1
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Mejia CD, Malat GE, Boyle SM, Ranganna K, Lee DH. Experience with a six-month regimen of Pneumocystis pneumonia prophylaxis in 122 HIV-positive kidney transplant recipients. Transpl Infect Dis 2020; 23:e13511. [PMID: 33217136 DOI: 10.1111/tid.13511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 10/28/2020] [Accepted: 11/08/2020] [Indexed: 11/29/2022]
Abstract
Anti-Pneumocystis pneumonia (PCP) prophylaxis is recommended for 3 to 6 months post-transplant in HIV-negative kidney transplant recipients. For HIV-positive kidney transplant recipients, there is no definite duration of primary prophylaxis and is often prescribed life-long. The objective of this study was to determine the incidence of PCP in HIV-positive recipients who received 6 months of prophylaxis with trimethoprim-sulfamethoxazole or an alternative agent. One hundred and twenty-two HIV-positive recipients received a kidney transplant from 2001 to 2017 at Hahnemann University Hospital. Most patients received induction immunosuppression with an IL-2 receptor antagonist, with or without intravenous immunoglobulin. Only one patient received anti-thymocyte globulin. Maintenance immunosuppression included a calcineurin-inhibitor (tacrolimus or cyclosporine), an antiproliferative agent (mycophenolate or sirolimus), and prednisone. Mean CD4 cell count was 461 ± 127 cells/uL prior to transplant and 463 ± 229 cells/μL at 6 to 12 months after transplant. None of the recipients developed PCP after a median follow-up of 2.88 years (IQR 1.16-4.87). Based on our observation, a 6-month regimen of PCP prophylaxis may be sufficient among HIV-positive recipients, similar to those without HIV infection.
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Affiliation(s)
- Christina D Mejia
- Division of Nephrology, Johns Hopkins University, Baltimore, MD, USA
| | - Gregory E Malat
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Suzanne M Boyle
- Division of Nephrology, Hypertension, and Kidney Transplantation, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Karthik Ranganna
- Division of Nephrology, Drexel University College of Medicine, West Reading, PA, USA
| | - Dong Heun Lee
- Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA
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2
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Harhay MN, Harhay MO, Ranganna K, Boyle SM, Levin Mizrahi L, Guy S, Malat GE, Xiao G, Reich DJ, Patzer RE. Association of the kidney allocation system with dialysis exposure before deceased donor kidney transplantation by preemptive wait-listing status. Clin Transplant 2018; 32:e13386. [PMID: 30132986 DOI: 10.1111/ctr.13386] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/08/2018] [Accepted: 08/16/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND It is unknown whether the new kidney transplant allocation system (KAS) has attenuated the advantages of preemptive wait-listing as a strategy to minimize pretransplant dialysis exposure. METHODS We performed a retrospective study of adult US deceased donor kidney transplant (DDKT) recipients between December 4, 2011-December 3, 2014 (pre-KAS) and December 4, 2014-December 3, 2017 (post-KAS). We estimated pretransplant dialysis durations by preemptive listing status in the pre- and post-KAS periods using multivariable gamma regression models. RESULTS Among 65 385 DDKT recipients, preemptively listed recipients (21%, n = 13 696) were more likely to be white (59% vs 34%, P < 0.001) and have private insurance (64% vs 30%, P < 0.001). In the pre- and post-KAS periods, average adjusted pretransplant dialysis durations for preemptively listed recipients were <2 years in all racial groups. Compared to recipients who were listed after starting dialysis, preemptively listed recipients experienced 3.85 (95% Confidence Interval [CI] 3.71-3.99) and 4.53 (95% CI 4.32-4.74) fewer average years of pretransplant dialysis in the pre- and post-KAS periods, respectively (P < 0.001 for all comparisons). CONCLUSIONS Preemptively wait-listed DDKT recipients continue to experience substantially fewer years of pretransplant dialysis than recipients listed after dialysis onset. Efforts are needed to improve both socioeconomic and racial disparities in preemptive wait-listing.
