1
|
Jalbert J, Weller JN, Boivin PL, Lavigne S, Taobane M, Pieper M, Lodi A, Cardinal H. Predicting Time to and Average Quality of Future Offers for Kidney Transplant Candidates Declining a Current Deceased Donor Kidney Offer: A Retrospective Cohort Study. Can J Kidney Health Dis 2023; 10:20543581231177844. [PMID: 37313365 PMCID: PMC10259098 DOI: 10.1177/20543581231177844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 04/10/2023] [Indexed: 06/15/2023] Open
Abstract
Background At the time a kidney offer is made by an organ donation organization (ODO), transplant physicians must inform candidates on the pros and cons of accepting or declining the offer. Although physicians have a general idea of expected wait time to kidney transplantation by blood group in their ODO, there are no tools that provide quantitative estimates based on the allocation score used and donor/candidate characteristics. This limits the shared decision-making process at the time of kidney offer as (1) the consequences of declining an offer in terms of wait-time prolongation cannot be provided and (2) the quality of the current offer cannot be compared with that of offers that could be made to the specific candidate in the future. This is especially relevant to older transplant candidates as many ODOs use some form of utility matching in their allocation score. Objective We aimed to develop a novel method to provide personalized estimates of wait time to next offer and quality of future offers for kidney transplant candidates if they refused a current deceased donor offer from an ODO. Design A retrospective cohort study. Setting Administrative data from Transplant Quebec. Patients All patients who were actively registered on the kidney transplant wait list at any point between March 29, 2012 and December 13, 2017. Measurements The time to next offer was defined as the number of days between the time of the current offer and the next offer if the current one were declined. The quality of the offers was measured with the 10-variable Kidney Donor Risk Index (KDRI) equation. Methods Candidate-specific kidney offer arrival was modeled with a marked Poisson process. To derive the lambda parameter for the marked Poisson process for each candidate, the arrival of donors was examined in the 2 years prior to the time of the current offer. The Transplant Quebec allocation score was calculated for each ABO-compatible offer with the characteristics that the candidate presented at the time of the current offer. Offers where the candidate's score was lower than the scores of actual recipients of the second kidneys transplanted were filtered out from the candidate-specific kidney offer arrival. The KDRIs of offers that remained were averaged to provide an estimate of the quality of future offers, to be compared with that of the current offer. Results During the study period, there were 848 unique donors and 1696 transplant candidates actively registered. The models provide the following information: average time to next offer, time to which there is a 95% probability of receiving a next offer, average KDRI of future offers. The C-index of the model was 0.72. When compared with providing average group estimates of wait time and KDRI of future offers, the model reduced the root-mean-square error in the predicted time to next offer from 137 to 84 days and that of predicted KDRI of future offers from 0.64 to 0.55. The precision of the model's predictions was higher when observed times to next offer were 5 months or less. Limitations The models assume that patients declining an offer remain wait-listed until the next one. The model only updates wait time every year after the time of an offer and not in a continuous fashion. Conclusion By providing personalized quantitative estimates of time to and quality of future offers, our new approach can inform the shared decision-making process between transplant candidates and physicians when a kidney offer from a deceased donor is made by an ODO.
Collapse
Affiliation(s)
- Jonathan Jalbert
- Department of Mathematics and Industrial Engineering, Polytechnique Montréal, QC, Canada
| | - Jean-Noel Weller
- Canada Excellence Research Chair, Polytechnique Montréal, QC, Canada
| | - Pierre-Luc Boivin
- Department of Mathematics and Industrial Engineering, Polytechnique Montréal, QC, Canada
| | | | - Mehdi Taobane
- Canada Excellence Research Chair, Polytechnique Montréal, QC, Canada
| | - Mike Pieper
- Canada Excellence Research Chair, Polytechnique Montréal, QC, Canada
| | - Andrea Lodi
- Canada Excellence Research Chair, Polytechnique Montréal, QC, Canada
- Jacobs Technion-Cornell Institute, Cornell Tech, Technion—Israel Institute of Technology, New York City, New York, USA
| | - Héloise Cardinal
- Research Centre, Centre Hospitalier de l’Université de Montréal, QC, Canada
- Université de Montréal, QC, Canada
- The Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| |
Collapse
|
2
|
Vinson AJ, Cardinal H, Parsons C, Tennankore KK, Mainra R, Maru K, Treleaven D, Gill J. Disparities in Deceased Donor Kidney Offer Acceptance: A Survey of Canadian Transplant Nephrologists, General Surgeons and Urologists. Can J Kidney Health Dis 2023; 10:20543581231156855. [PMID: 36861114 PMCID: PMC9969426 DOI: 10.1177/20543581231156855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 12/19/2022] [Indexed: 02/26/2023] Open
Abstract
Background Significant variability in organ acceptance thresholds have been demonstrated across the United States, but data regarding the rate and rationale for kidney donor organ decline in Canada are lacking. Objective To examine decision making regarding deceased kidney donor acceptance and non-acceptance in a population of Canadian transplant professionals. Design A survey study of theoretical deceased donor kidney cases of increasing complexity. Setting Canadian transplant nephrologists, urologists, and surgeons making donor call decisions responding to an electronic survey between July 22 and October 4, 2022. Participants Invitations to participate were distributed to 179 Canadian transplant nephrologists, surgeons, and urologists through e-mail. Participants were identified by contacting each transplant program and requesting a list of physicians who take donor call. Measurements Survey respondents were asked whether they would accept or decline a given donor, assuming there was a suitable recipient. They were also asked to cite reasons for donor non-acceptance. Methods Donor scenario-specific acceptance rates (total acceptance divided by total number of respondents for a given scenario and overall) and reasons for decline were determined and presented as a percentage of the total cases declined. Results In all, 72 respondents from 7 provinces completed at least one question of the survey, with considerable variability between acceptance rates for centers; the most conservative center declined 60.9% of donor cases, whereas the most aggressive center declined only 28.1%, P-value < .001. There was an increased risk of non-acceptance with advancing age, donation after cardiac death, acute kidney injury, chronic kidney disease, and comorbidities. Limitations As with any survey, there is the potential for participation bias. In addition, this study examines donor characteristics in isolation, however, asks respondent to assume there is a suitable candidate available. In reality, whenever donor quality is considered, it should be considered in the context of the intended recipient. Conclusion In a survey of increasingly medically complex deceased kidney donor cases, there was significant variability in donor decline among Canadian transplant specialists. Given relatively high rates of donor decline and apparent heterogeneity in acceptance decisions, Canadian transplant specialists may benefit from additional education regarding the benefits achieved from even medically complex kidney donors for appropriate candidates relative to remaining on dialysis on the transplant waitlist.
