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Palaniyappan N, Peach E, Pearce F, Dhaliwal A, Campos-Varela I, Cant MR, Dopazo C, Trotter J, Divani-Patel S, Hatta AAZ, Hopkins L, Testa G, Bilbao A, Kasmani Z, Faloon S, Mirza DF, Klintmalm GB, Bilbao I, Asrani SK, Rajoriya N, Aravinthan AD. Long-term outcomes (beyond 5 years) of liver transplant recipients-A transatlantic multicenter study. Liver Transpl 2024; 30:170-181. [PMID: 37589505 DOI: 10.1097/lvt.0000000000000244] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 07/06/2023] [Indexed: 08/18/2023]
Abstract
The long-term (>5 y) outcomes following liver transplantation (LT) have not been extensively reported. The aim was to evaluate outcomes of LT recipients who have survived the first 5 years. A multicenter retrospective analysis of prospectively collected data from 3 high volume LT centers (Dallas-USA, Birmingham-UK, and Barcelona-Spain) was undertaken. All adult patients, who underwent LT since the inception of the program to December 31, 2010, and survived at least 5 years since their LT were included. Patient survival was the primary outcome. A total of 3682 patients who survived at least 5 years following LT (long-term survivors) were included. Overall, median age at LT was 52 years (IQR 44-58); 53.1% were males; and 84.6% were Caucasians. A total of 49.4% (n=1820) died during a follow-up period of 36,828 person-years (mean follow-up 10 y). A total of 80.2% (n=1460) of all deaths were premature deaths. Age-standardized all-cause mortality as compared to general population was 3 times higher for males and 5 times higher for females. On adjusted analysis, besides older recipients and older donors, predictors of long-term mortality were malignancy, cardiovascular disease, and dialysis. Implementation of strategies such as noninvasive cancer screening, minimizing immunosuppression, and intensive primary/secondary cardiovascular prevention could further improve survival.
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Affiliation(s)
- Naaventhan Palaniyappan
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, UK
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, UK
| | - Emily Peach
- Lifespan and Population Health, School of Medicine, University of Nottingham, UK
| | - Fiona Pearce
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, UK
- Lifespan and Population Health, School of Medicine, University of Nottingham, UK
| | | | - Isabel Campos-Varela
- Liver Unit, Department of Medicine, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Matthew R Cant
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Cristina Dopazo
- Department of Hepatobiliopancreatic Surgery and Transplants, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - James Trotter
- Baylor University Medical Center, Dallas, Texas, USA
| | | | | | - Laurence Hopkins
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | - Angela Bilbao
- Department of Hepatobiliopancreatic Surgery and Transplants, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Zain Kasmani
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Sarah Faloon
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Darius F Mirza
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Centre for Liver and Gastrointestinal Research, NIHR Birmingham Biomedical Research, University of Birmingham, Birmingham, UK
| | | | - Itxarone Bilbao
- Department of Hepatobiliopancreatic Surgery and Transplants, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Neil Rajoriya
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Institute of Immunology & Immunotherapy, University of Birmingham, UK
| | - Aloysious D Aravinthan
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, UK
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, UK
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2
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O’Leary JG, Farris AB, Gebel HM, Asrani SK, Askar M, Garcia V, Snipes GJ, Lo DJ, Knechtle SJ, Klintmalm GB, Demetris AJ. Detailed Analysis of Simultaneous Renal and Liver Allografts in the Presence of DSA. Transplant Direct 2023; 9:e1500. [PMID: 37456590 PMCID: PMC10348731 DOI: 10.1097/txd.0000000000001500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/12/2023] [Accepted: 04/25/2023] [Indexed: 07/18/2023] Open
Abstract
Liver allografts protect renal allografts from the same donor from some, but not all, preformed donor specific alloantibodies (DSA). However, the precise mechanisms of protection and the potential for more subtle alterations/injuries within the grafts resulting from DSA interactions require further study. Methods We reevaluated allograft biopsies from simultaneous liver-kidney transplant recipients who had both allografts biopsied within 60 d of one another and within 30 d of DSA being positive in serum (positive: mean florescence intensity ≥5000). Routine histology, C4d staining, and specialized immunohistochemistry for Kupffer cells (KCs; CD163) and a C4d receptor immunoglobulin-like transcript-4 were carried out in 4 patients with 6 paired biopsies. Results Overt antibody-mediated rejection was found in 3 of 4 renal and liver allografts. One patient had biopsy-confirmed renal and liver allograft antibody-mediated rejection despite serum clearance of DSA. All biopsies showed KC hypertrophy (minimal: 1; mild: 2; moderate: 1; severe: 2) and cytoplasmic C4d KC staining was easily detected in 2 biopsies from 2 patients; minimal and negative in 2 biopsies each. Implications of which are discussed. Control 1-y protocol liver allograft biopsies from DSA- recipients showed neither KC hypertrophy nor KC C4d staining (n = 6). Conclusions Partial renal allograft protection by a liver allograft from the same donor may be partially mediated by phagocytosis/elimination of antibody and complement split products by KCs, as shown decades ago in controlled sensitized experimental animal experiments.
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Affiliation(s)
| | - Alton B. Farris
- Department of Pathology, Emory University Hospital, Atlanta, GA
| | - Howard M. Gebel
- Department of Pathology, Emory University Hospital, Atlanta, GA
| | - Sumeet K. Asrani
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas TX
| | - Medhat Askar
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas TX
| | - Vanessa Garcia
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas TX
| | - George J. Snipes
- Department of Pathology, Baylor University Medical Center, Dallas TX
| | - Denise J. Lo
- Department of Surgery, Duke University, Durham, NC
| | | | - Goran B. Klintmalm
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas TX
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3
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Tran BV, Moris D, Markovic D, Zaribafzadeh H, Henao R, Lai Q, Florman SS, Tabrizian P, Haydel B, Ruiz RM, Klintmalm GB, Lee DD, Taner CB, Hoteit M, Levine MH, Cillo U, Vitale A, Verna EC, Halazun KJ, Tevar AD, Humar A, Chapman WC, Vachharajani N, Aucejo F, Lerut J, Ciccarelli O, Nguyen MH, Melcher ML, Viveiros A, Schaefer B, Hoppe-Lotichius M, Mittler J, Nydam TL, Markmann JF, Rossi M, Mobley C, Ghobrial M, Langnas AN, Carney CA, Berumen J, Schnickel GT, Sudan DL, Hong JC, Rana A, Jones CM, Fishbein TM, Busuttil RW, Barbas AS, Agopian VG. Development and validation of a REcurrent Liver cAncer Prediction ScorE (RELAPSE) following liver transplantation in patients with hepatocellular carcinoma: Analysis of the US Multicenter HCC Transplant Consortium. Liver Transpl 2023; 29:683-697. [PMID: 37029083 DOI: 10.1097/lvt.0000000000000145] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 01/31/2023] [Indexed: 04/09/2023]
Abstract
HCC recurrence following liver transplantation (LT) is highly morbid and occurs despite strict patient selection criteria. Individualized prediction of post-LT HCC recurrence risk remains an important need. Clinico-radiologic and pathologic data of 4981 patients with HCC undergoing LT from the US Multicenter HCC Transplant Consortium (UMHTC) were analyzed to develop a REcurrent Liver cAncer Prediction ScorE (RELAPSE). Multivariable Fine and Gray competing risk analysis and machine learning algorithms (Random Survival Forest and Classification and Regression Tree models) identified variables to model HCC recurrence. RELAPSE was externally validated in 1160 HCC LT recipients from the European Hepatocellular Cancer Liver Transplant study group. Of 4981 UMHTC patients with HCC undergoing LT, 71.9% were within Milan criteria, 16.1% were initially beyond Milan criteria with 9.4% downstaged before LT, and 12.0% had incidental HCC on explant pathology. Overall and recurrence-free survival at 1, 3, and 5 years was 89.7%, 78.6%, and 69.8% and 86.8%, 74.9%, and 66.7%, respectively, with a 5-year incidence of HCC recurrence of 12.5% (median 16 months) and non-HCC mortality of 20.8%. A multivariable model identified maximum alpha-fetoprotein (HR = 1.35 per-log SD, 95% CI,1.22-1.50, p < 0.001), neutrophil-lymphocyte ratio (HR = 1.16 per-log SD, 95% CI,1.04-1.28, p < 0.006), pathologic maximum tumor diameter (HR = 1.53 per-log SD, 95% CI, 1.35-1.73, p < 0.001), microvascular (HR = 2.37, 95%-CI, 1.87-2.99, p < 0.001) and macrovascular (HR = 3.38, 95% CI, 2.41-4.75, p < 0.001) invasion, and tumor differentiation (moderate HR = 1.75, 95% CI, 1.29-2.37, p < 0.001; poor HR = 2.62, 95% CI, 1.54-3.32, p < 0.001) as independent variables predicting post-LT HCC recurrence (C-statistic = 0.78). Machine learning algorithms incorporating additional covariates improved prediction of recurrence (Random Survival Forest C-statistic = 0.81). Despite significant differences in European Hepatocellular Cancer Liver Transplant recipient radiologic, treatment, and pathologic characteristics, external validation of RELAPSE demonstrated consistent 2- and 5-year recurrence risk discrimination (AUCs 0.77 and 0.75, respectively). We developed and externally validated a RELAPSE score that accurately discriminates post-LT HCC recurrence risk and may allow for individualized post-LT surveillance, immunosuppression modification, and selection of high-risk patients for adjuvant therapies.
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Affiliation(s)
- Benjamin V Tran
- Department of Surgery, David Geffen School of Medicine at UCLA, Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Los Angeles, California, USA
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Daniela Markovic
- Department of Medicine, Statistics Core, University of California, Los Angeles, USA
| | - Hamed Zaribafzadeh
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ricardo Henao
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, Sapienza University, AOU Policlinico Umberto I, Rome, Italy
| | - Sander S Florman
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, New York, USA
| | - Parissa Tabrizian
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, New York, USA
| | - Brandy Haydel
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, New York, USA
| | - Richard M Ruiz
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Goran B Klintmalm
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - David D Lee
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA
| | - C Burcin Taner
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA
| | - Maarouf Hoteit
- Penn Transplant Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew H Levine
- Penn Transplant Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Umberto Cillo
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- New York-Presbyterian Hospital, Weill Cornell, New York, New York, USA
| | - Alessandro Vitale
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- New York-Presbyterian Hospital, Weill Cornell, New York, New York, USA
| | - Elizabeth C Verna
- New York-Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Karim J Halazun
- New York-Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Amit D Tevar
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Abhinav Humar
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - William C Chapman
- Section of Transplantation, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Neeta Vachharajani
- Section of Transplantation, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | | | - Jan Lerut
- Department of Abdominal and Transplantation Surgery, Institute for Experimental and Clinical Research, Universite Catholique Louvain, Brussels, Belgium
| | - Olga Ciccarelli
- Department of Abdominal and Transplantation Surgery, Institute for Experimental and Clinical Research, Universite Catholique Louvain, Brussels, Belgium
| | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, California, USA
| | - Marc L Melcher
- Department of Surgery, Stanford University, Palo Alto, California, USA
| | - Andre Viveiros
- Department of Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Benedikt Schaefer
- Department of Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Maria Hoppe-Lotichius
- Clinic for General, Visceral and Transplantation Surgery, Universitatsmedizin Mainz, Mainz, Germany
| | - Jens Mittler
- Clinic for General, Visceral and Transplantation Surgery, Universitatsmedizin Mainz, Mainz, Germany
| | - Trevor L Nydam
- Department of Surgery, Division of Transplant Surgery, University of Colorado School of Medicine, Denver, Colorado, USA
| | - James F Markmann
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Massimo Rossi
- General Surgery and Organ Transplantation Unit, Sapienza University, AOU Policlinico Umberto I, Rome, Italy
| | - Constance Mobley
- Sherrie & Alan Conover Center for Liver Disease & Transplantation, Houston Methodist Hospital, Houston, Texas, USA
| | - Mark Ghobrial
- Sherrie & Alan Conover Center for Liver Disease & Transplantation, Houston Methodist Hospital, Houston, Texas, USA
| | - Alan N Langnas
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Carol A Carney
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jennifer Berumen
- Department of Surgery, Division of Transplantation and Hepatobiliary Surgery, University of California, San Diego, San Diego, California, USA
| | - Gabriel T Schnickel
- Department of Surgery, Division of Transplantation and Hepatobiliary Surgery, University of California, San Diego, San Diego, California, USA
| | - Debra L Sudan
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Johnny C Hong
- Department of Hepatobiliary Surgery & Transplantation, Division of Transplantation, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Abbas Rana
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Christopher M Jones
- Section of Hepatobiliary and Transplant Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Thomas M Fishbein
- Medstar Georgetown Transplant Institute, Georgetown University, Washington, District of Columbia, USA
| | - Ronald W Busuttil
- Department of Surgery, David Geffen School of Medicine at UCLA, Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Los Angeles, California, USA
| | - Andrew S Barbas
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Vatche G Agopian
- Department of Surgery, David Geffen School of Medicine at UCLA, Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Los Angeles, California, USA
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4
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Hannon VN, Tinguely P, McKenna GJ, Brustia R, Kaldas FM, Scatton O, Spiro M, Raptis DA, Busuttil RW, Klintmalm GB. New ERAS in liver transplantation - Past, present, and next steps. Clin Transplant 2022; 36:e14625. [PMID: 35238415 DOI: 10.1111/ctr.14625] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 02/18/2022] [Indexed: 02/04/2023]
Abstract
There are parallels between the history of Enhanced Recovery after Surgery (ERAS) and liver transplantation. Both have been established and advanced by innovative individuals, often going against perceived wisdom and convention. Liver transplantation has traditionally been considered too complex for ERAS pathways, despite a small number of trials showing them to be both safe and of benefit. To date, there are very few randomized controlled trials and cohort studies publishing outcomes on liver transplant patients enrolled in comprehensive ERAS pathways. To progress our field, the 2022 International Liver Transplantation Society's Consensus Conference has created expert panels to analyze the evidence in 32 domains of the liver transplantation pathway using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to generate expert recommendations. These recommendations will be voted on by the international community to gain consensus using the Danish model, and create the ERAS4OLT.org Enhanced Recovery after Liver Transplantation Pathway.