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Affiliation(s)
- Meera N Harhay
- Division of Nephrology and Hypertension, Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania.,Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania
| | - Michael O Harhay
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karthik Ranganna
- Division of Nephrology and Hypertension, Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Suzanne M Boyle
- Division of Nephrology and Hypertension, Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Lissa Levin Mizrahi
- Division of Nephrology and Hypertension, Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Stephen Guy
- Division of Multi-Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Gregory E Malat
- Division of Multi-Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Gary Xiao
- Division of Multi-Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - David J Reich
- Division of Multi-Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Rachel E Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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3
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Harhay MN, McKenna RM, Boyle SM, Ranganna K, Mizrahi LL, Guy S, Malat GE, Xiao G, Reich DJ, Harhay MO. Association between Medicaid Expansion under the Affordable Care Act and Preemptive Listings for Kidney Transplantation. Clin J Am Soc Nephrol 2018; 13:1069-1078. [PMID: 29929999 PMCID: PMC6032587 DOI: 10.2215/cjn.00100118] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 04/13/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Before 2014, low-income individuals in the United States with non-dialysis-dependent CKD had fewer options to attain health insurance, limiting their opportunities to be preemptively wait-listed for kidney transplantation. We examined whether expanding Medicaid under the Affordable Care Act was associated with differences in the number of individuals who were pre-emptively wait-listed with Medicaid coverage. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using the United Network of Organ Sharing database, we performed a retrospective observational study of adults (age≥18 years) listed for kidney transplantation before dialysis dependence between January 1, 2011-December 31, 2013 (pre-Medicaid expansion) and January 1, 2014-December 31, 2016 (post-Medicaid expansion). In multinomial logistic regression models, we compared trends in insurance types used for pre-emptive wait-listing in states that did and did not expand Medicaid with a difference-in-differences approach. RESULTS States that fully implemented Medicaid expansion on January 1, 2014 ("expansion states," n=24 and the District of Columbia) had a 59% relative increase in Medicaid-covered pre-emptive listings from the pre-expansion to postexpansion period (from 1094 to 1737 listings), compared with an 8.8% relative increase (from 330 to 359 listings) among 19 Medicaid nonexpansion states (P<0.001). From the pre- to postexpansion period, the adjusted proportion of listings with Medicaid coverage decreased by 0.3 percentage points among nonexpansion states (from 4.0% to 3.7%, P=0.09), and increased by 3.0 percentage points among expansion states (from 7.0% to 10.0%, P<0.001). Medicaid expansion was associated with absolute increases in Medicaid coverage by 1.4 percentage points among white listings, 4.0 percentage points among black listings, 5.9 percentage points among Hispanic listings, and 5.3 percentage points among other listings (P<0.001 for all comparisons). CONCLUSIONS Medicaid expansion was associated with an increase in the proportion of new pre-emptive listings for kidney transplantation with Medicaid coverage, with larger increases in Medicaid coverage among racial and ethnic minority listings than among white listings.
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Affiliation(s)
- Meera N. Harhay
- Division of Nephrology and Hypertension, Department of Medicine, and
- Epidemiology and Biostatistics and
| | - Ryan M. McKenna
- Health Management and Policy, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania
| | - Suzanne M. Boyle
- Division of Nephrology and Hypertension, Department of Medicine, and
| | - Karthik Ranganna
- Division of Nephrology and Hypertension, Department of Medicine, and
| | | | - Stephen Guy
- Division of Multi-Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania; Departments of
| | - Gregory E. Malat
- Division of Multi-Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania; Departments of
| | - Gary Xiao
- Division of Multi-Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania; Departments of
| | - David J. Reich
- Division of Multi-Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania; Departments of
| | - Michael O. Harhay
- Palliative and Advanced Illness Research Center and
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; and
- Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Pennsylvania
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4
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Malat GE, Boyle SM, Jindal RM, Guy S, Xiao G, Harhay MN, Lee DH, Ranganna KM, Anil Kumar MS, Doyle AM. Kidney Transplantation in HIV-Positive Patients: A Single-Center, 16-Year Experience. Am J Kidney Dis 2018; 73:112-118. [PMID: 29705074 DOI: 10.1053/j.ajkd.2018.02.352] [Citation(s) in RCA: 14] [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] [Received: 10/03/2017] [Accepted: 02/14/2018] [Indexed: 11/11/2022]
Abstract
Hahnemann University Hospital has performed 120 kidney transplantations in human immunodeficiency virus (HIV)-positive individuals during the last 16 years. Our patient population represents ∼10% of the entire US population of HIV-positive kidney recipients. In our earlier years of HIV transplantation, we noted increased rejection rates, often leading to graft failure. We have established a multidisciplinary team and over the years have made substantial protocol modifications based on lessons learned. These modifications affected our approach to candidate evaluation, donor selection, perioperative immunosuppression, and posttransplantation monitoring and resulted in excellent posttransplantation outcomes, including 100% patient and graft survival at 1 year and patient and graft survival at 3 years of 100% and 96%, respectively. We present key clinical data, including a granular patient-level analysis of the associations of antiretroviral therapy regimens with long-term survival, cellular and antibody-mediated rejection rates, and the causes of allograft failures. In summary, we provide details on the evolution of our approach to HIV transplantation during the last 16 years, including strategies that may improve outcomes among HIV-positive kidney transplantation candidates throughout the United States.
