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Kotton CN, Kamar N, Wojciechowski D, Eder M, Hopfer H, Randhawa P, Sester M, Comoli P, Tedesco Silva H, Knoll G, Brennan DC, Trofe-Clark J, Pape L, Axelrod D, Kiberd B, Wong G, Hirsch HH. The Second International Consensus Guidelines on the Management of BK Polyomavirus in Kidney Transplantation. Transplantation 2024:00007890-990000000-00727. [PMID: 38605438 DOI: 10.1097/tp.0000000000004976] [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: 04/13/2024]
Abstract
BK polyomavirus (BKPyV) remains a significant challenge after kidney transplantation. International experts reviewed current evidence and updated recommendations according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Risk factors for BKPyV-DNAemia and biopsy-proven BKPyV-nephropathy include recipient older age, male sex, donor BKPyV-viruria, BKPyV-seropositive donor/-seronegative recipient, tacrolimus, acute rejection, and higher steroid exposure. To facilitate early intervention with limited allograft damage, all kidney transplant recipients should be screened monthly for plasma BKPyV-DNAemia loads until month 9, then every 3 mo until 2 y posttransplant (3 y for children). In resource-limited settings, urine cytology screening at similar time points can exclude BKPyV-nephropathy, and testing for plasma BKPyV-DNAemia when decoy cells are detectable. For patients with BKPyV-DNAemia loads persisting >1000 copies/mL, or exceeding 10 000 copies/mL (or equivalent), or with biopsy-proven BKPyV-nephropathy, immunosuppression should be reduced according to predefined steps targeting antiproliferative drugs, calcineurin inhibitors, or both. In adults without graft dysfunction, kidney allograft biopsy is not required unless the immunological risk is high. For children with persisting BKPyV-DNAemia, allograft biopsy may be considered even without graft dysfunction. Allograft biopsies should be interpreted in the context of all clinical and laboratory findings, including plasma BKPyV-DNAemia. Immunohistochemistry is preferred for diagnosing biopsy-proven BKPyV-nephropathy. Routine screening using the proposed strategies is cost-effective, improves clinical outcomes and quality of life. Kidney retransplantation subsequent to BKPyV-nephropathy is feasible in otherwise eligible recipients if BKPyV-DNAemia is undetectable; routine graft nephrectomy is not recommended. Current studies do not support the usage of leflunomide, cidofovir, quinolones, or IVIGs. Patients considered for experimental treatments (antivirals, vaccines, neutralizing antibodies, and adoptive T cells) should be enrolled in clinical trials.
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Affiliation(s)
- Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases Unit, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Toulouse Rangueil University Hospital, INSERM UMR 1291, Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University Paul Sabatier, Toulouse, France
| | - David Wojciechowski
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Michael Eder
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Helmut Hopfer
- Division of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Parmjeet Randhawa
- Division of Transplantation Pathology, The Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
| | - Martina Sester
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
| | - Patrizia Comoli
- Cell Factory and Pediatric Hematology/Oncology Unit, Department of Mother and Child Health, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Helio Tedesco Silva
- Division of Nephrology, Hospital do Rim, Fundação Oswaldo Ramos, Paulista School of Medicine, Federal University of São Paulo, Brazil
| | - Greg Knoll
- Department of Medicine (Nephrology), University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Jennifer Trofe-Clark
- Renal-Electrolyte Hypertension Division, Associated Faculty of the Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA
- Transplantation Division, Associated Faculty of the Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA
| | - Lars Pape
- Pediatrics II, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
| | - David Axelrod
- Kidney, Pancreas, and Living Donor Transplant Programs at University of Iowa, Iowa City, IA
| | - Bryce Kiberd
- Division of Nephrology, Dalhousie University, Halifax, NS, Canada
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| | - Hans H Hirsch
- Division of Transplantation and Clinical Virology, Department of Biomedicine, Faculty of Medicine, University of Basel, Basel, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
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2
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Chandraker A, Regmi A, Gohh R, Sharma A, Woodle ES, Ansari MJ, Nair V, Chen LX, Alhamad T, Norman S, Cibrik D, Singh M, Alper A, Jain D, Zaky Z, Knechtle S, Sharfuddin A, Gupta G, Lonze BE, Young JAH, Adey D, Faravardeh A, Dadhania DM, Rossi AP, Florescu D, Cardarelli F, Ma J, Gilmore S, Vasileiou S, T Jindra P, Wojciechowski D. Posoleucel in Kidney Transplant Recipients with BK Viremia: Multicenter, Randomized, Double-Blind, Placebo-Controlled Phase 2 Trial. J Am Soc Nephrol 2024:00001751-990000000-00268. [PMID: 38470444 DOI: 10.1681/asn.0000000000000329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/05/2024] [Indexed: 03/13/2024] Open
Abstract
Key Points
Posoleucel was generally safe, well tolerated, and associated with a greater reduction of BK viremia compared with placebo.BK viremia reduction occurred coincident with an increase in the circulating frequency of BK virus–specific T cells in posoleucel recipients.The presence and persistence of posoleucel was confirmed by T-cell receptor variable β sequencing.
Background
Kidney transplant recipients with BK virus infection are at risk of developing BK virus–associated nephropathy, allograft rejection, and subsequent graft loss. There are no approved treatments for BK virus infection. Posoleucel is an off-the-shelf, allogeneic, multivirus-specific T-cell investigational therapy targeting BK virus, as well as five other opportunistic viruses: adenovirus, cytomegalovirus, Epstein–Barr virus, human herpesvirus 6, and John Cunningham virus.
Methods
In this phase 2, double-blind study, kidney transplant recipients with BK viremia were randomized 1:1:1 to receive posoleucel weekly for 3 weeks and then every 14 days (bi-weekly dosing) or every 28 days (monthly dosing) or placebo for 12 weeks. Participants were followed for 12 weeks after completing treatment. The primary objective was safety; the secondary objective was plasma BK viral load reduction.
Results
Sixty-one participants were randomized and dosed. Baseline characteristics were similar across groups. No deaths, graft-versus-host disease, or cytokine release syndrome occurred. The proportion of patients who had adverse events (AEs) judged by the investigators to be treatment-related was slightly lower in recipients of posoleucel: 20% (4 of 20 patients) and 18% (4 of 22) in those infused on a bi-weekly and monthly schedule, respectively, and 26% (5 of 19) in placebo recipients. None of the grade 3–4 AEs or serious AEs in any group were deemed treatment-related. No deaths, graft-versus-host disease, or cytokine release syndrome occurred. Three participants had allograft rejection, but none were deemed treatment-related by investigators. In posoleucel recipients, BK viremia reduction was associated with an increase in the circulating frequency of BK virus–specific T cells, and the presence and persistence of posoleucel was confirmed by T-cell receptor sequencing.
Conclusions
Posoleucel was generally safe, well tolerated, and associated with a larger reduction of BK viremia compared with placebo. Limitations of this study include the relatively short duration of follow-up and lack of power to detect significant differences in clinical outcomes.
Clinical Trial registry name and registration number:
Study of Posoleucel (Formerly Known as ALVR105; Viralym-M) in Kidney Transplant Patients With BK Viremia, NCT04605484.
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Affiliation(s)
- Anil Chandraker
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Division of Renal Medicine, Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Anil Regmi
- Inova Transplant Center, Falls Church, Virginia
| | | | - Akhil Sharma
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | - Vinay Nair
- Northwell Health, New Hyde Park, New York
| | - Ling-Xin Chen
- University of California Davis, Sacramento, California
| | - Tarek Alhamad
- Washington University School of Medicine at St. Louis, St. Louis, Missouri
| | | | | | | | | | | | | | | | - Asif Sharfuddin
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Gaurav Gupta
- Virginia Commonwealth University, Richmond, Virginia
| | | | | | - Deborah Adey
- University of California, San Francisco, California
| | - Arman Faravardeh
- SHARP Kidney and Pancreas Transplant Center, San Diego, California
| | | | - Ana P Rossi
- Piedmont Transplant Institute, Atlanta, Georgia
| | | | | | - Julie Ma
- AlloVir, Inc., Waltham, Massachusetts
| | | | - Spyridoula Vasileiou
- AlloVir, Inc., Waltham, Massachusetts
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Peter T Jindra
- Immune Evaluation Laboratory, Baylor College of Medicine, Houston, Texas
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3
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Motter JD, Hussain S, Brown DM, Florman S, Rana MM, Friedman-Moraco R, Gilbert AJ, Stock P, Mehta S, Mehta SA, Stosor V, Elias N, Pereira MR, Haidar G, Malinis M, Morris MI, Hand J, Aslam S, Schaenman JM, Baddley J, Small CB, Wojciechowski D, Santos CA, Blumberg EA, Odim J, Apewokin SK, Giorgakis E, Bowring MG, Werbel WA, Desai NM, Tobian AA, Segev DL, Massie AB, Durand CM. Wait Time Advantage for Transplant Candidates With HIV Who Accept Kidneys From Donors With HIV Under the HOPE Act. Transplantation 2024; 108:759-767. [PMID: 38012862 PMCID: PMC11037099 DOI: 10.1097/tp.0000000000004857] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND Kidney transplant (KT) candidates with HIV face higher mortality on the waitlist compared with candidates without HIV. Because the HIV Organ Policy Equity (HOPE) Act has expanded the donor pool to allow donors with HIV (D + ), it is crucial to understand whether this has impacted transplant rates for this population. METHODS Using a linkage between the HOPE in Action trial (NCT03500315) and Scientific Registry of Transplant Recipients, we identified 324 candidates listed for D + kidneys (HOPE) compared with 46 025 candidates not listed for D + kidneys (non-HOPE) at the same centers between April 26, 2018, and May 24, 2022. We characterized KT rate, KT type (D + , false-positive [FP; donor with false-positive HIV testing], D - [donor without HIV], living donor [LD]) and quantified the association between HOPE enrollment and KT rate using multivariable Cox regression with center-level clustering; HOPE was a time-varying exposure. RESULTS HOPE candidates were more likely male individuals (79% versus 62%), Black (73% versus 35%), and publicly insured (71% versus 52%; P < 0.001). Within 4.5 y, 70% of HOPE candidates received a KT (41% D + , 34% D - , 20% FP, 4% LD) versus 43% of non-HOPE candidates (74% D - , 26% LD). Conversely, 22% of HOPE candidates versus 39% of non-HOPE candidates died or were removed from the waitlist. Median KT wait time was 10.3 mo for HOPE versus 60.8 mo for non-HOPE candidates ( P < 0.001). After adjustment, HOPE candidates had a 3.30-fold higher KT rate (adjusted hazard ratio = 3.30, 95% confidence interval, 2.14-5.10; P < 0.001). CONCLUSIONS Listing for D + kidneys within HOPE trials was associated with a higher KT rate and shorter wait time, supporting the expansion of this practice for candidates with HIV.
