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Solera JT, Árbol BG, Mittal A, Hall V, Marinelli T, Bahinskaya I, Selzner N, McDonald M, Schiff J, Sidhu A, Humar A, Kumar D. Longitudinal outcomes of COVID-19 in solid organ transplant recipients from 2020 to 2023. Am J Transplant 2024:S1600-6135(24)00207-7. [PMID: 38499087 DOI: 10.1016/j.ajt.2024.03.011] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 03/08/2024] [Accepted: 03/08/2024] [Indexed: 03/20/2024]
Abstract
Data regarding coronavirus disease 2019 (COVID-19) outcomes in solid organ transplant recipients (SOTr) across severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) waves, including the impact of different measures, are lacking. This cohort study, conducted from March 2020 to May 2023 in Toronto, Canada, aimed to analyze COVID-19 outcomes in 1975 SOTr across various SARS-CoV-2 waves and assess the impact of preventive and treatment measures. The primary outcome was severe COVID-19, defined as requiring supplemental oxygen, with secondary outcomes including hospitalization, length of stay, intensive care unit (ICU) admission, and 30-day and 1-year all-cause mortality. SARS-CoV-2 waves were categorized as Wildtype/Alpha/Delta (318 cases, 16.1%), Omicron BA.1 (268, 26.2%), Omicron BA.2 (268, 13.6%), Omicron BA.5 (561, 28.4%), Omicron BQ.1.1 (188, 9.5%), and Omicron XBB.1.5 (123, 6.2%). Severe COVID-19 rate was highest during the Wildtype/Alpha/Delta wave (44.6%), and lower in Omicron waves (5.7%-16.1%). Lung transplantation was associated with severe COVID-19 (OR: 4.62, 95% CI: 2.71-7.89), along with rituximab treatment (OR: 4.24, 95% CI: 1.04-17.3), long-term corticosteroid use (OR: 3.11, 95% CI: 1.46-6.62), older age (OR: 1.51, 95% CI: 1.30-1.76), chronic lung disease (OR: 2.11, 95% CI: 1.36-3.30), chronic kidney disease (OR: 2.18, 95% CI: 1.17-4.07), and diabetes (OR: 1.97, 95% CI: 1.37-2.83). Early treatment and ≥3 vaccine doses were associated with reduced severity (OR: 0.29, 95% CI: 0.19-0.46, and 0.35, 95% CI: 0.21-0.60, respectively). Tixagevimab/cilgavimab and bivalent boosters did not show a significant impact. The study concludes that COVID-19 severity decreased across different variants in SOTr. Lung transplantation was associated with worse outcomes and may benefit more from preventive and early therapeutic interventions.
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Affiliation(s)
- Javier T Solera
- Department of Medicine, Ajmera Transplant Centre, University Health Network, Toronto, Canada.
| | - Berta G Árbol
- Department of Medicine, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Ankit Mittal
- Department of Medicine, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Victoria Hall
- Department of Medicine, Ajmera Transplant Centre, University Health Network, Toronto, Canada; University of Melbourne, Sir Peter MacCallum Department of Oncology, Parkville, VIC, Australia; Peter MacCallum Cancer Centre, Department of Infectious Diseases, Melbourne, VIC, Australia
| | - Tina Marinelli
- Department of Infectious Diseases and Microbiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Ilona Bahinskaya
- Department of Medicine, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Nazia Selzner
- Department of Medicine, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Michael McDonald
- Department of Medicine, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Jeffrey Schiff
- Department of Medicine, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Aman Sidhu
- Department of Medicine, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Atul Humar
- Department of Medicine, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Deepali Kumar
- Department of Medicine, Ajmera Transplant Centre, University Health Network, Toronto, Canada.
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2
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Ray S, Yousuf A, Dharia A, Ayoub G, Parmentier C, Norgate A, Schiff J, Shwaartz C, Selzner M, Reichman TW. Outcomes of pancreas transplantation in patients with underlying inflammatory bowel disease (IBD): a retrospective case series. Ann Med Surg (Lond) 2023; 85:732-737. [PMID: 37113957 PMCID: PMC10129204 DOI: 10.1097/ms9.0000000000000408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 03/07/2023] [Indexed: 04/05/2023] Open
Abstract
Despite having emerged as a definitive treatment for diabetes mellitus (DM), pancreas transplantation remains a formidable surgical task owing to complications like graft pancreatitis, enteric leaks, and rejection. This becomes more challenging in the setting of underlying bowel pathology, such as inflammatory bowel disease (IBD), which has a strong immune-genomic association of co-existence with DM. Risk of anastomotic leaks, dose adjustments of immunosuppressants and biologicals, and management of IBD flares constitute some of the major perioperative challenges calling for a protocol-based, systematic, multidisciplinary approach. Patients and methods This was a retrospective case series of patients between January 1996 and July 2021, with all patients being followed up until December 2021. All consecutive patients with end-stage DM who underwent pancreas transplantation (alone, simultaneous with kidney transplantation or after kidney transplantation) and had pre-existing IBD were included in the study. A Comparison of 1-, 5-, 10-year survival was done with pancreas transplant recipients without underlying IBD using Kaplan-Meir curves. Results Of the total 630 pancreas transplants performed between 1996 and 2021, eight patients had IBD, mostly Crohn's disease. Following pancreas transplantation, two of the eight patients had duodenal leaks, with one a requiring graft pancreatectomy. The 5-year graft survival rate for the cohort was 75% compared to 81.6% for the overall cohort of patients undergoing pancreas transplantation (P=0.48) with a median graft survival of 48.4 months compared to 68.1 months in the latter (P=0.56). Conclusion The findings of the series provide a snapshot of the outcome of pancreas transplantation in the background of IBD, suggesting a graft and overall patient survival rates comparable with pancreas transplantation in patients without underlying IBD, with further validation of the findings required in a larger cohort of patients in the future.
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Vaisbourd Y, Dahhou M, Zhang X, Sapir-Pichhadze R, Cardinal H, Johnston O, Blydt-Hansen TD, Tibbles LA, Hamiwka L, Urschel S, Birk P, Bissonnette J, Matsuda-Abedini M, BScPhm JH, Schiff J, Phan V, De Geest S, Allen U, Avitzur Y, Mital S, Foster BJ. Differences in medication adherence by sex and organ type among adolescent and young adult solid organ transplant recipients. Pediatr Transplant 2023; 27:e14446. [PMID: 36478059 DOI: 10.1111/petr.14446] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/26/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Identification of differences in medication adherence by sex or organ type may help in planning interventions to optimize outcomes. We compared immunosuppressive medication adherence between males and females, and between kidney, liver and heart transplant recipients. METHODS This multicenter study of prevalent kidney, liver and heart transplant recipients 14-25 years assessed adherence 3 times (0, 3, 6 months post-enrollment) with the BAASIS self-report tool. At each visit, participants were classified as adherent if they missed no doses in the prior 4 weeks and non-adherent otherwise. Adherence was also assessed using the coefficient of variation (CV) of tacrolimus trough levels; CV < 30% was classified as adherent. We used multivariable mixed effects logistic regression models adjusted for potential confounders to compare adherence by sex and by organ. RESULTS Across all visits, males (n = 150, median age 20.4 years, IQR 17.2-23.3) had lower odds of self-reported adherence than females (n = 120, median age 19.8 years, IQR 17.1-22.7) (OR 0.41, 95% CI 0.21-0.80) but higher odds of adherence by tacrolimus CV (OR 2.50, 95% CI 1.30-4.82). No significant differences in adherence (by self-report or tacrolimus CV) were noted between the 184 kidney, 58 liver, and 28 heart recipients. CONCLUSION Females show better self-reported adherence than males but greater variability in tacrolimus levels. Social desirability bias, more common in females than males, may contribute to better self-reported adherence among females. Higher tacrolimus variability among females may reflect biologic differences in tacrolimus metabolism between males and females rather than sex differences in adherence. There were no significant differences in adherence by organ type.
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Affiliation(s)
| | - Mourad Dahhou
- Research Institute of The McGill University Health Centre, Quebec, Canada
| | - Xun Zhang
- Research Institute of The McGill University Health Centre, Quebec, Canada
| | - Ruth Sapir-Pichhadze
- Research Institute of The McGill University Health Centre, Quebec, Canada.,Department of Medicine, McGill University, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Quebec, Canada
| | | | - Olwyn Johnston
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tom D Blydt-Hansen
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lee Anne Tibbles
- Department of Medicine and Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lorraine Hamiwka
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Simon Urschel
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Patricia Birk
- Section of Pediatric Nephrology, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Mina Matsuda-Abedini
- Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Harrison BScPhm
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.,Ajmera Transplant Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jeffrey Schiff
- Ajmera Transplant Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | | | - Sabina De Geest
- Department Public Health, Institute of Nursing Science, University of Basel, Basel, Switzerland.,Department of Primary Care and Public Health, Academic Center of Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Upton Allen
- Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, Ontario, Canada
| | - Seema Mital
- Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, Ontario, Canada
| | - Bethany J Foster
- Department of Pediatrics, McGill University, Quebec, Canada.,Research Institute of The McGill University Health Centre, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Quebec, Canada
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Mimouni M, Cole E, Kim SJ, Schiff J, Cardella C, Tinckam KJ, Slomovic AR, Chan CC. Outcomes of keratolimbal allograft from ABO compatible donors for severe bilateral limbal stem cell deficiency. Ocul Surf 2023; 27:48-53. [PMID: 36371055 DOI: 10.1016/j.jtos.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/05/2022] [Accepted: 11/08/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE To report outcomes of keratolimbal allograft (KLAL) compatible for both human leukocyte (HLA) and/or blood type using oral prednisone, mycophenolate, and tacrolimus, with basiliximab if panel reactive antibodies (PRA) are present. Intravenous immunoglobulin (IVIG) was used post-operatively if donor-specific anti-HLA antibodies (DSA) were present. METHODS Retrospective interventional series of consecutive patients with KLAL for limbal stem cell deficiency (LSCD) from HLA and/or blood type compatible deceased donors with a minimum follow-up time of 12 months. Main outcome measures were ocular surface stability, visual acuity and systemic immunosuppression (SI) adverse events. RESULTS Eight eyes of eight patients with mean age of 48.6 ± 10.1 years (range 34-65 years) were included. Mean follow-up time was 37.3 ± 22.7 months (range 12-71 months) following KLAL; four (50%) had combined LR-CLAL surgery. The etiologies of LSCD were Stevens-Johnson Syndrome (n = 4/8), aniridia (n = 2/8), chemical injury (n = 1/8) and atopic eye disease (n = 1/8). All patients had PRA present and received basiliximab infusions. 5/8 patients received IVIG based on DSA identified pre-operatively. At last follow-up, 7 eyes (87.5%) had a stable ocular surface; 1 eye (12.5%) developed failure and had keratoprosthesis implantation. There was a significant improvement in visual acuity from 1.65 ± 0.48 to 0.68 ± 0.34 logMAR (p = 0.01). SI was tolerated well with minimal adverse events. CONCLUSIONS Preliminary outcomes of KLAL with ABO compatible tissue using the Cincinnati protocol, preoperative basiliximab (when PRA present) and post-operative IVIG (when DSA present) are encouraging. This protocol may allow for utilization of deceased donor tissue with results approximating those of living donor tissue transplanted for severe bilateral LSCD.