Collapse
Affiliation(s)
- A. J. Vinson
- Nova Scotia Health Authority, Halifax,
Canada,Division of Nephrology, Department of
Medicine, Dalhousie University, Halifax, NS, Canada,A. J. Vinson, Division of Nephrology,
Department of Medicine, Dalhousie University, Room 5081, 5th Floor Dickson
Building, Victoria General Hospital, 5820 University Ave, Halifax, NS B3H 1V8,
Canada.
| | - H. Cardinal
- Centre de recherche du Centre
hospitalier de l’Université de Montréal, QC, Canada
| | - C. Parsons
- Organ and Tissue Donation and
Transplantation, Canadian Blood Services, Ottawa, ON, Canada
| | - K. K. Tennankore
- Nova Scotia Health Authority, Halifax,
Canada,Division of Nephrology, Department of
Medicine, Dalhousie University, Halifax, NS, Canada
| | - R. Mainra
- Division of Nephrology, Department of
Medicine, University of Saskatchewan, Regina, Canada
| | - K. Maru
- Canadian Blood Services, Ottawa, ON,
Canada
| | - D. Treleaven
- Division of Nephrology, Department of
Medicine, McMaster University, Hamilton, ON, Canada
| | - J. Gill
- Division of Nephrology, Department of
Medicine, The University of British Columbia, Vancouver, Canada
| |
Collapse
|
3
|
Worthen G, Vinson A, Cardinal H, Doucette S, Gogan N, Gunaratnam L, Keough-Ryan T, Kiberd BA, Prasad B, Rockwood K, Sills L, Suri RS, Tangri N, Walsh M, West K, Yohanna S, Tennankore K. Prevalence of Frailty in Patients Referred to the Kidney Transplant Waitlist. Kidney360 2021; 2:1287-1295. [PMID: 35369656 PMCID: PMC8676383 DOI: 10.34067/kid.0001892021] [Citation(s) in RCA: 4] [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] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/13/2021] [Indexed: 02/07/2023]
Abstract
Background Comparisons between frailty assessment tools for waitlist candidates are a recognized priority area for kidney transplantation. We compared the prevalence of frailty using three established tools in a cohort of waitlist candidates. Methods Waitlist candidates were prospectively enrolled from 2016 to 2020 across five centers. Frailty was measured using the Frailty Phenotype (FP), a 37-variable frailty index (FI), and the Clinical Frailty Scale (CFS). The FI and CFS were dichotomized using established cutoffs. Agreement was compared using κ coefficients. Area under the receiver operating characteristic (ROC) curves were generated to compare the FI and CFS (treated as continuous measures) with the FP. Unadjusted associations between each frailty measure and time to death or waitlist withdrawal were determined using an unadjusted Cox proportional hazards model. Results Of 542 enrolled patients, 64% were male, 80% were White, and the mean age was 54±14 years. The prevalence of frailty by the FP was 16%. The mean FI score was 0.23±0.14, and the prevalence of frailty was 38% (score of ≥0.25). The median CFS score was three (IQR, 2-3), and the prevalence was 15% (score of ≥4). The κ values comparing the FP with the FI (0.44) and CFS (0.27) showed fair to moderate agreement. The area under the ROC curves for the FP and FI/CFS were 0.86 (good) and 0.69 (poor), respectively. Frailty by the CFS (HR, 2.10; 95% CI, 1.04 to 4.24) and FI (HR, 1.79; 95% CI, 1.00 to 3.21) was associated with death or permanent withdrawal. The association between frailty by the FP and death/withdrawal was not statistically significant (HR, 1.78; 95% CI, 0.79 to 3.71). Conclusion Frailty prevalence varies by the measurement tool used, and agreement between these measurements is fair to moderate. This has implications for determining the optimal frailty screening tool for use in those being evaluated for kidney transplant.
Collapse
Affiliation(s)
- George Worthen
- Division of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Amanda Vinson
- Division of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Héloise Cardinal
- Division of Nephrology, Centre de Recherche du CHUM, Montreal, Quebec, Canada
| | | | - Nessa Gogan
- Division of Nephrology, Horizon Health Network, Saint John, New Brunswick, Canada
| | - Lakshman Gunaratnam
- Division of Nephrology, London Health Sciences Center, London, Ontario, Canada
| | - Tammy Keough-Ryan
- Division of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bryce A. Kiberd
- Division of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bhanu Prasad
- Division of Nephrology, Regina General Hospital, Regina, Saskatchewan, Canada
| | - Kenneth Rockwood
- Division of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Laura Sills
- Nova Scotia Health Authority, Halifax, Canada
| | - Rita S. Suri
- Research Institute of the McGill University Health Center and Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Navdeep Tangri
- Chronic Disease Innovation Center, Winnipeg, Manitoba, Canada
| | - Michael Walsh
- Division of Nephrology, McMaster University, Hamilton, Ontario, Canada
| | - Kenneth West
- Division of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Seychelle Yohanna
- Division of Nephrology, McMaster University, Hamilton, Ontario, Canada
| | - Karthik Tennankore
- Division of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada
| |
Collapse
|
4
|
Côté JM, Zhang X, Dahhou M, Sapir-Pichhadze R, Foster B, Cardinal H. The impact of repeated mismatches in kidney transplantations performed after nonrenal solid organ transplantation. Am J Transplant 2018; 18:238-244. [PMID: 28891113 DOI: 10.1111/ajt.14495] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/21/2017] [Accepted: 08/30/2017] [Indexed: 01/25/2023]
Abstract
The aim of this study was to determine whether kidney transplantations performed after previous nonrenal solid organ transplants are associated with worse graft survival when there are repeated HLA mismatches (RMM) with the previous donor(s). We performed a retrospective cohort study using data from the Scientific Registry of Transplant Recipients. Our cohort comprised 6624 kidney transplantations performed between January 1, 1990 and January 1, 2015. All patients had previously received 1 or more nonrenal solid organ transplants. RMM were observed in 35.3% of kidney transplantations and 3012 grafts were lost over a median follow-up of 5.4 years. In multivariate Cox regression analyses, we found no association between overall graft survival and either RMM in class 1 (hazard ratio [HR]: 0.97, 95% confidence interval [CI] 0.89-1.07) or class 2 (HR: 0.95, 95% CI 0.85-1.06). Results were similar for the associations between RMM, death-censored graft survival, and patient survival. Our results suggest that the presence of RMM with previous donor(s) does not have an important impact on allograft survival in kidney transplant recipients who have previously received a nonrenal solid organ transplant.
Collapse
Affiliation(s)
- J M Côté
- Research centre, Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada
| | - X Zhang
- Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - M Dahhou
- Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | | | - B Foster
- Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - H Cardinal
- Research centre, Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada
| |
Collapse
|
5
|
Lepeytre F, Cardinal H, Fradette L, Verhave J, Dorais M, LeLorier J, Pichette V, Madore F. The impact of renal protection clinics on prescription of and adherence to cardioprotective drug therapy in chronic kidney disease patients. Clin Kidney J 2017; 10:375-380. [PMID: 28616215 PMCID: PMC5466117 DOI: 10.1093/ckj/sfw144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 11/14/2016] [Indexed: 11/24/2022] Open
Abstract
Background: The aim of this study was to assess the impact of follow-up in renal protection clinics on the prescription of and adherence to cardioprotective drugs in patients with chronic kidney disease (CKD). Methods: We studied stage 4 and 5 CKD patients who initiated follow-up in three renal protection clinics. The prescription pattern of antihypertensive agents (AHA) and lipid-lowering agents (LLAs) was measured as the percentage of patients who are prescribed the agents of interest at a given time. Adherence to drug therapy was defined as the percentage of days, during a pre-defined observation period, in which patients have an on-hand supply of their prescribed medications. Results: A total of 259 CKD patients were enrolled and followed for up to 1 year after referral to renal protection clinics. There was a significant increase in the prescription of angiotensin-converting enzyme inhibitors (34–39%), angiotensin II receptor blockers (11–14%), beta-blockers (40–51%), calcium channel blockers (62–74%), diuretics (66–78%) and LLAs (39–47%) during follow-up in the renal protection clinic compared with baseline (P-values <0.01 for all comparisons). The proportions of patients with good (≥ 80%) and poor (< 80%) adherence to AHA (P = 0.41) and LLAs (P = 0.11) were similar in the year preceding and the year following the first visit to the renal protection clinics. Conclusion: Our results suggest that referral and follow-up in a renal protection clinic may increase the prescription of cardioprotective agents in CKD patients, but does not appear to improve adherence to these medications.