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Affiliation(s)
| | | | - Rahul M Jindal
- USU-Walter Reed Department of Surgery, Uniformed Services University, Bethesda, MD.
| | - Stephen Guy
- Department of Surgery, Drexel University, Philadelphia, PA
| | - Gary Xiao
- Department of Surgery, Drexel University, Philadelphia, PA
| | - Meera N Harhay
- Department of Medicine, Drexel University, Philadelphia, PA
| | - Dong H Lee
- Department of Medicine, Drexel University, Philadelphia, PA
| | | | | | - Alden M Doyle
- Department of Medicine, Drexel University, Philadelphia, PA.
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5
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Rosenthal S, Decano AG, Bandali A, Lai D, Malat GE, Bias TE. Oritavancin (Orbactiv): A New-Generation Lipoglycopeptide for the Treatment Of Acute Bacterial Skin and Skin Structure Infections. P T 2018; 43:143-179. [PMID: 29491695 PMCID: PMC5821239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Oritavancin (Orbactiv): a new-generation lipoglycopeptide for the treatment of acute bacterial skin and skin structure infections.
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6
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Lee DH, Boyle SM, Malat GE, Kern C, Milrod C, DeBellis S, Harhay MN, Ranganna K, Guy S, Talluri S, Bias T, Doyle A. Barriers to listing for HIV-infected patients being evaluated for kidney transplantation. Transpl Infect Dis 2017; 19. [PMID: 28921783 DOI: 10.1111/tid.12777] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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: 09/12/2016] [Revised: 06/04/2017] [Accepted: 06/14/2017] [Indexed: 12/14/2022]
Abstract
Human immunodeficiency virus (HIV)-infected patients have excellent outcomes following kidney transplantation (KT) but still might face barriers in the evaluation and listing process. The aim of this study was to characterize the patient population, referral patterns, and outcomes of HIV-infected patients who present for KT evaluation. We performed a single-center retrospective cohort study of HIV-infected patients who were evaluated for KT. The primary outcome was time to determination of eligibility for KT. Between 2011 and 2015, 105 HIV-infected patients were evaluated for KT. Of the 105 patients, 73 were listed for transplantation by the end of the study period. For those who were deemed ineligible, the most common reasons cited were active substance abuse (n = 7, 22%) and failure to complete the full transplant evaluation (n = 7, 22%). Our cohort demonstrated a higher proportion of HIV-infected patients eligible for KT than in previous studies, likely secondary to advances in HIV management. Among those who were denied access to transplantation, we identified that many were unable to complete the evaluation process, and that active substance abuse was common. Future prospective studies should examine reasons and potential interventions for the lack of follow-through and drug use we observed in this population.
