.0). Seven chains ended because potential donors became unavailable to donate after their recipient received a kidney; however, every recipient whose intended donor donated was transplanted. The remaining 47 chains were eventually closed by having the last donor donate to the waiting list. Of the 272 chain recipients 46% were ethnic minorities and 63% of grafts were shipped from other centers. The number of blood type O-patients receiving a transplant (n = 90) was greater than the number of blood type O-non-directed donors (n = 32) initiating chains. We have 1-year follow up on the first 100 transplants. The mean 1-year creatinine of the first 100 transplants from this series was 1.3 mg/dL. Chain transplantation enables many recipients with immunologically incompatible donors to be transplanted with high quality grafts.
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Affiliation(s)
- M L Melcher
- Department of Surgery, Stanford University, CA, USA.
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Leeser DB, Aull MJ, Afaneh C, Dadhania D, Charlton M, Walker JK, Hartono C, Serur D, Del Pizzo JJ, Kapur S. Living donor kidney paired donation transplantation: experience as a founding member center of the National Kidney Registry. Clin Transplant 2012; 26:E213-22. [DOI: 10.1111/j.1399-0012.2012.01606.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- David B. Leeser
- Division of Transplant Surgery; Department of Surgery; Weill Cornell Medical College; New York; NY; USA
| | - Meredith J. Aull
- Division of Transplant Surgery; Department of Surgery; Weill Cornell Medical College; New York; NY; USA
| | - Cheguevara Afaneh
- Division of Transplant Surgery; Department of Surgery; Weill Cornell Medical College; New York; NY; USA
| | - Darshana Dadhania
- Division of Nephrology; Department of Medicine; Weill Cornell Medical College; New York; NY; USA
| | - Marian Charlton
- Division of Transplant Surgery; Department of Surgery; Weill Cornell Medical College; New York; NY; USA
| | - Jennifer K. Walker
- Division of Transplant Surgery; Department of Surgery; Weill Cornell Medical College; New York; NY; USA
| | - Choli Hartono
- Division of Nephrology; Department of Medicine; Weill Cornell Medical College; New York; NY; USA
| | - David Serur
- Division of Nephrology; Department of Medicine; Weill Cornell Medical College; New York; NY; USA
| | | | - Sandip Kapur
- Division of Transplant Surgery; Department of Surgery; Weill Cornell Medical College; New York; NY; USA
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Afaneh C, Sheth S, Aull MJ, Leeser DB, Kapur S, Del Pizzo JJ. Laparoendoscopic Single-Site Nephrectomy in Obese Living Renal Donors. J Endourol 2012; 26:140-6. [DOI: 10.1089/end.2011.0251] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Cheguevara Afaneh
- Division of Transplantation Surgery, Department of Surgery, New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York
| | - Seema Sheth
- James Buchanan Brady Department of Urology, New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York
| | - Meredith J. Aull
- Division of Transplantation Surgery, Department of Surgery, New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York
| | - David B. Leeser
- Division of Transplantation Surgery, Department of Surgery, New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York
| | - Sandip Kapur
- Division of Transplantation Surgery, Department of Surgery, New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York
| | - Joseph J. Del Pizzo
- Division of Transplantation Surgery, Department of Surgery, New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York
- James Buchanan Brady Department of Urology, New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York
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Afaneh C, Aull MJ, Gimenez E, Wang G, Charlton M, Leeser DB, Kapur S, Del Pizzo JJ. Comparison of laparoendoscopic single-site donor nephrectomy and conventional laparoscopic donor nephrectomy: donor and recipient outcomes. Int Braz J Urol 2011. [DOI: 10.1590/s1677-55382011000600019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- C Afaneh
- New York Presbyterian Weill Cornell Medical College
| | - MJ Aull
- New York Presbyterian Weill Cornell Medical College
| | - E Gimenez
- New York Presbyterian Weill Cornell Medical College
| | - G Wang
- New York Presbyterian Weill Cornell Medical College
| | - M Charlton
- New York Presbyterian Weill Cornell Medical College
| | - DB Leeser
- New York Presbyterian Weill Cornell Medical College
| | - S Kapur
- New York Presbyterian Weill Cornell Medical College
| | - JJ Del Pizzo
- New York Presbyterian Weill Cornell Medical College