Collapse
Affiliation(s)
- Fanny Lepeytre
- Research Center and Renal Division of Hôpital du Sacré-Cœur de Montréal, 5400 Blvd Gouin O, Montreal, Quebec, Canada H4J 1C5
| | - Héloise Cardinal
- Research Center and Renal Division of Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Lorraine Fradette
- Research Center and Renal Division of Hôpital du Sacré-Cœur de Montréal, 5400 Blvd Gouin O, Montreal, Quebec, Canada H4J 1C5
| | - Jacobien Verhave
- Research Center and Renal Division of Hôpital du Sacré-Cœur de Montréal, 5400 Blvd Gouin O, Montreal, Quebec, Canada H4J 1C5
| | - Marc Dorais
- StatSciences Inc., Notre-Dame-de-l'Île-Perrot, Quebec, Canada
| | - Jacques LeLorier
- Research Center and Renal Division of Hôpital du Sacré-Cœur de Montréal, 5400 Blvd Gouin O, Montreal, Quebec, Canada H4J 1C5
| | - Vincent Pichette
- Research Center and Renal Division of Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - François Madore
- Research Center and Renal Division of Hôpital du Sacré-Cœur de Montréal, 5400 Blvd Gouin O, Montreal, Quebec, Canada H4J 1C5
| |
Collapse
|
6
|
Yang B, Dieudé M, Hamelin K, Hénault-Rondeau M, Patey N, Turgeon J, Lan S, Pomerleau L, Quesnel M, Peng J, Tremblay J, Shi Y, Chan JS, Hébert MJ, Cardinal H. Anti-LG3 Antibodies Aggravate Renal Ischemia-Reperfusion Injury and Long-Term Renal Allograft Dysfunction. Am J Transplant 2016; 16:3416-3429. [PMID: 27172087 DOI: 10.1111/ajt.13866] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 05/04/2016] [Accepted: 05/07/2016] [Indexed: 01/25/2023]
Abstract
Pretransplant autoantibodies to LG3 and angiotensin II type 1 receptors (AT1R) are associated with acute rejection in kidney transplant recipients, whereas antivimentin autoantibodies participate in heart transplant rejection. Ischemia-reperfusion injury (IRI) can modify self-antigenic targets. We hypothesized that ischemia-reperfusion creates permissive conditions for autoantibodies to interact with their antigenic targets and leads to enhanced renal damage and dysfunction. In 172 kidney transplant recipients, we found that pretransplant anti-LG3 antibodies were associated with an increased risk of delayed graft function (DGF). Pretransplant anti-LG3 antibodies are inversely associated with graft function at 1 year after transplantation in patients who experienced DGF, independent of rejection. Pretransplant anti-AT1R and antivimentin were not associated with DGF or its functional outcome. In a model of renal IRI in mice, passive transfer of anti-LG3 IgG led to enhanced dysfunction and microvascular injury compared with passive transfer with control IgG. Passive transfer of anti-LG3 antibodies also favored intrarenal microvascular complement activation, microvascular rarefaction and fibrosis after IRI. Our results suggest that anti-LG3 antibodies are novel aggravating factors for renal IRI. These results provide novel insights into the pathways that modulate the severity of renal injury at the time of transplantation and their impact on long-term outcomes.
Collapse
Affiliation(s)
- B Yang
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada.,Canadian National Transplant Research Program, Edmonton, Alberta, T6G 2E1, Canada.,Université de Montréal, Montreal, QC, Canada
| | - M Dieudé
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada.,Canadian National Transplant Research Program, Edmonton, Alberta, T6G 2E1, Canada.,Université de Montréal, Montreal, QC, Canada
| | - K Hamelin
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada.,Canadian National Transplant Research Program, Edmonton, Alberta, T6G 2E1, Canada.,Université de Montréal, Montreal, QC, Canada
| | - M Hénault-Rondeau
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada.,Canadian National Transplant Research Program, Edmonton, Alberta, T6G 2E1, Canada.,Université de Montréal, Montreal, QC, Canada
| | - N Patey
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada.,Canadian National Transplant Research Program, Edmonton, Alberta, T6G 2E1, Canada.,Université de Montréal, Montreal, QC, Canada.,Department of Pathology, CHU Ste-Justine, Université de Montréal, Montreal, QC, Canada
| | - J Turgeon
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada.,Canadian National Transplant Research Program, Edmonton, Alberta, T6G 2E1, Canada.,Université de Montréal, Montreal, QC, Canada
| | - S Lan
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada.,Canadian National Transplant Research Program, Edmonton, Alberta, T6G 2E1, Canada.,Université de Montréal, Montreal, QC, Canada
| | - L Pomerleau
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada
| | - M Quesnel
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada
| | - J Peng
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada
| | - J Tremblay
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada
| | - Y Shi
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada.,Université de Montréal, Montreal, QC, Canada
| | - J S Chan
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada.,Université de Montréal, Montreal, QC, Canada
| | - M J Hébert
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada.,Canadian National Transplant Research Program, Edmonton, Alberta, T6G 2E1, Canada.,Université de Montréal, Montreal, QC, Canada
| | - H Cardinal
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada.,Canadian National Transplant Research Program, Edmonton, Alberta, T6G 2E1, Canada.,Université de Montréal, Montreal, QC, Canada
| |
Collapse
|
7
|
Abstract
Antibodies that are specific to organ donor HLA have been involved in the majority of cases of antibody-mediated rejection in solid organ transplant recipients. However, recent data show that production of non-HLA autoantibodies can occur before transplant in the form of natural autoantibodies. In contrast to HLAs, which are constitutively expressed on the cell surface of the allograft endothelium, autoantigens are usually cryptic. Tissue damage associated with ischemia-reperfusion, vascular injury, and/or rejection creates permissive conditions for the expression of cryptic autoantigens, allowing these autoantibodies to bind antigenic targets and further enhance vascular inflammation and renal dysfunction. Antiperlecan/LG3 antibodies and antiangiotensin II type 1 receptor antibodies have been found before transplant in patients with de novo transplants and portend negative long-term outcome in patients with renal transplants. Here, we review mounting evidence suggesting an important role for autoantibodies to cryptic antigens as novel accelerators of kidney dysfunction and acute or chronic allograft rejection.