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Affiliation(s)
- Dong Heun Lee
- Department of Medicine, Drexel University, Philadelphia, PA, USA
| | - Suzanne M Boyle
- Department of Medicine, Drexel University, Philadelphia, PA, USA
| | - Gregory E Malat
- Department of Surgery, Drexel University, Philadelphia, PA, USA
| | - Christopher Kern
- Department of Medicine, Drexel University, Philadelphia, PA, USA
| | - Charles Milrod
- Department of Medicine, Drexel University, Philadelphia, PA, USA
| | - Shannon DeBellis
- Department of Medicine, Drexel University, Philadelphia, PA, USA
| | - Meera N Harhay
- Department of Medicine, Drexel University, Philadelphia, PA, USA
| | - Karthik Ranganna
- Department of Medicine, Drexel University, Philadelphia, PA, USA
| | - Stephen Guy
- Department of Surgery, Drexel University, Philadelphia, PA, USA
| | - Sindhura Talluri
- Department of Medicine, Drexel University, Philadelphia, PA, USA
| | - Tiffany Bias
- Department of Medicine, Drexel University, Philadelphia, PA, USA
| | - Alden Doyle
- Department of Medicine, Drexel University, Philadelphia, PA, USA
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7
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Bias TE, Malat GE, Lee DH, Sharma A, Doyle AM. Clinical outcomes associated with carbapenem resistant Klebsiella pneumoniae (CRKP) in abdominal solid organ transplant (SOT) recipients. Infect Dis (Lond) 2017; 50:67-70. [DOI: 10.1080/23744235.2017.1354259] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Tiffany E. Bias
- Division of Infectious Diseases, Department of Pharmacy, Hahnemann University Hospital, Philadelphia, PA, USA
- Division of Infectious Diseases and HIV Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Gregory E. Malat
- Division of Solid Organ Transplantation, Department of Pharmacy, Hahnemann University Hospital, Philadelphia, PA, USA
- Division of Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Dong H. Lee
- Department of Infectious Diseases, Division of Infectious Diseases and HIV Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Akshay Sharma
- Division of Nephrology, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Alden M. Doyle
- Kidney and Pancreas Transplantation, Division of Nephrology, University of Virginia Health System, Charlottesville, VA, USA
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8
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Chung CL, Nadhan KS, Shaver CM, Ogrich LM, Abdelmalek M, Cusack CA, Malat GE, Pritchett EN, Doyle A. Comparison of Posttransplant Dermatologic Diseases by Race. JAMA Dermatol 2017; 153:552-558. [PMID: 28273280 DOI: 10.1001/jamadermatol.2017.0045] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance The risk for skin cancer has been well characterized in white organ transplant recipients (OTRs); however, most patients on the waiting list for organ transplant in the United States are nonwhite. Little is known about cutaneous disease and skin cancer risk in this OTR population. Objective To compare the incidence of cutaneous disease between white and nonwhite OTRs. Design, Setting, and Participants This retrospective review of medical records included 412 OTRs treated from November 1, 2011, through April 22, 2016, at an academic referral center. Prevalence and characteristics of cutaneous disease were compared in 154 white and 258 nonwhite (ie, Asian, Hispanic, and black) OTRs. Clinical factors of cutaneous disease and other common diagnoses assessed in OTRs included demographic characteristics, frequency and type of cancer, anatomical location, time course, sun exposure, risk awareness, and preventive behavior. Main Outcomes and Measures Primary diagnosis of malignant or premalignant, infectious, and inflammatory disease. Results The 412 patients undergoing analysis included 264 men (64.1%) and 148 women (35.9%), with a mean age of 60.1 years (range, 32.1-94.3 years). White OTRs more commonly had malignant disease at their first visit (82 [67.8%]), whereas nonwhite OTRs presented more commonly with infectious (63 [37.5%]) and inflammatory (82 [48.8%]) conditions. Skin cancer was diagnosed in 64 (41.6%) white OTRs and 15 (5.8%) nonwhite OTRs. Most lesions in white (294 of 370 [79.5%]) and Asian (5 of 6 [83.3%]) OTRs occurred in sun-exposed areas. Among black OTRs, 6 of 9 lesions (66.7%) occurred in sun-protected areas, specifically the genitals. Fewer nonwhite than white OTRs reported having regular dermatologic examinations (5 [11.4%] vs 8 [36.4%]) and knowing the signs of skin cancer (11 [25.0%] vs 10 [45.4%]). Conclusions and Relevance Early treatment of nonwhite OTRs should focus on inflammatory and infectious diseases. Sun protection should continue to be emphasized in white, Asian, and Hispanic OTRs. Black OTRs should be counseled to recognize the signs of genital human papillomavirus infection. Optimal posttransplant dermatologic care may be determined based on the race or ethnicity of the patients, but a baseline full-skin assessment should be performed in all patients. All nonwhite OTRs should be counseled more effectively on the signs of skin cancer, with focused discussion points contingent on skin type and race or ethnicity.