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Affiliation(s)
| | - Sarah Hussain
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Diane M. Brown
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sander Florman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Meenakshi M. Rana
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Peter Stock
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Shikha Mehta
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Sapna A. Mehta
- Department of Medicine, NYU Grossman School of Medicine, New York, NY
| | - Valentina Stosor
- Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Nahel Elias
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Marcus R. Pereira
- Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Ghady Haidar
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Maricar Malinis
- Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Michele I. Morris
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Jonathan Hand
- Department of Medicine, Ochsner Health, New Orleans, LA
| | - Saima Aslam
- Department of Medicine, University of California San Diego, La Jolla, CA
| | - Joanna M. Schaenman
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - John Baddley
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Catherine B. Small
- Department of Medicine/Division of Infectious Diseases, Weill Cornell Medicine, New York, NY
| | | | | | - Emily A. Blumberg
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jonah Odim
- Division of Allergy, Immunology and Transplantation, National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Senu K. Apewokin
- Department of Medicine, University of Cincinnati Medical Center, Cincinnati, OH
| | - Emmanouil Giorgakis
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Mary Grace Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - William A. Werbel
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Niraj M. Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aaron A.R. Tobian
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, NYU Grossman School of Medicine, New York, NY
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
- Scientific Registry of Transplant Recipients, Minneapolis, MN
| | - Allan B. Massie
- Department of Surgery, NYU Grossman School of Medicine, New York, NY
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
| | - Christine M. Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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4
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Jones H, Bhakta A, Jia L, Wojciechowski D, Torrealba J. An Unusual Presentation of Metastatic BK Virus-Associated Urothelial Carcinoma Arising in the Allograft, Persisting After Transplant Nephrectomy. Int J Surg Pathol 2023; 31:1586-1592. [PMID: 37013271 PMCID: PMC10616992 DOI: 10.1177/10668969231160258] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
We report a 32-year-old male 14 years post-living-related kidney transplant presenting with new-onset hematuria and BK viremia. He was found to have BK virus-associated urothelial carcinoma originating in the renal allograft with locally advanced disease and metastases to multiple sites. He also developed acute T-cell-mediated rejection in the setting of immunosuppression reduction for BK viremia prior to undergoing transplant nephrectomy. Eight months following transplant nephrectomy and immunosuppression cessation, distant metastases persisted with partial response to chemotherapy and immunotherapy. Here, we discuss this unique presentation and compare it with other BK virus-associated allograft carcinomas reported in the literature, in addition to discussing evidence for the role of BK virus in oncogenesis.
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Affiliation(s)
- Heather Jones
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Anish Bhakta
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas TX, USA
| | - Liwei Jia
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - David Wojciechowski
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas TX, USA
| | - Jose Torrealba
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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5
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Benner SE, Zhu X, Hussain S, Florman S, Eby Y, Fernandez RE, Ostrander D, Rana M, Ottmann S, Hand J, Price JC, Pereira MR, Wojciechowski D, Simkins J, Stosor V, Mehta SA, Aslam S, Malinis M, Haidar G, Massie A, Smith ML, Odim J, Morsheimer M, Quinn TC, Laird GM, Siliciano R, Balagopal A, Segev DL, Durand CM, Redd AD, Tobian AAR. HIV-Positive Liver Transplant Does not Alter the Latent Viral Reservoir in Recipients With Antiretroviral Therapy-Suppressed HIV. J Infect Dis 2023; 228:1274-1279. [PMID: 37379584 PMCID: PMC10629701 DOI: 10.1093/infdis/jiad241] [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: 05/04/2023] [Revised: 06/02/2023] [Accepted: 06/22/2023] [Indexed: 06/30/2023] Open
Abstract
The latent viral reservoir (LVR) remains a major barrier to HIV-1 curative strategies. It is unknown whether receiving a liver transplant from a donor with HIV might lead to an increase in the LVR because the liver is a large lymphoid organ. We found no differences in intact provirus, defective provirus, or the ratio of intact to defective provirus between recipients with ART-suppressed HIV who received a liver from a donor with (n = 19) or without HIV (n = 10). All measures remained stable from baseline by 1 year posttransplant. These data demonstrate that the LVR is stable after liver transplantation in people with HIV. Clinical Trials Registration. NCT02602262 and NCT03734393.
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Affiliation(s)
- Sarah E Benner
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Xianming Zhu
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Sarah Hussain
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Sander Florman
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Yolanda Eby
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Reinaldo E Fernandez
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Darin Ostrander
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Meenakshi Rana
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shane Ottmann
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jonathan Hand
- Department of Infectious Diseases, Ochsner Health, New Orleans, Louisiana, USA
| | - Jennifer C Price
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Marcus R Pereira
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - David Wojciechowski
- Division of Nephrology, University of Texas Southwestern, Dallas, Texas, USA
| | - Jacques Simkins
- Department of Medicine/Division of Infectious Diseases, University of Miami School of Medicine, Miami, Florida, USA
| | - Valentina Stosor
- Departments of Medicine and Surgery, Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sapna A Mehta
- Department of Medicine, New York University Grossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - Saima Aslam
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
| | - Maricar Malinis
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ghady Haidar
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Allan Massie
- Department of Surgery, New York University Grossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - Melissa L Smith
- Department of Biochemistry and Molecular Genetics, University of Louisville, Louisville, Kentucky, USA
| | - Jonah Odim
- Division of Extramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Megan Morsheimer
- Division of Extramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Thomas C Quinn
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Robert Siliciano
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ashwin Balagopal
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Dorry L Segev
- Department of Surgery, New York University Grossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - Christine M Durand
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Andrew D Redd
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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6
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Sanchez-Vivaldi JA, Patel MS, Shah JA, Wang BK, Salcedo-Betancourt JD, Hwang CS, Wojciechowski D, La Hoz RM, Vagefi PA. Short-term kidney transplant outcomes from SARS-CoV-2 lower respiratory tract positive donors. Transpl Infect Dis 2022; 24:e13890. [PMID: 35751890 PMCID: PMC9349435 DOI: 10.1111/tid.13890] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/19/2022] [Accepted: 05/20/2022] [Indexed: 11/30/2022]
Abstract
Objective In this study, we aim to assess short‐term allograft outcomes following deceased donor kidney transplantation from severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) lower respiratory tract (LRT) nucleic acid testing (NAT) positive donors. Methods From September to December 2021, SARS‐CoV‐2 NAT positive organ donors, whose solid abdominal organs were transplanted at our academic medical center were identified. Donors were stratified into having tested positive for SARS‐CoV‐2 in an upper respiratory tract (URT) or LRT sample. For this study, the SARS‐CoV‐2 LRT NAT positive deceased kidney donors and their respective recipients were examined. Donor and recipient demographic data, coronavirus disease 2019 (COVID‐19)‐related history, patient outcomes, as well as postoperative graft function were evaluated. Results Thirteen SARS‐CoV‐2 positive deceased donors were identified. Of these, eight were LRT NAT positive and yielded nine kidneys. These allografts were successfully transplanted into vaccinated and unvaccinated recipients. All recipients received standard induction immunosuppression and did not receive any prophylactic therapy for SARS‐CoV‐2. Two recipients had delayed graft function. At 1‐month post‐transplant, there was no clinical evidence of donor‐derived COVID‐19 or graft loss, and all recipients were free from dialysis. Conclusion We describe the first case series of SARS‐CoV‐2 LRT NAT positive deceased kidney donors for vaccinated and unvaccinated recipients with excellent short‐term allograft outcomes and no clinical evidence of donor‐derived COVID‐19 post‐transplantation. Given the increasing prevalence of SARS‐CoV‐2 in the population, utilization of SARS‐CoV‐2 LRT NAT positive deceased donors could be considered an acceptable source of organs for renal transplantation, especially as multi‐center experiences and longer‐term follow‐up emerge.
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Affiliation(s)
- Jorge A Sanchez-Vivaldi
- Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, TX
| | - Madhukar S Patel
- Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jigesh A Shah
- Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, TX
| | - Benjamin K Wang
- Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Christine S Hwang
- Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, TX
| | - David Wojciechowski
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ricardo M La Hoz
- Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Parsia A Vagefi
- Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, TX
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7
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Durand CM, Florman S, Motter JD, Brown D, Ostrander D, Yu S, Liang T, Werbel WA, Cameron A, Ottmann S, Hamilton JP, Redd AD, Bowring MG, Eby Y, Fernandez RE, Doby B, Labo N, Whitby D, Miley W, Friedman-Moraco R, Turgeon N, Price JC, Chin-Hong P, Stock P, Stosor V, Kirchner V, Pruett T, Wojciechowski D, Elias N, Wolfe C, Quinn TC, Odim J, Morsheimer M, Mehta SA, Rana MM, Huprikar S, Massie A, Tobian AA, Segev DL. HOPE in action: A prospective multicenter pilot study of liver transplantation from donors with HIV to recipients with HIV. Am J Transplant 2022; 22:853-864. [PMID: 34741800 PMCID: PMC9997133 DOI: 10.1111/ajt.16886] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [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: 07/12/2021] [Revised: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 01/25/2023]
Abstract
Liver transplantation (LT) from donors-with-HIV to recipients-with-HIV (HIV D+/R+) is permitted under the HOPE Act. There are only three international single-case reports of HIV D+/R+ LT, each with limited follow-up. We performed a prospective multicenter pilot study comparing HIV D+/R+ to donors-without-HIV to recipients-with-HIV (HIV D-/R+) LT. We quantified patient survival, graft survival, rejection, serious adverse events (SAEs), human immunodeficiency virus (HIV) breakthrough, infections, and malignancies, using Cox and negative binomial regression with inverse probability of treatment weighting. Between March 2016-July 2019, there were 45 LTs (8 simultaneous liver-kidney) at 9 centers: 24 HIV D+/R+, 21 HIV D-/R+ (10 D- were false-positive). The median follow-up time was 23 months. Median recipient CD4 was 287 cells/µL with 100% on antiretroviral therapy; 56% were hepatitis C virus (HCV)-seropositive, 13% HCV-viremic. Weighted 1-year survival was 83.3% versus 100.0% in D+ versus D- groups (p = .04). There were no differences in one-year graft survival (96.0% vs. 100.0%), rejection (10.8% vs. 18.2%), HIV breakthrough (8% vs. 10%), or SAEs (all p > .05). HIV D+/R+ had more opportunistic infections, infectious hospitalizations, and cancer. In this multicenter pilot study of HIV D+/R+ LT, patient and graft survival were better than historical cohorts, however, a potential increase in infections and cancer merits further investigation.