Collapse
Affiliation(s)
- Héloise Cardinal
- Research Centre, Infection, Inflammation, Immunity and Tissue Injury Axis, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada.,Canadian National Transplant Research Program, Edmonton, Alberta, Canada; and
| | - Mélanie Dieudé
- Research Centre, Infection, Inflammation, Immunity and Tissue Injury Axis, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada.,Canadian National Transplant Research Program, Edmonton, Alberta, Canada; and
| | - Marie-Josée Hébert
- Research Centre, Infection, Inflammation, Immunity and Tissue Injury Axis, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada; .,Canadian National Transplant Research Program, Edmonton, Alberta, Canada; and.,Université de Montréal, Montreal, Quebec, Canada
| |
Collapse
|
8
|
Dieudé M, Bell C, Turgeon J, Beillevaire D, Pomerleau L, Yang B, Hamelin K, Qi S, Pallet N, Béland C, Dhahri W, Cailhier JF, Rousseau M, Duchez AC, Lévesque T, Lau A, Rondeau C, Gingras D, Muruve D, Rivard A, Cardinal H, Perreault C, Desjardins M, Boilard É, Thibault P, Hébert MJ. The 20
S
proteasome core, active within apoptotic exosome-like vesicles, induces autoantibody production and accelerates rejection. Sci Transl Med 2015; 7:318ra200. [DOI: 10.1126/scitranslmed.aac9816] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
9
|
Graham F, Lord M, Froment D, Cardinal H, Bollée G. The use of gallium-67 scintigraphy in the diagnosis of acute interstitial nephritis. Clin Kidney J 2015; 9:76-81. [PMID: 26798465 PMCID: PMC4720207 DOI: 10.1093/ckj/sfv129] [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: 07/29/2015] [Accepted: 11/04/2015] [Indexed: 11/16/2022] Open
Abstract
Background Gallium-67 scintigraphy has been suggested as a noninvasive method to diagnose acute interstitial nephritis (AIN). However, its diagnostic performance and usefulness remain controversial. Methods We retrospectively reviewed the charts of 76 patients who underwent gallium-67 scintigraphy for a suspicion of AIN. Patients were classified based on kidney biopsy and/or clinical probability of AIN. Gallium-67 scintigraphy results were reinterpreted blindly using both posterior planar and single photon emission computed tomography (SPECT) imaging. Intensity of radioisotope uptake in the kidney was graded from 0 to 5. Results The diagnosis of AIN was confirmed in 23 patients and excluded in 44. Nine patients with an uncertain diagnosis were excluded from subsequent analysis. A gallium-67 kidney uptake cutoff of 1 gave a negative predictive value of 100%, whereas a cutoff of 5 had an excellent specificity and positive predictive value for the diagnosis of AIN. When using a cutoff of 3, which had previously been used in the literature, we obtained a sensitivity of 61% and a specificity of 75% with posterior planar imaging. The results of both SPECT and posterior planar imaging modalities were comparable. Conclusions Gallium-67 scintigraphy may be of interest in patients with a clinical suspicion of AIN, especially in those who are unable to undergo kidney biopsy. However, results need to be interpreted with caution and depend on the intensity of gallium-67 kidney uptake.
Collapse
Affiliation(s)
- François Graham
- Department of Allergy and Immunology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada; Department of Nephrology, Centre Hospitalier de l'Université de Montréal, Hôpital Notre-Dame, Montreal, QC, Canada
| | - Martin Lord
- Department of Nuclear Medicine , Centre Hospitalier de l'Université de Montréal , Montreal, QC , Canada
| | - Daniel Froment
- Department of Nephrology , Centre Hospitalier de l'Université de Montréal, Hôpital Notre-Dame , Montreal, QC , Canada
| | - Héloise Cardinal
- Department of Nephrology , Centre Hospitalier de l'Université de Montréal, Hôpital Notre-Dame , Montreal, QC , Canada
| | - Guillaume Bollée
- Department of Nephrology , Centre Hospitalier de l'Université de Montréal, Hôpital Notre-Dame , Montreal, QC , Canada
| |
Collapse
|
10
|
Silver SA, Cardinal H, Colwell K, Burger D, Dickhout JG. Acute kidney injury: preclinical innovations, challenges, and opportunities for translation. Can J Kidney Health Dis 2015; 2:30. [PMID: 26331054 PMCID: PMC4556308 DOI: 10.1186/s40697-015-0062-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 07/02/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a clinically important condition that has attracted a great deal of interest from the biomedical research community. However, acute kidney injury AKI research findings have yet to be translated into significant changes in clinical practice. OBJECTIVE This article reviews many of the preclinical innovations in acute kidney injury AKI treatment, and explores challenges and opportunities to translate these finding into clinical practice. SOURCES OF INFORMATION MEDLINE, ISI Web of Science. FINDINGS This paper details areas in biomedical research where translation of pre-clinical findings into clinical trials is ongoing, or nearing a point where trial design is warranted. Further, the paper examines ways that best practice in the management of AKI can reach a broader proportion of the patient population experiencing this condition. LIMITATIONS This review highlights pertinent literature from the perspective of the research interests of the authors for new translational work in AKI. As such, it does not represent a systematic review of all of the AKI literature. IMPLICATIONS Translation of findings from biomedical research into AKI therapy presents several challenges. These may be partly overcome by targeting populations for interventional trials where the likelihood of AKI is very high, and readily predictable. Further, specific clinics to follow-up with patients after AKI events hold promise to provide best practice in care, and to translate therapies into treatment for the broadest possible patient populations.
Collapse
Affiliation(s)
- Samuel A. Silver
- />Division of Nephrology, St. Michael’s Hospital, University of Toronto, Toronto, Canada
| | - Héloise Cardinal
- />Division of Nephrology, Centre Hospitalier de l’Université de Montréal and CHUM research center, Montreal, Quebec Canada
| | - Katelyn Colwell
- />Department of Medicine, Division of Nephrology, McMaster University and St. Joseph’s Healthcare Hamilton, Hamilton, Ontario Canada
| | - Dylan Burger
- />Kidney Research Centre, Ottawa Hospital Research Institute, Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario Canada
| | - Jeffrey G. Dickhout
- />Department of Medicine, Division of Nephrology, McMaster University and St. Joseph’s Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6 Canada
| |
Collapse
|
11
|
Lévesque R, Marcelli D, Cardinal H, Caron ML, Grooteman M, Bots M, Blankestijn P, Nubé M, Grassmann A, Canaud B, Gandjour A. FP758COST-EFFECTIVENESS ANALYSIS OF HIGH-EFFICIENCY HEMODIAFILTRATION VS. LOW-FLUX HEMODIALYSIS BASED ON THE CANADIAN ARM OF THE CONTRAST STUDY. Nephrol Dial Transplant 2015. [DOI: 10.1093/ndt/gfv183.76] [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: 11/14/2022] Open
|
12
|
Cardinal H, Madore F, Brophy JM, Joseph L, Hébert MJ, Min S, Boyer L, Bogaty P. Longitudinal trends in sFas, a biomarker of apoptosis, after an acute coronary syndrome: clues to the pathogenesis underlying adverse events on follow-up. Int J Cardiol 2014; 173:603-7. [PMID: 24708933 DOI: 10.1016/j.ijcard.2014.03.139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 03/15/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Héloise Cardinal
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Canada.