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Affiliation(s)
| | - Kumar S Nadhan
- Department of Dermatology, Drexel University, Philadelphia, Pennsylvania
| | - Christine M Shaver
- Department of Dermatology, Drexel University, Philadelphia, Pennsylvania
| | - Lauren M Ogrich
- Department of Dermatology, Drexel University, Philadelphia, Pennsylvania
| | - Mark Abdelmalek
- Department of Dermatology, Drexel University, Philadelphia, Pennsylvania
| | - Carrie Ann Cusack
- Department of Dermatology, Drexel University, Philadelphia, Pennsylvania
| | - Gregory E Malat
- Department of Surgery, Drexel University, Philadelphia, Pennsylvania
| | | | - Alden Doyle
- Department of Internal Medicine, Drexel University, Philadelphia, Pennsylvania
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9
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Pritchett EN, Doyle A, Shaver CM, Miller B, Abdelmalek M, Cusack CA, Malat GE, Chung CL. Nonmelanoma Skin Cancer in Nonwhite Organ Transplant Recipients. JAMA Dermatol 2017; 152:1348-1353. [PMID: 27653769 DOI: 10.1001/jamadermatol.2016.3328] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Organ transplant recipients have a higher incidence of skin cancer. This risk is magnified over time and with continued exposure to immunosuppression. Skin cancer in nonwhite patients is associated with greater morbidity and mortality owing to diagnosis at a more advanced stage, which suggests that nonwhite organ transplant recipients are at even higher risk. Objective To describe demographic and clinical factors and the incidence of skin cancer in nonwhite organ transplant recipients. Design, Setting, and Participants We performed a retrospective medical record review of patients who were organ transplant recipients (154 were white and 259 nonwhite [black, Asian, Hispanic, Pacific Islander]) seen from November 1, 2011, to April 18, 2016 at an academic referral center. Main Outcomes and Measures Variables were analyzed and compared between racial groups, including sex, age, race/ethnicity, Fitzpatrick type, type and location of skin cancer, type of organ transplanted, time to diagnosis of skin cancer after transplantation, and history of condyloma acuminata and/or verruca vulgaris. Results Most of the 413 patients (62.7%) evaluated were nonwhite organ transplant recipients; 264 were men, and 149 were women. Their mean (SD) age was 60.09 (13.59) years. Nineteen skin cancers were identified in 15 patients (5.8%) representing 3 racial/ethnic groups: black (6 patients), Asian (5), and Hispanic (4). All squamous cell carcinomas in blacks were diagnosed in the in situ stage, located on sun-protected sites, and occurred in patients whose lesions tested positive for human papilloma virus (HPV) and/or who endorsed a history of condyloma acuminata or verruca vulgaris. Most skin cancers in Asians were located on sun-exposed areas and occurred in individuals who emigrated from equatorial locations. Conclusions and Relevance Nonwhite organ transplant recipients are at risk for developing skin cancer posttransplantation. Follow-up in a specialized transplant dermatology center and baseline total-body skin examination should be part of posttransplantation care in all organ transplant recipients, including nonwhite patients. A thorough inspection of the groin and genitalia is imperative in black organ transplant recipients. History of HPV infection, particularly in black organ transplant recipients, and sun exposure/emigration history in Asian organ transplant recipients should be documented. Vigilant photoprotection may be of lesser importance in the prevention of skin cancer in black organ transplant recipients. Risk factors for nonwhite organ transplant recipients differ between races/ethnicities and warrant further study in efforts to better counsel and prevent skin cancer in these patients.