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Afaneh C, Aull MJ, Gimenez E, Wang G, Charlton M, Leeser DB, Kapur S, Del Pizzo JJ. Comparison of Laparoendoscopic Single-site Donor Nephrectomy and Conventional Laparoscopic Donor Nephrectomy: Donor and Recipient Outcomes. Urology 2011; 78:1332-7. [DOI: 10.1016/j.urology.2011.04.077] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 04/16/2011] [Accepted: 04/16/2011] [Indexed: 01/14/2023]
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Wang GJ, Afaneh C, Aull M, Charlton M, Ramasamy R, Leeser DB, Kapur S, Del Pizzo JJ. Laparoendoscopic single site live donor nephrectomy: single institution report of initial 100 cases. J Urol 2011; 186:2333-7. [PMID: 22014813 DOI: 10.1016/j.juro.2011.07.071] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Indexed: 12/12/2022]
Abstract
PURPOSE Laparoendoscopic single site surgery is a recent advance in minimally invasive urology. We report outcomes from our initial 100 consecutive laparoendoscopic single site live donor nephrectomies done by a single surgeon and provide a matched comparison of conventional laparoscopic live donor nephrectomies done by the same surgeon. MATERIALS AND METHODS From 2009 to 2010 at a tertiary referral center 100 consecutive laparoendoscopic single site live donor nephrectomies were performed by a single surgeon through a periumbilical incision using the GelPoint® system. No extraumbilical incisions or punctures were made. A retrospective review was performed using a prospectively managed database of standard perioperative and convalescent parameters. Comparison was made using a matched cohort of conventional live donor nephrectomies done by the same surgeon. RESULTS Mean operative time was longer in the laparoendoscopic single site group (156 vs 130 minutes) but there was no difference in estimated blood loss or warm ischemia time. There was no difference in the complication rate between the 2 groups. Mean hospital stay and visual analog pain scores were similar in the groups but the laparoendoscopic group showed improved convalescence with faster return to work, normal activity and 100% recovery. Recipient graft function was equivalent in the 2 groups. CONCLUSIONS In this retrospective, matched comparison laparoendoscopic single site live donor nephrectomy was associated with longer operative time but equivalent recipient graft function and improved convalescence. The benefits of laparoendoscopic single site surgery over conventional laparoscopy may be limited. However, with respect to live donor nephrectomy the benefits of laparoendoscopic single site surgery may nevertheless prove beneficial to decrease barriers to live organ donation.
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Affiliation(s)
- Gerald J Wang
- James Buchanan Brady Department of Urology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
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Afaneh C, Ramasamy R, Leeser DB, Kapur S, Del Pizzo JJ. Is Right-sided Laparoendoscopic Single-site Donor Nephrectomy Feasible? Urology 2011; 77:1365-9. [DOI: 10.1016/j.urology.2010.09.064] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Revised: 08/26/2010] [Accepted: 09/03/2010] [Indexed: 11/16/2022]
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Abstract
BACKGROUND In kidney, liver, heart, and lung transplantation, extremes of body mass index (BMI) have been reported to influence post-operative outcomes and even survival. Given the limited data in pancreas transplantation, we sought to elucidate the influence of BMI on outcomes. METHODS We reviewed 139 consecutive pancreas transplants performed at our institution and divided them into four categories based on BMI: underweight (≤18.5 kg/m(2)), normal (18.6-24.9 kg/m(2)), overweight (25-29.9 kg/m(2)), and obese (≥30 kg/m(2)). Parameters analyzed included post-operative complications, early graft loss, one-yr acute rejection rate (AR), non-surgical infections, and survival. RESULTS Demographic data were similar between the groups. Compared with normal, only obese patients trended toward more post-operative complications (p = 0.06). Underweight and obese patients had significantly more post-operative infectious complications than normal (p = 0.0005 and p = 0.03, respectively). Obese patients had more complications requiring percutaneous drainage compared with normal (p = 0.03). Overweight and obese patients had significantly more complications requiring re-laparotomy (p = 0.03 and p = 0.048, respectively). Early graft loss, AR, non-surgical infections, and patient and graft survival rates were not different between normal and underweight, overweight, or obese patients (p > 0.05). CONCLUSIONS Extremes of BMI were associated with increased morbidity. Donors and recipients should be carefully selected to maximize potential for successful outcomes.