| | - François Madore
- Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Canada
| | - James M Brophy
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Canada; Department of Medicine, McGill University Health Centre, Canada
| | - Lawrence Joseph
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Canada; Department of Medicine, McGill University Health Centre, Canada
| | - Marie-Josée Hébert
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Canada
| | - Sooyeon Min
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Canada
| | - Luce Boyer
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ), Canada
| | - Peter Bogaty
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ), Canada
| |
Collapse
|
13
|
Cardinal H, Dieudé M, Brassard N, Qi S, Patey N, Soulez M, Beillevaire D, Echeverry F, Daniel C, Durocher Y, Madore F, Hébert MJ. Antiperlecan antibodies are novel accelerators of immune-mediated vascular injury. Am J Transplant 2013; 13:861-874. [PMID: 23432943 DOI: 10.1111/ajt.12168] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 11/23/2012] [Accepted: 11/25/2012] [Indexed: 01/25/2023]
Abstract
Acute vascular rejection (AVR) is characterized by immune-mediated vascular injury and heightened endothelial cell (EC) apoptosis. We reported previously that apoptotic ECs release a bioactive C-terminal fragment of perlecan referred to as LG3. Here, we tested the possibility that LG3 behaves as a neoantigen, fuelling the production of anti-LG3 antibodies of potential importance in regulating allograft vascular injury. We performed a case-control study in which we compared anti-LG3 IgG titers in kidney transplant recipients with AVR (n=15) versus those with acute tubulo-interstitial rejection (ATIR) (n=15) or stable graft function (n=30). Patients who experienced AVR had elevated anti-LG3 titers pre and posttransplantation compared to subjects with ATIR or stable graft function (p<0.05 for both mediators). Elevated pretransplant anti-LG3 titers (OR: 4.62, 95% CI: 1.08-19.72) and pretransplant donor-specific antibodies (DSA) (OR 4.79, 95% CI: 1.03-22.19) were both independently associated with AVR. To address the functional role of anti-LG3 antibodies in AVR, we turned to passive transfer of anti-LG3 antibodies in an animal model of vascular rejection based on orthotopic aortic transplantation between fully MHC-mismatched mice. Neointima formation, C4d deposition and allograft inflammation were significantly increased in recipients of an ischemic aortic allograft passively transferred with anti-LG3 antibodies. Collectively, these data identify anti-LG3 antibodies as novel accelerators of immune-mediated vascular injury and obliterative remodeling.
Collapse
Affiliation(s)
- H Cardinal
- Research Centre, Centre hospitalier de l'Université de Montréal (CRCHUM)-Hôpital Notre-Dame and Université de Montréal, Montreal, QC, Canada
| | - M Dieudé
- Research Centre, Centre hospitalier de l'Université de Montréal (CRCHUM)-Hôpital Notre-Dame and Université de Montréal, Montreal, QC, Canada
| | - N Brassard
- Research Centre, Centre hospitalier de l'Université de Montréal (CRCHUM)-Hôpital Notre-Dame and Université de Montréal, Montreal, QC, Canada
| | - S Qi
- Research Centre, Centre hospitalier de l'Université de Montréal (CRCHUM)-Hôpital Notre-Dame and Université de Montréal, Montreal, QC, Canada
| | - N Patey
- Research Centre, Hôpital Ste-Justine, Montreal, Quebec, Canada
| | - M Soulez
- Research Centre, Centre hospitalier de l'Université de Montréal (CRCHUM)-Hôpital Notre-Dame and Université de Montréal, Montreal, QC, Canada
| | - D Beillevaire
- Research Centre, Centre hospitalier de l'Université de Montréal (CRCHUM)-Hôpital Notre-Dame and Université de Montréal, Montreal, QC, Canada
| | - F Echeverry
- INRS-Institut Armand-Frappier, Laval, QC, Canada
| | - C Daniel
- INRS-Institut Armand-Frappier, Laval, QC, Canada
| | - Y Durocher
- Biotechnology Research Institute, Montreal, QC, Canada
| | - F Madore
- Research Centre, Hôpital du Sacré-Coeur de Montréal, Montreal, QC, Canada
| | - M J Hébert
- Research Centre, Centre hospitalier de l'Université de Montréal (CRCHUM)-Hôpital Notre-Dame and Université de Montréal, Montreal, QC, Canada
| |
Collapse
|
14
|
Renoult E, Coutlée F, Pâquet M, St Louis G, Girardin C, Fortin MC, Cardinal H, Lévesque R, Schürch W, Latour M, Barama A, Hébert MJ. Evaluation of a Preemptive Strategy for BK Polyomavirus-Associated Nephropathy Based on Prospective Monitoring of BK Viremia: A Kidney Transplantation Center Experience. Transplant Proc 2010; 42:4083-7. [DOI: 10.1016/j.transproceed.2010.09.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 09/09/2010] [Indexed: 10/18/2022]
|
15
|
Cardinal H, Brophy JM, Bogaty P, Joseph L, Hébert MJ, Boyer L, Madore F. Usefulness of soluble fas levels for improving diagnostic accuracy and prognosis for acute coronary syndromes. Am J Cardiol 2010; 105:797-803. [PMID: 20211322 DOI: 10.1016/j.amjcard.2009.10.061] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Revised: 10/28/2009] [Accepted: 10/28/2009] [Indexed: 10/19/2022]
Abstract
Although both inflammation and apoptosis occur in acute coronary syndromes (ACSs), previous studies have not tested the diagnostic and prognostic utility of an approach that measures circulating markers of these pathways. The aim of the present study was to assess whether measuring soluble Fas (sFas) and high-sensitivity C-reactive protein (hs-CRP), as markers of apoptosis and inflammation, improve ACS diagnostic and prognostic accuracy. In a prospective cohort of consecutive subjects admitted to the hospital for suspicion of ACS, we measured sFas, hs-CRP, and troponin T in those who had a final noncardiac chest pain diagnosis (n = 100), those who had an ACS diagnosis and experienced (n = 218) or did not experience (n = 170) recurrent cardiac events during 1 year of follow-up. sFas was strongly and independently associated with a discharge diagnosis of an ACS versus noncardiac chest pain during the index hospitalization (odds ratio 16.16 for the second vs first tertile, 95% confidence interval [CI] 7.07 to 36.91; and odds ratio 25.40 for the third vs first tertile, 95% CI 9.38 to 68.75). However, hs-CRP was not. sFas significantly improved the diagnostic accuracy for ACSs (C statistic increased from 0.85 to 0.93, difference +0.08, 95% CI for the difference 0.05 to 0.11). The sFas levels were high and did not vary with time in the subjects having early versus late measurements (beta 0.00 ln pg/ml/hour, 95% CI -0.01 to 0.01). In contrast, troponin increased with time since the beginning of the symptoms (beta 0.07 ln microg/L/hour, 95% CI 0.04 to 0.10). Baseline sFas and hs-CRP did not predict recurrent cardiac events. In conclusion, our results suggest that in suspected ACS cases, sFas, but not hs-CRP, helps to improve the diagnostic accuracy and timeliness over and above standard diagnostic criteria.