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Affiliation(s)
- Vivienne N Hannon
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK
| | - Pascale Tinguely
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | | | - Raffaele Brustia
- Department of Hepatobiliary and Liver Transplantation Surgery, Pitié-Salpêtrière Hospital, Paris, France
| | - Fady M Kaldas
- Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Olivier Scatton
- Department of Hepatobiliary and Liver Transplantation Surgery, Pitié-Salpêtrière Hospital, Paris, France.,Pierre et Marie Curie University, Paris, France
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Ronald W Busuttil
- Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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5
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Qian T, Fujiwara N, Koneru B, Ono A, Kubota N, Jajoriya AK, Tung MG, Crouchet E, Song WM, Marquez CA, Panda G, Hoshida A, Raman I, Li QZ, Lewis C, Yopp A, Rich NE, Singal AG, Nakagawa S, Goossens N, Higashi T, Koh AP, Bian CB, Hoshida H, Tabrizian P, Gunasekaran G, Florman S, Schwarz ME, Hiotis SP, Nakahara T, Aikata H, Murakami E, Beppu T, Baba H, Warren A, Bhatia S, Kobayashi M, Kumada H, Fobar AJ, Parikh ND, Marrero JA, Rwema SH, Nair V, Patel M, Kim-Schulze S, Corey K, O’Leary JG, Klintmalm GB, Thomas DL, Dibas M, Rodriguez G, Zhang B, Friedman SL, Baumert TF, Fuchs BC, Chayama K, Zhu S, Chung RT, Hoshida Y. Molecular Signature Predictive of Long-Term Liver Fibrosis Progression to Inform Antifibrotic Drug Development. Gastroenterology 2022; 162:1210-1225. [PMID: 34951993 PMCID: PMC8934284 DOI: 10.1053/j.gastro.2021.12.250] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND & AIMS There is a major unmet need to assess the prognostic impact of antifibrotics in clinical trials because of the slow rate of liver fibrosis progression. We aimed to develop a surrogate biomarker to predict future fibrosis progression. METHODS A fibrosis progression signature (FPS) was defined to predict fibrosis progression within 5 years in patients with hepatitis C virus and nonalcoholic fatty liver disease (NAFLD) with no to minimal fibrosis at baseline (n = 421) and was validated in an independent NAFLD cohort (n = 78). The FPS was used to assess response to 13 candidate antifibrotics in organotypic ex vivo cultures of clinical fibrotic liver tissues (n = 78) and cenicriviroc in patients with nonalcoholic steatohepatitis enrolled in a clinical trial (n = 19, NCT02217475). A serum protein-based surrogate FPS was developed and tested in a cohort of compensated cirrhosis patients (n = 122). RESULTS A 20-gene FPS was defined and validated in an independent NAFLD cohort (adjusted odds ratio, 10.93; area under the receiver operating characteristic curve, 0.86). Among computationally inferred fibrosis-driving FPS genes, BCL2 was confirmed as a potential pharmacologic target using clinical liver tissues. Systematic ex vivo evaluation of 13 candidate antifibrotics identified rational combination therapies based on epigallocatechin gallate, which were validated for enhanced antifibrotic effect in ex vivo culture of clinical liver tissues. In patients with nonalcoholic steatohepatitis treated with cenicriviroc, FPS modulation was associated with 1-year fibrosis improvement accompanied by suppression of the E2F pathway. Induction of the PPARα pathway was absent in patients without fibrosis improvement, suggesting a benefit of combining PPARα agonism to improve the antifibrotic efficacy of cenicriviroc. A 7-protein serum protein-based surrogate FPS was associated with the development of decompensation in cirrhosis patients. CONCLUSION The FPS predicts long-term fibrosis progression in an etiology-agnostic manner, which can inform antifibrotic drug development.
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Affiliation(s)
- Tongqi Qian
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, U.S
| | - Naoto Fujiwara
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, U.S.,Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Bhuvaneswari Koneru
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, U.S
| | - Atsushi Ono
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, U.S.,Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Naoto Kubota
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, U.S
| | - Arun K Jajoriya
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, U.S
| | - Matthew G Tung
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, U.S
| | - Emilie Crouchet
- Institut de Recherche sur les Maladies Virales et Hépatiques, Inserm U1110, University of Strasbourg, Strasbourg, France
| | - Won-Min Song
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, U.S
| | - Cesia Ammi Marquez
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, U.S
| | - Gayatri Panda
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, U.S
| | - Ayaka Hoshida
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, U.S
| | - Indu Raman
- Microarray Core Facility, Department of Immunology, BioCenter, University of Texas Southwestern Medical Center, Dallas, U.S
| | - Quan-Zhen Li
- Microarray Core Facility, Department of Immunology, BioCenter, University of Texas Southwestern Medical Center, Dallas, U.S
| | - Cheryl Lewis
- Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, U.S
| | - Adam Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, U.S
| | - Nicole E Rich
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, U.S
| | - Amit G Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, U.S
| | - Shigeki Nakagawa
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Nicolas Goossens
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Switzerland
| | - Takaaki Higashi
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Anna P Koh
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, U.S
| | - C Billie Bian
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, U.S
| | - Hiroki Hoshida
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, U.S
| | - Parissa Tabrizian
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, U.S
| | - Ganesh Gunasekaran
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, U.S
| | - Sander Florman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, U.S
| | - Myron E Schwarz
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, U.S
| | - Spiros P Hiotis
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, U.S
| | - Takashi Nakahara
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroshi Aikata
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Eisuke Murakami
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toru Beppu
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, U.S
| | - Hideo Baba
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, U.S
| | | | | | | | | | - Austin J Fobar
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, U.S
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, U.S
| | - Jorge A Marrero
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, U.S.,Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, U.S
| | | | - Venugopalan Nair
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, U.S
| | - Manishkumar Patel
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, U.S
| | | | - Kathleen Corey
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, U.S
| | | | | | - David L Thomas
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, U.S
| | | | | | - Bin Zhang
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, U.S
| | - Scott L Friedman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, U.S
| | - Thomas F Baumert
- Institut de Recherche sur les Maladies Virales et Hépatiques, Inserm U1110, University of Strasbourg, Strasbourg, France.,IHU, Pole hépato-digestif, Strasbourg University Hospitals, Strasbourg, France
| | - Bryan C Fuchs
- Department of Surgery, Massachusetts General Hospital, Boston, U.S., Ferring Pharmaceuticals, San Diego, U.S
| | - Kazuaki Chayama
- Collaborative Research Laboratory of Medical Innovation, Research Center for Hepatology and Gastroenterology, Hiroshima University, Hiroshima, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
| | - Shijia Zhu
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Raymond T Chung
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Yujin Hoshida
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
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6
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Eng NAM, Arjunan V, Prabhakar V, Mannalithara A, Ghaziani T, Ahmed A, Kwo P, Nguyen M, Melcher ML, Busuttil RW, Florman SS, Haydel B, Ruiz RM, Klintmalm GB, Lee DD, Taner CB, Hoteit MA, Verna EC, Halazun KJ, Tevar AD, Humar A, Chapman WC, Vachharajani N, Aucejo F, Nydam TL, Markmann JF, Mobley C, Ghobrial M, Langnas AN, Carney CA, Berumen J, Schnickel GT, Sudan DL, Hong JC, Rana A, Jones CM, Fishbein TM, Agopian V, Dhanasekaran R. Posttransplant Outcomes in Older Patients With Hepatocellular Carcinoma Are Driven by Non-Hepatocellular Carcinoma Factors. Liver Transpl 2021; 27:684-698. [PMID: 33306254 PMCID: PMC8140549 DOI: 10.1002/lt.25974] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/13/2020] [Accepted: 11/05/2020] [Indexed: 01/10/2023]
Abstract
The incidence of hepatocellular carcinoma (HCC) is growing in the United States, especially among the elderly. Older patients are increasingly receiving transplants as a result of HCC, but the impact of advancing age on long-term posttransplant outcomes is not clear. To study this, we used data from the US Multicenter HCC Transplant Consortium of 4980 patients. We divided the patients into 4 groups by age at transplantation: 18 to 64 years (n = 4001), 65 to 69 years (n = 683), 70 to 74 years (n = 252), and ≥75 years (n = 44). There were no differences in HCC tumor stage, type of bridging locoregional therapy, or explant residual tumor between the groups. Older age was confirmed to be an independent and significant predictor of overall survival even after adjusting for demographic, etiologic, and cancer-related factors on multivariable analysis. A dose-response effect of age on survival was observed, with every 5-year increase in age older than 50 years resulting in an absolute increase of 8.3% in the mortality rate. Competing risk analysis revealed that older patients experienced higher rates of non-HCC-related mortality (P = 0.004), and not HCC-related death (P = 0.24). To delineate the precise cause of death, we further analyzed a single-center cohort of patients who received a transplant as a result of HCC (n = 302). Patients older than 65 years had a higher incidence of de novo cancer (18.1% versus 7.6%; P = 0.006) after transplantation and higher overall cancer-related mortality (14.3% versus 6.6%; P = 0.03). Even carefully selected elderly patients with HCC have significantly worse posttransplant survival rates, which are mostly driven by non-HCC-related causes. Minimizing immunosuppression and closer surveillance for de novo cancers can potentially improve the outcomes in elderly patients who received a transplant as a result of HCC.