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Affiliation(s)
- Michael Mimouni
- University of Toronto, Department of Ophthalmology and Vision Sciences, Toronto, Ontario, Canada; Department of Ophthalmology, Rambam Health Care Campus affiliated with the Bruce and Ruth Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Edward Cole
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - S Joseph Kim
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Jeffrey Schiff
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Carl Cardella
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Kathryn J Tinckam
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Allan R Slomovic
- University of Toronto, Department of Ophthalmology and Vision Sciences, Toronto, Ontario, Canada
| | - Clara C Chan
- University of Toronto, Department of Ophthalmology and Vision Sciences, Toronto, Ontario, Canada.
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Elterman D, Alshak MN, Martinez Diaz S, Shore N, Gittleman M, Motola J, Pike S, Hermann C, Terens W, Kohan A, Gonzalez R, Katz A, Schiff J, Goldfischer E, Grunberger I, Tu L, Kaminetsky J, Chughtai B. An Evaluation of Sexual Function in the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia in Men Treated with the Temporarily Implanted Nitinol Device. J Endourol 2022; 37:74-79. [PMID: 36070450 PMCID: PMC9810348 DOI: 10.1089/end.2022.0226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Purpose: To document the effect of the temporarily implanted nitinol device (iTind; Medi-Tate Ltd, Israel) on sexual function from a multicenter, randomized, single-blinded, sham-controlled trial. Materials and Methods: Men were randomized 2:1 between iTind and sham procedure arms. The iTind was placed for 5-7 days and an 18F Foley catheter was inserted and removed for the iTind and sham group, respectively. Patients were assessed at baseline, 3, and 12 months postoperatively using the Sexual Health Inventory for Men (SHIM) and International Index of Erectile Function (IIEF). Unblinding occurred at 3 months. Results: We studied 185 men with a mean age of 61.1 ± 6.5 years. There was no difference in SHIM or total IIEF between iTind and sham at 3 months or in the iTind arm at 12 months compared with baseline. Men in the iTind arm without erectile dysfunction at baseline showed an improvement in total IIEF score of +6.07 ± 21.17 points (p = 0.034) at 12 months, in addition to an improvement in ejaculatory function. SHIM scores remained unchanged in all groups, regardless of age, prostate volume, or baseline erectile function. Conclusion: No changes were observed in sexual and ejaculatory function of patients with iTind regardless of a man's age, prostate volume, and baseline sexual function. Clinicaltrials.gov: NCT02506465.
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Affiliation(s)
- Dean Elterman
- Division of Urology, University Health Network, University of Toronto, Toronto, Canada
| | - Mark N. Alshak
- Department of Urology, Weill Cornell Medicine, New York, New York, USA
| | | | - Neal Shore
- Department of Urology, Carolina Urology Research Center, Myrtle Beach, South Carolina, USA
| | - Marc Gittleman
- Department of Urology, South Florida Medical Research, Miami, Florida, USA
| | - Jay Motola
- Department of Urology, Mt Sinai Hospital, New York, New York, USA
| | - Sheldon Pike
- Department of Urology, St John's Episcopal, New York, New York, USA
| | - Craig Hermann
- Department of Urology, Clinical Research Center of Florida, Miami, Florida, USA
| | - William Terens
- Department of Urology, Premier Urology Group, Edison, New Jersey, USA
| | - Alfred Kohan
- Department of Urology, Integrated Medical Professionals, Long Island, New York, USA
| | - Ricardo Gonzalez
- Department of Urology, Houston Metro Urology, Houston, Texas, USA
| | - Aaron Katz
- Department of Urology, NYU Winthrop Hospital, Long Island, New York, USA
| | - Jeffrey Schiff
- Department of Urology, NYU Winthrop Hospital, Long Island, New York, USA
| | - Evan Goldfischer
- Department of Urology, Premier Medical Group of the Hudson Valley, Poughkeepsie, New York, USA
| | - Ivan Grunberger
- Department of Urology, New York Methodist Hospital, Brooklyn, New York, USA
| | - Le Tu
- Department of Urology, Sherbrooke University Hospital, Sherbrooke, Canada
| | - Jed Kaminetsky
- Department of Urology, Manhattan Medical Research, Manhattan, New York, USA
| | - Bilal Chughtai
- Department of Urology, Weill Cornell Medicine, New York, New York, USA.,Address correspondence to: Bilal Chughtai, MD, Department of Urology, Weill Cornell Medicine, 425 East 61st Street, 12th Floor, New York, NY 10065, USA
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Dabirzadeh A, Dahhou M, Zhang X, Sapir-Pichhadze R, Cardinal H, White M, Johnston O, Blydt-Hansen TD, Tibbles LA, Hamiwka L, Urschel S, Birk P, Bissonnette J, Matsuda-Abedini M, Harrison J, Schiff J, Phan V, De Geest S, Allen U, Mital S, Foster BJ. Care processes and structures associated with higher medication adherence in adolescent and young adult transplant recipients. Pediatr Transplant 2021; 25:e14106. [PMID: 34339090 DOI: 10.1111/petr.14106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 07/19/2021] [Accepted: 07/24/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND We aimed to identify care processes and structures that were independently associated with higher medication adherence among young transplant recipients. METHODS We conducted a prospective, observational cohort study of 270 prevalent kidney, liver, and heart transplant recipients 14-25 years old. Patients were ≥3 months post-transplant, ≥2 months post-discharge, and followed in one of 14 pediatric or 14 adult transplant programs in Canada. Patients were enrolled between June 2015 and March 2018 and followed for 6 months. Adherence was assessed at baseline, 3, and 6 months using the BAASIS© self-report tool. Patients were classified as adherent if no doses were missed in the prior 4 weeks. Transplant program directors and nurses completed questionnaires regarding care organization and processes. RESULTS Of the 270 participants, 99 were followed in pediatric programs and 171 in adult programs. Median age was 20.3 years, and median time since transplant was 5 years. At baseline, 71.5% were adherent. Multivariable mixed effects logistic regression models with program as a random effect identified two program-level factors as independently associated with better adherence: minimum number of prescribed blood draws per year for those >3 years post-transplant (per 1 additional) (OR 1.12 [95% CI 1.00, 1.26]; p = .047), and average time nurses spend with patients in clinic (per 5 additional minutes) (OR 1.15 [1.03, 1.29]; p = .017). CONCLUSION Program-level factors including protocols with a greater frequency of routine blood testing and more nurse time with patients were associated with better medication adherence. This suggests that interventions at the program level may support better adherence.
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Affiliation(s)
| | - Mourad Dahhou
- Research Institute of The McGill University Health Centre, Montreal, QC, Canada
| | - Xun Zhang
- Research Institute of The McGill University Health Centre, Montreal, QC, Canada
| | - Ruth Sapir-Pichhadze
- Research Institute of The McGill University Health Centre, Montreal, QC, Canada.,Department of Medicine, McGill University, Montreal, QC, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Heloise Cardinal
- Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Michel White
- Institut de Cardiologie, Université de Montréal, Montreal, QC, Canada
| | - Olwyn Johnston
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Tom D Blydt-Hansen
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Lee Anne Tibbles
- Department of Medicine and Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lorraine Hamiwka
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Simon Urschel
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Patricia Birk
- Section of Pediatric Nephrology, University of Manitoba, Winnipeg, MB, Canada
| | | | - Mina Matsuda-Abedini
- Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, ON, Canada
| | - Jennifer Harrison
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Multi-Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada
| | - Jeffrey Schiff
- Multi-Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada
| | - Veronique Phan
- CHU Ste-Justine, Université de Montréal, Montréal, QC, Canada
| | - Sabina De Geest
- Department Public Health, Institute of Nursing Science, University of Basel, Basel, Switzerland.,Academic Center of Nursing and Midwifery, Department of Primary Care and Public Health, KU Leuven, Leuven, Belgium
| | - Upton Allen
- Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, ON, Canada
| | - Seema Mital
- Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, ON, Canada
| | - Bethany J Foster
- Research Institute of The McGill University Health Centre, Montreal, QC, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.,Department of Pediatrics, McGill University, Montreal, QC, Canada
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7
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Marinelli T, Ferreira VH, Ierullo M, Ku T, Lilly L, Kim SJ, Schiff J, Sidhu A, McDonald M, Hosseini-Moghaddam SM, Husain S, Rotstein C, Majchrzak-Kita B, Kulasingam V, Humar A, Kumar D. Prospective Clinical, Virologic, and Immunologic Assessment of COVID-19 in Transplant Recipients. Transplantation 2021; 105:2175-2183. [PMID: 34149003 PMCID: PMC8487707 DOI: 10.1097/tp.0000000000003860] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 06/03/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Several studies have described the clinical features of COVID-19 in solid-organ transplant recipients. However, many have been retrospective or limited to more severe cases (hospitalized) and have not routinely included serial virological sampling (especially in outpatients) and immunologic assessment. METHODS Transplant patients diagnosed with COVID-19 based on a respiratory sample PCR were prospectively followed up to 90 d. Patients provided consent for convalescent serum samples and serial nasopharyngeal swabs for SARS-CoV-2 antibody (antinucleoprotein and anti-RBD) and viral load, respectively. RESULTS In the 161 SOT recipients diagnosed with COVID-19, the spectrum of disease ranged from asymptomatic infection (4.3%) to hospitalization (60.6%), supplemental oxygen requirement (43.1%), mechanical ventilation (22.7%), and death (15.6%). Increasing age (OR, 1.031; 95% CI, 1.001-1.062; P = 0.046) and ≥2 comorbid conditions (OR, 3.690; 95% CI, 1.418-9.615; P = 0.007) were associated with the need for supplemental oxygen. Allograft rejection was uncommon (3.7%) despite immunosuppression modification. Antibody response at ≥14 d postsymptoms onset was present in 90% (anti-RBD) and 76.7% (anti-NP) with waning of anti-NP titers and stability of anti-RBD over time. Median duration of nasopharyngeal positivity was 10.0 d (IQR, 5.5-18.0) and shedding beyond 30 d was observed in 6.7% of patients. The development of antibody did not have an impact on viral shedding. CONCLUSIONS This study demonstrates the spectrum of COVID-19 illness in transplant patients. Risk factors for severe disease are identified. The majority form antibody by 2 wk with differential stability over time. Prolonged viral shedding was observed in a minority of patients. Reduction of immunosuppression was a safe strategy.