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Affiliation(s)
- Christine M. Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sander Florman
- Recanati-Miller Transplantation Institute, The Mount Sinai Hospital, New York, NY
| | - Jennifer D. Motter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Diane Brown
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Darin Ostrander
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sile Yu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tao Liang
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - William A. Werbel
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shane Ottmann
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - James P. Hamilton
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew D. Redd
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Mary G. Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yolanda Eby
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Nazzarena Labo
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Denise Whitby
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Wendell Miley
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | | | | | - Jennifer C. Price
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Peter Chin-Hong
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Peter Stock
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Valentina Stosor
- Divisions of Infectious Diseases and Organ Transplantation Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | | | - Cameron Wolfe
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC
| | - Thomas C. Quinn
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Jonah Odim
- Division of Allergy, Immunology and Transplantation, National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Megan Morsheimer
- Division of Allergy, Immunology and Transplantation, National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Sapna A. Mehta
- New York University Langone Transplant Institute, New York, NY
| | - Meenakshi M. Rana
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York NY
| | - Shirish Huprikar
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York NY
| | - Allan Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aaron A.R. Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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AbdulRahim N, McAdams M, Xu P, Wojciechowski D, La Hoz RM, Lu C, Vazquez MA, Hedayati SS. Association of Inflammatory Biomarkers with Immunosuppression Management and Outcomes in Kidney Transplant Recipients with COVID-19. Transplant Proc 2021; 53:2451-2467. [PMID: 34465422 PMCID: PMC8349691 DOI: 10.1016/j.transproceed.2021.08.002] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 07/23/2021] [Accepted: 08/02/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Kidney transplant recipients with coronavirus disease 2019 (COVID-19) are at increased risk for adverse outcomes, such as acute kidney injury (AKI), intensive care unit (ICU) admission, and death. The association of inflammatory biomarkers with outcomes and the impact of changes in immunosuppression on biomarker levels are unknown. METHODS We investigated factors associated with a composite of AKI, ICU admission, or death, and whether immunosuppression changes correlated with changes in inflammatory biomarkers and outcomes in kidney transplant recipients with a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction. RESULTS Of 59 patients, 50% had estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. Patients who discontinued calcineurin inhibitors (CNIs) had higher peak high-sensitivity C-reactive protein (hs-CRP) than those who maintained the same dose (median, 344; interquartile range [IQR], 145-374 vs median, 41; IQR, 22-116 mg/L, P = .03). Of the patients, 73% were hospitalized, 22% had admissions to the ICU, and 20% died. Of the 56% with AKI, 35% required dialysis. All patients with AKI but without pulmonary manifestations recovered to 10% of baseline creatinine levels. Factors associated with the composite outcome were eGFR <60 mL/min/1.73 m2 (odds ratio [OR], 5.833; 95% confidence interval [CI], 1.880-18.099; P = .002), hs-CRP (OR, 1.011/unit increase; 95% CI, 1.002-1.021; P = .019), white blood cell count (OR, 1.173/unit increase; 95% CI, 1.006-1.368; P = .041), and decreased or discontinued CNI (OR, 4.286; 95% CI, 1.353-13.572; P = .013). eGFR<60 mL/min/1.73 m2 (OR, 11.176; 95% CI, 1.581-79.001; P = .016), and peak hs-CRP (OR, 1.010/unit increase; 95% CI, 1.000-1.020; P = .049) remained associated with the composite in the multivariable model. CONCLUSIONS Kidney transplant recipients with COVID-19 have high rates of ICU admissions, AKI, and death. Those with eGFR<60 mL/min/1.73 m2 are at highest risk. CNI reduction is associated with higher inflammatory biomarkers, correlating with worse outcomes. More studies are needed to determine if this association should drive clinical management.
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Affiliation(s)
- Nashila AbdulRahim
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Hospital and Health System, Dallas, Texas
| | - Meredith McAdams
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Pin Xu
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - David Wojciechowski
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ricardo M La Hoz
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christopher Lu
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Miguel A Vazquez
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Hospital and Health System, Dallas, Texas
| | - S Susan Hedayati
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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9
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Abstract
The long-term management of maintenance immunosuppression in kidney transplant recipients remains complex. The vast majority of patients are treated with the calcineurin inhibitor tacrolimus as the primary agent in combination with mycophenolate, with or without corticosteroids. A tacrolimus trough target 5-8 ng/ml seems to be optimal for rejection prophylaxis, but long-term tacrolimus-related side effects and nephrotoxicity support the ongoing evaluation of noncalcineurin inhibitor-based regimens. Current alternatives include belatacept or mammalian target of rapamycin inhibitors. For the former, superior kidney function at 7 years post-transplant compared with cyclosporin generated initial enthusiasm, but utilization has been hampered by high initial rejection rates. Mammalian target of rapamycin inhibitors have yielded mixed results as well, with improved kidney function tempered by higher risk of rejection, proteinuria, and adverse effects leading to higher discontinuation rates. Mammalian target of rapamycin inhibitors may play a role in the secondary prevention of squamous cell skin cancer as conversion from a calcineurin inhibitor to an mammalian target of rapamycin inhibitor resulted in a reduction of new lesion development. Early withdrawal of corticosteroids remains an attractive strategy but also is associated with a higher risk of rejection despite no difference in 5-year patient or graft survival. A major barrier to long-term graft survival is chronic alloimmunity, and regardless of agent used, managing the toxicities of immunosuppression against the risk of chronic antibody-mediated rejection remains a fragile balance.
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Affiliation(s)
- David Wojciechowski
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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Pai A, Swan JT, Wojciechowski D, Qazi Y, Dholakia S, Shekhtman G, Abou-Ismail A, Kumar D. Clinical Rationale for a Routine Testing Schedule Using Donor-Derived Cell-Free DNA After Kidney Transplantation. Ann Transplant 2021; 26:e932249. [PMID: 34210952 PMCID: PMC8259349 DOI: 10.12659/aot.932249] [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] [Indexed: 11/10/2022] Open
Abstract
Kidney transplant recipients require meticulous clinical and laboratory surveillance to monitor allograft health. Conventional biomarkers, including serum creatinine and proteinuria, are lagging indicators of allograft injury, often rising only after significant and potentially irreversible damage has occurred. Immunosuppressive medication levels can be followed, but their utility is largely limited to guiding dosing changes or assessing adherence. Kidney biopsy, the criterion standard for the diagnosis and characterization of injury, is invasive and thus poorly suited for frequent surveillance. Donor-derived cell-free DNA (dd-cfDNA) is a sensitive, noninvasive, leading indicator of allograft injury, which offers the opportunity for expedited intervention and can improve long-term allograft outcomes. This article describes the clinical rationale for a routine testing schedule utilizing dd-cfDNA surveillance at months 1, 2, 3, 4, 6, 9, and 12 during the first year following kidney transplantation and quarterly thereafter. These time points coincide with major immunologic transition points after transplantation and provide clinicians with molecular information to help inform decision making.
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Affiliation(s)
- Akshta Pai
- Division of Renal Diseases and Hypertension, University of Texas McGovern Medical School, Houston, TX, USA
| | - Joshua T Swan
- Department of Pharmacy, Houston Methodist, Houston, TX, USA.,Department of Surgery Research and Center for Outcomes Research, Houston Methodist Academic Institute, Houston, TX, USA
| | - David Wojciechowski
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yasir Qazi
- Division of Nephrology, University of Southern California, Los Angeles, CA, USA
| | | | | | | | - Dhiren Kumar
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
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11
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Germain MJ, Greco BA, Hodgins S, Chapagain B, Thadhani R, Wojciechowski D, Crisalli K, Nathanson BH, Chait Y. Assessing accuracy of estimated dry weight in dialysis patients post transplantation: the kidney knows best. J Nephrol 2021; 34:2093-2097. [PMID: 34031847 DOI: 10.1007/s40620-021-01029-7] [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: 01/27/2021] [Accepted: 03/16/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Estimated dry weight is used to guide fluid removal during outpatient hemodialysis sessions. Errors in estimated dry weight can result in intradialytic hypotension and interdialytic fluid overload. The goal of this study was to assess the accuracy of estimated dry weight by comparing it to the 2-week post-transplant weight in two cohorts of hemodialysis patients. METHODS This observational, multi-center, retrospective cohort study included maintenance hemodialysis patients who underwent kidney transplantation at two medical centers in Massachusetts. The relationship between estimated dry weight pre-transplant and weight at week 2 post-transplant in patients with good allograft function (serum creatinine ≤ 1.5 mg/dL) was analyzed. Estimated dry weight was considered accurate if it was within ± 2% of the week 2 post-transplant weight. RESULTS Fifty seven patients with good allograft function were identified: mean age 54 ± 14 years, 32 (58%) from deceased donors, 22 (38.6%) females. 38 were Caucasian (66.7%), 11 Hispanic (19.3%), 3 black (5.3%), and 5 others (8.8%). 2-week mean post transplantation serum creatinine was 1.2 ± 0.2 mg/dL. Mean (SD) estimated dry weight was 71.4 ± 15.9. Before transplantation, only 14 (24.6%) patients were within ± 2% of the 2-week post-transplant weight; 23 (40.3%) were above and 20 (35.1%) were below. CONCLUSIONS Our point of view, based on the assumption that the weight of patients with good allograft function at 2 weeks post-transplant approaches their accurate dry weight, is that a majority of maintenance hemodialysis patients (75.4%) are hypervolemic or hypovolemic prior to renal transplantation. This highlights the importance of finding novel tools to achieve euvolemia in patients undertaking dialysis. Timely feedback regarding achieved weight 2 weeks post-transplant to treating nephrologists and dialysis centers may be a starting point for assessing accuracy of dry weight.