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Affiliation(s)
| | - Vinodhini Arjunan
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | | | - Ajitha Mannalithara
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | - Tara Ghaziani
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | - Paul Kwo
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | - Mindie Nguyen
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | - Marc L. Melcher
- Department: Surgery - Multi-Organ Transplantation, Stanford University, Stanford, CA
| | - Ronald W. Busuttil
- Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Sander S. Florman
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY
| | - Brandy Haydel
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY
| | - Richard M. Ruiz
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Goran B. Klintmalm
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - David D. Lee
- Department of Transplantation, Mayo Clinic, Jacksonville, FL
| | - C. Burcin Taner
- Department of Transplantation, Mayo Clinic, Jacksonville, FL
| | - Maarouf A. Hoteit
- Division of Gastroenterology and Hepatology, Penn Transplant Institute, University of Pennsylvania
| | | | | | - Amit D. Tevar
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Abhinav Humar
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - William C. Chapman
- Section of Transplantation, Department of Surgery, Washington University in St. Louis, St. Louis, MO
| | - Neeta Vachharajani
- Section of Transplantation, Department of Surgery, Washington University in St. Louis, St. Louis, MO
| | | | - Trevor L. Nydam
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Denver, CO
| | - James F. Markmann
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Constance Mobley
- Sherrie & Alan Conover Center for Liver Disease & Transplantation, Houston Methodist Hospital, Houston, TX
| | - Mark Ghobrial
- Sherrie & Alan Conover Center for Liver Disease & Transplantation, Houston Methodist Hospital, Houston, TX
| | - Alan N. Langnas
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Carol A. Carney
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Jennifer Berumen
- Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, University of California, San Diego, San Diego, CA
| | - Gabriel T. Schnickel
- Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, University of California, San Diego, San Diego, CA
| | - Debra L. Sudan
- Department of Surgery, Duke University Medical Center; Durham, NC
| | - Johnny C. Hong
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Abbas Rana
- Department of Surgery, Baylor College of Medicine, Houston, TX
| | | | - Thomas M. Fishbein
- Section of Hepatobiliary and Transplant Surgery, University of Louisville School of Medicine, Louisville, KY,Medstar Georgetown Transplant Institute, Georgetown University, Washington, District of Columbia
| | - Vatche Agopian
- Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
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7
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Agopian VG, Markovic D, Klintmalm GB, Saracino G, Chapman WC, Vachharajani N, Florman SS, Tabrizian P, Haydel B, Nasralla D, Friend PJ, Boteon YL, Ploeg R, Harlander-Locke MP, Xia V, DiNorcia J, Kaldas FM, Yersiz H, Farmer DG, Busuttil RW. Multicenter validation of the liver graft assessment following transplantation (L-GrAFT) score for assessment of early allograft dysfunction. J Hepatol 2021; 74:881-892. [PMID: 32976864 DOI: 10.1016/j.jhep.2020.09.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 08/29/2020] [Accepted: 09/15/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Early allograft dysfunction (EAD) following liver transplantation (LT) negatively impacts graft and patient outcomes. Previously we reported that the liver graft assessment following transplantation (L-GrAFT7) risk score was superior to binary EAD or the model for early allograft function (MEAF) score for estimating 3-month graft failure-free survival in a single-center derivation cohort. Herein, we sought to externally validate L-GrAFT7, and compare its prognostic performance to EAD and MEAF. METHODS Accuracies of L-GrAFT7, EAD, and MEAF were compared in a 3-center US validation cohort (n = 3,201), and a Consortium for Organ Preservation in Europe (COPE) normothermic machine perfusion (NMP) trial cohort (n = 222); characteristics were compared to assess generalizability. RESULTS Compared to the derivation cohort, patients in the validation and NMP trial cohort had lower recipient median MELD scores; were less likely to require pretransplant hospitalization, renal replacement therapy or mechanical ventilation; and had superior 1-year overall (90% and 95% vs. 84%) and graft failure-free (88% and 93% vs. 81%) survival, with a lower incidence of 3-month graft failure (7.4% and 4.0% vs. 11.1%; p <0.001 for all comparisons). Despite significant differences in cohort characteristics, L-GrAFT7 maintained an excellent validation AUROC of 0.78, significantly superior to binary EAD (AUROC 0.68, p = 0.001) and MEAF scores (AUROC 0.72, p <0.001). In post hoc analysis of the COPE NMP trial, the highest tertile of L-GrAFT7 was significantly associated with time to liver allograft (hazard ratio [HR] 2.17, p = 0.016), Clavien ≥IIIB (HR 2.60, p = 0.034) and ≥IVa (HR 4.99, p = 0.011) complications; post-LT length of hospitalization (p = 0.002); and renal replacement therapy (odds ratio 3.62, p = 0.016). CONCLUSIONS We have validated the L-GrAFT7 risk score as a generalizable, highly accurate, individualized risk assessment of 3-month liver allograft failure that is superior to existing scores. L-GrAFT7 may standardize grading of early hepatic allograft function and serve as a clinical endpoint in translational studies (www.lgraft.com). LAY SUMMARY Early allograft dysfunction negatively affects outcomes following liver transplantation. In independent multicenter US and European cohorts totaling 3,423 patients undergoing liver transplantation, the liver graft assessment following transplantation (L-GrAFT) risk score is validated as a superior measure of early allograft function that accurately discriminates 3-month graft failure-free survival and post-liver transplantation complications.
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Affiliation(s)
- Vatche G Agopian
- Dumont-UCLA Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA.
| | - Daniela Markovic
- Department of Biomathematics, David Geffen School of Medicine at UCLA
| | - Goran B Klintmalm
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Giovanna Saracino
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - William C Chapman
- Section of Transplantation, Department of Surgery, Washington University in St. Louis, St. Louis, MO
| | - Neeta Vachharajani
- Section of Transplantation, Department of Surgery, Washington University in St. Louis, St. Louis, MO
| | - Sander S Florman
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY
| | - Parissa Tabrizian
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY
| | - Brandy Haydel
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY
| | - David Nasralla
- Department of Hepatopancreaticobiliary and Liver Transplant Surgery, Royal Free Hospital, London, UK
| | - Peter J Friend
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | - Rutger Ploeg
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Michael P Harlander-Locke
- Dumont-UCLA Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA
| | - Victor Xia
- Department of Anesthesia, David Geffen School of Medicine at UCLA
| | - Joseph DiNorcia
- Dumont-UCLA Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA
| | - Fady M Kaldas
- Dumont-UCLA Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA
| | - Hasan Yersiz
- Dumont-UCLA Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA
| | - Douglas G Farmer
- Dumont-UCLA Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA
| | - Ronald W Busuttil
- Dumont-UCLA Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA
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8
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O'Leary JG, Philippe A, Freeman R, Heidecke H, Jennings LW, Catar R, Klintmalm GB, Dragun D. Non-HLA Autoantibodies at 1 Year Negatively Affect 5-Year Native Renal Function in Liver Transplant Recipients. Transplant Proc 2021; 53:1019-1024. [PMID: 33579550 DOI: 10.1016/j.transproceed.2021.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 11/20/2020] [Accepted: 01/08/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Angiotensin II type-1 receptor (AT1R) and endothelin-1 type A receptor (ETAR) autoantibodies, in addition to allograft injury, can bind native endothelial cells and cause vascular vasoconstriction and fibrosis progression in nontransplanted organs. Therefore, we investigated long-term native renal function in liver transplant (LT) recipients with and without anti-AT1R-Abs and/or anti-ETAR-Abs present in serum. METHODS Primary LT recipients at our single center from January 2000 to April 2009 had their prospectively collected pre-LT (1269 patients) and year 1 post-LT (795 patients) serum tested retrospectively for anti-AT1R-Abs and/or anti-ETAR-Abs. Anti-AT1R-Abs and anti-ETAR-Abs testing was accomplished with a standardized solid phase assay in which >10 U was considered positive. RESULTS Pretransplant anti-AT1R-Abs and/or anti-ETAR-Abs did not change the median delta creatinine from pretransplant to 1 year post-transplant. In multivariable analysis controlling for diabetes (DM) and calcineurin inhibitor (CNI) use, anti-AT1R-Abs and/or anti-ETAR-Abs at 1-year remained statistically significantly associated with a decline in GFR (measured by Modification of Diet in Renal Disease-6) from years 1-5 post-LT (P = .04). In diabetic patients the association with a decline in renal function was more pronounced with (-9.29 mL/min) vs without (-2.28 mL/min) anti-AT1R-Abs and/or anti-ETAR-Abs at year 1, respectively (P = .004). CONCLUSION At 1-year post-LT, the autoantibodies anti-AT1R-Abs and/or anti-ETAR-Abs are associated in multivariable analysis with an increased risk of native renal function decline especially in diabetic patients.
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Affiliation(s)
| | - Aurélie Philippe
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Nephrology and Intensive Care Medicine, Campus Virchow Klinikum, Berlin, Germany
| | - Robert Freeman
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Harald Heidecke
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Nephrology and Intensive Care Medicine, Campus Virchow Klinikum, Berlin, Germany
| | - Linda W Jennings
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Rusan Catar
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Nephrology and Intensive Care Medicine, Campus Virchow Klinikum, Berlin, Germany
| | - Goran B Klintmalm
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Duska Dragun
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Nephrology and Intensive Care Medicine, Campus Virchow Klinikum, Berlin, Germany; Berlin Institute of Health (BIH), Berlin, Germany
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9
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Kardashian A, Florman SS, Haydel B, Ruiz RM, Klintmalm GB, Lee DD, Taner CB, Aucejo F, Tevar AD, Humar A, Verna EC, Halazun KJ, Chapman WC, Vachharajani N, Hoteit M, Levine MH, Nguyen MH, Melcher ML, Langnas AN, Carney CA, Mobley C, Ghobrial M, Amundsen B, Markmann JF, Sudan DL, Jones CM, Berumen J, Hemming AW, Hong JC, Kim J, Zimmerman MA, Nydam TL, Rana A, Kueht ML, Fishbein TM, Markovic D, Busuttil RW, Agopian VG. Liver Transplantation Outcomes in a U.S. Multicenter Cohort of 789 Patients With Hepatocellular Carcinoma Presenting Beyond Milan Criteria. Hepatology 2020; 72:2014-2028. [PMID: 32124453 DOI: 10.1002/hep.31210] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [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: 09/12/2019] [Revised: 12/29/2019] [Accepted: 02/05/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS The Organ Procurement and Transplantation Network recently approved liver transplant (LT) prioritization for patients with hepatocellular carcinoma (HCC) beyond Milan Criteria (MC) who are down-staged (DS) with locoregional therapy (LRT). We evaluated post-LT outcomes, predictors of down-staging, and the impact of LRT in patients with beyond-MC HCC from the U.S. Multicenter HCC Transplant Consortium (20 centers, 2002-2013). APPROACH AND RESULTS Clinicopathologic characteristics, overall survival (OS), recurrence-free survival (RFS), and HCC recurrence (HCC-R) were compared between patients within MC (n = 3,570) and beyond MC (n = 789) who were down-staged (DS, n = 465), treated with LRT and not down-staged (LRT-NoDS, n = 242), or untreated (NoLRT-NoDS, n = 82). Five-year post-LT OS and RFS was higher in MC (71.3% and 68.2%) compared with DS (64.3% and 59.5%) and was lowest in NoDS (n = 324; 60.2% and 53.8%; overall P < 0.001). DS patients had superior RFS (60% vs. 54%, P = 0.043) and lower 5-year HCC-R (18% vs. 32%, P < 0.001) compared with NoDS, with further stratification by maximum radiologic tumor diameter (5-year HCC-R of 15.5% in DS/<5 cm and 39.1% in NoDS/>5 cm, P < 0.001). Multivariate predictors of down-staging included alpha-fetoprotein response to LRT, pathologic tumor number and size, and wait time >12 months. LRT-NoDS had greater HCC-R compared with NoLRT-NoDS (34.1% vs. 26.1%, P < 0.001), even after controlling for clinicopathologic variables (hazard ratio [HR] = 2.33, P < 0.001) and inverse probability of treatment-weighted propensity matching (HR = 1.82, P < 0.001). CONCLUSIONS In LT recipients with HCC presenting beyond MC, successful down-staging is predicted by wait time, alpha-fetoprotein response to LRT, and tumor burden and results in excellent post-LT outcomes, justifying expansion of LT criteria. In LRT-NoDS patients, higher HCC-R compared with NoLRT-NoDS cannot be explained by clinicopathologic differences, suggesting a potentially aggravating role of LRT in patients with poor tumor biology that warrants further investigation.
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Affiliation(s)
- Ani Kardashian
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California, Los Angeles, Los Angeles, CA
| | - Sander S Florman
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY
| | - Brandy Haydel
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY
| | - Richard M Ruiz
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Goran B Klintmalm
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - David D Lee
- Department of Transplantation, Mayo Clinic, Jacksonville, FL
| | - C Burcin Taner
- Department of Transplantation, Mayo Clinic, Jacksonville, FL
| | | | - Amit D Tevar
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Abhinav Humar
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | - William C Chapman
- Section of Transplantation, Department of Surgery, Washington University in St. Louis, St. Louis, MO
| | - Neeta Vachharajani
- Section of Transplantation, Department of Surgery, Washington University in St. Louis, St. Louis, MO
| | - Maarouf Hoteit
- Penn Transplant Institute, University of Pennsylvania, Philadelphia, PA
| | - Matthew H Levine
- Penn Transplant Institute, University of Pennsylvania, Philadelphia, PA
| | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA
| | - Marc L Melcher
- Department of Surgery, Stanford University, Palo Alto, CA
| | - Alan N Langnas
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Carol A Carney
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Constance Mobley
- Sherrie & Alan Conover Center for Liver Disease & Transplantation, Houston Methodist Hospital, Houston, TX
| | - Mark Ghobrial
- Sherrie & Alan Conover Center for Liver Disease & Transplantation, Houston Methodist Hospital, Houston, TX
| | - Beth Amundsen
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - James F Markmann
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Debra L Sudan
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Christopher M Jones
- Section of Hepatobiliary and Transplant Surgery, University of Louisville School of Medicine, Louisville, KY
| | - Jennifer Berumen
- Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, University of California, San Diego, San Diego, CA
| | - Alan W Hemming
- Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, University of California, San Diego, San Diego, CA
| | - Johnny C Hong
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Joohyun Kim
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Michael A Zimmerman
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Trevor L Nydam
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Denver, CO
| | - Abbas Rana
- Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Michael L Kueht
- Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Thomas M Fishbein
- Medstar Georgetown Transplant Institute, Georgetown University, Washington, DC
| | - Daniela Markovic
- Department of Biomathematics, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Ronald W Busuttil
- Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Vatche G Agopian
- Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
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10
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Hasan MM, Wang Y, Blaji U, Gu J, Nattamai D, Nyarige V, Thompson-Snipes L, Klintmalm GB, O’Leary JG, Wang J, Joo H, Oh S. Critical roles of TIGIT+ human regulatory B cells in the suppression of antibody-mediated allograft rejection. The Journal of Immunology 2020. [DOI: 10.4049/jimmunol.204.supp.87.10] [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] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Abstract
TIGIT (T cell immunoreceptor with Ig and ITIM domains) is a co-inhibitory receptor, highly expressed by Tregs, and contributes to the suppressive function of Tregs by limiting pro-inflammatory Th1 and Th17 cell responses. Herein, we report that subsets of human regulatory B cells (Bregs) express surface TIGIT and can thus play a critical role in immune regulation. Using data from human B cell surface arrays and RNA-seq, we identified two major TIGIT+ human Bregs subsets, exhibiting CD24hiCD27+CD39hiIgD+IgMhiCD1chi marginal zone (MZ)-like and CD24hiCD27+CD39+IgD−IgM+CD1c+ memory Bregs. We further demonstrated that TIGIT+ Bregs were also capable of suppressing immune responses by their ability to express not only IL-10 and PD-L1, but also granzyme B and TGFb1. In addition, TIGIT+ Bregs can also suppress immune responses by altering dendritic cell functions. In line with these observations, liver allograft recipients with donor-specific alloantibody (DSA) had significantly lower numbers of TIGIT+ Bregs than those without DSA. Moreover, the frequency of TIGIT+ Bregs correlated with that of CD4+CD25+CD127lo Tregs, while it inversely correlated with the frequency of follicular helper T cells. We thus concluded that TIGIT+ Bregs play critical roles in immune regulation in liver allograft recipients.