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Affiliation(s)
- Cheguevara Afaneh
- Division of Transplantation, Department of Surgery, Weill Cornell Medical College, New York, NY, USA.
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Abstract
In 2007, Rane presented the first single port nephrectomy for a small non-functioning kidney at the World Congress of Endourology. Since that time, the use of single port surgery for nephrectomy has expanded to include donor nephrectomy. Over the next two years the technique was adopted for many others types of nephrectomies to include donor nephrectomy. We present our technique for single port donor nephrectomy using the Gelpoint device. We have successfully performed this surgery in over 100 patients and add this experience to our experience of over 1000 laparoscopic nephrectomies. With the proper equipment and technique, single port donor nephrectomy can be performed safely and effectively in the majority of live donors. We have found that our operative times and most importantly our transplant outcomes have not changed significantly with the adoption of the single port donor nephrectomy. We believe that single port donor nephrectomy represents a step forward in the care of living donors.
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Affiliation(s)
- David B Leeser
- Surgery, Weill Cornell Medical College of Cornell University, USA.
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23
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Segev DL, Veale JL, Berger JC, Hiller JM, Hanto RL, Leeser DB, Geffner SR, Shenoy S, Bry WI, Katznelson S, Melcher ML, Rees MA, Samara ENS, Israni AK, Cooper M, Montgomery RJ, Malinzak L, Whiting J, Baran D, Tchervenkov JI, Roberts JP, Rogers J, Axelrod DA, Simpkins CE, Montgomery RA. Transporting live donor kidneys for kidney paired donation: initial national results. Am J Transplant 2011; 11:356-60. [PMID: 21272238 DOI: 10.1111/j.1600-6143.2010.03386.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Optimizing the possibilities for kidney-paired donation (KPD) requires the participation of donor-recipient pairs from wide geographic regions. Initially it was envisaged that donors would travel to the recipient center; however, to minimize barriers to participation and simplify logistics, recent trends have involved transporting the kidneys rather than the donors. The goal of this study was to review outcomes of this practice. KPD programs throughout the United States were directly queried about all transplants involving live donor kidney transport. Early graft function was assessed by urine output in the first 8 h, postoperative serum creatinine trend, and incidence of delayed graft function. Between April 27, 2007 and April 29, 2010, 56 live donor kidneys were transported among 30 transplant centers. Median CIT was 7.2 h (IQR 5.5-9.7, range 2.5-14.5). Early urine output was robust (>100 cc/h) in all but four patients. Creatinine nadir was <2.0 mg/dL in all (including the four with lower urine output) but one patient, occurring at a median of 3 days (IQR 2-5, range 1-49). No patients experienced delayed graft function as defined by the need for dialysis in the first week. Current evidence suggests that live donor kidney transport is safe and feasible.
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Affiliation(s)
- D L Segev
- Department of Surgery Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA.