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Affiliation(s)
- Tina Marinelli
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Victor H. Ferreira
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Matthew Ierullo
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Terrance Ku
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Les Lilly
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - S. Joseph Kim
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Jeffrey Schiff
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Aman Sidhu
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Michael McDonald
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | | | - Shahid Husain
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Coleman Rotstein
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | | | - Vathany Kulasingam
- Department of Biochemistry, University Health Network, Toronto, ON, Canada
| | - Atul Humar
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Deepali Kumar
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
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8
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Hall VG, Ferreira VH, Ku T, Ierullo M, Majchrzak-Kita B, Chaparro C, Selzner N, Schiff J, McDonald M, Tomlinson G, Kulasingam V, Kumar D, Humar A. Randomized Trial of a Third Dose of mRNA-1273 Vaccine in Transplant Recipients. N Engl J Med 2021; 385:1244-1246. [PMID: 34379917 PMCID: PMC8385563 DOI: 10.1056/nejmc2111462] [Citation(s) in RCA: 395] [Impact Index Per Article: 131.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | | | - Terrance Ku
- University Health Network, Toronto, ON, Canada
| | | | | | | | | | | | | | | | | | | | - Atul Humar
- University Health Network, Toronto, ON, Canada
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9
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Schiff J, Sittig M, Cook-Wiens G, Mirhadi A, Burnison M, Amersi F, Chung A, Dang C, Giuliano A, Karlan S, Basho R, el-Masry M, McAndrew P, McArthur H, Mita M, Park D, Shiao S. Impact of Age in Women with Stage I-III Triple Negative Breast Cancer (TNBC): A National Cancer Data Base (2004-2014) Report. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.1130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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L'huillier AG, Ferreira VH, Hirzel C, Natori Y, Slomovic J, Ku T, Hoschler K, Ierullo M, Selzner N, Schiff J, Singer LG, Humar A, Kumar D. Cell-Mediated Immune Responses After Influenza Vaccination of Solid Organ Transplant Recipients: Secondary Outcomes Analyses of a Randomized Controlled Trial. J Infect Dis 2020; 221:53-62. [PMID: 31550354 DOI: 10.1093/infdis/jiz471] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 07/05/2019] [Accepted: 09/12/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Despite annual immunization, solid organ transplant (SOT) patients remain at increased risk for severe influenza infection because of suboptimal vaccine immunogenicity. We aimed to compare the CD4+ and CD8+ T-cell responses of the high-dose (HD) and the standard-dose (SD) trivalent inactivated vaccine. METHODS We collected peripheral blood mononuclear cells pre- and postimmunization from 60 patients enrolled in a randomized trial of HD versus SD vaccine (30 HD; 30 SD) during the 2016-2017 influenza season. RESULTS The HD vaccine elicited significantly greater monofunctional and polyfunctional CD4+ and CD8+ T-cell responses against influenza A/H1N1, A/H3N2, and B. For example, median vaccine-elicited influenza-specific polyfunctional CD4+ T cells were higher in recipients of the HD than SD vaccine after stimulation with influenza A/H1N1 (1193 vs 0 per 106 CD4+ T cells; P = .003), A/H3N2 (1154 vs 51; P = .008), and B (1102 vs 0; P = .001). Likewise, vaccine-elicited influenza-specific polyfunctional CD8+ T cells were higher in recipients of the HD than SD vaccine after stimulation with influenza B (367 vs 0; P = .002). CONCLUSIONS Our study provides novel evidence that HD vaccine elicits greater cellular responses compared with the SD vaccine in SOT recipients, which provides support to preferentially consider use of HD vaccination in the SOT setting.
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Affiliation(s)
| | - Victor H Ferreira
- Multi-Organ Transplant Program, University Health Network, Toronto, Canada
| | - Cedric Hirzel
- Multi-Organ Transplant Program, University Health Network, Toronto, Canada
| | - Yoichiro Natori
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine and Miami Transplant Institute, Miami, Florida, USA
| | - Jaclyn Slomovic
- Multi-Organ Transplant Program, University Health Network, Toronto, Canada
| | - Terrance Ku
- Multi-Organ Transplant Program, University Health Network, Toronto, Canada
| | | | - Matthew Ierullo
- Multi-Organ Transplant Program, University Health Network, Toronto, Canada
| | - Nazia Selzner
- Multi-Organ Transplant Program, University Health Network, Toronto, Canada
| | - Jeffrey Schiff
- Multi-Organ Transplant Program, University Health Network, Toronto, Canada
| | - Lianne G Singer
- Multi-Organ Transplant Program, University Health Network, Toronto, Canada
| | - Atul Humar
- Multi-Organ Transplant Program, University Health Network, Toronto, Canada
| | - Deepali Kumar
- Multi-Organ Transplant Program, University Health Network, Toronto, Canada
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Ziemann S, Coburn M, Rossaint R, Van Waesberghe J, Bürkle H, Fries M, Henrich M, Henzler D, Iber T, Karst J, Kunitz O, Löb R, Meißner W, Meybohm P, Mierke B, Pabst F, Schaelte G, Schiff J, Soehle M, Winterhalter M, Kowark A. Implementation of anesthesia quality indicators in Germany : A prospective, national, multicenter quality improvement study. Anaesthesist 2020; 70:38-47. [PMID: 32377798 PMCID: PMC8674175 DOI: 10.1007/s00101-020-00773-y] [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: 12/20/2019] [Revised: 03/25/2020] [Accepted: 04/01/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND In 2016 the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthetists (BDA) published 10 quality indicators (QI) to compare and improve the quality of anesthesia care in Germany. So far, there is no evidence for the feasibility of implementation of these QI in hospitals. OBJECTIVE This study tested the hypothesis that the implementation of the 10 QI is feasible in German hospitals. MATERIAL AND METHODS This prospective three-phase national multicenter quality improvement study was conducted in 15 German hospitals and 1 outpatient anesthesia center from March 2017 to February 2018. The trial consisted of an initial evaluation of pre-existing structures and processes by the heads of the participating anesthesia departments, followed by a 6-month implementation phase of the QI as well as a final re-evaluation phase. The implementation procedure was supported by web-based implementation aids ( www.qi-an.org ) and internal quality management programs. The primary endpoint was the difference in the number of implemented QI per center before and after implementation. Secondary endpoints were the number of newly implemented QI per center, the overall number of successful implementations of each QI, the identification of problems during the implementation as well as the kind of impediments preventing the QI implementation. RESULTS The average number of implemented QI increased from 5.8 to 6.8 (mean of the differences 1.1 ± 1.3; P < 0.01). Most frequently the QI perioperative morbidity and mortality report (5 centers) and the QI temperature management (4 centers) could be implemented. After the implementation phase, the QI incidence management and patient blood management were implemented in all 16 centers. Implementation of other quality indicators failed mainly due to a lack of time and lack of structural resources. CONCLUSION In this study the implementation of QI was proven to be mostly feasible in the participating German hospitals. Although several QI could be implemented with minor effort, more time, financial and structural resources would be required for some QI, such as the QI postoperative visit.
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Affiliation(s)
- S Ziemann
- Department of Anaesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - M Coburn
- Department of Anaesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - R Rossaint
- Department of Anaesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - J Van Waesberghe
- Department of Anaesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - H Bürkle
- Department of Anaesthesiology and Critical Care Medicine, Faculty of Medicine, University Hospital Freiburg, Freiburg, Germany
| | - M Fries
- Department of Anaesthesiology, St. Vincenz Hospital Limburg, Limburg, Germany
| | - M Henrich
- Department of Anaesthesiology and Critical Care Medicine, St.-Vincentius Hospital Karlsruhe, Karlsruhe, Germany
| | - D Henzler
- Department of Anaesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Klinikum Herford, Ruhr-University Bochum, Herford, Germany
| | - T Iber
- Department of Anaesthesiology, Critical Care and Pain Medicine, Klinikum Mittelbaden, Baden-Baden, Germany
| | - J Karst
- Outpatient Anaesthesia Care Centre Karst, Berlin, Germany
| | - O Kunitz
- Department of Anaesthesiology and Critical Care Medicine, Klinikum Mutterhaus der Borromäerinnen, Trier, Germany
| | - R Löb
- Department of Anaesthesiology, Critical Care, Emergency and Pain Medicine, St. Barbara Hospital, Hamm, Germany
| | - W Meißner
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Jena, Jena, Germany
| | - P Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Würzburg, Würzburg, Germany
| | - B Mierke
- Department of Anaesthesiology and Critical Care Medicine, Hospital St. Elisabeth, Damme, Germany
| | - F Pabst
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Rostock, Rostock, Germany
| | - G Schaelte
- Department of Anaesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - J Schiff
- Department of Anaesthesiology and Surgical Intensive Care Medicine, Klinikum Stuttgart, Stuttgart, Germany
| | - M Soehle
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Bonn, Bonn, Germany
| | - M Winterhalter
- Department of Anaesthesiology and Pain Medicine, Klinikum Bremen-Mitte, Bremen, Germany
| | - A Kowark
- Department of Anaesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
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12
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Ziemann S, Coburn M, Rossaint R, Van Waesberghe J, Bürkle H, Fries M, Henrich M, Henzler D, Iber T, Karst J, Kunitz O, Löb R, Meißner W, Meybohm P, Mierke B, Pabst F, Schaelte G, Schiff J, Soehle M, Winterhalter M, Kowark A. [Implementation of anesthesia quality indicators in Germany : A prospective, national, multicenter quality improvement study]. Anaesthesist 2020; 69:544-554. [PMID: 32617630 DOI: 10.1007/s00101-020-00775-w] [Citation(s) in RCA: 2] [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] [Indexed: 01/09/2023]
Abstract
BACKGROUND In 2016 the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthetists (BDA) published 10 quality indicators (QI) to compare and improve the quality of anesthesia care in Germany. So far, there is no evidence for the feasibility of implementation of these QI in hospitals. OBJECTIVE This study tested the hypothesis that the implementation of the 10 QI is feasible in German hospitals. MATERIAL AND METHODS This prospective three-phase national multicenter quality improvement study was conducted in 15 German hospitals and 1 outpatient anesthesia center from March 2017 to February 2018. The trial consisted of an initial evaluation of pre-existing structures and processes by the heads of the participating anesthesia departments, followed by a 6-month implementation phase of the QI as well as a final re-evaluation phase. The implementation procedure was supported by web-based implementation aids ( www.qi-an.org ) and internal quality management programs. The primary endpoint was the difference in the number of implemented QI per center before and after implementation. Secondary endpoints were the number of newly implemented QI per center, the overall number of successful implementations of each QI, the identification of problems during the implementation as well as the kind of impediments preventing the QI implementation. RESULTS The average number of implemented QI increased from 5.8 to 6.8 (mean of the differences 1.1 ± 1.3; P < 0.01). Most frequently the QI perioperative morbidity and mortality report (5 centers) and the QI temperature management (4 centers) could be implemented. After the implementation phase, the QI incidence management and patient blood management were implemented in all 16 centers. Implementation of other quality indicators failed mainly due to a lack of time and lack of structural resources. CONCLUSION In this study the implementation of QI was proven to be mostly feasible in the participating German hospitals. Although several QI could be implemented with minor effort, more time, financial and structural resources would be required for some QI, such as the QI postoperative visit.