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Affiliation(s)
- Md Mahmudul Hasan
- 1Department of Immunology, Mayo Clinic Arizona, Scottsdale, AZ 85259
- 2Institute of Biomedical Studies, Baylor University, Waco, TX 76712
| | - Yuanyuan Wang
- 3Baylor Scott and White Research Institute, Dallas, TX 75204
| | - Uthra Blaji
- 3Baylor Scott and White Research Institute, Dallas, TX 75204
| | - Jinghua Gu
- 3Baylor Scott and White Research Institute, Dallas, TX 75204
| | - Durga Nattamai
- 3Baylor Scott and White Research Institute, Dallas, TX 75204
| | - Verah Nyarige
- 4Department of Health Sciences Research, Mayo Clinic Arizona, Scottsdale, AZ 85259
| | | | - Goran B. Klintmalm
- 5Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas 75246
| | - Jacqueline G. O’Leary
- 5Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas 75246
| | - Junwen Wang
- 4Department of Health Sciences Research, Mayo Clinic Arizona, Scottsdale, AZ 85259
| | - HyeMee Joo
- 1Department of Immunology, Mayo Clinic Arizona, Scottsdale, AZ 85259
- 2Institute of Biomedical Studies, Baylor University, Waco, TX 76712
| | - SangKon Oh
- 1Department of Immunology, Mayo Clinic Arizona, Scottsdale, AZ 85259
- 2Institute of Biomedical Studies, Baylor University, Waco, TX 76712
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11
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Shaked A, DesMarais MR, Kopetskie H, Feng S, Punch JD, Levitsky J, Reyes J, Klintmalm GB, Demetris AJ, Burrell BE, Priore A, Bridges ND, Sayre PH. Outcomes of immunosuppression minimization and withdrawal early after liver transplantation. Am J Transplant 2019; 19:1397-1409. [PMID: 30506630 PMCID: PMC6482056 DOI: 10.1111/ajt.15205] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 11/08/2018] [Accepted: 11/23/2018] [Indexed: 01/25/2023]
Abstract
The Immune Tolerance Network ITN030ST A-WISH assessed immunosuppression withdrawal in liver transplant recipients with hepatitis C or nonimmune nonviral liver disease. Of 275 recipients enrolled before transplantation, 95 were randomly assigned 4:1 to withdrawal (n = 77) or maintenance (n = 18) 1- to 2-years posttransplant. Randomization eligibility criteria included stable immunosuppression monotherapy; adequate liver and kidney function; ≤Stage 2 Ishak fibrosis; and absence of rejection on biopsy. Immunosuppression withdrawal followed an 8-step reduction algorithm with ≥8 weeks per level. Fifty-two of 77 subjects (67.5%) reduced to ≤50% of baseline dose, and 10 of 77 (13.0%) discontinued all immunosuppression for ≥1 year. Acute rejection and/or abnormal liver tests were treated with increased immunosuppression; 5 of 32 rejection episodes required a methylprednisolone bolus. The composite end point (death or graft loss; grade 4 secondary malignancy or opportunistic infection; Ishak stage ≥3; or >25% decrease in glomerular filtration rate within 24 months of randomization) occurred in 12 of 66 (18%) and 4 of 13 (31%) subjects in the withdrawal and maintenance groups. Early immunosuppression minimization is feasible in selected liver recipients, while complete withdrawal is successful in only a small proportion. The composite end point comparison was inconclusive for noninferiority of the withdrawal to the maintenance group.
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Affiliation(s)
| | | | | | - Sandy Feng
- University of California San Francisco, San Francisco, CA, USA
| | | | | | | | | | | | | | - Allison Priore
- National Institutes of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Nancy D. Bridges
- National Institutes of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Peter H. Sayre
- Immune Tolerance Network, San Francisco, CA, USA,University of California San Francisco, San Francisco, CA, USA
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12
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Klintmalm GB, Kaplan B, Kirk AD. FDA jeopardizes the lives of lung transplant recipients and in the process severely increases the cost to develop new immunosuppression. Am J Transplant 2019; 19:971-972. [PMID: 30552744 DOI: 10.1111/ajt.15215] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 11/21/2018] [Accepted: 11/26/2018] [Indexed: 01/25/2023]
Affiliation(s)
- Goran B Klintmalm
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Dallas, Texas
| | - Bruce Kaplan
- Transplant Services, Baylor Scott & White Health, Temple, Texas
| | - Allan D Kirk
- Department of Surgery, Duke University, Durham, North Carolina
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13
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Leal-Leyte P, McKenna GJ, Ruiz RM, Anthony TL, Saracino G, Testa G, Klintmalm GB, T W Kim P. Eversion Bile Duct Anastomosis: A Safe Alternative for Bile Duct Size Discrepancy in Deceased Donor Liver Transplantation. Liver Transpl 2018; 24:1011-1018. [PMID: 29637692 DOI: 10.1002/lt.25075] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 03/05/2018] [Accepted: 03/26/2018] [Indexed: 12/12/2022]
Abstract
Bile duct size discrepancy in liver transplantation may increase the risk of biliary complications (BCs). The aim of this study was to evaluate the safety and outcomes of the eversion bile duct anastomosis technique in deceased donor liver transplantation (DDLT) with duct-to-duct anastomosis. A total of 210 patients who received a DDLT with duct-to-duct anastomosis from 2012 to 2017 were divided into 2 groups: those who had eversion bile duct anastomosis (n = 70) and those who had standard bile duct anastomosis (n = 140). BC rates were compared between the 2 groups. There was no difference in the cumulative incidence of biliary strictures (P = 0.20) and leaks (P = 0.17) between the 2 groups. The BC rate in the eversion group was 14.3% and 11.4% in the standard anastomosis group. All the BCs in the eversion group were managed with endoscopic stenting. A severe size mismatch (≥3:1 ratio) was associated with a significantly higher incidence of biliary strictures (44.4%) compared with a 2:1 ratio (8.2%; P = 0.002). In conclusion, the use of the eversion technique is a safe alternative for bile duct discrepancy in DDLT. However, severe bile duct size mismatch may be a risk factor for biliary strictures with such a technique.
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Affiliation(s)
- Pilar Leal-Leyte
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Greg J McKenna
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Richard M Ruiz
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Tiffany L Anthony
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Giovanna Saracino
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Giuliano Testa
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Goran B Klintmalm
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Peter T W Kim
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
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14
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Testa G, McKenna GJ, Gunby RT, Anthony T, Koon EC, Warren AM, Putman JM, Zhang L, dePrisco G, Mitchell JM, Wallis K, Klintmalm GB, Olausson M, Johannesson L. First live birth after uterus transplantation in the United States. Am J Transplant 2018; 18:1270-1274. [PMID: 29575738 DOI: 10.1111/ajt.14737] [Citation(s) in RCA: 147] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 03/09/2018] [Accepted: 03/09/2018] [Indexed: 01/25/2023]
Abstract
Uterus transplantation has proven to be a successful treatment for women with absolute uterine infertility, caused either by the absence of a uterus or the presence of a nonfunctioning uterus. We report the first birth of a healthy child following uterus transplantation in the United States, from a recipient of a uterus allograft procured from an altruistic living donor. Two major modifications from the previously reported live births characterized this uterus transplant. First, the transplanted uterus relied upon and sustained the pregnancy while having only the utero-ovarian vein as venous outflow. The implication is a significantly simplified living donor surgery that paves the way for minimally invasive laparoscopic or robot-assisted techniques for the donor hysterectomy. Second, the time from transplantation to embryo transfer was significantly shortened from prior protocols, allowing for an overall shorter exposure to immunosuppression by the recipient and lowering the risk for potential adverse effects from these medications.
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Affiliation(s)
- G Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - G J McKenna
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - R T Gunby
- Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX, USA
| | - T Anthony
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - E C Koon
- Obstetrics and Gynecology/Gynecologic Oncology, Baylor University Medical Center, Dallas, TX, USA
| | - A M Warren
- Division of Trauma, Acute Care and Critical Care Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - J M Putman
- Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX, USA.,Fertility Center of Dallas, Dallas, TX, USA
| | - L Zhang
- Fertility Center of Dallas, Dallas, TX, USA
| | - G dePrisco
- Diagnostic Radiology, Baylor University Medical Center, Dallas, TX, USA
| | - J M Mitchell
- Pathology, Baylor University Medical Center, Dallas, TX, USA
| | - K Wallis
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - G B Klintmalm
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - M Olausson
- Transplantation Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - L Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
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15
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Warren AM, Testa G, Anthony T, McKenna GJ, Klintmalm GB, Wallis K, Koon EC, Gunby RT, Johannesson L. Live nondirected uterus donors: Psychological characteristics and motivation for donation. Am J Transplant 2018; 18:1122-1128. [PMID: 29364592 DOI: 10.1111/ajt.14670] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 01/16/2018] [Accepted: 01/18/2018] [Indexed: 01/25/2023]
Abstract
Emerging research suggests that uterus transplantation is a viable option for women without a uterus who want to become pregnant and carry a child to term. Currently, no knowledge exists regarding nondirected uterus donors. This study (NCT 02656550) explored the baseline psychological characteristics of nondirected uterus donors at a single study site. Of the 62 potential donors who underwent initial screening, 6 nondirected donors were chosen and participated in uterus donation. Participants received a comprehensive evaluation, which included clinical history and psychological assessments. The mean age of the donors was 42 years; most (83%) were white/not Hispanic, and all had a college degree. Current depression was reported by 2 participants, past depression was reported in 2 participants, and past anxiety was reported in 3 participants. Based on several different psychological measures, donors had a higher general well-being than the normative sample, and none of the participants' scores indicated psychological distress. All 6 women indicated that giving another woman an opportunity to carry her own child was a motivation for pursuing uterus donation. Further research on potential psychological motives and gains for the donor as well as long-term effects on donors is crucial for ethical practice.
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Affiliation(s)
- A M Warren
- Division of Trauma, Acute Care and Critical Care Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - G Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - T Anthony
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - G J McKenna
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - G B Klintmalm
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - K Wallis
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - E C Koon
- Gynecologic Oncology/Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX, USA
| | - R T Gunby
- Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX, USA
| | - L Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
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16
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Affiliation(s)
- Peter T W Kim
- University of British Columbia, Vancouver, BC, Canada.,Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Goran B Klintmalm
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
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17
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Johannesson L, Wallis K, Koon EC, McKenna GJ, Anthony T, Leffingwell SG, Klintmalm GB, Gunby RT, Testa G. Living uterus donation and transplantation: experience of interest and screening in a single center in the United States. Am J Obstet Gynecol 2018; 218:331.e1-331.e7. [PMID: 29221944 DOI: 10.1016/j.ajog.2017.11.594] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [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] [Received: 08/22/2017] [Revised: 11/07/2017] [Accepted: 11/29/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Little is known about attitudes toward uterus donation and transplantation in society and the interest of the women the treatment is aimed to assist. OBJECTIVE This study examined the interest of recipients and living donors in our uterus transplantation program; it describes the screening protocol we developed and the results of the screening and reports demographic data and characteristics of screened candidates. STUDY DESIGN Initial screening and evaluation included physical examinations by a gynecologist and a transplant surgeon; psychological evaluation; imaging (x-ray, computed tomography, ultrasound); blood tests; immunological testing; viral, bacterial, and fungal testing; drug screen; hormonal testing; Papanicolau smear; urinalysis; and electrocardiogram. For selected recipients, the process also included in vitro fertilization. RESULTS A total of 351 women contacted our department with interest in participating in uterus transplantation; 272 were potential recipients and 79 were potential donors. Among these women, 179 potential recipients and 62 potential donors continued the evaluation after the initial telephone screening. The mean age of the donor candidates was 40 years; all had completed their own family, and 80% were nondirected. Most recipient candidates (92%) had an anatomical lack of the uterus, and of these, 36% had a congenital malformation. The women with a congenital uterine absence were in general younger than the women in the group whose uterus had been removed (mean of 28 and 33 years, respectively). In every step of the initial screening and evaluation process, there were donor and recipient candidates that chose not to continue the process. The reasons for self-withdrawal after expressing interest were not returning phone calls or e-mails (17 donors and 76 recipients); after initial phone screening, no longer interested (1 donor and 9 recipients); in step 1, health history questionnaire not returned after 1 reminder (10 donors and 9 recipients); step 2, not right in their current life situation (2 donors and 2 recipients), and in step 3, chose another way to achieve motherhood (1 recipient). Most donor and recipient candidates (52% and 78%, respectively) could be screened out (because of self-withdrawal or transplant team's decision) during the noninvasive and cost-efficient initial screening. CONCLUSION Our initial experience shows a great interest in participating in a trial of uterus transplantation by both potential recipients and donors. It is the first study to show interest in nondirected donation. A sufficient but thoughtful screening process of living donors and recipients is essential and should aim both to assure donor/recipient safety and to provide good quality grafts.