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24
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Afaneh C, Halpern J, Cheng E, Aull M, Figueiro J, Kapur S, Leeser DB. Steroid avoidance in two-haplotype-matched living donor renal transplants with basiliximab induction therapy. Transplant Proc 2010; 42:4526-9. [PMID: 21168729 DOI: 10.1016/j.transproceed.2010.09.156] [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] [Received: 05/28/2010] [Accepted: 09/22/2010] [Indexed: 11/17/2022]
Abstract
BACKGROUND Induction therapy and haplotype matching are utilized to mitigate immunologic risk in renal transplantation. The incidence of acute rejection (AR) of renal allografts has been reported to be as low as 9.3% within the first year among two-haplotype-matched siblings with no induction and triple-drug maintenance immunosuppression. We report our use of basiliximab induction in a series of two-haplotype-matched living donor renal transplants (LDRT). METHODS We retrospectively reviewed 25 patients who received a two-haplotype-matched LDRT with basiliximab induction therapy. The primary endpoints were acute rejection (AR) episodes at 6 and 12 months and 1-year patient and graft survival rates. The secondary endpoints were the incidence of delayed graft function (DGF), cytomegalovirus (CMV), and BK virus (BKV). RESULTS The rate of AR at 6 months was 0% (0/25) and 4% (1/25) at 12 months. The 1-year graft and patient survival rates were 100%. The incidence of DGF was 4% (1/25), while the incidences of CMV and BKV were 0%. CONCLUSION Basiliximab induction therapy with a steroid-sparing regimen yields favorable results in two-haplotype-matched LDRT, including a notable reduction in the rates of AR as compared to triple-drug maintenance immunosuppression without induction. These patients have excellent graft survival with no increased incidences of secondary infections.
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Affiliation(s)
- C Afaneh
- Department of Surgery, Weill Cornell Medical Center, New York, NY 10068, USA.
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25
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Elster EA, Hawksworth JS, Cheng O, Leeser DB, Ring M, Tadaki DK, Kleiner DE, Eberhardt JS, Brown TS, Mannon RB. Probabilistic (Bayesian) modeling of gene expression in transplant glomerulopathy. J Mol Diagn 2010; 12:653-63. [PMID: 20688906 DOI: 10.2353/jmoldx.2010.090101] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Transplant glomerulopathy (TG) is associated with rapid decline in glomerular filtration rate and poor outcome. We used low-density arrays with a novel probabilistic analysis to characterize relationships between gene transcripts and the development of TG in allograft recipients. Retrospective review identified TG in 10.8% of 963 core biopsies from 166 patients; patients with stable function were studied for comparison. The biopsies were analyzed for expression of 87 genes related to immune function and fibrosis by using real-time PCR, and a Bayesian model was generated and validated to predict histopathology based on gene expression. A total of 57 individual genes were increased in TG compared with stable function biopsies (P < 0.05). The Bayesian analysis identified critical relationships between ICAM-1, IL-10, CCL3, CD86, VCAM-1, MMP-9, MMP-7, and LAMC2 and allograft pathology. Moreover, Bayesian models predicted TG when derived from either immune function (area under the curve [95% confidence interval] of 0.875 [0.675 to 0.999], P = 0.004) or fibrosis (area under the curve [95% confidence interval] of 0.859 [0.754 to 0.963], P < 0.001) gene networks. Critical pathways in the Bayesian models were also analyzed by using the Fisher exact test and had P values <0.005. This study demonstrates that evaluating quantitative gene expression profiles with Bayesian modeling can identify significant transcriptional associations that have the potential to support the diagnostic capability of allograft histology. This integrated approach has broad implications in the field of transplant diagnostics.
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Affiliation(s)
- Eric A Elster
- Regenerative Medicine Department, Combat Casualty Care, Naval Medical Research Center, Silver Spring, Maryland 20910, USA.
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26
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Cheng EY, Leeser DB, Kapur S, Del Pizzo J. Outcomes of Laparoscopic Donor Nephrectomy Without Intraoperative Systemic Heparinization. J Urol 2010; 183:2282-6. [DOI: 10.1016/j.juro.2010.02.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Indexed: 11/25/2022]
Affiliation(s)
- Elaine Y. Cheng
- Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - David B. Leeser
- Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Sandip Kapur
- Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Joseph Del Pizzo
- Department of Urology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
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27
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Gorbach AM, Leeser DB, Wang H, Tadaki DK, Fernandez C, Destephano D, Hale D, Kirk AD, Gage FA, Elster EA. Assessment of cadaveric organ viability during pulsatile perfusion using infrared imaging. Transplantation 2009; 87:1163-6. [PMID: 19384162 DOI: 10.1097/tp.0b013e31819e3e02] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Assessment of pulsatile perfusion (PP) is limited to measurements of flow (V) and resistance (R). We investigated infrared (IR) imaging during PP as a means for precise organ assessment. IR was used to monitor 10 porcine kidneys during 18 hr of PP in an uncontrolled Donation after Cardiac Death model. An IR camera (Lockheed Martin) was focused on the anterior surfaces of the kidneys. The degree of temperature homogeneity was compared with standard measurements of V and R. IR thermal images correlated with V and R (R=0.92, P<0.001). IR detected an increase in homogeneity during PP by comparing standard deviation differences before and after PP (P=0.002), which was not evident by standard measurements of V and R. Finally, IR assessment allowed for measurement of dynamic changes in perfusion.