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Affiliation(s)
| | - Alden Doyle
- Department of Internal Medicine, Drexel University, Philadelphia, Pennsylvania
| | - Christine M Shaver
- Department of Dermatology, Drexel University, Philadelphia, Pennsylvania
| | - Brett Miller
- Department of Dermatology, Drexel University, Philadelphia, Pennsylvania
| | - Mark Abdelmalek
- Department of Dermatology, Drexel University, Philadelphia, Pennsylvania
| | - Carrie Ann Cusack
- Department of Dermatology, Drexel University, Philadelphia, Pennsylvania
| | - Gregory E Malat
- Department of Surgery, Drexel University, Philadelphia, Pennsylvania
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10
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Rogala BG, Malat GE, Lee DH, Harhay MN, Doyle AM, Bias TE. Identification of Risk Factors Associated With Clostridium difficile Infection in Liver Transplantation Recipients: A Single-Center Analysis. Transplant Proc 2017; 48:2763-2768. [PMID: 27788814 DOI: 10.1016/j.transproceed.2016.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 07/07/2016] [Accepted: 08/03/2016] [Indexed: 12/18/2022]
Abstract
Clostridium difficile remains the leading cause of health care-associated infectious diarrhea, and its incidence and severity are increasing in liver transplant recipients. Several known risk factors for C difficile infection (CDI) are inherently associated with liver transplantation, such as severe underlying illness, immunosuppression, abdominal surgery, and broad-spectrum antibiotic use. We conducted a single-center retrospective case control study to characterize risk factors for CDI among patients who received a liver transplant from January 2008 to December 2012. We also examined the associations of post-transplantation CDI with transplant outcomes. Cases were defined as having diarrhea with a positive test for C difficile by either toxin A/B enzyme immunoassay (EIA) or glutamate dehydrogenase EIA and polymerase chain reaction within 1 year after transplantation. Sixty-five consecutive patients were evaluated, of which 15 (23%) developed CDI. The median time from transplantation to CDI diagnosis was 65 days (interquartile range [IQR] 13-208) and more than one-half (53%) had severe infection. Risk factors that were associated with CDI among liver transplant recipients included: (1) previous history of CDI (20% vs 0%; P = .001); (2) exposure to proton-pump inhibitor therapy (93% vs 60%; P = .015); (3) antimicrobial therapy before transplantation (47% vs 18%; P = .039); (4) a prolonged length of stay before transplantation (1 day [IQR, 1-19] vs 1 day [IQR, 0-1]; P = .028); and (5) chronic kidney disease (53% vs 20%; P = .011). There was no significant differences in patient survivals at 6 months (93% vs 96%; P = .67) and 12 months (87% vs 94%; P = .35) among CDI case and control subjects, respectively.
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Affiliation(s)
- B G Rogala
- Department of Pharmacy, University of Vermont Medical Center, Burlington, Vermont
| | - G E Malat
- Department of Pharmacy, Hahnemann University Hospital, Philadelphia, Pennsylvania; Division of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - D H Lee
- Division of Infectious Diseases and HIV Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - M N Harhay
- Division of Nephrology, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - A M Doyle
- Division of Nephrology, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - T E Bias
- Department of Pharmacy, Hahnemann University Hospital, Philadelphia, Pennsylvania; Division of Infectious Diseases and HIV Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania.
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11
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Lee DH, Malat GE, Bias TE, Harhay MN, Ranganna K, Doyle AM. Serum creatinine elevation after switch to dolutegravir in a human immunodeficiency virus-positive kidney transplant recipient. Transpl Infect Dis 2016; 18:625-7. [PMID: 27159656 DOI: 10.1111/tid.12545] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [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: 12/10/2015] [Revised: 03/23/2016] [Accepted: 04/03/2016] [Indexed: 12/21/2022]
Abstract
Dolutegravir is a preferred antiretroviral drug for human immunodeficiency virus (HIV)-infected patients following solid organ transplantation. It has potent antiretroviral activity and does not interact with calcineurin inhibitors. We describe a case of an HIV-infected kidney transplant patient, who was noted to have a rising serum creatinine following initiation of dolutegravir. At first, an acute rejection episode was suspected, but this finding was later attributed to inhibition of creatinine secretion by dolutegravir. We suggest that an awareness of this potential effect of dolutegravir is important for providers who take care of HIV-positive kidney transplant recipients, in order to prevent potentially unnecessary testing.