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Affiliation(s)
- Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX.
| | - Kristin Wallis
- Baylor Research Institute, Baylor University Medical Center, Dallas, TX
| | - E Colin Koon
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX
| | - Greg J McKenna
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Tiffany Anthony
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | | | - Goran B Klintmalm
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Robert T Gunby
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
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18
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Testa G, Anthony T, McKenna GJ, Koon EC, Wallis K, Klintmalm GB, Reese JC, Johannesson L. Deceased donor uterus retrieval: A novel technique and workflow. Am J Transplant 2018; 18:679-683. [PMID: 28858421 DOI: 10.1111/ajt.14476] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/03/2017] [Accepted: 08/18/2017] [Indexed: 01/25/2023]
Abstract
Uterus transplantation has proven successful when performed with a living donor. Subsequently, interest in the novel field of reproductive transplantation is growing. The procedure is still considered experimental, with fewer than 25 cases performed worldwide, and the techniques of both uterus procurement and transplantation are still developing. We detail a new approach to deceased donor uterus procurement. In contrast to reported techniques and our own initial experience, in which the deceased donor uterus was procured post cross-clamp and after other organs were procured, our approach now is to perform the uterus procurement prior to the procurement of other organs in a multiorgan donor and hence prior to cross-clamp. We describe our practical experience in developing and implementing the logistical workflow for deceased donor uterus procurement in a deceased multiorgan donor setting.
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Affiliation(s)
- G Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - T Anthony
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - G J McKenna
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - E C Koon
- Obstetrics and Gynecology/Gynecologic Oncology, Baylor University Medical Center, Dallas, TX, USA
| | - K Wallis
- Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - G B Klintmalm
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - J C Reese
- Southwest Transplant Alliance, Dallas, TX, USA
| | - L Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
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19
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Klintmalm GB, Kaplan B. The kidney allocation system claims equity: It is time to review utility and fairness. Am J Transplant 2017; 17:2999-3000. [PMID: 28787775 DOI: 10.1111/ajt.14457] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 07/27/2017] [Accepted: 07/29/2017] [Indexed: 01/25/2023]
Affiliation(s)
- Goran B Klintmalm
- Annette C. and Harold C. Simmons Transplant Institute, Dallas, TX, USA.,Baylor University Medical Center, Dallas, TX, USA
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20
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Testa G, Koon EC, Johannesson L, McKenna GJ, Anthony T, Klintmalm GB, Gunby RT, Warren AM, Putman JM, dePrisco G, Mitchell JM, Wallis K, Olausson M. Living Donor Uterus Transplantation: A Single Center's Observations and Lessons Learned From Early Setbacks to Technical Success. Am J Transplant 2017; 17:2901-2910. [PMID: 28432742 DOI: 10.1111/ajt.14326] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [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: 01/12/2017] [Revised: 04/04/2017] [Accepted: 04/13/2017] [Indexed: 01/25/2023]
Abstract
Uterus transplantation is a vascularized composite allograft transplantation. It allows women who do not have a uterus to become pregnant and deliver a baby. In this paper, we analyze the first five cases of living donor uterus transplantation performed in the United States. The first three recipients lost their uterus grafts at days 14, 12, and 6, respectively, after transplant. Vascular complications, related to both inflow and outflow problems, were identified as the primary reason for the graft losses. Two recipients, at 6 and 3 mo, respectively, after transplant, have functioning grafts with regular menstrual cycles. Ultimate success will be claimed only after a live birth. This paper is an in-depth analysis of evaluation, surgical technique, and follow-up of these five living donor uterus transplants. The lessons learned were instrumental in allowing us to evolve from failure to technical and functional success. We aim to share our conclusions and build on knowledge in the evolving field of uterus transplantation.
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Affiliation(s)
- G Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - E C Koon
- Obstetrics and Gynecology/Gynecologic Oncology, Baylor University Medical Center, Dallas, TX
| | - L Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX.,Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - G J McKenna
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - T Anthony
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - G B Klintmalm
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - R T Gunby
- Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX
| | - A M Warren
- Baylor Medical Psychology Consultants, Baylor University Medical Center, Dallas, TX
| | - J M Putman
- Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX
| | - G dePrisco
- Diagnostic Radiology, Baylor University Medical Center, Dallas, TX
| | - J M Mitchell
- Pathology, Baylor University Medical Center, Dallas, TX
| | - K Wallis
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - M Olausson
- Transplantation Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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21
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Draoua M, Titze N, Gupta A, Fernandez HT, Ramsay M, Saracino G, McKenna G, Testa G, Klintmalm GB, Kim PTW. Significance of measured intraoperative portal vein flows after thrombendvenectomy in deceased donor liver transplantations with portal vein thrombosis. Liver Transpl 2017; 23:1032-1039. [PMID: 28425187 DOI: 10.1002/lt.24779] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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: 11/13/2016] [Revised: 03/07/2017] [Accepted: 03/16/2017] [Indexed: 02/07/2023]
Abstract
Adequate portal vein (PV) flow in liver transplantation is essential for a good outcome, and it may be compromised in patients with portal vein thrombosis (PVT). This study evaluated the impact of intraoperatively measured PV flow after PV thrombendvenectomy on outcomes after deceased donor liver transplantation (DDLT). The study included 77 patients over a 16-year period who underwent PV thrombendvenectomy with complete flow data. Patients were classified into 2 groups: high PV flow (>1300 mL/minute; n = 55) and low PV flow (≤1300 mL/minute; n = 22). Postoperative complications and graft survival were analyzed according to the PV flow. The 2 groups were similar in demographic characteristics. Low PV flow was associated with higher cumulative rates of biliary strictures (P = 0.02) and lower 1-, 2-, and 5-year graft survival (89%, 85%, and 68% versus 64%, 55%, and 38%, respectively; P = 0.002). There was no difference in the incidence of postoperative PVT between the groups (1.8% versus 9.1%; P = 0.19). No biliary leaks or hepatic artery thromboses were reported in either group. By multivariate analyses, age >60 years (hazard ratio [HR], 3.04, 95% confidence interval [CI], 1.36-6.82; P = 0.007) and low portal flow (HR, 2.31; 95% CI, 1.15-4.65; P = 0.02) were associated with worse survival. In conclusion, PV flow <1300 mL/minute after PV thrombendvenectomy for PVT during DDLT was associated with higher rates of biliary strictures and worse graft survival. Consideration should be given to identifying reasons for low flow and performing maneuvers to increase PV flow when intraoperative PV flows are <1300 mL/minute. Liver Transplantation 23 1032-1039 2017 AASLD.
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Affiliation(s)
| | - Nicole Titze
- Department of Pediatrics, University of California, Irvine, CA
| | - Amar Gupta
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Hoylan T Fernandez
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Michael Ramsay
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Giovanna Saracino
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Gregory McKenna
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Giuliano Testa
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Goran B Klintmalm
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Peter T W Kim
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
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22
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Hasan MM, Joo H, Klintmalm GB, Oh S, Thompson-Snipes L. Regulatory B cells in the blood of plasma cell hepatitis patients who have undergone liver transplantation. The Journal of Immunology 2017. [DOI: 10.4049/jimmunol.198.supp.82.33] [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] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Abstract
Alloreactive T cells and antibody-mediated rejection (AMR) appear to be barriers to long-term organ engraftment. Regulatory B cells (Bregs), a B cell subset, can protect against autoimmune/inflammatory damage, in part, by producing IL-10, an anti-inflammatory cytokine. However, the role of Bregs in solid organ transplantation is poorly understood. In this study, we examined IL-10 producing human Bregs in the blood of healthy controls compared to liver transplanted patients with plasma cell hepatitis (PCH), a variant of late onset rejection. First, we optimized conditions for human Breg differentiation in vitro. Based on the presence of differentially expressed cell surface markers on IL-10+ CD19+ B cells, we then established a profile of Bregs from several human tissues including tonsils and spleens and demonstrated that in vitro generated IL-10+CD19+ B cells are capable to suppress alloantigen stimulated T cell proliferation and cytokine production. Finally, we find that the frequency of CpG B activated IL-10+CD19+ B cells is negligible in PCH+ liver transplant patients compared with healthy controls. In line with this, the frequency of transitional B cells (CD19+CD24hiCD38hi) is significantly lower in PCH+ liver transplanted patients than healthy controls. Our findings suggest that a lack of immunosuppressive Bregs could be associated with the rejection in the PCH+ patients
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Affiliation(s)
- Md Mahmudul Hasan
- 1Institute of Biomedical Studies, Baylor University
- 2Baylor Institute for Immunology Research
| | - HyeMee Joo
- 1Institute of Biomedical Studies, Baylor University
- 2Baylor Institute for Immunology Research
- 3Baylor Scott and White Research Institute
| | | | - SangKon Oh
- 1Institute of Biomedical Studies, Baylor University
- 2Baylor Institute for Immunology Research
- 3Baylor Scott and White Research Institute
| | - LuAnn Thompson-Snipes
- 1Institute of Biomedical Studies, Baylor University
- 2Baylor Institute for Immunology Research
- 3Baylor Scott and White Research Institute
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23
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Gupta A, Klintmalm GB, Kim PTW. Reply. Liver Transpl 2016; 22:1740. [PMID: 27543857 DOI: 10.1002/lt.24612] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 08/12/2016] [Indexed: 01/13/2023]
Affiliation(s)
- Amar Gupta
- Transplant Surgery, Baylor University Medical Center, Dallas, TX
| | | | - Peter T W Kim
- Transplant Surgery, Baylor University Medical Center, Dallas, TX
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Klintmalm GB, Vincenti F, Kirk A. Steroid-Responsive Acute Rejection Should Not Be the End Point for Immunosuppressive Trials. Am J Transplant 2016; 16:3077-3078. [PMID: 27232598 DOI: 10.1111/ajt.13889] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 05/25/2016] [Accepted: 05/26/2016] [Indexed: 01/25/2023]
Affiliation(s)
| | - F Vincenti
- University of California San Francisco, San Francisco, CA
| | - A Kirk
- Duke University, Durham, NC
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Demetris AJ, Bellamy C, Hübscher SG, O'Leary J, Randhawa PS, Feng S, Neil D, Colvin RB, McCaughan G, Fung JJ, Del Bello A, Reinholt FP, Haga H, Adeyi O, Czaja AJ, Schiano T, Fiel MI, Smith ML, Sebagh M, Tanigawa RY, Yilmaz F, Alexander G, Baiocchi L, Balasubramanian M, Batal I, Bhan AK, Bucuvalas J, Cerski CTS, Charlotte F, de Vera ME, ElMonayeri M, Fontes P, Furth EE, Gouw ASH, Hafezi-Bakhtiari S, Hart J, Honsova E, Ismail W, Itoh T, Jhala NC, Khettry U, Klintmalm GB, Knechtle S, Koshiba T, Kozlowski T, Lassman CR, Lerut J, Levitsky J, Licini L, Liotta R, Mazariegos G, Minervini MI, Misdraji J, Mohanakumar T, Mölne J, Nasser I, Neuberger J, O'Neil M, Pappo O, Petrovic L, Ruiz P, Sağol Ö, Sanchez Fueyo A, Sasatomi E, Shaked A, Shiller M, Shimizu T, Sis B, Sonzogni A, Stevenson HL, Thung SN, Tisone G, Tsamandas AC, Wernerson A, Wu T, Zeevi A, Zen Y. 2016 Comprehensive Update of the Banff Working Group on Liver Allograft Pathology: Introduction of Antibody-Mediated Rejection. Am J Transplant 2016; 16:2816-2835. [PMID: 27273869 DOI: 10.1111/ajt.13909] [Citation(s) in RCA: 361] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 06/01/2016] [Accepted: 05/25/2016] [Indexed: 02/06/2023]
Abstract
The Banff Working Group on Liver Allograft Pathology reviewed and discussed literature evidence regarding antibody-mediated liver allograft rejection at the 11th (Paris, France, June 5-10, 2011), 12th (Comandatuba, Brazil, August 19-23, 2013), and 13th (Vancouver, British Columbia, Canada, October 5-10, 2015) meetings of the Banff Conference on Allograft Pathology. Discussion continued online. The primary goal was to introduce guidelines and consensus criteria for the diagnosis of liver allograft antibody-mediated rejection and provide a comprehensive update of all Banff Schema recommendations. Included are new recommendations for complement component 4d tissue staining and interpretation, staging liver allograft fibrosis, and findings related to immunosuppression minimization. In an effort to create a single reference document, previous unchanged criteria are also included.