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Affiliation(s)
- Michael J Germain
- Renal and Transplant Associates of New England, PC, Springfield, MA, 01107, USA.,Baystate Medical Center, Springfield, MA, 01199, USA
| | - Barbara A Greco
- Renal and Transplant Associates of New England, PC, Springfield, MA, 01107, USA.,Baystate Medical Center, Springfield, MA, 01199, USA
| | - Spencer Hodgins
- Kidney Care and Transplant Service of New England, Springfield, MA, 01104, USA
| | - Bikash Chapagain
- MidState Nephrology Associates, 85 Church St, Middletown, CT, 06457, USA
| | - Ravi Thadhani
- Massachusetts General Brigham, Boston, MA, 02199, USA
| | | | | | | | - Yossi Chait
- University of Massachusetts, Amherst, MA, 01106, USA. .,MIE Department, University of Massachusetts, 160 Governors Drive, Amherst, MA, 01003-2210, USA.
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12
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Kirk AD, Adams AB, Durrbach A, Ford ML, Hildeman DA, Larsen CP, Vincenti F, Wojciechowski D, Woodle ES. Optimization of de novo belatacept-based immunosuppression administered to renal transplant recipients. Am J Transplant 2021; 21:1691-1698. [PMID: 33128812 PMCID: PMC8246831 DOI: 10.1111/ajt.16386] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 10/13/2020] [Accepted: 10/24/2020] [Indexed: 01/25/2023]
Abstract
Kidney transplant recipients administered belatacept-based maintenance immunosuppression present with a more favorable metabolic profile, reduced incidence of de novo donor-specific antibodies (DSAs), and improved renal function and long-term patient/graft survival relative to individuals receiving calcineurin inhibitor (CNI)-based immunosuppression. However, the rates and severity of acute rejection (AR) are greater with the approved belatacept-based regimen than with CNI-based immunosuppression. Although these early co-stimulation blockade-resistant rejections are typically steroid sensitive, the higher rate of cellular AR has led many transplant centers to adopt immunosuppressive regimens that differ from the approved label. This article summarizes the available data on these alternative de novo belatacept-based maintenance regimens. Steroid-sparing, belatacept-based immunosuppression (following T cell-depleting induction therapy) has been shown to yield AR rates comparable to those seen with CNI-based regimens. Concomitant treatment with belatacept plus a mammalian target of rapamycin inhibitor (mTORi; sirolimus or everolimus) has yielded AR rates ranging from 0 to 4%. Because the optimal induction agent and number of induction doses; blood levels of mTORi; and dose, duration, and use of corticosteroids have yet to be determined, larger prospective clinical trials are needed to establish the optimal alternative belatacept-based regimen for minimizing early cellular AR occurrence.
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Affiliation(s)
- Allan D. Kirk
- Department of SurgeryDuke UniversityDurhamNorth Carolina
| | | | - Antoine Durrbach
- Assistance Publique‐Hôpitaux de ParisNephrology and Renal Transplantation DepartmentHôpital Henri‐MondorUniversité Paris‐SaclayCreteilFrance
| | - Mandy L. Ford
- Emory Transplant CenterEmory UniversityAtlantaGeorgia
| | - David A. Hildeman
- Division of ImmunobiologyCincinnati Children's Hospital Medical Center and Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhio
| | | | - Flavio Vincenti
- Division of Transplant SurgeryUniversity of CaliforniaSan FranciscoCalifornia
| | | | - E. Steve Woodle
- Division of TransplantationDepartment of SurgeryUniversity of Cincinnati College of MedicineCincinnatiOhio
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13
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Chandran S, Wojciechowski D. Converting Maintenance Kidney-Transplant Patients From Belatacept to Another Immunosuppressive Regimen: A Cautionary Tale. Kidney Int Rep 2020; 5:2123-2124. [PMID: 33306045 PMCID: PMC7710880 DOI: 10.1016/j.ekir.2020.10.028] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Sindhu Chandran
- Division of Nephrology, UCSF Medical Center, San Francisco, California, USA
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14
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Olaitan O, Guerra G, Burke G, Alhamad T, Wojciechowski D. USE OF DD-CFDNA AS A SURROGATE MARKER OF INJURY FOLLOWING HYPOTHERMIC MACHINE PERFUSION. Transplantation 2020. [DOI: 10.1097/01.tp.0000698968.54009.b2] [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: 11/25/2022]
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15
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Sise ME, Strohbehn IA, Chute DF, Gustafson J, Van Deerlin VM, Smith JR, Gentile C, Wojciechowski D, Williams WW, Elias N, Chung RT. Preemptive Treatment With Elbasvir and Grazoprevir for Hepatitis C-Viremic Donor to Uninfected Recipient Kidney Transplantation. Kidney Int Rep 2020; 5:459-467. [PMID: 32280841 PMCID: PMC7136432 DOI: 10.1016/j.ekir.2020.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 10/02/2019] [Revised: 01/03/2020] [Accepted: 01/06/2020] [Indexed: 01/25/2023] Open
Abstract
Introduction Long wait times for kidney transplants have prompted investigation into strategies to decrease the discarding of potentially viable organs. Recent reports suggest that kidneys from hepatitis C virus (HCV)-infected donors may be transplanted into HCV-naive donors followed by direct-acting antiviral therapy. Methods This was a pilot clinical trial to transplant kidneys from HCV-infected donors into HCV-naive recipients with preemptive use of elbasvir and grazoprevir for 12 weeks. The primary outcome was sustained virologic response 12 weeks after completion of therapy. Secondary outcomes were safety, quality of life, and early viral kinetics. Results A total of 33 patients were screened, and 8 underwent kidney transplantation from a HCV-viremic donors from August 2017 to March 2019. The median donor kidney donor profile index was 31% (range, 29%-65%), and patients who underwent transplantation waited a median of 6.5 months (range, 1-19 months). None had detectable HCV viremia beyond 2 weeks post-transplantation, and all achieved sustained virologic response 12 weeks after therapy (SVR12). There were no study-related severe adverse events. One patient experienced early graft loss due to venous thrombosis, whereas the remaining 7 patients had excellent allograft function at 6 months. Conclusion Preemptive elbasvir and grazoprevir eliminated HCV infection in HCV-naive patients who received a kidney transplant from an HCV-infected donor.
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Affiliation(s)
- Meghan E Sise
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ian A Strohbehn
- Department of Medicine, Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Donald F Chute
- Department of Medicine, Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jenna Gustafson
- Department of Medicine, Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vivianna M Van Deerlin
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Jennifer R Smith
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Caren Gentile
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - David Wojciechowski
- Division of Nephrology, University of Texas Southwestern, Dallas, Texas, USA
| | - Winfred W Williams
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nahel Elias
- Department of Surgery, Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raymond T Chung
- Department of Medicine, Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts, USA
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16
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McGann K, DeWolfe D, Jacobs M, Wojciechowski D, Pavlakis M, Tan CS. Comparing Urine and Blood Screening Methods to Detect BK Virus After Renal Transplant. EXP CLIN TRANSPLANT 2019; 19:104-109. [PMID: 31801449 DOI: 10.6002/ect.2019.0295] [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: 11/05/2022]
Abstract
OBJECTIVES BK polyomavirus can infect healthy individuals; however, in renal transplant recipients, it can cause nephropathy, which can lead to renal allograftfailure. There are currently no effective antiviral agents against BK polyomavirus. Surveillance after kidney transplant for BK polyomavirus is the only means to prevent allograft failure. Transplant centers routinely screen for BK polyomavirus in either urine or blood. If BK polyomavirus replication occurs, itis usually detected first in urine, which is followed by detection in blood in a subset of cases. Screening for BK polyomavirus in urine has the potential for earlier detection of viralreactivation.However, not all patients with BK polyomavirus in urine will progress to BK viremia. Therefore, adding urine screening could increase the cost oftests without a clear clinical benefit. MATERIALS AND METHODS We conducted an analysis of BK polyomavirus screening methods at 2 different centers and compared their clinical outcomes and efficiency of testing. RESULTS We analyzed 209 patientswith BK polyomavirus reactivation after kidney transplant at 2 different institutions from 2008 to 2018. BK polyomavirus reactivation in blood was detected earlierifthe patient was screened by urine screening protocol. However, measurable clinical outcomes were similarin all groups with different screening methods. CONCLUSIONS Although screening for BK polyomavirus in urine did detect viralreactivation earlier,there were no differences in graft or clinical outcomes when either the urine or blood screening method was used.
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Affiliation(s)
- Kevin McGann
- From the Center for Virology and Vaccines Research, , Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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17
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Kim Y, Wojciechowski D, Pattanayak V, Lee H, Asgari MM. Association between Human Leukocyte Antigen Type and Keratinocyte Carcinoma Risk in Renal Transplant Recipients. J Invest Dermatol 2019; 140:995-1002. [PMID: 31669059 DOI: 10.1016/j.jid.2019.09.016] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/30/2019] [Accepted: 09/30/2019] [Indexed: 10/25/2022]
Abstract
Keratinocyte carcinoma (KC), defined as squamous cell carcinoma and basal cell carcinoma, is the most common malignancy among white, non-Hispanic renal transplant recipients. Although recent genome-wide association studies reported that class II HLA is associated with KC risk, epidemiologic data on HLA type and KC risk in renal transplant recipients is limited. Using an institutional cohort of white, non-Hispanic renal transplant recipients transplanted between 1993 and 2017, we examined the association between pretransplant molecular HLA types and KC risk. Posttransplant KCs were captured using the International Classification of Diseases codes and validated using pathology reports. Cox proportional hazards regression models were used to estimate hazard ratios of incident KC, squamous cell carcinoma, and basal cell carcinoma, adjusting for age, male sex, history of KC, Charlson comorbidity index, HLA mismatch, transplant type, year of transplant, and the type of immunosuppression. Among 617 subjects (mean age 53 years, 67% male), 10% developed posttransplant KC. Multivariable Cox regression analyses showed HLA-DRB1∗13 was associated with KC risk (hazard ratio, 1.84; 95% confidence interval, 1.00-3.38) and squamous cell carcinoma risk (hazard ratio, 2.24; 95% confidence interval, 1.12-4.49), whereas HLA-DRB1∗14 (hazard ratio, 2.81; 95% confidence interval, 1.14-6.91) was associated with basal cell carcinoma risk. Our findings suggest that a subset of renal transplant recipients with specific HLA polymorphisms may be at increased KC risk.
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Affiliation(s)
- Yuhree Kim
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts; Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
| | - David Wojciechowski
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vikram Pattanayak
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Hang Lee
- MGH Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Maryam M Asgari
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts; Department of Population Medicine, Harvard Medical School, Boston, Massachusetts.