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Affiliation(s)
- S Ziemann
- Klinik für Anästhesiologie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - M Coburn
- Klinik für Anästhesiologie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
| | - R Rossaint
- Klinik für Anästhesiologie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - J Van Waesberghe
- Klinik für Anästhesiologie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - H Bürkle
- Klinik für Anästhesiologie und Intensivmedizin, Fakultät für Medizin, Universitätsklinikum, Freiburg, Freiburg, Deutschland
| | - M Fries
- Klinik für Anästhesiologie, St. Vincenz-Krankenhaus Limburg, Limburg, Deutschland
| | - M Henrich
- Klinik für Anästhesie, Intensiv- und Notfallmedizin, St.-Vincentius-Kliniken Karlsruhe, Karlsruhe, Deutschland
| | - D Henzler
- Klinik für Anästhesiologie, operative Intensiv‑, Rettungsmedizin und Schmerztherapie, Klinikum Herford, Ruhr-Universität Bochum, Herford, Deutschland
| | - T Iber
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Klinikum Mittelbaden, Baden-Baden, Deutschland
| | - J Karst
- Ambulantes Anästhesie MVZ Karst, Berlin, Deutschland
| | - O Kunitz
- Klinik für Anästhesie und Intensivmedizin, Klinikum Mutterhaus der Borromäerinnen, Trier, Deutschland
| | - R Löb
- Klinik für Anästhesiologie, Intensiv‑, Notfall- und Schmerzmedizin, St. Barbara-Klinik, Hamm, Deutschland
| | - W Meißner
- Klinik für Anästhesie und Intensivmedizin, Universitätsklinikum Jena, Jena, Deutschland
| | - P Meybohm
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - B Mierke
- Klinik für Anästhesie und Intensivmedizin, Krankenhaus St. Elisabeth, Damme, Deutschland
| | - F Pabst
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Rostock, Deutschland
| | - G Schaelte
- Klinik für Anästhesiologie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - J Schiff
- Klinik für Anästhesiologie, operative Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinikum Stuttgart, Stuttgart, Deutschland
| | - M Soehle
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn, Deutschland
| | - M Winterhalter
- Klinik für Anästhesiologie und Schmerztherapie, Klinikum Bremen-Mitte, Bremen, Deutschland
| | - A Kowark
- Klinik für Anästhesiologie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
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13
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Feld JJ, Cypel M, Kumar D, Dahari H, Pinto Ribeiro RV, Marks N, Kamkar N, Bahinskaya I, Onofrio FQ, Zahoor MA, Cerrochi O, Tinckam K, Kim SJ, Schiff J, Reichman TW, McDonald M, Alba C, Waddell TK, Sapisochin G, Selzner M, Keshavjee S, Janssen HLA, Hansen BE, Singer LG, Humar A. Short-course, direct-acting antivirals and ezetimibe to prevent HCV infection in recipients of organs from HCV-infected donors: a phase 3, single-centre, open-label study. Lancet Gastroenterol Hepatol 2020; 5:649-657. [PMID: 32389183 PMCID: PMC7391837 DOI: 10.1016/s2468-1253(20)30081-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/28/2020] [Accepted: 03/12/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND An increasing percentage of potential organ donors are infected with hepatitis C virus (HCV). After transplantation from an infected donor, establishment of HCV infection in uninfected recipients is near-universal, with the requirement for post-transplant antiviral treatment. The aim of this study was to determine if antiviral drugs combined with an HCV entry blocker given before and for 7 days after transplant would be safe and reduce the likelihood of HCV infection in recipients of organs from HCV-infected donors. METHODS HCV-uninfected organ recipients without pre-existing liver disease were treated with ezetimibe (10 mg; an HCV entry inhibitor) and glecaprevir-pibrentasvir (300 mg/120 mg) before and after transplantation from HCV-infected donors aged younger than 70 years without co-infection with HIV, hepatitis B virus, or human T-cell leukaemia virus 1 or 2. Recipients received a single dose 6-12 h before transplant and once a day for 7 days after surgery (eight doses in total). HCV RNA was assessed once a day for 14 days and then once a week until 12 weeks post-transplant. The primary endpoint was prevention of chronic HCV infection, as evidenced by undetectable serum HCV RNA at 12 weeks after transplant, and assessed in the intention-to-treat population. Safety monitoring was according to routine post-transplant practice. 12-week data are reported for the first 30 patients. The trial is registered on ClinicalTrials.gov, NCT04017338. The trial is closed to recruitment but follow-up is ongoing. FINDINGS 30 patients (23 men and seven women; median age 61 years (IQR 48-66) received transplants (13 lung, ten kidney, six heart, and one kidney-pancreas) from 18 HCV-infected donors. The median donor viral load was 5·11 log10IU/mL (IQR 4·55-5·63) and at least three HCV genotypes were represented (nine [50%] donors with genotype 1, two [11%] with genotype 2, five [28%] with genotype 3, and two [11%] with unknown genotype). All 30 (100%) transplant recipients met the primary endpoint of undetectable HCV RNA at 12 weeks post-transplant, and were HCV RNA-negative at last follow-up (median 36 weeks post-transplant [IQR 25-47]). Low-level viraemia was transiently detectable in 21 (67%) of 30 recipients in the early post-transplant period but not after day 14. Treatment was well tolerated with no dose reductions or treatment discontinuations; 32 serious adverse events occurred in 20 (67%) recipients, with one grade 3 elevation in alanine aminotransferase (ALT) possibly related to treatment. Non-serious transient elevations in ALT and creatine kinase during the study dosing period resolved with treatment completion. Among the serious adverse events were two recipient deaths due to causes unrelated to study drug treatment (sepsis at 49 days and subarachnoid haemorrhage at 109 days post-transplant), with neither patient ever being viraemic for HCV. INTERPRETATION Ezetimibe combined with glecaprevir-pibrentasvir given one dose before and for 7 days after transplant prevented the establishment of chronic HCV infection in recipients of different organs from HCV-infected donors. This study shows that an ultra-short course of direct-acting antivirals and ezetimibe can prevent the establishment of chronic HCV infection in the recipient, alleviating many of the concerns with transplanting organs from HCV-infected donors. FUNDING Canadian Institutes of Health Research; the Organ Transplant Program, University Health Network.
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Affiliation(s)
- Jordan J Feld
- Toronto Centre for Liver Disease, Toronto, ON, Canada; Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.
| | - Marcelo Cypel
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Deepali Kumar
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Harel Dahari
- Program for Experimental and Theoretical Modeling, Division of Hepatology, Department of Medicine, Loyola University Chicago, Chicago, IL, USA
| | | | - Nikki Marks
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Nellie Kamkar
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ilona Bahinskaya
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Fernanda Q Onofrio
- Toronto Centre for Liver Disease, Toronto, ON, Canada; Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Mohamed A Zahoor
- Toronto Centre for Liver Disease, Toronto, ON, Canada; Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Orlando Cerrochi
- Toronto Centre for Liver Disease, Toronto, ON, Canada; Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Kathryn Tinckam
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - S Joseph Kim
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jeffrey Schiff
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Trevor W Reichman
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Michael McDonald
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Carolina Alba
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Thomas K Waddell
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Gonzalo Sapisochin
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Markus Selzner
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto, ON, Canada; Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto, ON, Canada; Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Lianne G Singer
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Atul Humar
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
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Natori Y, Alghamdi A, Husain S, Rotstein C, Selzner N, Tikkanen J, Schiff J, Humar A, Kumar D. Clinical predictors of progression and clearance of low-level CMV DNAemia in solid organ transplant recipients. Transpl Infect Dis 2019; 22:e13207. [PMID: 31677321 DOI: 10.1111/tid.13207] [Citation(s) in RCA: 9] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/10/2019] [Accepted: 10/04/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Low-level CMV DNAemia is common and in the absence of treatment may either progress to higher viral loads that require therapy, or may spontaneously resolve. The clinical predictors of progression and spontaneous viral clearance are not well defined. METHODS We performed a retrospective cohort study of organ transplant recipients who had untreated low-level CMV DNAemia (<1000 IU/mL). Outcomes were evaluated for 8 weeks after initial viral detection, and progression to CMV high viral load was defined as CMV viral load ≥1000 IU/mL. CMV DNAemia doubling time was calculated for a subset of patients with sufficient viral load timepoints. RESULTS Of the 297 patients analyzed, 118/297 (39.7%) patients progressed to a high viral load and the remaining cleared DNAemia spontaneously (46.8%) or remained at low level (13.4%). In multivariate analysis, progression was significantly more likely in lung transplant recipients (odds ratio 3.09) and less likely in those with an episode of previously treated CMV infection (odds ratio 0.081). In a subset of 27 patients with progression, the doubling time for CMV DNAemia was a median of 6.1 days (range 2.4-21.8). CONCLUSION We found that previous CMV infection significantly decreased the likelihood of low-level DNAemia progression suggesting that CMV immunity plays a role in progression vs spontaneous clearance.