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Affiliation(s)
- A J Demetris
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - C Bellamy
- The University of Edinburgh, Edinburgh, Scotland
| | | | - J O'Leary
- Baylor University Medical Center, Dallas, TX
| | - P S Randhawa
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - S Feng
- University of California San Francisco Medical Center, San Francisco, CA
| | - D Neil
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - R B Colvin
- Massachusetts General Hospital, Boston, MA
| | - G McCaughan
- Royal Prince Alfred Hospital, Sydney, Australia
| | | | | | - F P Reinholt
- Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - H Haga
- Kyoto University Hospital, Kyoto, Japan
| | - O Adeyi
- University Health Network and University of Toronto, Toronto, Canada
| | - A J Czaja
- Mayo Clinic College of Medicine, Rochester, MN
| | - T Schiano
- Mount Sinai Medical Center, New York, NY
| | - M I Fiel
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - M L Smith
- Mayo Clinic Health System, Scottsdale, AZ
| | - M Sebagh
- AP-HP Hôpital Paul-Brousse, Paris, France
| | - R Y Tanigawa
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - F Yilmaz
- University of Ege, Faculty of Medicine, Izmir, Turkey
| | | | - L Baiocchi
- Policlinico Universitario Tor Vergata, Rome, Italy
| | | | - I Batal
- Columbia University College of Physicians and Surgeons, New York, NY
| | - A K Bhan
- Massachusetts General Hospital, Boston, MA
| | - J Bucuvalas
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - C T S Cerski
- Universidade Federal do Rio Grande do Sul, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | | | | | - M ElMonayeri
- Ain Shams University, Wady El-Neel Hospital, Cairo, Egypt
| | - P Fontes
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - E E Furth
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - A S H Gouw
- University Medical Center Groningen, Groningen, the Netherlands
| | | | - J Hart
- University of Chicago Hospitals, Chicago, IL
| | - E Honsova
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - W Ismail
- Beni-Suef University, Beni-Suef, Egypt
| | - T Itoh
- Kobe University Hospital, Kobe, Japan
| | | | - U Khettry
- Lahey Hospital and Medical Center, Burlington, MA
| | | | - S Knechtle
- Duke University Health System, Durham, NC
| | - T Koshiba
- Soma Central Hospital, Soma, Fukushima, Japan
| | - T Kozlowski
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - C R Lassman
- David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - J Lerut
- Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - J Levitsky
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - L Licini
- Pope John XXIII Hospital, Bergamo, Italy
| | - R Liotta
- Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, University of Pittsburgh Medical Center, Palermo, Italy
| | - G Mazariegos
- Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA
| | - M I Minervini
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - J Misdraji
- Massachusetts General Hospital, Boston, MA
| | - T Mohanakumar
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ
| | - J Mölne
- University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - I Nasser
- Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - J Neuberger
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - M O'Neil
- University of Kansas Medical Center, Kansas City, KS
| | - O Pappo
- Hadassah Medical Center, Jerusalem, Israel
| | - L Petrovic
- University of Southern California, Los Angeles, CA
| | - P Ruiz
- University of Miami, Miami, FL
| | - Ö Sağol
- School of Medicine, Dokuz Eylul University, Izmir, Turkey
| | | | - E Sasatomi
- University of North Carolina School of Medicine, Chapel Hill, NC
| | - A Shaked
- University of Pennsylvania Health System, Philadelphia, PA
| | - M Shiller
- Baylor University Medical Center, Dallas, TX
| | - T Shimizu
- Toda Chuo General Hospital, Saitama, Japan
| | - B Sis
- University of Alberta Hospital, Edmonton, Canada
| | - A Sonzogni
- Pope John XXIII Hospital, Bergamo, Italy
| | | | - S N Thung
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - G Tisone
- University of Rome-Tor Vergata, Rome, Italy
| | | | - A Wernerson
- Karolinska University Hospital, Stockholm, Sweden
| | - T Wu
- Tulane University School of Medicine, New Orleans, LA
| | - A Zeevi
- University of Pittsburgh, Pittsburgh, PA
| | - Y Zen
- Kobe University Hospital, Kobe, Japan
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Klein JA, Gonzalez SA, Fischbach BV, Yango AF, Rajagopal A, Rice KM, Saim M, Barri YM, Melton LB, Klintmalm GB, Chandrakantan A. Routine ultrasonography surveillance of native kidneys for renal cell carcinoma in kidney transplant candidates. Clin Transplant 2016; 30:946-53. [DOI: 10.1111/ctr.12769] [Citation(s) in RCA: 6] [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] [Accepted: 05/15/2016] [Indexed: 12/14/2022]
Affiliation(s)
| | | | | | | | | | - Kim M. Rice
- Baylor University Medical Center; Dallas TX USA
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Gupta A, Klintmalm GB, Kim PTW. Ligating coronary vein varices: An effective treatment of "coronary vein steal" to increase portal flow in liver transplantation. Liver Transpl 2016; 22:1037-9. [PMID: 27028766 DOI: 10.1002/lt.24448] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 03/14/2016] [Accepted: 03/21/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Amar Gupta
- Transplant Surgery, Baylor University Medical Center, Dallas, TX
| | | | - Peter T W Kim
- Transplant Surgery, Baylor University Medical Center, Dallas, TX
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Abstract
Type I diabetes mellitus continues to be a serious disease with long-term morbidity from complications of the disease, despite better knowledge of physiology and better patient care. Pancreatic islet cell transplantation, still experimental, is gaining acceptance as a treatment strategy for individuals with type 1 diabetes who have poor glucose control and frequent hypoglycemic episodes despite maximal care. The procedure can improve glucose control, avoiding further hypoglycemic episodes, and can achieve insulin-independence at the expense of immunosuppression treatment. Islet cell transplantation does not correct all the metabolic abnormalities seen in type 1 diabetes, and glucose tolerance can remain abnormal. The dietary management of the patients still needs to be defined. Further research is focused at improvement in islet isolation and the refinement of immunosuppression strategies aiming toward immune tolerance, bringing hope for a cure of diabetes.
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Affiliation(s)
- Nicholas Onaca
- Transplant Services, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, Texas 75246, USA.
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O'Leary JG, Cai J, Freeman R, Banuelos N, Hart B, Johnson M, Jennings LW, Kaneku H, Terasaki PI, Klintmalm GB, Demetris AJ. Proposed Diagnostic Criteria for Chronic Antibody-Mediated Rejection in Liver Allografts. Am J Transplant 2016; 16:603-14. [PMID: 26469278 DOI: 10.1111/ajt.13476] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 06/11/2015] [Accepted: 07/19/2015] [Indexed: 01/25/2023]
Abstract
Donor-specific alloantibodies (DSA) can cause acute antibody-mediated rejection (AMR) in all solid organ allografts. However, long-term outcome in patients with posttransplant DSA needs further study. We retrospectively evaluated prospectively collected paired serum, tissue, and data on 45 matched DSA- positive [DSA+; mean florescence intensity (MFI) ≥10,000] and -negative (DSA-) recipients of a primary liver-only allograft from January 2000 to April 2009. Blinded histopathologic evaluation demonstrated that DSA+ versus DSA- patients were more likely to have subtle inflammation and unique patterns of fibrosis, despite normal or near-normal liver function tests. Stepwise multivariable modeling developed a score (putatively named the chronic AMR [cAMR] score) that included interface activity, lobular inflammation, portal tract collagenization, portal venopathy, sinusoidal fibrosis, and hepatitis C virus status. The score was developed (c = 0.811) and cross-validated (c = 0.704) to predict allograft failure. Two cutoffs were employed to optimize sensitivity and specificity (80% each); a value >27.5 predicted 50% 10-year allograft failure. We propose chronic AMR as a potential new entity defined by (1) a high cAMR score, (2) DSA, and (3) elimination of other potential causes of a similar injury pattern. In conclusion, cAMR score calculation identified liver allograft recipients with DSA at highest risk for allograft loss, although independent validation is needed.
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Affiliation(s)
- J G O'Leary
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - J Cai
- Terasaki Foundation Laboratory, Los Angeles, CA
| | - R Freeman
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - N Banuelos
- Terasaki Foundation Laboratory, Los Angeles, CA
| | - B Hart
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - M Johnson
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - L W Jennings
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - H Kaneku
- Terasaki Foundation Laboratory, Los Angeles, CA
| | | | - G B Klintmalm
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - A J Demetris
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
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Engels EA, Jennings L, Kemp TJ, Chaturvedi AK, Pinto LA, Pfeiffer RM, Trotter JF, Acker M, Onaca N, Klintmalm GB. Circulating TGF-β1 and VEGF and risk of cancer among liver transplant recipients. Cancer Med 2015; 4:1252-7. [PMID: 25919050 PMCID: PMC4559036 DOI: 10.1002/cam4.455] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [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: 12/04/2014] [Revised: 02/13/2015] [Accepted: 02/22/2015] [Indexed: 12/31/2022] Open
Abstract
Transplant recipients have elevated cancer risk, perhaps partly due to direct carcinogenic effects of immunosuppressive medications. Experimental evidence indicates that calcineurin inhibitors given to transplant recipients increase cellular expression of transforming growth factor β1 (TGF-β1) and vascular endothelial growth factor (VEGF), which could promote cancer. To assess the potential role of these pathways in the transplantation setting, we conducted a case–control study nested in a cohort of liver recipients. Cases had nonmelanoma skin cancer (N = 84), cancer of the lung (N = 29), kidney (N = 20), or colorectum (N = 17), or melanoma (N = 3). We selected N = 463 recipients without cancer as controls. TGF-β1 and VEGF levels were measured in sera obtained, on average, approximately 3 years before case diagnosis/control selection. We also measured platelet factor 4 (PF4), a marker of ex vivo platelet degranulation, because TGF-β1 and VEGF can be released from platelets, and we developed a statistical model to isolate the platelet-derived fraction from the remaining circulating component. Compared with controls, lung cancer cases had higher levels of TGF-β1 (median 22.8 vs. 19.4 ng/mL, P = 0.02) and VEGF (277 vs. 186 pg/mL, P = 0.02). However, lung cancer cases also had higher platelet counts (P = 0.08) and PF4 levels (P = 0.02), while residual serum levels of TGF-β1 and VEGF, after accounting for PF4, were unassociated with lung cancer (P = 0.40 and P = 0.15, respectively). Associations were not seen for other cancers. In conclusion, TGF-β1 and VEGF levels were increased in association with lung cancer among transplant recipients, which may be explained by increased platelet counts and platelet degranulation in lung cancer cases.
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Affiliation(s)
- Eric A Engels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Linda Jennings
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Troy J Kemp
- HPV Immunology Laboratory, Leidos Biomedical Research Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | - Anil K Chaturvedi
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Ligia A Pinto
- HPV Immunology Laboratory, Leidos Biomedical Research Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | - Ruth M Pfeiffer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - James F Trotter
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Michelle Acker
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Nicholas Onaca
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Goran B Klintmalm
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
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Klintmalm GB. Renal toxicity of ciclosporin. Clinical studies. Contrib Nephrol 2015; 51:126-32. [PMID: 3552408 DOI: 10.1159/000413108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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O'Leary JG, Kaneku H, Banuelos N, Jennings LW, Klintmalm GB, Terasaki PI. Impact of IgG3 subclass and C1q-fixing donor-specific HLA alloantibodies on rejection and survival in liver transplantation. Am J Transplant 2015; 15:1003-13. [PMID: 25772599 DOI: 10.1111/ajt.13153] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 10/08/2014] [Accepted: 10/29/2014] [Indexed: 01/25/2023]
Abstract
Recent literature confirms donor-specific HLA alloantibodies (DSA) impair 5-year survival in some but not all liver transplant recipients. In an effort to improve DSA testing's association with rejection and death, we retrospectively evaluated 1270 liver transplant recipients for the presence of IgG3 and C1q-fixing DSA. In patients with preformed DSA, 29 and 51% had IgG3 and C1q-fixing DSA, respectively. In patients with de novo DSA, 62% and 67% had IgG3 and C1q-fixing DSA, respectively. When different types of DSA positive patients were compared to DSA negative patients, multivariable analysis showed that IgG3 DSA positivity had the highest numerical hazard ratio for death (IgG3: HR = 2.4, p < 0.001; C1q: HR = 1.9, p < 0.001; standard DSA: HR = 1.6, p < 0.001). Similarly, multivariable analysis demonstrated de novo IgG3 DSA positivity compared to no DSA had the highest hazard ratio for death (IgG3: HR = 2.1, p = 0.004; C1q: HR = 1.9, p = 0.02; standard DSA: HR = 1.8, p = 0.007). Preformed C1q-fixing class II DSA showed the strongest correlation with early rejection. In conclusion, preformed and de novo IgG3 subclass DSA positive patients had the highest absolute HR for death in side-by-side comparison with C1q and standard DSA positive versus DSA negative patients; however, IgG3 negative DSA positive patients still had inferior outcomes compared to DSA negative patients.