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Affiliation(s)
- Alexander M Gorbach
- Bioengineering and Physical Science, National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health, Bethesda, MD, USA
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28
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Oliver JD, Neff RT, Leeser DB, Swanson SJ, Yuan CM, Falta EM, Elster E, Reinmuth B, Bohen EM, Jindal RM, Abbott KC. Influence of race on kidney transplantation in the Department of Defense healthcare system. Am J Nephrol 2009; 29:327-33. [PMID: 18849603 DOI: 10.1159/000163558] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2008] [Accepted: 08/09/2008] [Indexed: 11/19/2022]
Abstract
BACKGROUND We report the influence of race on transplant outcomes in the Department of Defense (DOD) system. METHODS Retrospective cohort analysis of all kidney transplants performed at WRAMC from 1996 to 2005. Kaplan-Meier analysis was used to assess for differences in graft survival, and Cox regression was used to calculate adjusted hazard ratios for graft loss. For our analyses, we used the cutoff of 6 years (year 2000) when we introduced thymoglobulin induction; maintenance immunosuppression consisted of mycophenolate mofetil and tacrolimus, and rapid steroid taper (completed withdrawal at 6 weeks) was used for all patients. RESULTS There were 220 transplants (91 Blacks, 107 Caucasians and 22 Asians). Because the curve for graft survival for Blacks over time violated the proportional hazards assumption (at 6 years post-transplant), analysis was segregated into two segments. Through 6 years of follow-up, graft survival was 77% for Blacks and 81% for non-Blacks (p = 0.74 by log rank). Through 9 potential years of follow-up, graft survival for Blacks was 56% and 78% for Whites (p = 0.005). In Cox regression analysis, Black race, compared with non-Black race, was not significantly associated with graft loss at 6 years, but was significantly associated with graft loss occurring after 6 years. CONCLUSIONS In the DOD health system, no significant differences were seen in graft survival among recipients of different races at 6 years. Black recipients who received a kidney transplant before the year 2000 showed decreased graft survival compared to non-Blacks. This was consistent with change in immunosuppressive regimen in our institution with the introduction of thymoglobulin induction and maintenance therapy with tacrolimus, mycophenolate mofetil and withdrawal of prednisone at 6 weeks.
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Affiliation(s)
- James D Oliver
- Organ Transplantation, Walter Reed Army Medical Center, Washington, D.C. 20307, USA
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29
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Elster EA, Leeser DB, Morrissette C, Pepek JM, Quiko A, Hale DA, Chamberlain C, Salaita C, Kirk AD, Mannon RB. Obesity following kidney transplantation and steroid avoidance immunosuppression. Clin Transplant 2008; 22:354-9. [DOI: 10.1111/j.1399-0012.2008.00792.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Mechanisms for the generation of memory CD4 T cells and their delineation into diverse subsets remain largely unknown. In this study, we demonstrate in two Ag systems, divergent generation of heterogeneous memory CD4 T cells from activated precursors in distinct differentiation stages. Specifically, we show that influenza hemagglutinin- and OVA-specific CD4 T cells activated for 1, 2, and 3 days, respectively, exhibit gradations of differentiation by cell surface phenotype, IFN-gamma production, and proliferation, yet all serve as direct precursors for functional memory CD4 T cells when transferred in vivo into Ag-free mouse hosts. Using a conversion assay to track the immediate fate of activated precursors in vivo, we show that day 1- to 3-activated cells all rapidly convert from an activated phenotype (CD25(high)IL-7R(low)CD44(high)) to a resting memory phenotype (IL-7R(high)CD25(low)CD44(high)) 1 day after antigenic withdrawal. Paradoxically, stable memory subset delineation from undifferentiated (day 1- to 2-activated) precursors was predominantly an effector memory (CD62L(low)) profile, with an increased proportion of central memory (CD62L(high)) T cells arising from more differentiated (day 3-activated) precursors. Our findings support a divergent model for generation of memory CD4 T cells directly from activated precursors in multiple differentiation states, with subset heterogeneity maximized by increased activation and differentiation during priming.