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Affiliation(s)
- Yoichiro Natori
- Division of Infectious Diseases, Miami Transplant Institute, Jackson Health System, University of Miami, Miami, FL, USA
| | - Ali Alghamdi
- Division of Infectious Diseases, Miami Transplant Institute, Jackson Health System, University of Miami, Miami, FL, USA.,Division of Infectious Diseases, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Shahid Husain
- Multi Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Coleman Rotstein
- Multi Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Nazia Selzner
- Multi Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Jussi Tikkanen
- Multi Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Jeffrey Schiff
- Multi Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Atul Humar
- Multi Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Deepali Kumar
- Multi Organ Transplant Program, University Health Network, Toronto, ON, Canada
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15
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Natori Y, Shiotsuka M, Slomovic J, Hoschler K, Ferreira V, Ashton P, Rotstein C, Lilly L, Schiff J, Singer L, Humar A, Kumar D. A Double-Blind, Randomized Trial of High-Dose vs Standard-Dose Influenza Vaccine in Adult Solid-Organ Transplant Recipients. Clin Infect Dis 2019; 66:1698-1704. [PMID: 29253089 DOI: 10.1093/cid/cix1082] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/13/2017] [Indexed: 12/21/2022] Open
Abstract
Background The annual standard-dose (SD) influenza vaccine has suboptimal immunogenicity in solid organ transplant recipients (SOTRs). Influenza vaccine that contains higher doses of antigens may lead to greater immunogenicity in this population. Methods We conducted a randomized, double-blind trial to compare the safety and immunogenicity of the 2016-2017 high-dose (HD; FluzoneHD, Sanofi) vs SD (Fluviral, GSK) influenza vaccine in adult SOTRs. Preimmunization and 4-week postimmunization sera underwent strain-specific hemagglutination inhibition assay. Results We enrolled 172 patients who received study vaccine, and 161 (84 HD; 77 SD) were eligible for analysis. Seroconversion to at least 1 of 3 vaccine antigens was present in 78.6% vs 55.8% in HD vs SD vaccine groups (P < .001), respectively. Seroconversions to A/ H1N1, A/H3N2, and B strains were 40.5% vs 20.5%, 57.1% vs 32.5%, and 58.3% vs 41.6% in HD vs SD vaccine groups (P = .006, P = .002, P = .028, respectively). Post-immunization geometric mean titers of A/H1N1, A/H3N2, and B strains were significantly higher in the HD group (P = .007, P = .002, P = .033). Independent factors associated with seroconversion to at least 1 vaccine strain were the use of HD vaccine (odds ratio [OR], 3.23; 95% confidence interval [CI], 1.56-6.67) and use of mycophenolate doses <2 g daily (OR, 2.76; 95% CI, 1.12-6.76). Conclusions HD vaccine demonstrated significantly better immunogenicity than SD vaccine in adult transplant recipients and may be the preferred influenza vaccine for this population. Clinical Trials Registration NCT03139565.
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Affiliation(s)
- Yoichiro Natori
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - Mika Shiotsuka
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - Jaclyn Slomovic
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | | | - Victor Ferreira
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - Peter Ashton
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - Coleman Rotstein
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - Les Lilly
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - Jeffrey Schiff
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - Lianne Singer
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - Atul Humar
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - Deepali Kumar
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
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16
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Famure O, Caballero MN, Li A, Tang R, Chen PX, Ashwin M, Adcock L, Schiff J, Kim SJ. A Gap Analysis Assessing the Perceptions of Primary Care Physicians in the Management of Kidney Recipients After Transplantation. Prog Transplant 2019; 29:309-315. [PMID: 31510872 DOI: 10.1177/1526924819873911] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To examine the practice patterns and perceptions of primary care physicians in the management of chronic diseases in kidney recipients, assess care provided to recipients, and identify barriers to the optimal delivery of primary care to recipients. METHODS A self-administered questionnaire on the primary care of kidney recipients was developed and implemented. The survey investigated physician comfort and practice patterns in providing preventive and chronic care to recipients, patient self-management support, and physician perceptions on communication with transplant centers and barriers to ideal care. RESULTS A total of 210 physicians completed the survey (response rate of 22%). Among the respondents, 73% indicated they were currently providing care to kidney recipients. The majority of physicians specified that they rarely (57%) or never (20%) communicate with transplant centers. Most physicians felt comfortable providing care to recipients for non-transplant-related issues (92.5%), vaccinations (85%), and periodic health examinations (94%). The majority (75.3%) of physicians felt uncomfortable managing the immunosuppressive medications of recipients. Physicians' most commonly stated barriers to delivering optimal care to recipients were insufficient guidelines provided by the transplant center (68.9%) and lack of knowledge in managing recipients (58.8%). Suggested resources by physicians to improve their comfort level in managing recipients included guidelines and continuing medical educational activities related to transplantation. CONCLUSIONS Our results suggest that there are barriers to delivering optimal primary care to kidney recipients. The approach to providing resources needed to bridge the knowledge gap for physicians in the management of recipients requires further exploration.
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Affiliation(s)
- Olusegun Famure
- Division of Nephrology and the Kidney Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Myra N Caballero
- Division of Nephrology and the Kidney Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Anna Li
- Division of Nephrology and the Kidney Transplant Program, University Health Network, Toronto, Ontario, Canada.,Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Rosalind Tang
- Division of Nephrology and the Kidney Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Pei Xuan Chen
- Division of Nephrology and the Kidney Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Monika Ashwin
- Division of Nephrology and the Kidney Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Leslie Adcock
- Family Health Team, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Jeffrey Schiff
- Division of Nephrology and the Kidney Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - S Joseph Kim
- Division of Nephrology and the Kidney Transplant Program, University Health Network, Toronto, Ontario, Canada.,Division of Nephrology and the Renal Transplant Program, St Michael's Hospital and University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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17
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Schiff J, Ledet E, Cotogno P, Sartor O. Fracture Rate and Overall Survival in mCRPC Patients Treated with Radium-223 and Concomitant Abiraterone. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.07.271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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18
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Natori Y, Humar A, Shiotsuka M, Slomovic J, Hoschler K, Ferreira V, Ashton P, Rotstein C, Lilly L, Schiff J, Singer L, Kumar D. A Randomized Trial of High-dose Influenza Vaccine in Adult Solid-Organ Transplant Recipients. Open Forum Infect Dis 2017. [PMCID: PMC5631066 DOI: 10.1093/ofid/ofx180.000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background The annual influenza vaccine is recommended for solid-organ transplant recipients (SOTR) although studies have shown suboptimal immunogenicity. Influenza vaccine containing higher dose antigen may lead to greater immunogenicity in this population. Method We conducted a randomized, observer-blind trial comparing the safety and immunogenicity of high dose (HD; FluzoneHD, Sanofi) vs. standard dose (SD; Fluviral, GSK) influenza vaccine in adult SOTR. Patients were randomized 1:1 to receive the 2016–2017 influenza vaccine. Preimmunization and 4-week postimmunization sera underwent strain-specific hemagglutination inhibition assay for the three vaccine strains and an additional B strain not included in the vaccine. Result We randomized 172 patients and 161 (84 HD; 77 SD) were eligible for analysis. Median age was 57 years (range 18–86) and time from transplant was 38 (range 3–1402) months. Types of transplant were kidney 67 (39.0%), liver 38 (22.1%), lung 25 (14.5%), heart 23 (13.3%), and combined 19 (11.0%). Seroconversion to at least one of the three vaccine antigens (primary outcome) was present in 78.6% vs. 55.8% in HD vs. SD vaccine, respectively (P < 0.001). Seroconversion to A/H1N1, A/H3N2, and B strains were 40.5% vs. 20.5%, 57.1% vs. 32.5%, and 58.3% vs. 41.6% in HD vs. SD vaccine (P = 0.006, 0.002, 0.028, respectively). Postimmunization geometric mean titers of A/H1N1, A/H3N2, and B strains were significantly higher in the HD group
(P = 0.007, 0.002, 0.033). Independent factors associated with seroconversion to at least one vaccine strain were the use of HD vaccine and being on mycophenolate doses less than 2 g daily (P = 0.003, 0.013, respectively). Seroconversion rate to the B strain not included in the trivalent study vaccine was also higher in the HD vaccine group (33.3% vs. 14.1%, P = 0.004). Local and systemic adverse events were similar for the two vaccines. Biopsy-proven rejection was seen in 3.4% vs. 1.2% in HD vs. SD groups, respectively (P = 0.62). Two patients in the SD vaccine group and one in the HD group developed influenza infection during the follow-up. Conclusion High-dose vaccine demonstrated significantly better immunogenicity than SD vaccine in adult transplant recipients and may be the preferred influenza vaccine for this population. Disclosures D. Kumar, Sanofi: Speaker’s Bureau, Speaker honorarium. Pfizer: Speaker’s Bureau, Speaker honorarium. GSK: Grant Investigator, Grant recipient.
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Affiliation(s)
- Yoichiro Natori
- Transplant Infectious Diseases, University Health Network, Toronto, ON, Canada
| | - Atul Humar
- Transplantation, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | - Peter Ashton
- Transplant Infectious Diseases, University Health Network, Toronto, ON, Canada
| | | | - Les Lilly
- University Health Network, Toronto, ON, Canada
| | | | | | - Deepali Kumar
- Transplant Infectious Diseases, University Health Network, Toronto, ON, Canada
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19
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Rajasekeran H, Kim SJ, Cardella CJ, Schiff J, Cattral M, Cherney DZI, Singh SKS. Use of Canagliflozin in Kidney Transplant Recipients for the Treatment of Type 2 Diabetes: A Case Series. Diabetes Care 2017; 40:e75-e76. [PMID: 28416475 DOI: 10.2337/dc17-0237] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 03/02/2017] [Indexed: 02/03/2023]
Affiliation(s)
- Harindra Rajasekeran
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Canada.,Department of Physiology, University of Toronto, Toronto, Canada
| | - S Joseph Kim
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Canada.,Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Carl J Cardella
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Canada.,Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Jeffrey Schiff
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Canada.,Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Canada.,Pancreas Transplant Program, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Mark Cattral
- Pancreas Transplant Program, Toronto General Hospital, University Health Network, Toronto, Canada.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Canada.,Department of Physiology, University of Toronto, Toronto, Canada
| | - Sunita K S Singh
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Canada .,Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Canada.,Pancreas Transplant Program, Toronto General Hospital, University Health Network, Toronto, Canada
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20
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Kongnyuy M, Islam S, Halpern D, Kosinski K, Salcedo J, Schiff J, Corcoran A, Katz A. PD56-09 PSA TRENDS FOLLOWING PRIMARY FOCAL CRYOSURGERY FOR EARLY STAGE PROSTATE CANCER. J Urol 2017. [DOI: 10.1016/j.juro.2017.02.2598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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21
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Kongnyuy M, Lipsky M, Islam S, Robins D, Kosinski K, Halpern D, Hager S, Schiff J, Corcoran A, Wenske S, Katz A. MP70-09 PREDICTORS OF BIOCHEMICAL RECURRENCE AFTER PRIMARY FOCAL CRYOTHERAPY FOR LOCALIZED PROSTATE CANCER: A MULTI-INSTITUTIONAL ANALYTIC COMPARISON OF THE PHOENIX AND STUTTGART CRITERIA. J Urol 2017. [DOI: 10.1016/j.juro.2017.02.2285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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22
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Kosinski K, Fazzari M, Kongnyuy M, Halpern D, Smaldone M, Schiff J, Katz A, Corcoran A. PD67-06 PATHOLOGIC METRICS OF SURGICAL QUALITY IN OPEN AND ROBOTIC RADICAL CYSTECTOMY IMPROVED AT HIGHER VOLUME AND ACADEMIC CENTERS. J Urol 2017. [DOI: 10.1016/j.juro.2017.02.2982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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23
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Halpern D, Kongnyuy M, Kosinski K, Schiff J, Corcoran A, Katz A. MP70-04 3-T MULTIPARAMETRIC MRI CHARACTERISTICS OF PROSTATE CANCER PATIENTS SUSPICIOUS FOR BIOCHEMICAL RECURRENCE AFTER PRIMARY FOCAL CRYOSURGERY. J Urol 2017. [DOI: 10.1016/j.juro.2017.02.2280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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24
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Kosinski K, Fazzari M, Kongnyuy M, Halpern D, Smaldone M, Schiff J, Katz A, Corcoran A. PD67-05 FACILITY VOLUME AND TYPE IS ASSOCIATED WITH RECEIPT OF CONTINENT DIVERSION FOR BOTH OPEN AND ROBOTIC RADICAL CYSTECTOMY. J Urol 2017. [DOI: 10.1016/j.juro.2017.02.2981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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25
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Habibian DJ, Dao AE, Kumar S, Schiff J, Kosinski KE, Katz AE. Gross Findings of Widespread Visceral Metastasis of Prostatic Adenocarcinoma With Neuroendocrine Features: A Case Report. Urol Case Rep 2016; 8:49-51. [PMID: 27489779 PMCID: PMC4963249 DOI: 10.1016/j.eucr.2016.06.004] [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: 06/02/2016] [Accepted: 06/09/2016] [Indexed: 11/26/2022] Open
Abstract
Although prostate cancer is common in the western world and is associated with favorable overall survival, neuroendocrine prostate cancer is difficult to detect and is known to aggressively metastasize throughout the body. This subset of disease thus has a poor prognosis, and early detection and treatment of neuroendocrine prostate cancer may increase overall survival. We present a case of a now deceased 63 year old male with extensive epicardial, respiratory, hepato-bilary, adrenal, genitourinary, and osseous tissue metastasis.