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Affiliation(s)
- J G O'Leary
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
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Kim PTW, Saracino G, Jennings L, Ramsay M, McKenna GJ, Testa G, Anthony TL, Onaca N, Ruiz RM, Goldstein RM, Levy MF, Klintmalm GB. Ratio of hepatic arterial flow to recipient body weight predicts biliary complications after deceased donor liver transplantation. HPB (Oxford) 2014; 16:1083-7. [PMID: 25041738 PMCID: PMC4253331 DOI: 10.1111/hpb.12318] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [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: 03/05/2014] [Accepted: 06/04/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Adequate hepatic arterial (HA) flow to the bile duct is essential in liver transplantation. This study was conducted to determine if the ratio of directly measured HA flow to weight is related to the occurrence of biliary complications after deceased donor liver transplantation. METHODS A retrospective review of 2684 liver transplants carried out over a 25-year period was performed using data sourced from a prospectively maintained database. Rates of biliary complications (biliary leaks, anastomotic and non-anastomotic strictures) were compared between two groups of patients with HA flow by body weight of, respectively, <5 ml/min/kg (n = 884) and ≥5 ml/min/kg (n = 1800). RESULTS Patients with a lower ratio of HA flow to weight had higher body weight (92 kg versus 76 kg; P < 0.001) and lower HA flow (350 ml/min versus 550 ml/min; P < 0.001). A lower ratio of HA flow to weight was associated with higher rates of biliary complications at 2 months, 6 months and 12 months (19.8%, 28.2% and 31.9% versus 14.8%, 22.4% and 25.8%, respectively; P < 0.001). CONCLUSIONS A ratio of HA flow to weight of < 5 ml/min/kg is associated with higher rates of biliary complications. This ratio may be a useful parameter for application in the prevention and early detection of biliary complications.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Goran B Klintmalm
- Correspondence Goran B. Klintmalm, Simmons Transplant Institute, Baylor University Medical Center, 3410 Worth Street, Suite 950, Dallas, TX 75246, USA. Tel: + 1 214 820 1757. Fax: + 1 214 818 6491. E-mail:
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Kruel CR, Ruiz RM, Shiller SM, Anthony TL, Goldstein RM, Kim PTW, Levy MF, Mckenna GJ, Onaca N, Testa G, Klintmalm GB. Posttransplant Lymphoproliferative Disorder Presenting as a Small Bowel Obstruction in a Patient with Pancreas Transplantation Alone. Proc (Bayl Univ Med Cent) 2014; 27:346-8. [DOI: 10.1080/08998280.2014.11929155] [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: 10/18/2022] Open
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Klintmalm GB, Feng S, Lake JR, Vargas HE, Wekerle T, Agnes S, Brown KA, Nashan B, Rostaing L, Meadows-Shropshire S, Agarwal M, Harler MB, García-Valdecasas JC. Belatacept-based immunosuppression in de novo liver transplant recipients: 1-year experience from a phase II randomized study. Am J Transplant 2014; 14:1817-27. [PMID: 25041339 PMCID: PMC4140547 DOI: 10.1111/ajt.12810] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [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: 11/05/2013] [Revised: 03/07/2014] [Accepted: 03/23/2014] [Indexed: 01/25/2023]
Abstract
This exploratory phase II study evaluated the safety and efficacy of belatacept in de novo adult liver transplant recipients. Patients were randomized (N = 260) to one of the following immunosuppressive regimens: (i) basiliximab + belatacept high dose [HD] + mycophenolate mofetil (MMF), (ii) belatacept HD + MMF, (iii) belatacept low dose [LD] + MMF, (iv) tacrolimus + MMF, or (v) tacrolimus alone. All received corticosteroids. Demographic characteristics were similar among groups. The proportion of patients who met the primary end point (composite of acute rejection, graft loss, death by month 6) was higher in the belatacept groups (42–48%) versus tacrolimus groups (15–38%), with the highest number of deaths and grafts losses in the belatacept LD group. By month 12, the proportion surviving with a functioning graft was higher with tacrolimus + MMF (93%) and lower with belatacept LD (67%) versus other groups (90%: basiliximab + belatacept HD; 83%: belatacept HD; 88%: tacrolimus). Mean calculated GFR was 15–34 mL/min higher in belatacept-treated patients at 1 year. Two cases of posttransplant lymphoproliferative disease and one case of progressive multifocal leukoencephalopathy occurred in belatacept-treated patients. Follow-up beyond month 12 revealed an increase in death and graft loss in another belatacept group (belatacept HD), after which the study was terminated.
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Affiliation(s)
- G B Klintmalm
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical CenterDallas, TX,*Corresponding author: Göran B. Klintmalm,
| | - S Feng
- Division of Transplant Surgery, University of California, San FranciscoSan Francisco, CA
| | - J R Lake
- Liver Transplant Program, University of MinnesotaMinneapolis, MN
| | - H E Vargas
- Division of Hepatology, Mayo Clinic ArizonaPhoenix, AZ
| | - T Wekerle
- Division of Transplantation, Medical University of ViennaVienna, Austria
| | - S Agnes
- Department of General and Transplant Surgery, Catholic University, Policlinico “A. Gemelli”Rome, Italy
| | - K A Brown
- Division of Gastroenterology, Henry Ford Health SystemsDetroit, MI
| | - B Nashan
- Department of Hepatobiliary Surgery & Visceral Transplantation, University Medical Center Hamburg-EppendorfHamburg, Germany
| | - L Rostaing
- Department of Nephrology and Organ Transplantation, Toulouse University HospitalToulouse, France,INSERM U1043, IFR-BMT, CHU PurpanToulouse, France
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Zarghouni M, Cura M, Kim PTW, Testa G, Klintmalm GB. Segmental biliary duct N-butyl cyanoacrylate ablation in a transplant liver for a biliary leak after hepaticojejunostomy. Liver Transpl 2014; 20:739-41. [PMID: 24616272 DOI: 10.1002/lt.23862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 02/20/2014] [Indexed: 01/12/2023]
Affiliation(s)
- Mehrzad Zarghouni
- Department of Diagnostic Radiology, Baylor University Medical Center, Dallas, TX
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Klintmalm GB, Saab S, Hong JC, Nashan B. The role of mammalian target of rapamycin inhibitors in the management of post-transplant malignancy. Clin Transplant 2014; 28:635-48. [PMID: 24628264 DOI: 10.1111/ctr.12357] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2014] [Indexed: 01/04/2023]
Abstract
Post-transplant malignancies, which occur either de novo or as cancer recurrences, are due to chronic exposure to immunosuppressive agents and are often more aggressive than those that develop in the non-transplant setting. Mammalian target of rapamycin (mTOR) inhibitors have antitumor and immunosuppressive effects. The dual effects of this class of agents may provide adequate immunosuppression to prevent organ rejection while simultaneously reducing the risk of post-transplant malignancy. mTOR inhibitors have become established approved agents for treating renal cell carcinoma and other cancers and, as reviewed herein, accumulating experience among organ transplant recipients collectively points toward a potential to prevent the development of de novo malignancies of various types in the post-transplant period. To date, most research efforts surrounding mTOR inhibitors and cancer control in the transplant population have been in the area of skin cancer prevention, but there have also been interesting observations regarding regression of post-transplant Kaposi's sarcoma and post-transplantation lymphoproliferative disorder that warrant further study.
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Affiliation(s)
- Goran B Klintmalm
- Department of Transplant Surgery, Baylor University Medical Center at Dallas, Dallas, TX, USA
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Klintmalm GB, Nashan B. The Role of mTOR Inhibitors in Liver Transplantation: Reviewing the Evidence. J Transplant 2014; 2014:845438. [PMID: 24719752 PMCID: PMC3955586 DOI: 10.1155/2014/845438] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 09/20/2013] [Accepted: 09/21/2013] [Indexed: 12/14/2022] Open
Abstract
Despite the success of liver transplantation, long-term complications remain, including de novo malignancies, metabolic syndrome, and the recurrence of hepatitis C virus (HCV) and hepatocellular carcinoma (HCC). The current mainstay of treatment, calcineurin inhibitors (CNIs), can also worsen posttransplant renal dysfunction, neurotoxicity, and diabetes. Clearly there is a need for better immunosuppressive agents that maintain similar rates of efficacy and renal function whilst minimizing adverse effects. The mammalian target of rapamycin (mTOR) inhibitors with a mechanism of action that is different from other immunosuppressive agents has the potential to address some of these issues. In this review we surveyed the literature for reports of the use of mTOR inhibitors in adult liver transplantation with respect to renal function, efficacy, safety, neurological symptoms, de novo tumors, and the recurrence of HCC and HCV. The results of our review indicate that mTOR inhibitors are associated with efficacy comparable to CNIs while having benefits on renal function in liver transplantation. We also consider newer dosing schedules that may limit side effects. Finally, we discuss evidence that mTOR inhibitors may have benefits in the oncology setting and in relation to HCV-related allograft fibrosis, metabolic syndrome, and neurotoxicity.
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Affiliation(s)
- Goran B. Klintmalm
- Baylor Simmons Transplant Institute, Baylor University Medical Center, 3410 Worth Street, Suite 950, Dallas, TX 75246, USA
| | - Björn Nashan
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Eppendorf, Martinistraβe 52, 20246 Hamburg, Germany
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Kaneku H, O'Leary JG, Banuelos N, Jennings LW, Susskind BM, Klintmalm GB, Terasaki PI. De novo donor-specific HLA antibodies decrease patient and graft survival in liver transplant recipients. Am J Transplant 2013. [PMID: 23721554 DOI: 10.1111/ajt.12212] [Citation(s) in RCA: 188] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The role of de novo donor-specific HLA antibodies (DSA) in liver transplantation remains unknown as most of the previous studies have only focused on preformed HLA antibodies. To understand the significance of de novo DSA, we designed a retrospective cohort study of 749 adult liver transplant recipients with pre- and posttransplant serum samples that were analyzed for DSA. We found that 8.1% of patients developed de novo DSA 1 year after transplant; almost all de novo DSAs were against HLA class II antigens, and the majority were against DQ antigens. In multivariable modeling, the use of cyclosporine (as opposed to tacrolimus) and low calcineurin inhibitor levels increased the risk of de novo DSA formation, while a calculated MELD score >15 at transplant and recipient age >60 years old reduced the risk. Multivariable analysis also demonstrated that patients with de novo DSA at 1-year had significantly lower patient and graft survival. In conclusion, we demonstrate that de novo DSA development after liver transplantation is an independent risk factor for patient death and graft loss.
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Affiliation(s)
- H Kaneku
- University of California, Los Angeles, Los Angeles, CA, USA.
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McKenna GJ, Trotter JF, Klintmalm E, Ruiz R, Onaca N, Testa G, Saracino G, Levy MF, Goldstein RM, Klintmalm GB. Sirolimus and cardiovascular disease risk in liver transplantation. Transplantation 2013; 95:215-21. [PMID: 23232369 DOI: 10.1097/tp.0b013e318279090c] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Two adverse effects of sirolimus are hypertriglyceridemia and hypercholesterolemia. These elevated levels often lead clinicians to discontinue the sirolimus from concerns of an increased cardiovascular disease (CVD) risk; however, evidence suggests that sirolimus might be cardioprotective. There are no published reports of sirolimus CVD in liver transplantation. METHODS We reviewed all 1812 liver recipients who underwent transplantation from 1998 to 2010, identifying a cohort using sirolimus as part of the initial immunosuppression (SRL Cohort) and a control group of the remaining patients from this period where SRL was never given (Non-SRL Control). A prospectively maintained database identified all episodes of myocardial infarction (MI), congestive heart failure (CHF), abdominal aortic aneurysm (AAA), and cerebrovascular accident and tracked triglyceride, high-density and low-density lipoproteins, and total cholesterol levels. A Framingham Risk Model calculated the predicted 10-year risk of CVD for both groups. RESULTS The SRL Cohort (n=406) is older, more predominantly male, with more pretransplantation hypertension and diabetes and posttransplantation hypertension compared to Non-SRL Controls (n=1005). The SRL Cohort has significantly higher triglyceride, low-density lipoprotein, and cholesterol levels at 6 months and 1 year. There is no difference in MI incidence in the SRL Cohort (1.0% vs. 1.2%) and no difference in AAA, cerebrovascular accident, and CHF. The Framingham Risk Model predicts that the SRL Cohort should have almost double the 10-year risk of CVD compared to the Non-SRL Control (11% vs. 6%). CONCLUSIONS Sirolimus causes hypertriglyceridemia and hypercholesterolemia, but it does not increase the incidence of MI or other CVDs. Considering the SRL Cohort has more cardiac risk factors and nearly double 10-year predicted CVD risk, the fact that the CVD incidence is similar suggests that sirolimus is in fact cardioprotective.