Collapse
|
16
|
Cardinal H, Bogaty P, Madore F, Boyer L, Joseph L, Brophy JM. Therapeutic management in patients with renal failure who experience an acute coronary syndrome. Clin J Am Soc Nephrol 2009; 5:87-94. [PMID: 19875769 DOI: 10.2215/cjn.04290609] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Prior reports have suggested that patients with impaired renal function receive less aggressive care after an acute coronary syndrome (ACS). The aim of this study was to determine whether this held true in a contemporary cohort, after thorough adjustment for cotreatments/comorbidities. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients who were admitted for an ACS in eight participating hospitals were stratified into three groups according to estimated creatinine clearance (CrC): less than 45 ml/min, 45 to 60 ml/min, and reference >60 ml/min. RESULTS During hospitalization, uses of reperfusion therapy in tertiary care centers [difference between CrC < or =45 ml/min and reference group (Delta): 4%, 95% confidence interval (CI): (-13%, 21%)] and systemic anticoagulation [Delta: 0%, CI (-5%, 5%)] were similar in the three groups. Coronary angiography was performed less often in patients with lower CrC [Delta: -16%, CI: (-31%, -1%)]. At discharge, nearly all patients received either an antiplatelet agent or warfarin regardless of CrC [Delta: -1%, CI: (-3%, 1%)]. Discharge use of angiotensin converting enzyme (ACE) inhibitors or angiotensin-receptor blockers was comparable [Delta: 7%, CI: (-1%, 15%)]. beta-blockers [Delta: -9%, CI: (-17%, -1%)] and lipid-lowering drugs (LLDs) [Delta: -7%, CI: (-13%, -1%)] were used less frequently in patients with lower CrC. In multivariate analyses, decreased CrC predicted lower coronary angiography and LLD use, but not lower beta-blocker use at discharge. CONCLUSIONS These results suggest that in patients with ACS, the extent of undertreatment due to chronic kidney disease is less than reported previously, which is partially explained by more complete adjustment for cotreatments/comorbidities.
Collapse
Affiliation(s)
- Héloise Cardinal
- Centre Hospitalier de l'Université de Montréal, 1058 Saint-Denis, Montreal, Quebec, Canada, H2X 3J4.
| | | | | | | | | | | |
Collapse
|
17
|
Cardinal H, Froidure A, Dandavino R, Daloze P, Hébert M, Colette S, Boucher A. Conversion From Calcineurin Inhibitors to Sirolimus in Kidney Transplant Recipients: A Retrospective Cohort Study. Transplant Proc 2009; 41:3308-10. [DOI: 10.1016/j.transproceed.2009.08.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
18
|
Cardinal H, Poirier C, Fugère J, Ferraro P, Girardin C. The Evolution of Kidney Function After Lung Transplantation: A Retrospective Cohort Study. Transplant Proc 2009; 41:3342-4. [DOI: 10.1016/j.transproceed.2009.08.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
19
|
Cardinal H, Raymond MA, Hébert MJ, Madore F. Uraemic plasma decreases the expression of ABCA1, ABCG1 and cell-cycle genes in human coronary arterial endothelial cells. Nephrol Dial Transplant 2006; 22:409-16. [PMID: 17082211 DOI: 10.1093/ndt/gfl619] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Uraemia is associated with endothelial dysfunction, but the effect of uraemic plasma on the gene expression pattern of human coronary arterial endothelial cells (HCAEC) has never been defined. METHODS HCAECs were exposed for 48 h to a culture medium supplemented with 20% uraemic vs normal plasma. We extracted mRNA and hybridized it onto Affymetrix HG-U133 Plus2 microarrays. We validated our findings for five genes of interest by real-time PCR and performed evaluations of cell proliferation and apoptosis in HCAECs exposed to uraemic vs normal plasma. RESULTS Six genes involved in the regulation of cell-cycle progression (CDK-1, topoisomerase II, PDZ-binding kinase, CDCA1, protein SDP35, E2F transcription factor 8) and two genes of the cholesterol efflux system (ABCA1 and ABCG1) were down-regulated in HCAECs exposed to uraemic plasma (>1.75-fold change vs normal). Real-time PCR confirmed the down-regulation observed in the microarray experiment. Cell proliferation was significantly decreased in HCAECs exposed to uraemic vs normal plasma for 48 h (86 vs 95% of serum-starved control, P = 0.006). Exposure to uraemic plasma for 48 h was associated with increased apoptosis of HCAEC as compared with normal plasma (7.7 vs 2.8%, P < 0.001), a phenomenon that was further enhanced when oxidized LDLs (150 microg protein/ml) were added to the medium containing uraemic plasma (16.9 vs 7.7%, P < 0.001). CONCLUSIONS The down-regulation of genes involved in cell-cycle progression and cholesterol efflux from HCAECs exposed to uraemic conditions could contribute to enhancing endothelial dysfunction and atherosclerosis in patients with chronic renal failure.
Collapse
Affiliation(s)
- Héloise Cardinal
- Centre de Recherche, Hôpital du Sacré-Coeur de Montréal, 5400 Boulevard Gouin, Montreal, QC, Canada H4J 1C5
| | | | | | | |
Collapse
|
20
|
Abstract
PURPOSE To better communicate the impact of poor persistence when preventive therapies are initiated, we propose a new measure that is intuitively understandable for clinicians. This measure is the percent wasted patients (PWP). METHODS The PWP is the percentage of patients, out of the new users of a given preventive treatment, who have discontinued therapy before the time point at which clinical benefits become apparent on the cumulative incidence curves in randomized controlled trials (RCTs) comparing active treatment to placebo. To calculate the PWP, the RCTs that demonstrated the efficacy of the therapy under study must be identified from a MEDLINE search. The point at which the cumulative incidence curves for the main outcome in the experimental and placebo group start diverging is identified and is called the point of visual divergence (PVD). Then, using pharmaceutical claims databases, the percent persistence at the PVD in new users of the therapy is determined. The PWP is then calculated as 100% persistence at PVD. RESULTS For primary prevention with statins, in the province of Quebec, the PWP is 44%. Of 100 patients starting statins for the primary prevention of coronary events, 44 will represent a waste in health resources because they will have discontinued therapy before any clinical benefit can be expected. CONCLUSIONS The PWP is a simple measure that can be used by clinicians to select the therapies that need the most reinforcement concerning the importance of persistence.