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Affiliation(s)
- David J. Habibian
- Department of Urology, Winthrop University Hospital, Mineola, New York, USA
| | - Alexander E. Dao
- Department of Urology, Winthrop University Hospital, Mineola, New York, USA
| | - Shauna Kumar
- Department of Pathology, Winthrop University Hospital, Mineola, New York, USA
| | - Jeffrey Schiff
- Department of Urology, Winthrop University Hospital, Mineola, New York, USA
| | | | - Aaron E. Katz
- Department of Urology, Winthrop University Hospital, Mineola, New York, USA
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26
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Singh SK, Kim SJ, Smail N, Schiff J, Paraskevas S, Cantarovich M. Outcomes of Recipients With Pancreas Transplant Alone Who Develop End-Stage Renal Disease. Am J Transplant 2016; 16:535-40. [PMID: 26523479 DOI: 10.1111/ajt.13494] [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: 01/04/2015] [Revised: 07/20/2015] [Accepted: 08/15/2015] [Indexed: 01/25/2023]
Abstract
Recipients of pancreas transplant alone (PTA) may be at increased risk for developing end-stage renal disease (ESRD). The survival experience of PTA recipients developing ESRD has not been described. Furthermore, the relative survival of these patients as compared to diabetics on chronic dialysis is unknown. We studied all adult PTA recipients from January 1, 1990 to September 1, 2008 using the Scientific Registry of Transplant Recipients. Each PTA recipient developing ESRD was matched to 10 diabetics on chronic dialysis from the United States Renal Data System. Cox proportional hazards models were fitted to determine the relation between ESRD and mortality among PTA recipients, and the relation between PTA and mortality among diabetics on chronic dialysis. There were 1597 PTA recipients in the study, of which 207 developed ESRD. Those with ESRD had a threefold increase in mortality versus those without (adjusted hazard ratio 3.28 [95% confidence interval: 2.27, 4.76]). There was no significant difference in the risk of death among PTA recipients with ESRD versus diabetics on dialysis. PTA recipients developing ESRD are three times more likely to die than PTA recipients without ESRD; however, the risk of death in these patients was similar to diabetics on chronic dialysis without PTA.
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Affiliation(s)
- S K Singh
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology and the Multi-Organ Transplant Program, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - S J Kim
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology and the Multi-Organ Transplant Program, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - N Smail
- Division of Nephrology and the Multi-Organ Transplant Program, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - J Schiff
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology and the Multi-Organ Transplant Program, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - S Paraskevas
- Department of Surgery, Multi-Organ Transplant Program, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - M Cantarovich
- Division of Nephrology and the Multi-Organ Transplant Program, McGill University Health Center, McGill University, Montreal, Quebec, Canada
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27
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Laurence JM, Barbas AS, Sapisochin G, Marquez MA, Bazerbachi F, Selzner M, Norgate A, McGilvray ID, Schiff J, Ross H, Cattral MS. The significance of pre-operative coronary interventions on outcome after pancreas transplantation. Clin Transplant 2015; 30:233-40. [PMID: 26700761 DOI: 10.1111/ctr.12681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2015] [Indexed: 11/28/2022]
Abstract
Pancreas transplant candidates are at very high risk of coronary vascular disease. We hypothesized that the requirement for pre-operative coronary intervention (PCI) may be associated with an adverse impact on short- and long-term outcomes. Retrospective analysis of 366 consecutive primary pancreas transplants was undertaken. Outcomes were compared between recipients who had undergone PCI (n = 48) and those who had not (n = 318). In 48% (23/48) of instances, the PCI was initiated by the transplant cardiology evaluation. The recipients undergoing PCI were older than those not undergoing PCI (47.6 yr vs. 41.9 yr, respectively, p < 0.0001). Although not statistically significant, there was a higher rate of post-operative major cardiovascular events (MCVE) in the PCI group (10.4%) compared with those not undergoing PCI (4.7%) (RR [95% CI]: 2.0 [0.90-4.5]; p = 0.17). In the long term, there were no differences in the rate of death with graft function (p = 0.77) or rejection (p = 0.17). There were no statistically significant differences between the groups with respect to patient (p = 0.54), kidney (p = 0.76), or pancreas (p = 0.63) graft survival. PCI is not a risk factor for short-term perioperative events, and long-term transplant outcomes are equivalent to patients not requiring PCI. PCI, by itself, should not be considered a contraindication for pancreas transplantation, but should raise awareness of perioperative risk.
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Affiliation(s)
- Jerome M Laurence
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada.,RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, University of Sydney, NSW, Australia
| | - Andrew S Barbas
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Gonzalo Sapisochin
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Max A Marquez
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Fateh Bazerbachi
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Markus Selzner
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Andrea Norgate
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Ian D McGilvray
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Jeffrey Schiff
- Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Heather Ross
- RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, University of Sydney, NSW, Australia
| | - Mark S Cattral
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
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28
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Abstract
A 33-year-old woman with congenital aniridia presented with decreased vision in her right eye. Slit lamp examination revealed diffuse conjunctivalisation of the ocular surface with mild subepithelial fibrosis consistent with aniridic keratopathy secondary to limbal stem cell deficiency. She underwent limbal stem cell transplantation with cadaver donor tissue (keratolimbal allograft (KLAL) surgery) and received systemic immunosuppression. Despite optimal combination immunosuppressive therapy managed by a renal transplant specialist, 2 weeks after the KLAL, the patient developed intractable eye pain, conjunctival injection, dilation of the KLAL graft blood vessels and limbal haemorrhages. There were no epithelial defects noted. Donor-specific antibody testing was positive, and intravenous immunoglobulin therapy was initiated. There was immediate symptomatic and objective improvement. Fifteen months postoperatively, the patient's vision was 20/400 with a stable corneal epithelium and no evidence of inflammation.
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Affiliation(s)
| | - Jeffrey Schiff
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Clara C Chan
- Department of Ophthalmology, University of Toronto, Toronto, Canada
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29
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Spetzler VN, Goldaracena N, Marquez MA, Singh SK, Norgate A, McGilvray ID, Schiff J, Greig PD, Cattral MS, Selzner M. Duodenal leaks after pancreas transplantation with enteric drainage - characteristics and risk factors. Transpl Int 2015; 28:720-8. [PMID: 25647150 DOI: 10.1111/tri.12535] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [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: 10/27/2014] [Revised: 11/27/2014] [Accepted: 01/29/2015] [Indexed: 01/10/2023]
Abstract
Pancreas-kidney transplantation with enteric drainage has become a standard treatment in diabetic patients with renal failure. Leaks of the graft duodenum (DL) remain a significant complication after transplantation. We studied incidence and predisposing factors of DLs in both simultaneous pancreas-kidney (SPK) and pancreas after kidney (PAK) transplantation. Between January 2002 and April 2013, 284 pancreas transplantations were performed including 191 SPK (67.3%) and 93 PAK (32.7%). Patient data were analyzed for occurrence of DLs, risk factors, leak etiology, and graft survival. Of 18 DLs (incidence 6.3%), 12 (67%) occurred within the first 100 days after transplantation. Six grafts (33%) were rescued by duodenal segment resection. Risk factors for a DL were PAK transplantation sequence (odds ratio 3.526, P = 0.008) and preoperative immunosuppression (odds ratio 3.328, P = 0.012). In the SPK subgroup, postoperative peak amylase as marker of preservation/reperfusion injury and recipient pretransplantation cardiovascular interventions as marker of atherosclerosis severity were associated with an increased incidence of DLs. CMV-mismatch constellations showed an increased incidence in the SPK subgroup, however without significance probability. Long-term immunosuppression in PAK transplantation is a major risk factor for DLs. Early surgical revision offers the chance of graft rescue.
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Affiliation(s)
- Vinzent N Spetzler
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Nicolas Goldaracena
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Max A Marquez
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Sunita K Singh
- Multi Organ Transplant Program, Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
| | - Andrea Norgate
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Ian D McGilvray
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Jeffrey Schiff
- Multi Organ Transplant Program, Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
| | - Paul D Greig
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Mark S Cattral
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Markus Selzner
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
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30
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Bergmann KR, Schloff S, Schiff J. Contralateral recurrence of idiopathic orbital inflammatory syndrome in a pediatric patient. Minn Med 2014; 97:46-47. [PMID: 25651640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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31
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Gidengil C, Mangione-Smith R, Bailey LC, Cawthon ML, McGlynn EA, Nakamura MM, Schiff J, Schuster MA, Schneider EC. Using Medicaid and CHIP claims data to support pediatric quality measurement: lessons from 3 centers of excellence in measure development. Acad Pediatr 2014; 14:S76-81. [PMID: 25169462 DOI: 10.1016/j.acap.2014.06.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 06/08/2014] [Accepted: 06/18/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We sought to explore the claims data-related issues relevant to quality measure development for Medicaid and the Children's Health Insurance Program (CHIP), illustrating the challenges encountered and solutions developed around 3 distinct performance measure topics: care coordination for children with complex needs, quality of care for high-prevalence conditions, and hospital readmissions. METHODS Each of 3 centers of excellence presents an example that illustrates the challenges of using claims data for quality measurement. RESULTS Our Centers of Excellence in pediatric quality measurement used innovative methods to develop algorithms that use Medicaid claims data to identify children with complex needs; overcome some shortcomings of existing data for measuring quality of care for common conditions such as otitis media; and identify readmissions after hospitalizations for lower respiratory infections. CONCLUSIONS Our experience constructing quality measure specifications using claims data suggests that it will be challenging to measure key quality of care constructs for Medicaid-insured children at a national level in a timely and consistent way. Without better data to underpin pediatric quality measurement, Medicaid and CHIP will have difficulty using some existing measures for accountability, value-based purchasing, and quality improvement both across states and within states.