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Affiliation(s)
- Vaishali R Moulton
- Department of Surgery, Division of Transplantation, University of Maryland School of Medicine, 685 West Baltimore Street, Baltimore, MD 21201, USA
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Abstract
Alloreactive memory T cells can significantly impact graft survival due to their enhanced functional capacities, diverse tissue distribution and resistance to tolerance induction and depletional strategies. However, their role in allograft rejection is not well understood primarily due to the lack of suitable in vivo models. In this study, we use a novel approach to generate long-lived polyclonal alloreactive memory CD4 T cells from adoptive transfer of alloantigen-activated precursors into mouse hosts. We demonstrate that CD25 upregulation is a marker for precursors to alloantigen-specific memory and have created a new mouse model that features an expanded population of polyclonal alloreactive memory T cells that is distinguishable from the naive T-cell population. Furthermore, we show that alloreactive memory T cells exhibit rapid recall effector responses with predominant IFN-gamma and IL-2 production, and mediate vigorous allograft rejection. Interestingly, while we found a heterogeneous distribution of allomemory T cells in lymphoid and nonlymphoid tissues, they were all predominantly of the effector-memory (CD62Llo) phenotype. Our results present a unique model for the generation and tracking of polyclonal allospecific memory CD4 T cells in vivo and reveal insights into the distinct and robust nature of alloreactive T-cell memory.
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Affiliation(s)
- A L Tang
- Division of Transplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Abstract
Pancreas transplant has become a reliably predictable treatment and cure for patients with type 1 diabetes mellitus and hypoglycemic unawareness or renal failure. During the past 2 years, the use of enteric drainage has been shown to decrease morbidity over traditional bladder drainage, and the use of the portal system for venous drainage continues to be explored. Technically, the use of circular staplers, over a hand-sown anastomosis for duodenal drainage, has gained popularity, and alternative arterial reconstruction methods have been developed. Living donor pancreas and kidney transplants are also becoming more common throughout the world. In the area of immunosuppression, steroid-free protocols, now commonplace in kidney transplants, are being applied successfully to pancreas transplantation. Finally, the benefit of solitary pancreas and pancreas after kidney transplantation has been questioned, and a more complete analysis of pancreas alone and pancreas after kidney transplants is anticipated in the near future.
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Affiliation(s)
- David B Leeser
- University of Maryland Medical School, Department of Surgery, Division of Transplantation, 29 South Greene Street, Suite 200, Baltimore, MD 21201, USA.
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Abstract
Machine pulsatile perfusion for whole pancreas preservation might improve yield, viability, and function of human islets recovered after prolonged cold ischemia times. Four human pancreata were procured from cadaver donors (1 non-heart-beating donor) and stored in cold University of Wisconsin (UW) solution for a mean 13 hours prior to placement on a machine pulsatile perfusion device. The four pancreata were perfused for 4 hours with UW solution before undergoing islet isolation. Islets were quantified, viability was assessed, and insulin secretion was measured. Results were compared with nonpumped islet isolations stratified for cold ischemia time (CIT) <8 hours or cold ischemia time >8 hours. The islet yield for the four pumped pancreata was 3435 (+/-1951) islet equivalents/gram pancreas tissue (IEQ/g), compared with a mean yield of 5134 (+/-2700) IEQ/g and 2640 (+/-1000) IEQ/g from pancreas with <8 hours and >8 hours CIT, respectively. The mean viability after machine pulsatile perfusion was 86% (vs 74% and 74% for the <8 hour and >8 hour CIT groups). The mean viable yield (total yield x viability) was 2937 IEQ/g for machine perfusion, compared with 3799 IEQ/g and 1937 IEQ/g from pancreata with <8 hours and >8 hours CIT, respectively. The insulin secretion index of islets after machine perfusion was 6.4, compared with indices of 1.9 and 1.8 for the <8 hour and >8 hour CIT groups. This preliminary data indicates that low-flow machine pulsatile perfusion of pancreata with prolonged cold ischemia time can result in excellent yield, viability, and function.