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Affiliation(s)
- D H Lee
- Division of Infectious Diseases and HIV Medicine, Drexel University, Philadelphia, Pennsylvania, USA
| | - G E Malat
- Department of Surgery, Drexel University, Philadelphia, Pennsylvania, USA
| | - T E Bias
- Division of Infectious Diseases and HIV Medicine, Drexel University, Philadelphia, Pennsylvania, USA
| | - M N Harhay
- Division of Nephrology, Drexel University, Philadelphia, Pennsylvania, USA
| | - K Ranganna
- Division of Nephrology, Drexel University, Philadelphia, Pennsylvania, USA
| | - A M Doyle
- Division of Nephrology, Drexel University, Philadelphia, Pennsylvania, USA
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Philosophe B, Malat GE, Soundararajan S, Barth RN, Manitpisikul W, Wilson NS, Ranganna K, Drachenberg CB, Papadimitriou JC, Neuman BP, Munivenkatappa RB. Validation of the Maryland Aggregate Pathology Index (MAPI), a pre-implantation scoring system that predicts graft outcome. Clin Transplant 2014; 28:897-905. [DOI: 10.1111/ctr.12400] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Benjamin Philosophe
- Department of Surgery; School of Medicine; Johns Hopkins University; Baltimore MD USA
| | - Gregory E. Malat
- Department of Pharmacy; College of Medicine; Drexel University; Philadelphia PA USA
| | | | - Rolf N. Barth
- Department of Surgery; School of Medicine; University of Maryland; Baltimore MD USA
| | - Wana Manitpisikul
- Department of Pharmacy; University of Maryland Medical Center; Baltimore MD USA
| | - Nikita S. Wilson
- Department of Pharmacy; University of Maryland Medical Center; Baltimore MD USA
| | - Karthik Ranganna
- Department of Surgery; School of Medicine; University of Maryland; Baltimore MD USA
- Department of Nephrology; College of Medicine; Drexel University; Philadelphia PA USA
| | | | - John C. Papadimitriou
- Department of Pathology; School of Medicine; University of Maryland; Baltimore MD USA
| | - Brian P. Neuman
- Department of Surgery; School of Medicine; Johns Hopkins University; Baltimore MD USA
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Malat GE, Culkin C, Palya A, Ranganna K, Kumar MSA. African American kidney transplantation survival: the ability of immunosuppression to balance the inherent pre- and post-transplant risk factors. Drugs 2010; 69:2045-62. [PMID: 19791826 DOI: 10.2165/11318570-000000000-00000] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Among organ transplant recipients, the African American population historically has received special attention. This is because secondary to their disposition to certain disease states, for example hypertension, an African American patient has a propensity to reach end-stage renal disease and require renal replacement earlier than a Caucasian patient. Regardless of the initiative to replace dialysis therapy with organ transplantation, the African American patient has many barriers to kidney transplantation, thus extending their time on dialysis and waiting time on the organ transplant list. These factors are among the many negative causes of decreased kidney graft survival, realized before kidney transplantation. Unfortunately, once the African American recipient receives a kidney graft, the literature documents that many post-transplant barriers exist which limit successful outcomes. The primary post-transplant barrier relates to designing proper immunosuppression protocols. The difficulty in designing protocols revolves around (i) altered genetic metabolism/lower absorption, (ii) increased immuno-active cytokines and (iii) detrimental effects of noncompliance. Based on the literature, dosing of immunosuppression must be aggressive and requires a diligent practitioner. Research has indicated that, despite some success with proven levels of immunosuppression, the African American recipient usually requires a higher 'dose per weight' regimen. However, even with aggressive immunosuppressant dosing, African Americans still have worse outcomes than Caucasian recipients. Additionally, many of the targeted sites of action that immunosuppression exerts its effects on have been found to be amplified in the African American population. Finally, noncompliance is the most discouraging inhibitor of long-term success in organ transplantation. The consequences of noncompliance are biased by ethnicity and affect the African American population more severely. All of these factors are discussed further in this review in the hope of identifying an ideal healthcare model for caring for the African American transplant recipient, from diagnosing chronic kidney disease through to successful kidney graft outcomes. An indepth review of the literature is described and organized in a fashion that highlights all of the issues affecting success in African Americans. The compilation of the literature in this review will enable the reader to get closer to understanding the caveats of kidney transplantation in the African American patient, but falls short of delivering an actual 'equation' for post-transplant care in an African American kidney recipient.
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Affiliation(s)
- Gregory E Malat
- Department of Pharmacy, Hahnemann University Hospital/Drexel University, Philadelphia, Pennsylvania, USA
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Malat GE, Dupuis RE, Kassman B, Rhoads JM, Freeman K, Lichtman S, Johnson MW, Gerber D, Andreoni K, Fair J. Tacrolimus-induced pain syndrome in a pediatric orthotopic liver transplant patient. Pediatr Transplant 2002; 6:435-8. [PMID: 12390434 DOI: 10.1034/j.1399-3046.2002.02030.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [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] [Indexed: 11/23/2022]
Abstract
Post-transplant complications are common among patients receiving immunosuppressive medications, including pain syndromes. Recently, a pain syndrome, calcineurin-inhibitor induced pain syndrome (CIPS) has been described. To our knowledge, this article is the second report of tacrolimus-associated CIPS, and the first report in the pediatric setting.
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Affiliation(s)
- G E Malat
- Department of Pharmacy, University of North Carolina Hospitals, 101 Manning Drive, Campus Box 7600, Chapel Hill, NC 27514, USA.
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