Collapse
Affiliation(s)
- Héloise Cardinal
- Department of Pharmacoepidemiology, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montreal, Que., Canada
| | | | | | | |
Collapse
|
21
|
Cardinal H, Hébert MJ, Rahme E, Houde I, Baran D, Masse M, Boucher A, Le Lorier J. Modifiable factors predicting patient survival in elderly kidney transplant recipients. Kidney Int 2005; 68:345-51. [PMID: 15954926 DOI: 10.1111/j.1523-1755.2005.00410.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Elderly transplant candidates represent an increasingly important group on the waiting list for kidney transplantation. Yet the factors that determine posttransplantation outcomes in this population remain poorly defined. METHODS We performed a population-based retrospective cohort study involving all patients aged 60 years or older who received a first cadaveric kidney transplantation between 1985 and 2000 in the province of Quebec. The main outcomes were patient survival, overall graft survival, and treatment failure (patient death or graft loss within the first posttransplant year). Survival analyses were performed using a Cox proportional hazard model. Logistic regression identified factors predicting treatment failure. RESULTS On multivariate analysis, the modifiable factors associated with patient survival were active smoking at transplantation [hazard ratio (HR) 2.09, 95% confidence interval (CI) 1.22-3.60)], body mass index (BMI) (HR 1.34 for a 5-point increase, 95% CI 1.05-1.67), and time on dialysis before transplantation (HR 1.10 for a 1-year increase, 95% CI 1.02-1.18). The only modifiable factor associated with graft survival was active smoking at transplantation (HR 2.04, 95% CI 1.24-3.30). Treatment failure was associated with time on dialysis before transplantation (odds ratio for dialysis >/=2 years 3.28, 95% CI 1.34-7.9). CONCLUSION Our results show that active smoking, obesity, and time on dialysis before transplantation are modifiable risk factors associated with an increased risk of mortality after transplantation in elderly recipients. They represent potential targets for interventions aimed at improving patient and graft survival in elderly patients.
Collapse
Affiliation(s)
- Héloise Cardinal
- Nephrology Department, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Quebec, Canada
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Cardinal H, Monfared AAT, Dorais M, LeLorier J. A comparison between persistence to therapy in ALLHAT and in everyday clinical practice: a generalizability issue. Can J Cardiol 2004; 20:417-21. [PMID: 15057318] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Persistence to therapy was very high in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) and was similar between treatment arms. Most patients were already on antihypertensive therapy before the trial began. Clinically, the results from this trial are more likely to be applied when antihypertensive therapy is initiated. OBJECTIVES To assess whether the conclusions drawn from ALLHAT could be applied to the initiation of antihypertensive therapy. METHODS A MEDLINE literature search was performed using the key words 'persistence', 'persistence to therapy', 'compliance' and 'adherence', and these were each linked with 'hypertension'. Studies from pharmaceutical databases were selected when they reported persistence to any antihypertensive therapy at one year according to which initial drug class (calcium channel blockers, angiotensin-converting enzyme inhibitors and thiazides) was initially prescribed. From the reported persistence rates, the number of patients was determined in whom treatment of hypertension results in a waste of health resources when each initial drug class was prescribed. RESULTS Persistence to antihypertensive therapy at one year reported in the pharmaceutical databases varies from 5% to 75%. It was lower when the initial drug that was prescribed was a diuretic versus an angiotensin-converting enzyme inhibitor or a calcium channel blocker. The number of patients in whom treatment of hypertension resulted in a waste of resource was also higher when a diuretic was initially prescribed. CONCLUSION Persistence to antihypertensive therapy is low for all the agents initiated and the lowest with diuretics. This should be considered as a word of caution when the ALLHAT conclusions are applied to the clinical setting.
Collapse
Affiliation(s)
- Héloise Cardinal
- Research Centre, Hôtel-Dieu du Centre Hospitalier de l'Université de Montréal, Quebec
| | | | | | | |
Collapse
|
23
|
Cardinal H, Barama AA, Fradet V, Lallier M, Lévesque R, St Louis G, Hébert MJ, Girardin C, Pâquet M, Daloze P. Total cholesterol correlates with cyclosporine C2 levels in kidney transplant recipients under maintenance immunosuppression. Transplant Proc 2004; 36:448S-450S. [PMID: 15041384 DOI: 10.1016/j.transproceed.2004.01.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this study was to assess the relationship between cyclosporine (CyA) trough level (C0) and 2-hour postdose (C2) and total cholesterol (TC) in kidney transplant (KT) recipients on Neoral maintenance immunosuppression. In KT recipients who had more than 5 years of follow-up, stable graft function, and stable Neoral dose, we measured C2 and C0 blood levels, serum creatinine, mean total cholesterol (TC) over the last 5 years, prednisone dose, use of beta-blockers and thiazides. Correlations between C0 and C2 levels and TC were performed with the Pearson coefficient. Receiver operating characteristics (ROCs) were used to define the threshold with greater accuracy for significant variables at the correlation test. Statistical tests were performed with SPSS 9.5 The C2 correlated with TC (0.31; P=.008) whereas C0 did not. The C2 level was an independent predictor for TC after adjusting for recipient age, gender, dose of prednisone, creatinine clearance, and use of beta-blockers and thiazides (B coefficient=1.124(E-3); P=.009). A threshold C2 value of 700 microg/L yielded to a TC level of 5.2 mmol/L. This is the first study to report a correlation between C2 levels and TC. Although C2 explained a small fraction of TC variability, it is an independent predictor of TC in KT recipients on Neoral maintenance immunosuppression. A long-term C2 value under 700 microg correlates with better control of hypercholesterolemia.
Collapse
Affiliation(s)
- H Cardinal
- Division of Nephrology, CHUM, Hôpital Notre-Dame, Montreal, Canada
| | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Affiliation(s)
- H Cardinal
- Centre Hospitalier de l'Université de Montréal, 3812 Northcliffe Street, Montreal, Quebec H4A 3L1, Canada
| | | | | | | |
Collapse
|
25
|
Virdis A, Ghiadoni L, Cardinal H, Favilla S, Duranti P, Birindelli R, Magagna A, Bernini G, Salvetti G, Taddei S, Salvetti A. Mechanisms responsible for endothelial dysfunction induced by fasting hyperhomocystinemia in normotensive subjects and patients with essential hypertension. J Am Coll Cardiol 2001; 38:1106-15. [PMID: 11583890 DOI: 10.1016/s0735-1097(01)01492-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.8] [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: 11/24/2022]
Abstract
OBJECTIVES We sought to evaluate whether fasting hyperhomocystinemia reduces endothelial function by oxidative stress in normotensive subjects and hypertensive patients. BACKGROUND Subjects with hyperhomocystinemia have endothelial dysfunction. METHODS In 23 normotensive subjects and 28 hypertensive patients, classified into normohomocystinemic and hyperhomocystinemic groups according to homocysteine plasma levels (< 8.7 and >14.6 micromol/l, respectively), we studied forearm blood flow changes (strain-gauge plethysmography) induced by intrabrachial administration of acetylcholine (0.15 to 15 microg/100 ml tissue per min) or sodium nitroprusside (1 to 4 microg/100 ml per min), an endothelium-dependent and -independent vasodilator, respectively. Acetylcholine was repeated with N(G)-monomethyl-L-arginine (L-NMMA; 100 microg/100 ml per min), vitamin C (8 mg/100 ml per min) and L-NMMA plus vitamin C. RESULTS Normotensive hyperhomocystinemic patients showed a blunted response to acetylcholine and a lower inhibiting effect of L-NMMA on acetylcholine, as compared with normohomocystinemic patients. Although vitamin C was ineffective in normohomocystinemic subjects, it increased the response to acetylcholine and restored the inhibiting effect of L-NMMA on acetylcholine in hyperhomocystinemic patients. Hypertensive hyperhomocystinemic patients showed a reduced response to acetylcholine, as compared with normohomocystinemic subjects. In both subgroups, L-NMMA failed to blunt the response to acetylcholine. The potentiating effect of vitamin C on acetylcholine was greater in hyperhomocystinemic patients than in normohomocystinemic subjects, although it restored the inhibitory effect of L-NMMA on acetylcholine-induced vasodilation to the same extent in both groups. Hyperhomocystinemia did not change the response to sodium nitroprusside. CONCLUSIONS In normotensive subjects and hypertensive patients, hyperhomocystinemia impairs endothelium-dependent vasodilation. It could be related to oxidant activity.