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Affiliation(s)
- Greg J McKenna
- Department of Surgery, Baylor University Medical Center, Dallas, TX 75246, USA.
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Kim PTW, Onaca N, Chinnakotla S, Davis GL, Jennings LW, McKenna GJ, Ruiz RM, Levy MF, Goldstein R, Klintmalm GB. Tumor biology and pre-transplant locoregional treatments determine outcomes in patients with T3 hepatocellular carcinoma undergoing liver transplantation. Clin Transplant 2013; 27:311-8. [DOI: 10.1111/ctr.12089] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2012] [Indexed: 01/06/2023]
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O'Connor JK, Trotter J, Davis GL, Dempster J, Klintmalm GB, Goldstein RM. Long-term outcomes of stereotactic body radiation therapy in the treatment of hepatocellular cancer as a bridge to transplantation. Liver Transpl 2012; 18:949-54. [PMID: 22467602 DOI: 10.1002/lt.23439] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [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] [Indexed: 12/13/2022]
Abstract
Hepatocellular carcinoma (HCC) is potentially curable with hepatic resection or transplantation. Few patients are eligible for resection, and many face a long wait for donor organ availability for liver transplantation. Here we report the safety and efficacy of stereotactic body radiation therapy (SBRT), the explant pathology findings and survival of patients treated with SBRT as a bridge to transplantation for HCC. From April 2005 to August 2010, 10 patients with 11 HCCs were treated with SBRT as a bridge to transplantation. All patients were evaluated by a liver transplant surgeon before radiosurgery. SBRT was delivered with the CyberKnife robotic radiosurgery system. After SBRT, all patients underwent orthotopic liver transplantation. The tumor response was determined by explant pathology. The median follow-up was 62 months from the time of SBRT. The mean time on the liver transplant wait list was 163 days. The median tumor size was 3.4 cm (range = 2.5-5.5 cm). The median SBRT dose was 51 Gy (range = 33-54 Gy) in 3 fractions. The median time from SBRT to liver transplantation was 113 days (range = 8-794 days). At 5 years, the overall survival rate and the disease-free survival rate were both 100%. Overall, 4 of the 10 patients (40%) experienced acute toxicity. Most toxicities were grade 1, and they included nausea, fatigue, and abdominal discomfort. One patient had grade 2 nausea/vomiting. Explant pathology revealed no viable tumor in 3 of the 11 tumors for a complete response rate of 27%. The remaining 8 tumors decreased or remained stable in size. In conclusion, with a median follow-up over 5 years, we have found that SBRT as a bridge to liver transplantation for HCC is feasible and well tolerated. SBRT for HCC may enable patients to remain on the list for frequently curative transplantation during the wait for organ availability.
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Affiliation(s)
- John K O'Connor
- Baylor Radiosurgery Center, Baylor University Medical Center, Dallas, TX 75246, USA.
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Ruiz R, Tomiyama K, Campsen J, Goldstein RM, Levy MF, McKenna GJ, Onaca N, Susskind B, Tillery GW, Klintmalm GB. Implications of a positive crossmatch in liver transplantation: a 20-year review. Liver Transpl 2012; 18:455-60. [PMID: 22139972 DOI: 10.1002/lt.22474] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [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] [Indexed: 12/31/2022]
Abstract
Whether a positive crossmatch result has any relevance to liver transplantation (LT) outcomes remains controversial. We assessed the impact of a positive crossmatch result on patient and graft survival and posttransplant complications. During a 20-year period, 2723 LT procedures with crossmatch results were identified: 2479 primary transplants and 244 retransplants. The rates of positive B cell and T cell crossmatches were 10.1% and 7.4%, respectively, for primary transplants and 14.6% and 6.4%, respectively, for retransplants (P = 0.049 for a B cell crossmatch). Across all primary transplants, females (P < 0.001) and patients with autoimmune hepatitis (P < 0.001) had greater frequencies of positive crossmatches. There was no effect from race or age. For both primary transplants and retransplants, patient survival and graft survival were not affected by the presence of a positive crossmatch. With respect to posttransplant complications, there were no differences in rejection episodes (hyperacute, acute, or chronic) or technical complications (biliary and vascular) between negative and positive crossmatch groups. However, there were significant differences in the pathological findings of preservation injury (PI) on liver biopsy samples taken at the time of transplantation and within the first week of transplantation (P = 0.003 for B cells and P = 0.03 for T cells). In summary, a positive crossmatch had no significant impact on patient survival or graft outcomes. However, there was a significantly higher incidence of PI in primary LT recipients with a positive crossmatch. This finding is important for a broader understanding of PI, which may include a significant immunological component.
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Affiliation(s)
- Richard Ruiz
- Annette C and Harold C Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA.
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McKenna GJ, Trotter JF, Klintmalm E, Onaca N, Ruiz R, Jennings LW, Neri M, O'Leary JG, Davis GL, Levy MF, Goldstein RM, Klintmalm GB. Limiting hepatitis C virus progression in liver transplant recipients using sirolimus-based immunosuppression. Am J Transplant 2011; 11:2379-87. [PMID: 21967703 DOI: 10.1111/j.1600-6143.2011.03767.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Hepatitis C virus (HCV) causes progressive liver fibrosis in liver transplant recipients and is the principal cause of long-term allograft failure. The antifibrotic effects of sirolimus are seen in animal models but have not been described in liver transplant recipients. We reviewed 1274 liver recipients from 2002 to 2010 and identified a cohort of HCV recipients exposed to sirolimus as primary immunosuppression (SRL Cohort) and an HCV Control Group of recipients who had never received sirolimus. Yearly protocol biopsies were done recording fibrosis stage (METAVIR score) with biopsy compliance of >80% at both year one and two. In an intent-to-treat analysis, the SRL Cohort had significantly less advanced fibrosis (stage ≥2) compared to the HCV Control Group at year one (15.3% vs. 36.2%, p < 0.0001) and year two (30.1% vs. 50.5%, p = 0.001). Because sirolimus is sometimes discontinued for side effects, the SRL Cohort was subgroup stratified for sirolimus duration, showing progressively less fibrosis with longer sirolimus duration. Multivariate analysis demonstrated sirolimus as an independent predictor of minimal fibrosis at year one, and year two. This is the first study among liver transplant recipients with recurrent HCV to describe the positive impact of sirolimus in respect of reduced fibrosis extent and rate of progression.
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Affiliation(s)
- G J McKenna
- Surgery Medicine, Baylor Transplant Institute, Baylor University Medical Center, Dallas, TX, USA.
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McKenna GJ, Trotter JF, Klintmalm E, Onaca N, Ruiz R, Jennings LW, Neri M, O'Leary JG, Davis GL, Levy MF, Goldstein RM, Klintmalm GB. Limiting hepatitis C virus progression in liver transplant recipients using sirolimus-based immunosuppression. Am J Transplant 2011. [PMID: 21967703 DOI: 10.1111/j.1600-6143.2011.03767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Hepatitis C virus (HCV) causes progressive liver fibrosis in liver transplant recipients and is the principal cause of long-term allograft failure. The antifibrotic effects of sirolimus are seen in animal models but have not been described in liver transplant recipients. We reviewed 1274 liver recipients from 2002 to 2010 and identified a cohort of HCV recipients exposed to sirolimus as primary immunosuppression (SRL Cohort) and an HCV Control Group of recipients who had never received sirolimus. Yearly protocol biopsies were done recording fibrosis stage (METAVIR score) with biopsy compliance of >80% at both year one and two. In an intent-to-treat analysis, the SRL Cohort had significantly less advanced fibrosis (stage ≥2) compared to the HCV Control Group at year one (15.3% vs. 36.2%, p < 0.0001) and year two (30.1% vs. 50.5%, p = 0.001). Because sirolimus is sometimes discontinued for side effects, the SRL Cohort was subgroup stratified for sirolimus duration, showing progressively less fibrosis with longer sirolimus duration. Multivariate analysis demonstrated sirolimus as an independent predictor of minimal fibrosis at year one, and year two. This is the first study among liver transplant recipients with recurrent HCV to describe the positive impact of sirolimus in respect of reduced fibrosis extent and rate of progression.
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Affiliation(s)
- G J McKenna
- Surgery Medicine, Baylor Transplant Institute, Baylor University Medical Center, Dallas, TX, USA.
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McKenna GJ, Trotter JF, Klintmalm E, Onaca N, Ruiz R, Jennings LW, Neri M, O'Leary JG, Davis GL, Levy MF, Goldstein RM, Klintmalm GB. Limiting hepatitis C virus progression in liver transplant recipients using sirolimus-based immunosuppression. Am J Transplant 2011. [PMID: 21967703 DOI: 10.1111/j.1600-6143.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hepatitis C virus (HCV) causes progressive liver fibrosis in liver transplant recipients and is the principal cause of long-term allograft failure. The antifibrotic effects of sirolimus are seen in animal models but have not been described in liver transplant recipients. We reviewed 1274 liver recipients from 2002 to 2010 and identified a cohort of HCV recipients exposed to sirolimus as primary immunosuppression (SRL Cohort) and an HCV Control Group of recipients who had never received sirolimus. Yearly protocol biopsies were done recording fibrosis stage (METAVIR score) with biopsy compliance of >80% at both year one and two. In an intent-to-treat analysis, the SRL Cohort had significantly less advanced fibrosis (stage ≥2) compared to the HCV Control Group at year one (15.3% vs. 36.2%, p < 0.0001) and year two (30.1% vs. 50.5%, p = 0.001). Because sirolimus is sometimes discontinued for side effects, the SRL Cohort was subgroup stratified for sirolimus duration, showing progressively less fibrosis with longer sirolimus duration. Multivariate analysis demonstrated sirolimus as an independent predictor of minimal fibrosis at year one, and year two. This is the first study among liver transplant recipients with recurrent HCV to describe the positive impact of sirolimus in respect of reduced fibrosis extent and rate of progression.
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Affiliation(s)
- G J McKenna
- Surgery Medicine, Baylor Transplant Institute, Baylor University Medical Center, Dallas, TX, USA.
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O'Leary JG, Susskind B, Savino D, McIntyre J, Wagenknecht D, Vaidya S, Baker JE, Klintmalm GB. 227-P Hyperacute liver allograft loss from antiphospholipid antibodies (APL). Hum Immunol 2011. [DOI: 10.1016/j.humimm.2011.07.252] [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: 11/16/2022]
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Qin H, Matsumoto S, Klintmalm GB, De Vol EB. A Meta-Analysis for Comparison of the Two-Layer and University of Wisconsin Pancreas Preservation Methods in Islet Transplantation. Cell Transplant 2011; 20:1127-37. [DOI: 10.3727/096368910x544942] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Conflicting results have been reported on the effectiveness of the two-layer method (TLM) compared with the University of Wisconsin (UW) method for preserving pancreata. The objective of this study was to compile the evidence for or against any difference in human islet yield and viability between these two. PubMed (January 2000 to May 2008) and Cochran Library searches were performed and 17 studies were included for the meta-analysis. Data on donor characteristics, preservation time, and outcomes were abstracted. Studies were subgrouped based on how TLM was used (UW + TLM or TLM alone), on mean cold ischemic time (CIT) (>20 h or <20 h), and on whether special chemical was used (yes or no). Meta-analysis of all studies and subgroups was performed and the pooled standardized mean differences (SMD) with 95% confidence intervals (CI) were reported. Overall, the use of TLM significantly increased islet yield [SMD, 0.74 (0.44–1.04)] and viability [SMD, 0.63 (0.14–1.12)]. The beneficial effects of TLM on islet yield were more evident when TLM was used following UW storage or when prolonged CIT was used. TLM used alone, shorter CIT, and no chemical use all resulted in similar islet viability between TLM and UW groups. Beneficial effects of TLM on islet viability were demonstrated only when TLM was used following UW storage, or with prolonged CIT, or with chemical use. In conclusion, the TLM was beneficial for prolonged pancreas preservation before human islet isolation; however, benefit of the TLM for short-term preservation was not clear.
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Affiliation(s)
- Huanying Qin
- Institute for Health Care Research and Improvement, Baylor Health Care System, Dallas, TX, USA
| | - Shinichi Matsumoto
- Baylor Institute for Immunology Research, Baylor Health Care System, Dallas, TX, USA
| | - Goran B. Klintmalm
- Baylor Regional Transplant Institute, Baylor Health Care System, Dallas, TX, USA
| | - Edward B. De Vol
- Institute for Health Care Research and Improvement, Baylor Health Care System, Dallas, TX, USA
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