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Affiliation(s)
- D B Leeser
- Department of Transplant Surgery, University of Maryland Medical Center, Baltimore, Maryland 21012, USA.
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Brown GC, Brown MM, Sharma S, Brown H, Smithen L, Leeser DB, Beauchamp G. Value-based medicine and ophthalmology: an appraisal of cost-utility analyses. Trans Am Ophthalmol Soc 2004; 102:177-85; discussion 185-8. [PMID: 15747756 PMCID: PMC1280098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
PURPOSE To ascertain the extent to which ophthalmologic interventions have been evaluated in value-based medicine format. METHODS Retrospective literature review. Papers in the healthcare literature utilizing cost-utility analysis were reviewed by researchers at the Center for Value-Based Medicine, Flourtown, Pennsylvania. A literature review of papers addressing the cost-utility analysis of ophthalmologic procedures in the United States over a 12-year period from 1992 to 2003 was undertaken using the National Library of Medicine and EMBASE databases. The cost-utility of ophthalmologic interventions in inflation-adjusted (real) year 2003 US dollars expended per quality-adjusted life-year (dollars/QALY) was ascertained in all instances. RESULTS A total of 19 papers were found, including a total of 25 interventions. The median cost-utility of ophthalmologic interventions was 5,219 dollars/QALY, with a range from 746 dollars/QALY to 6.5 million dollars/QALY. CONCLUSIONS The majority of ophthalmologic interventions are especially cost-effective by conventional standards. This is because of the substantial value that ophthalmologic interventions confer to patients with eye diseases for the resources expended.
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Affiliation(s)
- Gary C Brown
- Center for Value-Based Medicine, Flourtown, Pennsylvania, USA
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Leeser DB, Jeevanandam V, Furukawa S, Eisen H, Mather P, Silva P, Guy S, Foster CE. Simultaneous heart and kidney transplantation in patients with end-stage heart and renal failure. Am J Transplant 2001; 1:89-92. [PMID: 12095045 DOI: 10.1034/j.1600-6143.2001.010116.x] [Citation(s) in RCA: 23] [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: 01/25/2023]
Abstract
Combined simultaneous organ transplantation has become more common as selection criteria for transplantation have broadened. Broadening selection criteria is secondary to improved immunosuppression and surgical techniques. The kidney is the most common extrathoracic organ to be simultaneously transplanted with the heart. A series of 13 patients suffering from both end-stage heart and renal failure underwent 14 simultaneous heart and kidney transplantations at Temple University Hospital between 1990 and 1999. This is the largest series reported from a single center. Three patients died during the initial hospitalization for an in-hospital mortality of 21%. Of 10 patients who left the hospital, 1-year survival was 100% and 2-year survival 75%. One patient required retransplant for rejection within the first year. Overall mortality at 1 and 2 years was 25 and 41%, respectively. Four out of nine (44%) patients greater than 5 years post-transplant were alive. Of the 10 patients who left the hospital, 66% were alive at 5 years. One patient succumbed to primary nonfunction of the cardiac allograft, while the four other deaths were secondary to bacterial or fungal sepsis. The patient's racial backgrounds were equally divided between African-American and white. These results are similar to those reported in a United Network of Organ Sharing Database (UNOS) registry analysis of 84 simultaneous heart and kidney transplants that found 1- and 2-year survival to be 76 and 67%, respectively. Simultaneous heart and kidney transplantation continues to be a viable option for patients suffering from failure of these two organ systems, although the results do not match those of heart transplant alone.
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Affiliation(s)
- D B Leeser
- Department of Surgery, Temple University Hospital, Philadelphia, PA, USA
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