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19
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Sise ME, Wojciechowski D, Chute DF, Gustafson J, Chung RT, Williams WW, Elias N. Process of selecting and educating HCV-uninfected kidney waiting-list candidates for HCV-infected kidney transplantation. Artif Organs 2019; 43:913-920. [PMID: 31001828 PMCID: PMC6733639 DOI: 10.1111/aor.13473] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 01/15/2019] [Revised: 04/10/2019] [Accepted: 04/11/2019] [Indexed: 12/29/2022]
Abstract
Long waiting times for kidney transplant (KT) and the high risk of mortality on dialysis have prompted investigation into strategies to utilize hepatitis C virus (HCV)-infected organs to decrease discard rates of potentially viable kidneys. Due the opioid epidemic, the number of HCV-infected donors has increased significantly. With the development of direct-acting antiviral therapies for HCV infection, now more than 95% of patients who received treatment are cured. Experimental trials have used direct-acting antiviral therapy to treat HCV infection in HCV-uninfected transplant recipients of kidneys from HCV-viremic donors. To date, HCV has been eradicated in all cases. Though these strategies will potentially increase the donor pool of available kidneys, shorten waitlist times, and ultimately decrease mortality in patients waiting for KT, identifying the ideal candidates and educating them about a protocol to utilize direct-acting antiviral therapy to cure HCV after it is transmitted is essential. We present our approach to patient selection and education for a clinical trial in transplantation of HCV viremic kidneys into uninfected recipients.
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Affiliation(s)
- Meghan E Sise
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - David Wojciechowski
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - Donald F Chute
- Department of Medicine, Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Jenna Gustafson
- Department of Medicine, Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Raymond T Chung
- Department of Medicine, Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Winfred W Williams
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nahel Elias
- Department of Surgery, Division of Transplant Surgery, Massachusetts General Hospital, Boston, Massachusetts
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20
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Kumar D, Chin-Hong P, Kayler L, Wojciechowski D, Limaye AP, Osama Gaber A, Ball S, Mehta AK, Cooper M, Blanchard T, MacDougall J, Kotton CN. A prospective multicenter observational study of cell-mediated immunity as a predictor for cytomegalovirus infection in kidney transplant recipients. Am J Transplant 2019; 19:2505-2516. [PMID: 30768834 DOI: 10.1111/ajt.15315] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [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: 10/25/2018] [Revised: 01/24/2019] [Accepted: 02/01/2019] [Indexed: 01/25/2023]
Abstract
T cell immunity is essential for the control of cytomegalovirus (CMV) infection after transplantation. We evaluated a CMV-specific peptide-based enzyme-linked immunosorbent spot (ELISPOT) assay to determine whether assay results could predict subsequent CMV events. Adult kidney transplant recipients at 43 centers underwent ELISPOT testing to enumerate interferon gamma (IFN-γ) binding spot-forming units (sfu) after stimulation of cells with an overlapping peptide pool of CMV phosphoprotein 65 (pp65) and immediate early-1 (IE-1) protein at the end of antiviral prophylaxis (EOP) and various time points thereafter. The primary outcome was a CMV event in the first posttransplant year. In 583 kidney transplant recipients (260 seropositive donor [D+]/seronegative recipient [R-] and 277 R+), CMV events occurred in 44 of 368 eligible patients (11.8%) at a median of 227 days (range 92-360) posttransplant. A cutoff value of >40 sfu/2.5 × 105 cells for either IE-1 or pp65 was derived as a threshold for positivity, with a negative predictive value of >97% for CMV events. CMV events were significantly lower in assay positive vs assay negative patients (3.0% vs 19.5%, P < .0001 for pp65). Time to CMV event post-EOP was significantly greater in those with sfu >40 at EOP (P < .0001). In this large, multicenter trial of kidney transplant recipients, we show that an assessment of CMV-specific immunity using a novel ELISPOT assay is able to predict protection from CMV infection.
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Affiliation(s)
- Deepali Kumar
- Transplant Infectious Diseases and Multi-Organ Transplant Program, University Health Network, Toronto, Canada
| | - Peter Chin-Hong
- Division of Infectious Diseases, University of California - San Francisco, San Francisco, California
| | | | - David Wojciechowski
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ajit P Limaye
- University of Washington Medical Center, Seattle, Washington
| | | | | | - Aneesh K Mehta
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Matthew Cooper
- Medstar Georgetown Transplant Institute, Washington, District of Columbia
| | | | | | - Camille N Kotton
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts
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21
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Sise ME, Chute DF, Gustafson JL, Wojciechowski D, Elias N, Chung RT, Williams WW. Transplantation of hepatitis C virus infected kidneys into hepatitis C virus uninfected recipients. Hemodial Int 2019; 22 Suppl 1:S71-S80. [PMID: 29694722 DOI: 10.1111/hdi.12650] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 12/20/2022]
Abstract
Long wait times for kidney transplant and the high risk of mortality on dialysis have prompted investigation into strategies to increase organ allocation and decrease discard rates of potentially viable kidneys. Organs from hepatitis C virus (HCV) antibody positive donors are often rejected; nearly 500 HCV-infected kidneys are discarded annually in the United States. Due the opioid epidemic, the number of HCV-infected donors has increased because of a rise in both new HCV infections and drug-related deaths. In the past 5 years, HCV has been transformed into a curable illness with direct-acting antiviral therapies (DAAs) that are effective in >95% of patients treated and are extremely well tolerated. Recent data has shown several direct-acting antiviral combinations are safe and effective after kidney transplant, and can achieve the same high cure rate seen in the general population and without increasing the rate of acute rejection. Because of this, strategies to decrease discard of HCV-infected organs have been devised. Two recent studies have transplanted HCV-uninfected dialysis patients with kidneys from donors actively infected with HCV; recipients were treated with DAA in the peri-transplant period. More research is needed to determine the safety and efficacy of this approach, but it has the potential to dramatically increase the donor pool of available kidneys, shorten waitlist times and ultimately decreases mortality in patients waiting for kidney transplant.
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Affiliation(s)
- Meghan E Sise
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Donald F Chute
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jenna L Gustafson
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David Wojciechowski
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nahel Elias
- Department of Transplant Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Raymond T Chung
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Winfred W Williams
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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22
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Affiliation(s)
- David Wojciechowski
- From the Departments of Medicine (D.W., R.T.G.) and Pathology (I.A.R.), Massachusetts General Hospital, and the Departments of Medicine (D.W., R.T.G.) and Pathology (I.A.R.), Harvard Medical School - both in Boston
| | - Rajesh T Gandhi
- From the Departments of Medicine (D.W., R.T.G.) and Pathology (I.A.R.), Massachusetts General Hospital, and the Departments of Medicine (D.W., R.T.G.) and Pathology (I.A.R.), Harvard Medical School - both in Boston
| | - Ivy A Rosales
- From the Departments of Medicine (D.W., R.T.G.) and Pathology (I.A.R.), Massachusetts General Hospital, and the Departments of Medicine (D.W., R.T.G.) and Pathology (I.A.R.), Harvard Medical School - both in Boston
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23
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Durand CM, Halpern SE, Bowring MG, Bismut GA, Kusemiju OT, Doby B, Fernandez RE, Kirby CS, Ostrander D, Stock PG, Mehta SG, Turgeon NA, Wojciechowski D, Huprikar S, Florman S, Ottmann S, Desai NM, Cameron A, Massie AB, Tobian AA, Redd AD, Segev DL. Organs from deceased donors with false-positive HIV screening tests: An unexpected benefit of the HOPE act. Am J Transplant 2018; 18:2579-2586. [PMID: 29947471 PMCID: PMC6160348 DOI: 10.1111/ajt.14993] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [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: 05/04/2018] [Revised: 06/15/2018] [Accepted: 06/18/2018] [Indexed: 01/25/2023]
Abstract
Organs from deceased donors with suspected false-positive HIV screening tests were generally discarded due to the chance that the test was truly positive. However, the HIV Organ Policy Equity (HOPE) Act now facilitates use of such organs for transplantation to HIV-infected (HIV+) individuals. In the HOPE in Action trial, donors without a known HIV infection who unexpectedly tested positive for anti-HIV antibody (Ab) or HIV nucleic acid test (NAT) were classified as suspected false-positive donors. Between March 2016 and March 2018, 10 suspected false-positive donors had organs recovered for transplant for 21 HIV + recipients (14 single-kidney, 1 double-kidney, 5 liver, 1 simultaneous liver-kidney). Median donor age was 24 years; cause of death was trauma (n = 5), stroke (n = 4), and anoxia (n = 1); three donors were labeled Public Health Service increased infectious risk. Median kidney donor profile index was 30.5 (IQR 22-58). Eight donors were HIV Ab+/NAT-; two were HIV Ab-/NAT+. All 10 suspected false-positive donors were confirmed to be HIV-noninfected. Given the false-positive rates of approved assays used to screen > 20 000 deceased donors annually, we estimate 50-100 HIV false-positive donors per year. Organ transplantation from suspected HIV false-positive donors is an unexpected benefit of the HOPE Act that provides another novel organ source.
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Affiliation(s)
- Christine M. Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Samantha E. Halpern
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mary G. Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gilad A. Bismut
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Brianna Doby
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Charles S. Kirby
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Darin Ostrander
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Peter G. Stock
- Department of Surgery, University of California, San Francisco, CA
| | - Shikha G. Mehta
- Department of Medicine, University of Alabama, Birmingham, AL
| | | | | | - Shirish Huprikar
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sander Florman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Shane Ottmann
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Niraj M. Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Aaron A.R. Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Andrew D. Redd
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD,National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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24
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Gupta S, Rosales I, Wojciechowski D. Pilot Analysis of Late Conversion to Belatacept in Kidney Transplant Recipients for Biopsy-Proven Chronic Tacrolimus Toxicity. J Transplant 2018; 2018:1968029. [PMID: 29854421 PMCID: PMC5954857 DOI: 10.1155/2018/1968029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 03/01/2018] [Accepted: 03/21/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Calcineurin inhibitors are associated with chronic nephrotoxicity, manifesting as interstitial fibrosis/tubular atrophy (IF/TA) and arteriolar hyalinosis. Conversion from tacrolimus to belatacept may be one strategy to preserve renal function. METHODS We conducted a retrospective review of renal transplant patients followed at our institution who were converted to belatacept and found to have chronic tacrolimus toxicity on biopsy. The primary outcome was eGFR at conversion as compared to eGFR at 3, 6, 12, and 24 months after conversion. We also assessed incidence of infection and rates of allograft survival at 1 year. RESULTS The average time between transplant and conversion was 11.9 years. There was no decrease in eGFR at any postconversion time point as compared with preconversion. The mean eGFR at time of preconversion was 32.9 mL/min, as compared with 35.6 mL/min at 3 months (p = 0.09), 34.1 mL/min at 6 months (p = 0.63), 34.9 mL/min at 12 months (p = 0.57), and 39.6 mL/min at 24 months after conversion (p = 0.92). Four of 7 patients had increases in their eGFR after conversion. All grafts were functioning at 1 year after conversion. CONCLUSION While this study was limited by a small number of patients, belatacept conversion stabilized eGFR at all time points in patients with late allograft function due to chronic tacrolimus toxicity, with a trend towards increased eGFR at 3 months.