Collapse
Affiliation(s)
- A Virdis
- Department of Internal Medicine, University of Pisa, Pisa, Italy.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Virdis A, Cardinal H, Ghiadoni L, Haq BA, Taddei S, Salvetti A. PHENYLALKYLAMINE CALCIUM ANTAGONIST IMPROVES ENDOTHELIUM-DEPENDENT VASODILATION BY RESTORING NITRIC OXIDE AVAILABILITY IN ESSENTIAL HYPERTENSIVE PATIENTS. J Hypertens 2000. [DOI: 10.1097/00004872-200006001-00267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
27
|
Brossard JH, Lepage R, Cardinal H, Roy L, Rousseau L, Dorais C, D'Amour P. Influence of glomerular filtration rate on non-(1-84) parathyroid hormone (PTH) detected by intact PTH assays. Clin Chem 2000; 46:697-703. [PMID: 10794753] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND Commercial intact parathyroid hormone (I-PTH) assays detect molecular form(s) of human PTH, non-(1-84) PTH, different from the 84-amino acid native molecule. These molecular form(s) accumulate in hemodialyzed patients. We investigated the importance of non-(1-84) PTH in the interpretation of the increased I-PTH in progressive renal failure. METHODS Five groups were studied: 26 healthy individuals, 12 hemodialyzed patients, and 31 patients with progressive renal failure subdivided according to their glomerular filtration rate (GFR) into 11 with a GFR between 60 and 100 mL. min(-1). 1.73 m(-2), 12 with a GFR between 30 and 60 mL. min(-1). 1.73 m(-2), and 8 with a GFR between 5 and 30 mL. min(-1). 1.73 m(-2). We evaluated indicators of calcium and phosphorus metabolism and creatinine clearance (CrCl) in the progressive renal failure groups, and the HPLC profile of I-PTH and C-terminal PTH in all groups. RESULTS Only patients with a GFR <30 mL. min(-1). 1.73 m(-2) and hemodialyzed patients had decreased Ca(2+) and 1,25-dihydroxyvitamin D, and increased phosphate. In patients with progressive renal failure, I-PTH was related to Ca(2+) (r = -0.66; P <0.0001), CrCl (r = -0.61; P <0.001), 1,25-dihydroxyvitamin D (r = -0.40; P <0.05), and 25-hydroxyvitamin D (r = -0.49; P <0.01) by simple linear regression. The importance of non-(1-84) PTH in the composition of I-PTH increased with each GFR decrease, being 21% in healthy individuals, 32% in progressive renal failure patients with a GFR <30 mL. min(-1). 1.73 m(-2), and 50% in hemodialyzed patients, with PTH(1-84) making up the difference. CONCLUSIONS As I-PTH increases progressively with GFR decrease, part of the increase is associated with the accumulation of non-(1-84) PTH, particularly when the GFR is <30 mL. min(-1). 1.73 m(-2). Concentrations of I-PTH 1.6-fold higher than in healthy individuals are necessary in hemodialyzed patients to achieve PTH(1-84) concentrations similar to those in the absence of renal failure.
Collapse
Affiliation(s)
- J H Brossard
- Centre de Recherche et, Hôpital Saint-Luc, Montreal, Quebec H2X 1P1, Canada
| | | | | | | | | | | | | |
Collapse
|
28
|
Cardinal H, Brossard JH, Roy L, Lepage R, Rousseau L, D'Amour P. The set point of parathyroid hormone stimulation by calcium is normal in progressive renal failure. J Clin Endocrinol Metab 1998; 83:3839-44. [PMID: 9814455 DOI: 10.1210/jcem.83.11.5256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
An increased set point of PTH stimulation by ionized calcium (Ca++) has been observed in renal failure patients with severe secondary hyperparathyroidism. The extension of this concept to all renal failure patients has remained problematic, even if it could explain elevated PTH levels in the absence of other biochemical abnormalities. We were particularly interested in seeing whether the concept could fit patients with progressive renal failure (PRF). To achieve this, we studied 26 normals (N), 9 patients with PRF, and 12 hemodialyzed patients (HD) in the basal state and during parathyroid function tests. The latter two groups were studied at the end of winter and end of summer, respectively. Patients with PRF had normal levels of Ca++, PO4, and 1,25(OH)2D, and they had low-normal concentrations of 25(OH)D; their basal I- and C-PTH levels were 3- and 4-fold higher than N, as were their creatinine levels. HD had significantly lower levels of Ca++ and 1,25(OH)2D, and they had higher levels of phosphate, creatinine, I-PTH, and C-PTH than N or PRF. Stimulated levels of I-PTH were similar in N (13.6 +/- 4.3 pmol/L) and PFR (18 +/- 3.3 pmol/L) and elevated in HD (37.1 +/- 28.7 pmol/L; P < 0.001 vs. N, and P < 0.05 vs. PRF). Nonsuppressible I-PTH was increased 2-fold in PRF (N = 0.64 +/- 0.19 vs. PRF = 1.28 +/- 0.46 pmol/L; P < 0.01) and 6-fold in HD (3.95 +/- 2.85 pmol/L; P < 0.001 vs. others). But the set point of I-PTH stimulation by Ca++ was normal in PRF (N = 1.18 +/- 0.03 vs. PRF = 1.20 +/- 0.04 mmol/L; not significant) and decreased in HD (1.09 +/- 0.04 mmol/L; P < 0.001 vs. others). Similar results were obtained with the set point of C-PTH and of the C-PTH/I-PTH ratio. A positive correlation was observed between serum Ca++ concentration and the set point value when all three populations were analyzed together (r = 0.759, n = 47, P < 0.0001). These results indicate that the set point of PTH stimulation is normal in PRF and decreased in hypocalcemic HD. The set point seems to adjust to the ambient Ca++ concentration of the patients, by mechanisms yet to be elucidated. This does not suggest participation of this factor to the genesis of the secondary hyperparathyroidism of PRF.
Collapse
Affiliation(s)
- H Cardinal
- Centre Hospitalier de l'Université de Montréal Research Center, Saint-Luc Campus, Quebec, Canada
| | | | | | | | | | | |
Collapse
|