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Affiliation(s)
- Courtney Gidengil
- RAND Corporation, Boston, Mass; Division of Infectious Diseases, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Wash; Seattle Children's Research Institute, Seattle, Wash
| | | | - Mary Lawrence Cawthon
- Research and Data Analysis Division, Washington Department of Social and Health Services, Olympia, Wash
| | - Elizabeth A McGlynn
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, Calif
| | - Mari M Nakamura
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Division of General Pediatrics, Boston Children's Hospital, Boston, Mass
| | - Jeffrey Schiff
- Office of the Medicaid Medical Director, Minnesota Department of Human Services, St Paul, Minn
| | - Mark A Schuster
- Harvard Medical School, Boston, Mass; Division of General Pediatrics, Boston Children's Hospital, Boston, Mass
| | - Eric C Schneider
- RAND Corporation, Boston, Mass; Harvard Medical School, Boston, Mass; Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
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Laurence J, Seal J, Marquez M, Bazerbachi F, Norgate A, Mcgilvary I, Selzner M, Schiff J, Cattral M. The Significance of Preoperative Cardiovascular Intervention for Pancreas Transplant Outcomes. Transplantation 2014. [DOI: 10.1097/00007890-201407151-02935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Molnar MZ, Ichii H, Lineen J, Foster CE, Mathe Z, Schiff J, Kim SJ, Pahl MV, Amin AN, Kalantar-Zadeh K, Kovesdy CP. Timing of return to dialysis in patients with failing kidney transplants. Semin Dial 2013; 26:667-74. [PMID: 24016076 DOI: 10.1111/sdi.12129] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In the last decade, the number of patients starting dialysis after a failed kidney transplant has increased substantially. These patients appear to be different from their transplant-naïve counterparts, and so may be the timing of dialysis therapy initiation. An increasing number of studies suggest that in transplant-naïve patients, later dialysis initiation is associated with better outcomes. Very few data are available on timing of dialysis reinitiation in failed transplant recipients, and they suggest that an earlier return to dialysis therapy tended to be associated with worse survival, especially among healthier and younger patients and women. Failed transplant patients may also have unique issues such as continuation of immunosuppression versus withdrawal or the need for remnant allograft nephrectomy with regard to dialysis reinitiation. These patients may have a different predialysis preparation work-up, worse blood pressure control, higher or lower serum phosphorus levels, lower serum bicarbonate concentration, and worse anemia management. The choice of dialysis modality may also represent an important question for these patients, even though there appears to be no difference in mortality between patients starting peritoneal versus hemodialysis. Finally, failed transplant patients returning to dialysis appear to have a higher mortality rate compared with transplant-naïve incident dialysis patients, especially in the first several months of dialysis therapy. In this review, we will summarize the available data related to the timing of dialysis initiation and outcomes in failed kidney transplant patients after returning to dialysis.
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Affiliation(s)
- Miklos Z Molnar
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine Medical Center, Orange, California; Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, UC Irvine School of Medicine, Irvine, California
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Mohamed N, Goldstein J, Schiff J, John R. Collapsing Glomerulopathy Following Anthracycline Therapy. Am J Kidney Dis 2013; 61:778-81. [DOI: 10.1053/j.ajkd.2012.08.048] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 08/13/2012] [Indexed: 11/11/2022]
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Bazerbachi F, Selzner M, Marquez MA, Norgate A, Aslani N, McGilvray ID, Schiff J, Cattral MS. Portal venous versus systemic venous drainage of pancreas grafts: impact on long-term results. Am J Transplant 2012; 12:226-32. [PMID: 22054257 DOI: 10.1111/j.1600-6143.2011.03756.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Portal venous (PV) and systemic venous (SV) drainage methods are used in pancreas transplantation. The impact of the reconstruction technique on long-term outcome remains unclear. We compared the efficacy and side effects of both methods in 192 recipients who received synchronous pancreas kidney transplants between November 1995 and November 2007. SV and PV drainage were used in 147 and 45 cases, respectively. Pancreas function was determined by hemoglobin A1c levels and annual oral glucose tolerance test. Serum creatinine assessed kidney function. Serum lipid (low-density lipoprotein, high-density lipoprotein and cholesterol) levels and body mass index were measured annually. Patient and graft survival were calculated by log-rank analysis. Pancreas survival for SV versus PV patients was similar after 5 years (81.8% vs. 75.5%) and 10 years (65.1% vs. 60%; p = NS). Similarly, no difference was detected between the groups regarding kidney survival after 5 years (92.9% vs. 84.4%) and 10 years (81.6% vs. 75.5%; p = NS). Patient survival did not differ at 5 years (94.3% vs. 88.8%) and 10 years (85.1% vs. 84.4%; p = NS). Pancreas and kidney function and the lipid profiles were similar in both groups. SV and PV drainage of pancreas grafts offer similar long-term graft survival and function and choice of method should remain the preference of the surgeon.
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Affiliation(s)
- F Bazerbachi
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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Mangione-Smith R, Schiff J, Dougherty D. Identifying children's health care quality measures for Medicaid and CHIP: an evidence-informed, publicly transparent expert process. Acad Pediatr 2011; 11:S11-21. [PMID: 21570013 DOI: 10.1016/j.acap.2010.11.003] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2010] [Revised: 11/01/2010] [Accepted: 11/06/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To describe the process used to identify the recommended core set of quality measures as mandated by the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) and provide an overview of the measures selected. METHODS In May 2009, the multidisciplinary Agency for Healthcare Research and Quality (AHRQ) National Advisory Council for Healthcare Research and Quality Subcommittee on Children's Healthcare Quality Measures for Medicaid and CHIP Programs (SNAC) was formed. The SNAC established criteria to evaluate quality measures on the basis of their validity, feasibility, and importance. Subsequently, AHRQ implemented a measure nomination process. Nominators supplied key information related to measure validity, feasibility, and importance. Oxford Centre for Evidence-Based Medicine (CEBM) criteria were used to assess evidence supporting the validity/scientific soundness of nominated measures. SNAC members applied an adaptation of the RAND-UCLA modified Delphi process to all nominated measures. Measures passing the Delphi process were further assessed on the basis of criteria pertaining to legislative priorities. RESULTS Seventy of 119 nominated measures met criteria for validity, feasibility, and importance according to Delphi scoring. After further prioritization, 25 measures were recommended for the initial core set. Twelve of the recommended measures focus on preventive care and health promotion including prenatal/perinatal care (4), well-child care (1), immunizations (2), screening for: developmental delays (1), obesity (1), and sexually transmitted infections (1), and receipt of preventive dental services (2). Five acute care measures were recommended which focus on management of upper respiratory illnesses (2), receipt of acute care dental services (1), emergency department utilization (1), and inpatient rates of central line associated bloodstream infections (1). Five of the recommended measures focus on chronic care, specifically asthma (1), attention-deficit/hyperactivity disorder (1), diabetes (1), and care for children with mental health conditions (2). Two of the measures focus on family experiences with care, and one of the measures assesses utilization of outpatient primary care services. Thirteen (52%) of the measures were derived from the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS). Eighteen of the measures were supported by relatively high levels of evidence (Oxford CEBM grade A or B). CONCLUSIONS An open national public process combined with an evidence-informed evaluation methodology resulted in identification of a balanced, grounded, and parsimonious core set of measures that should become feasible to implement on a widespread scale over time.
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Affiliation(s)
- Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Center for Child Health, Behavior and Development, Seattle Children’s Hospital Research Institute, 1100 Olive Way, Suite 500, Seattle, Washington 98101, USA.
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Tanna GV, Sood MM, Schiff J, Schwartz D, Naimark DM. Do e-mail alerts of new research increase knowledge translation? A "Nephrology Now" randomized control trial. Acad Med 2011; 86:132-138. [PMID: 21099399 DOI: 10.1097/acm.0b013e3181ffe89e] [Citation(s) in RCA: 8] [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] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
PURPOSE As the volume of medical literature increases exponentially, maintaining current clinical practice is becoming more difficult. Multiple, Internet-based journal clubs and alert services have recently emerged. The purpose of this study is to determine whether the use of the e-mail alert service, Nephrology Now, increases knowledge translation regarding current nephrology literature. METHOD Nephrology Now is a nonprofit, monthly e-mail alert service that highlights clinically relevant articles in nephrology. In 2007-2008, the authors randomized 1,683 subscribers into two different groups receiving select intervention articles, and then they used an online survey to assess both groups on their familiarity with the articles and their acquisition of knowledge. RESULTS Of the randomized subscribers, 803 (47.7%) completed surveys, and the two groups had a similar number of responses (401 and 402, respectively). The authors noted no differences in baseline characteristics between the two groups. Familiarity increased as a result of the Nephrology Now alerts (0.23 ± 0.087 units on a familiarity scale; 95% confidence interval [CI]: 0.06-0.41; P = .007) especially in physicians (multivariate odds ratio 1.83; P = .0002). No detectable improvement in knowledge occurred (0.03 ± 0.083 units on a knowledge scale; 95% CI: -0.13 to 0.20; P = .687). CONCLUSIONS An e-mail alert service of new literature improved a component of knowledge translation--familiarity--but not knowledge acquisition in a large, randomized, international population.
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Affiliation(s)
- Gemini V Tanna
- Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
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Rabbani F, Schiff J, Piecuch M, Yunis LH, Eastham JA, Scardino PT, Mulhall JP. Time Course of Recovery of Erectile Function After Radical Retropubic Prostatectomy: Does Anyone Recover After 2 Years? J Sex Med 2010; 7:3984-90. [DOI: 10.1111/j.1743-6109.2010.01969.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kaag MG, Toyen C, Russo P, Cronin A, Thompson RH, Schiff J, Bernstein M, Bains M. Radical nephrectomy with vena caval thrombectomy: a contemporary experience. BJU Int 2010; 107:1386-93. [PMID: 20883481 DOI: 10.1111/j.1464-410x.2010.09661.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE • To report on the contemporary Memorial Sloan-Kettering Cancer Center experience with radical nephrectomy and vena caval thrombectomy. PATIENTS AND METHODS • Patients who underwent radical nephrectomy and vena caval thrombectomy without the use of bypass techniques were retrospectively identified. • Data were collected on intraoperative and pathological findings as well as postoperative complications and oncological outcomes. RESULTS • In all, 78 patients underwent radical nephrectomy with off-bypass resection of vena caval thrombus between 1989 and 2009. • The median (interquartile range, IQR) operation duration was 293 (226-370) min, and median (IQR) blood loss was 1300 (750-2500) mL. In all, 10 patients (13%) were confirmed to have intra- or supra-hepatic tumour thrombus (level 3/4), eight of whom required supra-hepatic control of the inferior vena cava (IVC). • Major (grade 3-5) postoperative complications occurred in 14 (18%), with five postoperative deaths. Disease recurred in 27/62 patients who were considered completely resected at surgery and had adequate follow-up. • The overall 5-year survival (95% confidence interval) probability was 48% (35-60%). CONCLUSIONS • Radical nephrectomy with vena caval thrombectomy is associated with acceptable postoperative morbidity and mortality, and long-term survival is possible in some patients. • Many level 3/4 thrombi could be safely approached without the use of bypass techniques.