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Affiliation(s)
| | - Ivy Rosales
- Massachusetts General Hospital, Boston, MA, USA
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25
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Vincenti F, Chandran S, Wojciechowski D, Leung C, Tavares E, Tang Q, Shoji J. SP729CLINICAL AND IMMUNOLOGIC PREDICTORS OF OUTCOME WITH A NOVEL BELATACEPT REGIMEN. Nephrol Dial Transplant 2018. [DOI: 10.1093/ndt/gfy104.sp729] [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: 11/13/2022] Open
Affiliation(s)
- Flavio Vincenti
- Kidney Transplant, University of California, San Francisco, San Francisco, CA, United States
| | - Sindhu Chandran
- Kidney Transplant, University of California, San Francisco, San Francisco, CA, United States
| | | | - Chung Leung
- Kidney Transplant, University of California, San Francisco, San Francisco, CA, United States
| | - Erica Tavares
- Kidney Transplant, University of California, San Francisco, San Francisco, CA, United States
| | - Qizhi Tang
- Transplant Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Jun Shoji
- Kidney Transplant, University of California, San Francisco, San Francisco, CA, United States
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26
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Azzi J, Raimondi G, Mas V, Riella LV, Elfadawy N, Safa K, Wojciechowski D, Kanak M, Nog R, Maltzman JS, Ford ML, Pober JS, Luo XR, Rothstein D, Miller ML, Matthews D, Burlingham W, Levings M, Heeger P, Higdon L, Gill J, Gill RG, Alegre ML. The outstanding questions in transplantation: It's about time…. Am J Transplant 2018; 18:271-272. [PMID: 28758364 DOI: 10.1111/ajt.14450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Jamil Azzi
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Valeria Mas
- University of Virginia, Charlottesville, VA, USA
| | - Leonardo V Riella
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Kassem Safa
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Mazhar Kanak
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Rajat Nog
- Westchester Medical Center, Valhalla, NY, USA
| | | | | | | | | | | | | | | | | | - Megan Levings
- University of British Columbia, Vancouver, BC, Canada
| | - Peter Heeger
- Mount Sinai School of Medicine, New York, NY, USA
| | | | - John Gill
- University of British Columbia, Vancouver, BC, Canada
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27
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Wojciechowski D, Chandran S, Yang JYC, Sarwal MM, Vincenti F. Retrospective evaluation of the efficacy and safety of belatacept with thymoglobulin induction and maintenance everolimus: A single-center clinical experience. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.13042] [Citation(s) in RCA: 9] [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] [Accepted: 06/22/2017] [Indexed: 12/28/2022]
Affiliation(s)
| | - Sindhu Chandran
- Division of Nephrology; University of California San Francisco; San Francisco CA USA
| | - Joshua Y. C. Yang
- Division of Transplant Surgery; University of California San Francisco; San Francisco CA USA
| | - Minnie M. Sarwal
- Division of Transplant Surgery; University of California San Francisco; San Francisco CA USA
| | - Flavio Vincenti
- Division of Nephrology; University of California San Francisco; San Francisco CA USA
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28
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Axelrod DA, Kynard-Amerson CS, Wojciechowski D, Jacobs M, Lentine KL, Schnitzler M, Peipert JD, Waterman AD. Cultural competency of a mobile, customized patient education tool for improving potential kidney transplant recipients’ knowledge and decision-making. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.12944] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2017] [Indexed: 01/05/2023]
Affiliation(s)
- David A. Axelrod
- Brody School of Medicine; East Carolina University; Greenville NC USA
- XynManagement Inc; Boerne TX USA
| | | | | | - Marie Jacobs
- Department of Medicine; Massachusetts General Hospital; Boston MA USA
| | - Krista L. Lentine
- XynManagement Inc; Boerne TX USA
- Abdominal Transplant Center; St. Louis University; St. Louis MO USA
| | - Mark Schnitzler
- XynManagement Inc; Boerne TX USA
- Abdominal Transplant Center; St. Louis University; St. Louis MO USA
| | - John D. Peipert
- David Geffen School of Medicine; University of California at Los Angeles; Los Angeles CA USA
| | - Amy D. Waterman
- David Geffen School of Medicine; University of California at Los Angeles; Los Angeles CA USA
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29
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Wojciechowski D, Chandran S, Vincenti F. Early post-transplant conversion from tacrolimus to belatacept for prolonged delayed graft function improves renal function in kidney transplant recipients. Clin Transplant 2017; 31. [PMID: 28190259 DOI: 10.1111/ctr.12930] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [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: 02/07/2017] [Indexed: 01/21/2023]
Abstract
Prolonged delayed graft function (DGF) in kidney transplant recipients imparts a risk of poor allograft function; tacrolimus may be detrimental in this setting. We conducted a retrospective single center analysis of the first 20 patients converted to belatacept for prolonged DGF as part of a clinical protocol as a novel treatment strategy to treat prolonged DGF. Prior to conversion, patients underwent an allograft biopsy to rule out rejection and confirm tubular injury. The primary outcome was the estimated glomerular filtration rate (eGFR) at 12 months post-transplant; secondary outcome was the change in eGFR 30 days post-belatacept conversion. At 1 year post-transplant, the mean eGFR was 54.2 (SD 19.2) mL/min/1.73 m2 . The mean eGFR on the day of belatacept conversion was 16 (SD 12.7) mL/min/1.73 m2 and rose to 43.1 (SD 15.8) mL/min/1.73 m2 30 days post-conversion (P<.0001). The acute rejection rate was 20% with 100% patient survival at 12 months post-transplant. There was one graft loss in the setting of an invasive Aspergillus infection that resulted in withdrawal of immunosuppression and transplant nephrectomy. Belatacept conversion for prolonged DGF is a novel treatment strategy that resulted in an improvement in eGFR. Additional follow-up is warranted to confirm the long-term benefits of this strategy.
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Affiliation(s)
| | - Sindhu Chandran
- Division of Nephrology, University of California San Francisco, San Francisco, CA, USA
| | - Flavio Vincenti
- Division of Nephrology, University of California San Francisco, San Francisco, CA, USA
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30
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Sircar M, Kotton C, Wojciechowski D, Safa K, Gilligan H, Heher E, Williams W, Thadhani R, Tolkoff-Rubin N. Voriconazole-Induced Periostitis & Enthesopathy in Solid Organ Transplant Patients: Case Reports. ACTA ACUST UNITED AC 2016; 4:8-17. [PMID: 27990445 PMCID: PMC5158005 DOI: 10.4236/jbm.2016.411002] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Voriconazole is frequently used to treat fungal infections in solid organ transplant patients. Recently, there have been reports suggesting that prolonged voriconazole therapy may lead to periostitis. Aim Here we present two cases of voriconazole-induced periostitis in solid organ transplant patients. Case Presentation Voriconazole was given to two transplant patients-one with a liver transplant and the second with a heart transplant, to treat their fungal infections. Both developed voriconazole-induced toxicity. While undergoing voriconazole therapy, they had incapacitating bone pain. The liver transplant patient had to be taken off voriconazole, and the heart transplant patient succumbed to non-voriconazole related causes. Conclusions Voriconazole therapy in two solid organ transplant patients resulted in periostitis. We provide potential etiologies underlying voriconazole-induced periostitis, including fluoride toxicity, abnormalities in the pulmonary vascular bed leading to the production of downstream inflammatory mediators, and abnormal pharmacokinetics of hepatic drug metabolism. In addition to monitoring blood voriconazole trough levels, we suggest careful assessment for musculoskeletal pain in patients undergoing voriconazole treatment for two months or more, particularly if their daily dosages of voriconazole exceed 500 mg per day. Appropriate workup should include measurement of alkaline phosphatase, voriconazole trough and fluoride levels as well as a bone scan. Overall, early recognition of voriconazole-induced musculoskeletal toxicity is important for better morbidity outcomes.
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Affiliation(s)
- Monica Sircar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Camille Kotton
- Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - David Wojciechowski
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; MGH Transplant Center, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kassem Safa
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; MGH Transplant Center, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Hannah Gilligan
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; MGH Transplant Center, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Eliot Heher
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; MGH Transplant Center, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Winfred Williams
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; MGH Transplant Center, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ravi Thadhani
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Nina Tolkoff-Rubin
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; MGH Transplant Center, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA, USA
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31
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Abstract
The last three decades have witnessed significant advances in the development of immunosuppressive medications used in kidney transplantation leading to a remarkable gain in short-term graft function and outcomes. Despite these major breakthroughs, improvements in long-term outcomes lag behind due to a stalemate between drug-related nephrotoxicity and chronic rejection typically due to donor-specific antibodies. Regulatory T cells (Tregs) have been shown to modulate the alloimmune response and can exert suppressive activity preventing allograft rejection in kidney transplantation. Currently available immunosuppressive agents impact Tregs in the alloimmune milieu with some of these interactions being deleterious to the allograft while others may be beneficial. Variable effects are seen with common antibody induction agents such that basiliximab, an IL-2 receptor blocker, decreases Tregs while lymphocyte depleting agents such as antithymocyte globulin increase Tregs. Calcineurin inhibitors, a mainstay of maintenance immunosuppression since the mid-1980s, seem to suppress Tregs while mammalian targets of rapamycin (less commonly used in maintenance regimens) expand Tregs. The purpose of this review is to provide an overview of Treg biology in transplantation, identify in more detail the interactions between commonly used immunosuppressive agents and Tregs in kidney transplantation and lastly describe future directions in the use of Tregs themselves as therapy for tolerance induction.
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Affiliation(s)
- Kassem Safa
- Division of Nephrology and Transplant Center, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA
| | - Sindhu Chandran
- Division of Nephrology, Department of Medicine, University of California San Francisco Medical center, San Francisco, CA, USA
| | - David Wojciechowski
- Division of Nephrology and Transplant Center, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA.
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32
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Wojciechowski D, Vincenti F. Costimulatory Blockade and Use of mTOR Inhibitors: Avoiding Injury Part 2. Adv Chronic Kidney Dis 2016; 23:306-311. [PMID: 27742385 DOI: 10.1053/j.ackd.2016.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Kidney transplantation immunosuppression relies on a calcineurin inhibitor backbone. Calcineurin inhibitors have reduced early-acute rejection rates but failed to improve long-term allograft survival. Their nephrotoxicity has shifted the focus of investigation to calcineurin inhibitor-free regimens. Costimulation blockade with belatacept, a second generation, higher avidity variant of CTLA4-Ig, has emerged as part of a calcineurin inhibitor-free regimen. Belatacept has demonstrated superior glomerular filtration rate compared with calcineurin inhibitors albeit with an increased risk of early and histologically severe rejection. Focus on optimizing the belatacept regimen to reduce the acute rejection rate while maintaining superior renal function is underway. Belatacept has also been utilized as part of a calcineurin inhibitor-free conversion strategy in stable renal transplant recipients and has demonstrated superior improvement in glomerular filtration rate with conversion vs calcineurin inhibitor continuation. Additional work is underway to better define the role of belatacept in patients on calcineurin inhibitors with allograft dysfunction not due to rejection.
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Aparici CM, Bains SN, Carlson D, Qian J, Liou D, Wojciechowski D, Werner J, Khan S, Kroll C, Sandhu M, Nguyen N, Hawkins R. Recovery of Native Renal Function in Patients with Hepatorenal Syndrome Following Combined Liver and Kidney Transplant with Mercaptoacetyltriglycine-3 Renogram: Developing a Methodology. World J Nucl Med 2016; 15:44-9. [PMID: 26912978 PMCID: PMC4729014 DOI: 10.4103/1450-1147.172140] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Many patients with hepatorenal syndrome (HRS) end up receiving a combined liver and kidney transplant (CKLT) with preservation of native kidneys, specially type 1 HRS since is characterizes by a very rapid deterioration of renal function. Eventually, most of the patients regain renal function, but it is unknown if this is due to the transplanted kidney, the recovery of native renal function, or both. The aim of this study is to evaluate if there is recovery of native renal function in patients with HRS following CKLT. 22 patients (16 men; 6 women) with history of HRS and status post CKLT were studied. Mercapto-acetyltriglycine-3 renograms in the anterior and posterior views with the three kidneys in the field of view were simultaneously acquired. The renograms were analyzed by creating regions of interest around the transplanted and native kidneys. Relative contribution to the renal function, clearance, and effective renal plasma flow for the transplanted and native kidneys were obtained. 1/22 (4.5%) patients presented with a very poor functioning transplanted kidney, in 15/22 (68%) cases the combined native renal function was markedly poorer than the transplanted renal function and in 6/22 (27%) native kidneys showed a contribution to the renal function similar to the transplanted kidney. In conclusion, our series show that around 32% of the HRS patients recovered their native renal function after CKLT. Identification of common factors that affect recovery of native renal function may help to avoid unnecessary renal transplants, significantly reducing morbidity and cost, while facilitating a reallocation of scarce donor resources.
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Affiliation(s)
- Carina Mari Aparici
- Department of Radiology, Division of Nuclear Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA; Department of Radiology, Nuclear Medicine Division, San Francisco VAMC, San Francisco, California, USA
| | - Sukhkarn N Bains
- Department of Radiology, Division of Nuclear Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - David Carlson
- Department of Radiology, Division of Nuclear Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Jesse Qian
- Department of Medicine, Division of Nephrology, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Douglas Liou
- Department of Radiology, Division of Nuclear Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - David Wojciechowski
- Department of Medicine, Division of Nephrology, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Jacob Werner
- Department of Radiology, Division of Nuclear Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Sana Khan
- Department of Radiology, Division of Nuclear Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Cameron Kroll
- Department of Radiology, Division of Nuclear Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Manreet Sandhu
- Department of Radiology, Division of Nuclear Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Nhan Nguyen
- Department of Radiology, Division of Nuclear Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Randall Hawkins
- Department of Radiology, Division of Nuclear Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
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Safa K, Chandran S, Wojciechowski D. Erratum to: Pharmacologic Targeting of Regulatory T Cells for Solid Organ Transplantation: Current and Future Prospects. Drugs 2015; 75:2171. [PMID: 26553341 DOI: 10.1007/s40265-015-0501-z] [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: 11/28/2022]
Affiliation(s)
- Kassem Safa
- Division of Nephrology and Transplant Center, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA
| | - Sindhu Chandran
- Division of Nephrology, Department of Medicine, University of California San Francisco Medical center, San Francisco, CA, USA
| | - David Wojciechowski
- Division of Nephrology and Transplant Center, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA.
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Wu EH, Wojciechowski D, Chandran S, Yeh BM, Park M, Westphalen A, Wang ZJ. Prevalence of abdominal aortic calcifications in older living renal donors and its effect on graft function and histology. Transpl Int 2015; 28:1172-8. [DOI: 10.1111/tri.12612] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 04/10/2015] [Accepted: 05/19/2015] [Indexed: 11/28/2022]
Affiliation(s)
- En-Haw Wu
- Department of Radiology and Biomedical Imaging; UCSF; San Francisco CA USA
| | | | - Sindhu Chandran
- Department of Medicine; Division of Nephrology; UCSF; San Francisco CA USA
| | - Benjamin M. Yeh
- Department of Radiology and Biomedical Imaging; UCSF; San Francisco CA USA
| | - Meyeon Park
- Department of Medicine; Division of Nephrology; UCSF; San Francisco CA USA
| | - Antonio Westphalen
- Department of Radiology and Biomedical Imaging; UCSF; San Francisco CA USA
| | - Zhen J. Wang
- Department of Radiology and Biomedical Imaging; UCSF; San Francisco CA USA
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Safa K, Heher E, Gilligan H, Williams W, Tolkoff-Rubin N, Wojciechowski D. BK Virus After Kidney Transplantation: A Review of Screening and Treatment Strategies and a Summary of the Massachusetts General Hospital Experience. Clin Transpl 2015; 31:257-263. [PMID: 28514587] [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
BK virus (BKV) is a common infection encountered after kidney transplantation. BKV is associated with a spectrum of manifestations, starting with sub-clinical viruria, followed by viremia and BKV-associated nephropathy. Standard of care includes routine post-transplant screening for BK viruria and/or viremia. Both the Kidney Disease Improving Global Outcomes and the American Society of Transplantation Infectious Diseases Community of Practice have published screening recommendations. Although they vary slightly, they both highlight the importance of early detection with serial screening. Once BK viremia is detected, the standard management approach includes a reduction of immunosuppression. Guidelines differ slightly about the sequence of the immunosuppression reduction, but the end result is the same: lowering the overall immunosuppressive burden in the patient with BKV infection. At the Massachusetts General Hospital, from 2007 to 2009, there was no BKV screening protocol in place. The rate of screening during this time period increased from 62% to 81%. A total of 29 of the 243 patients were diagnosed with BK viremia (11.9%), with 23 identified as a result of screening and 6 as a result of testing for graft dysfunction. We developed a BKV screening protocol consisting of BKV polymerase chain reaction testing in blood starting 2 months after kidney transplantation and every 2 months thereafter, continuing through month 24 regardless of the allograft function. Additional screening for 6 more months is performed in patients who receive anti-lymphocyte globulin for the treatment of acute rejection. Finally, all patients with otherwise unexplained allograft dysfunction are screened. Currently, work is being done investigating the use of mammalian target of rapamycin inhibitors to treat BKV infection. Trials are also ongoing evaluating cell-based therapies for BKV. Research to develop a vaccine or a direct-acting antiviral agent is in critical need and an area of research that should be given high priority.
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Hui C, Kern R, Wojciechowski D, Kukreja J, Golden JA, Hays SR, Singer JP. Belatacept for Maintenance Immunosuppression in Lung Transplantation. J Investig Med High Impact Case Rep 2014; 2:2324709614546866. [PMID: 26425619 PMCID: PMC4528899 DOI: 10.1177/2324709614546866] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Belatacept is a novel immunosuppressant that blocks a T-cell costimulation pathway and is approved for use in adult kidney transplant recipients. Its safety and efficacy have not been established after lung transplantation. We present a case of a lung transplant recipient treated with belatacept. A 56-year-old man underwent bilateral lung retransplantation for bronchiolitis obliterans syndrome (BOS). In the third year posttransplant, he developed hemolytic uremic syndrome (HUS) attributed to tacrolimus. Tacrolimus was changed to sirolimus. One month later, he presented with worsening renal function and HUS attributed to sirolimus. Plasmapheresis and steroid pulse were initiated with clinical improvement, and sirolimus was switched to belatacept. He experienced no episodes of cellular rejection but developed recurrent BOS. Complications during treatment included anemia and recurrent pneumonias. The safety and efficacy of belatacept in lung transplantation remains unclear; further studies are needed.
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Affiliation(s)
| | - Ryan Kern
- UCSF Medical Center, San Francisco, CA, USA
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Abstract
INTRODUCTION This review will discuss the mechanism of action and important kidney transplant clinical trial data for the small molecule Janus kinase (JAK) 3 inhibitor tofacitinib , formerly known as CP-690,550 and tasocitinib. AREAS COVERED Successful kidney transplantation requires adequate immunosuppression. Current maintenance immunosuppressive protocols which rely on calcineurin inhibitors have long-term nephrotoxicity and negative impact on cardiometabolic risk factors. JAKs are cytoplasmic tyrosine kinases that participate in the signaling of a broad range of cell surface receptors, particularly members of the cytokine receptor common gamma (cγ) chain family. JAK3 inhibition has immunosuppressive effects and treatment with tofacitinib in clinical trials has demonstrated efficacy in autoimmune disorders such as psoriasis and rheumatoid arthritis. Nonhuman primate models of renal transplantation demonstrated prolonged graft survival with tofacitinib compared to control. Renal transplant clinical trials in humans have demonstrated tofacitinib to be noninferior to cyclosporine in terms of rejection rates and graft survival. There was also a lower rate of new onset diabetes after transplant. However, there was a trend toward more infections, including cytomegalovirus and BK virus nephritis. EXPERT OPINION Tofacitinib may be a promising alternative to calcineurin inhibitors. The optimal therapeutic window is still being determined.
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Affiliation(s)
- David Wojciechowski
- University of California, Kidney Transplant Service, San Francisco, CA 94143-0780, USA
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Vagefi PA, Qian JJ, Carlson DM, Aparici CM, Hirose R, Vincenti F, Wojciechowski D. Native renal function after combined liver-kidney transplant for type 1 hepatorenal syndrome: initial report on the use of postoperative Technetium-99 m-mercaptoacetyltriglycine scans. Transpl Int 2013; 26:471-6. [DOI: 10.1111/tri.12066] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 12/18/2012] [Accepted: 12/31/2012] [Indexed: 01/09/2023]
Affiliation(s)
- Parsia A. Vagefi
- Department of Surgery; Massachusetts General Hospital/Harvard Medical School; Boston; MA
| | | | - David M. Carlson
- Department of Radiology; University of California; San Francisco; CA
| | | | - Ryutaro Hirose
- Department of Surgery; University of California; San Francisco; CA
| | - Flavio Vincenti
- Department of Medicine; University of California; San Francisco; CA
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Abstract
In June 2011, the US Food and Drug Administration approved belatacept for the prophylaxis of organ rejection in adult kidney transplant recipients. This review discusses the use of belatacept for the prevention of acute rejection as part of a maintenance immunosuppression regimen. Belatacept is a selective costimulation blocker designed to provide effective immunosuppression while avoiding the toxicities associated with calcineurin inhibitors. Phase III trial data have demonstrated that belatacept is noninferior to cyclosporine in 1-year patient and allograft survival. Three-year data demonstrate an ongoing improvement in mean measured glomerular filtration rate in belatacept-treated versus cyclosporine-treated patients. However, the rate of acute rejection was higher in belatacept-treated patients compared with cyclosporine. Specifically, there was a higher incidence of Banff type II rejections in patients treated with belatacept. Despite the higher Banff grade, rejections on belatacept were not associated with other factors associated with poor outcomes, such as the development of donor-specific antibodies or reduced estimated glomerular filtration rate. One safety issue that must be considered when using belatacept is the potential for increased risk of post-transplant lymphoproliferative disease. There were more cases of post-transplant lymphoproliferative disease in belatacept-treated patients, especially in recipients seronegative for Epstein–Barr virus or patients treated with lymphocyte-depleting agents. Therefore, belatacept can be recommended for use in Epstein–Barr virus antibody-positive recipients.
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Wojciechowski D, Vincenti F. Challenges and opportunities in targeting the costimulation pathway in solid organ transplantation. Semin Immunol 2011; 23:157-64. [PMID: 21856169 DOI: 10.1016/j.smim.2011.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 07/10/2011] [Indexed: 02/08/2023]
Abstract
Signaling through the costimulatory pathway is critical in the regulation of T cell activation. Abatacept, a selective costimulatory antagonist FDA approved for the treatment of moderate to severe rheumatoid arthritis, binds to CD80 and CD86 on antigen presenting cells, blocking the interaction with CD28 on T cells. Belatacept, a second generation CTLA4-Ig with 2 amino acid substitutions, has shown considerable promise in clinical transplantation as part of a maintenance immunosuppression regimen. This review will summarize the role of costimulation in T cell activation, detail the development of costimulation antagonists and highlight the pertinent clinical trials completed and ongoing utilizing belatacept as part of an immunosuppressive regimen in organ transplantation.
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Affiliation(s)
- David Wojciechowski
- University of California, San Francisco, Kidney Transplant Service, CA 94143-0780, United States.
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Wojciechowski D, Hirose R, Stock P, Vincenti F, Baxter-Lowe LA, Salvatierra O. Kidney transplantation at UCSF: 8,300 transplants and onward. Clin Transpl 2010:161-167. [PMID: 21696039] [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: 05/31/2023]
Abstract
Overall, the kidney transplant experience at UCSF has been highly successful. The program has made significant contributions to the field of kidney transplantation with advancements in organ allocation, crossmatching, clinical trials, pediatric transplantation, organ preservation and transplantation in HIV-positive recipients, to name a few. The program was built on the shoulders of giants in kidney transplantation but continues to be innovative and bold and does not rely on past success to pave the future. The program is truly a tribute to the many surgeons, nephrologists, fellows and ancillary personnel who have made this program a premiere center for kidney transplantation over the past 40 years.
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Wojciechowski D, Papademetriou V, Faselis C, Fletcher R. Evaluation and Treatment of Resistant or Difficult-to-Control Hypertension. J Clin Hypertens (Greenwich) 2008; 10:837-43. [DOI: 10.1111/j.1751-7176.2008.00037.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Wojciechowski D, Kallakury B, Nouri P. A case of cocaine-induced acute interstitial nephritis. Am J Kidney Dis 2008; 52:792-5. [PMID: 18468752 DOI: 10.1053/j.ajkd.2008.03.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2007] [Accepted: 03/19/2008] [Indexed: 11/11/2022]
Affiliation(s)
- David Wojciechowski
- Department of Internal Medicine, Division of Nephrology and Hypertension, Georgetown University Hospital, Washington, DC 20007, USA.
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Abstract
Hypertension is a major cardiovascular risk factor but most patients remain asymptomatic for many years. Successful therapy not only needs to be effective, it also needs to be well tolerated. beta-blockers are well established as effective antihypertensive agents. However, one major drawback to the currently available beta-blockers, particularly the noncardioselective beta-blockers, is their side-effect profile, including sexual dysfunction, fatigue, depression and metabolic abnormalities such as impaired glucose tolerance and lipid abnormalities. Nebivolol (Bystolic), a novel, highly cardioselective, third-generation beta-blocker that recently received approval by the US FDA for the treatment of hypertension in the USA, is effective in treating blood pressure and has a favorable side-effect profile. Studies conducted in Europe, where nebivolol has been available for some time for the treatment of hypertension, have shown that nebivolol achieves blood pressure reductions comparable to other beta-blockers but with fewer side effects. Additionally, nebivolol has demonstrated similar efficacy in blood pressure reduction when compared with calcium channel blockers and inhibitors of the renin-angiotensin system. When combined with hydrochlorothiazide there was an additive antihypertensive effect. Lastly, nebivolol exhibits a vasodilatory property that is related to its effect on nitric oxide, an intrinsic vasodilator produced in the vascular endothelium. Nebivolol enhances nitric oxide bioavailability. Studies have also demonstrated nebivolol's ability to function as an antioxidant and decrease markers of oxidative stress. These effects are believed to ultimately produce a modulation of the endothelial dysfunction typically seen in hypertension.
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Affiliation(s)
- David Wojciechowski
- Department of Veterans Affairs Medical Center, Georgetown University Medical Center, Washington, DC 20422, USA.
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Peczalski K, Wojciechowski D, Sionek P, Dunajski Z, Palko T. Impedance cardiography vs clamp pletysmography of Penaz in diagnostic of patients with vasovagal syncope. J Biomech 2006. [DOI: 10.1016/s0021-9290(06)84853-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Wojciechowski D, Sionek P, Kowalewski M, Weichert-Kulikowska E, Piotrowska A, Zacharska-Kokot E, Swiderski J, Stopczyk M. [The value of the head-up tilt table test for with unexplained syncope in children and young adolescents]. Med Wieku Rozwoj 1999; 3:199-207. [PMID: 10910651] [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: 02/17/2023]
Abstract
UNLABELLED Syncope occurs in about 15% of children and young adolescents. The diagnosis of syncope of unknown origin is frequently difficult. In 1986, Kenny et al. introduced the Head-up Tilt Table Test (HUT), which enables to reproduce syncope. The aim of the study was to evaluate HUT in diagnosis of syncope in children and young adolescents. Ninety five children and young adolescents (57 females, 38 males, age range 7-18 years) with recurrent syncope of unexplained etiology were referred for HUT. The study group was divided into two subgroups: A--with history consistent with vasovagal syncope (VVS) and B--with non-characteristic symptoms for VVS. HUT was performed according to the Westminster protocol. The patient was tilted at 60 degree for 45 min. or until syncope occurred. Positive response to HUT was 36%. Negative outcome occurred in 59%. Non-diagnostic HUT was observed in 5%. The vasodepressive type of VVS was recognised in 35%, cardioinhibitory in 12% and mixed in 53%. In group A positive response of HUT occurred in 65% of pts., negative in 31%. In group B positive HUT was observed in 4% of pts. and negative in 89%. CONCLUSIONS 1. In children and young adolescents head-up tilt test is a very useful diagnostic method. 2. In patients referred for the head-up tilt test the history of syncope should be taken into consideration.
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Affiliation(s)
- D Wojciechowski
- Oddział Chorób Wewnetrznych i Kardiologii, Szpital Wolski w Warszawie
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Peczalski K, Wołczyk J, Kowalewski M, Wojciechowski D, Gromadzki J, Stopczyk M. [Use of skeletal muscle in cardiac assist]. Pol Tyg Lek 1996; 51:166-9. [PMID: 8927555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- K Peczalski
- Samodzielnej Pracowni Bioinzynierii Klinicznej Instytutu Biocybernetyk, Warszawje
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Suwalski K, Pytkowski M, Zelazny P, Wojciechowski D, Sitkowska E, Sadowski Z, Sitkowski W. Epicardial electric shock ablation of the left lateral accessory pathway. Cardiovasc Surg 1995; 3:545-7. [PMID: 8574541 DOI: 10.1016/0967-2109(95)94456-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Fifty patients with drug-resistant, recurrent tachyarrhythmias causing Wolff-Parkinson-White syndrome underwent surgery between 1990 and 1992. All recognized surgical methods for accessory pathway destruction were performed. Epicardial electric shock ablation was first used as a method of surgically destroying an accessory atrioventricular pathway in 1983. This technique avoids the need for cardioplegia and hypothermia during operation. The procedure is based on the application of a series of two to five electrical shocks (50-150 J) to the region of the atrioventricular groove where the accessory pathway has been previously located. Some 32 patients with a left free wall accessory pathway underwent this operation. Cardioplegia and hypothermia were not required in 22 patients with an accessory pathway located in the left lateral position. In the second group comprising ten patients with a left lateral accessory pathway, four were diagnosed as having a second pathway and four had concomitant heart pathology such as coronary artery disease -- one had an atrial septal defect and another had a ventricular septal defect. Accessory pathway ablation was carried out in these ten patients using epicardial electric shock under normothermic cardiopulmonary bypass. Concomitant heart pathology was corrected at the second stage of the operation under cardiopulmonary bypass with cardioplegia and hypothermia. Postoperative electrophysiological studies confirmed that the accessory pathway had been destroyed in all patients. The only side effects of epicardial electric shock application were transient ST elevation < 1 mm in four patients, transient atrioventricular bloc in two and moderate sinus tachycardia in three.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- K Suwalski
- Second Department of Cardiosurgery, National Institute of Cardiology, Warsaw, Poland
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