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Affiliation(s)
- Matthew G Kaag
- Urology Service and Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Narayanan R, Cardella CJ, Cattran DC, Cole EH, Tinckam KJ, Schiff J, Kim SJ. Delayed graft function and the risk of death with graft function in living donor kidney transplant recipients. Am J Kidney Dis 2010; 56:961-70. [PMID: 20870331 DOI: 10.1053/j.ajkd.2010.06.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2010] [Accepted: 06/25/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND The link between delayed graft function (DGF) and death with graft function (DWGF) in living donor kidney transplant recipients presently is unknown. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS 44,630 adult living donor kidney recipients (first transplants only) in the US Renal Data System from January 1, 1994, to December 31, 2004. PREDICTOR DGF, defined as the need for dialysis therapy in the first week after transplant. OUTCOME Time to DWGF. MEASUREMENTS Kaplan-Meier curves were constructed to assess the impact of DGF on DWGF. Recipients with DGF were 1:1 propensity score matched to those without DGF, and time-dependent Cox proportional hazards models were used to examine factors associated with DWGF. Subgroup and sensitivity analyses also were conducted. RESULTS DWGF occurred in 3,878 patients during 3.9 years' (median) follow-up. In patients with DGF, survival with graft function at 1, 3, 5, and 10 years was 91.9%, 86.8%, 81.6%, and 61.7%, respectively (in patients without DGF, these values were 98.0%, 95.2%, 91.6%, and 80.1%, respectively; P < 0.001 compared with the DGF group). In a fully adjusted time-dependent Cox model, HRs for DWGF in patients with DGF (vs without DGF) were 6.55 (95% CI, 4.78-8.97), 3.55 (95% CI, 2.46-5.11), 2.07 (95% CI, 1.53-2.81), and 1.48 (95% CI, 1.26-1.73) at 0-1, 1-3, 3-12, and longer than 12 months posttransplant, respectively. Propensity score analysis showed similar results. Inferences were unchanged after adjustment for kidney function and acute rejection at 6 months and 1 year posttransplant. Cardiovascular and infectious causes of DWGF were more prevalent in patients with DGF. The association was more marked in female recipients and robust to various sensitivity analyses. LIMITATIONS The impact of lesser decreases in early graft function could not be evaluated. CONCLUSIONS DGF is associated with an increased risk of DWGF in living donor kidney recipients. The mechanisms underlying this relation require further study.
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Affiliation(s)
- Ranjit Narayanan
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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Perkins RS, Marquez MA, Selzner M, Norgate A, Bazerbachi F, Schiff J, Ghanekar A, McGilvray ID, Grant DR, Greig PD, Cattral MS. LONG-TERM SURVIVAL OF PANCREAS ALLOGRAFTS IS SIMILAR IN PANCREAS-AFTER-KIDNEY AND SIMULTANEOUS PANCREAS-KIDNEY TRANSPLANT RECIPIENTS. Transplantation 2010. [DOI: 10.1097/00007890-201007272-00431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tapiawala SN, Tinckam KJ, Cardella CJ, Schiff J, Cattran DC, Cole EH, Kim SJ. Delayed graft function and the risk for death with a functioning graft. J Am Soc Nephrol 2009; 21:153-61. [PMID: 19875806 DOI: 10.1681/asn.2009040412] [Citation(s) in RCA: 138] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Delayed graft function (DGF) associates with an increased risk for graft failure, but its link with death with graft function (DWGF) is unknown. We used the US Renal Data System to assemble a cohort of all first, adult, deceased-donor kidney transplant recipients from January 1, 1998, through December 31, 2004. In total, 11,542 (23%) of 50,246 recipients required at least one dialysis session in the first week after transplantation. Compared with patients without DGF, patients with DGF were significantly more likely to die with a functioning graft (relative hazard 1.83 [95% confidence interval 1.73 to 1.93] and 1.53 [95% CI 1.45 to 1.63] for unadjusted and fully adjusted models, respectively). The risk for DWGF was slightly higher among women with DGF than among men. There was no significant heterogeneity among other subgroups, and the results were robust to sensitivity analyses. Acute rejection within the first year attenuated the DGF-DWGF association. Cardiovascular and infectious deaths were slightly more prevalent in the DGF group, but the relative hazards of cause-specific death were similar between DWGF and deaths during total follow-up. In summary, DGF associates with an increased risk for DWGF; the mechanisms underlying the negative impact of DGF require further study.
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Affiliation(s)
- Shruti N Tapiawala
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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Abstract
Steroids are effective immunosuppressants in renal transplantation but are associated with significant adverse effects. As a result, there has been increased interest in protocols utilizing steroid minimization. Initial trials stopped steroids at approximately 3 months, when the highest risk phase for acute rejection was over. As two randomized trials using cyclosporine and mycophenolate mofetil without induction therapy showed an unacceptably high acute rejection rate, more recent interest has focused on the cessation of steroids very early, usually within the first week after transplantation. Most protocols have used antibody induction combined with calcineurin inhibitors and mycophenolic acid derivatives. Uncontrolled studies have shown a low rate of acute rejection, but the most recent randomized controlled trials have demonstrated an increased risk of acute rejection. These trials have not shown any consistent difference in short-term patient or graft survival. Cardiovascular risk factors do not appear to be consistently improved by early steroid withdrawal. Most trials lack sufficient follow-up (5 years or more) to assess the impact of the increased acute rejection rate seen with early steroid withdrawal on long-term outcomes. Thus, the use of such protocols remains investigational.
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Affiliation(s)
- Jeffrey Schiff
- Division of Nephrology and Multi-Organ Transplant Program, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
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Hopyan JJ, Gladstone DJ, Mallia G, Schiff J, Fox AJ, Symons SP, Buck BH, Black SE, Aviv RI. Renal safety of CT angiography and perfusion imaging in the emergency evaluation of acute stroke. AJNR Am J Neuroradiol 2008; 29:1826-30. [PMID: 18719035 DOI: 10.3174/ajnr.a1257] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE Multimodal CT imaging with contrast-enhanced CT angiography (CTA) and CT perfusion (CTP) is increasingly being used to guide emergency management of acute stroke. However, little has been reported about the safety of intravenous contrast administration associated with these studies in the acute stroke population, including cases in which baseline creatinine values are unknown. We investigated the incidence of contrast-induced nephropathy (CIN), defined as a 25% or more increase in baseline creatinine levels within 72 hours of contrast administration and chronic kidney disease in patients receiving CTA+/-CTP at our regional stroke center. MATERIALS AND METHODS We analyzed 198 patients who underwent contrast CT studies for evaluation of acute ischemic or hemorrhagic stroke at our center (2003-2007). Through retrospective chart abstraction, we analyzed serial creatinine levels (baseline to day 3) and later values (>/=day 4) where available. The incidences of CIN and/or chronic kidney disease were documented. After power analysis, CIN and non-CIN groups were compared by using the unpaired t test, Wilcoxon rank sum test, or Fisher exact test. RESULTS None of the 198 patients developed chronic kidney disease or required dialysis. Of 175 patients with serial creatinine measurements between baseline and day 3, 5 (2.9%) developed CIN. The incidence of CIN was 2% in patients who were scanned before a baseline creatinine level was available. CONCLUSION The incidence of renal sequelae is relatively low in acute stroke patients undergoing emergent multimodal CT scanning. Prompt CTA/CTP imaging of acute stroke, if indicated, need not be delayed in those with no history of renal impairment.
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Affiliation(s)
- J J Hopyan
- Division of Neurology, Department of Medicine, North & East Greater Toronto Area Ontario Regional Stroke Centre, and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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Josephson CB, Delgado D, Schiff J, Ross H. The effectiveness of renal transplantation as a treatment for recurrent uremic cardiomyopathy. Can J Cardiol 2008; 24:315-7. [PMID: 18401475 DOI: 10.1016/s0828-282x(08)70184-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Congestive heart failure is more prevalent in patients with end-stage renal disease than in the general population. Although optimal treatment has yet to be defined, these patients are considered to be at high risk for renal transplantation. The present report of a 27-year-old man describes a full recovery from uremic cardiomyopathy following a renal transplant. Despite the patient developing recurrent cardiac dysfunction following graft failure, a second transplant was successful, which, again, resulted in complete resolution of the cardiomyopathy. Patients with recurrent uremic cardiomyopathy following failed kidney transplantation should be considered for a second kidney transplant.
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Bar-Chama N, Schiff J, Luna M, Dann B, Copperman A, Barritt J. The level of sperm vacuoles in the fresh post-processed sperm sample significantly affects IVF cycle outcomes. Fertil Steril 2007. [DOI: 10.1016/j.fertnstert.2007.07.078] [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: 11/16/2022]
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Abstract
BACKGROUND Cardiovascular (CV) disease is the foremost cause of mortality and an important cause of morbidity in renal transplant recipients. The disease burden is likely to increase as older patients are accepted for transplantation. The outcome of these high-CV risk patients after renal transplantation, especially with known pre-transplant coronary artery disease (CAD), has not been studied. Hence, we looked at the CV outcome in patients with known pre-transplant CAD. METHODS All renal transplants performed between 1998 and 2002 at our center, followed up to 2005, were divided into high- and low-risk groups, based on the presence of one or more of the following: pre-transplant angina, myocardial infarction, and positive coronary angiogram. The two groups were compared for post-transplant cardiac events and patient and graft survival. The factors predictive of post-transplant cardiac events were also determined by Cox-regression multivariate analysis. RESULTS Forty-five patients (10.5%), out of 429, had post-transplant cardiac events; 31.3% in the high risk, and 6.5% in the low-risk group (p = 0.001). Five-yr patient survival was lower in the high-risk group (82.8% vs. 93.1%, p = 0.004), while five-yr overall graft survival and death censored graft survival were statistically not different (74.8% vs. 84.1%, p = 0.08 and 87.3% vs. 90%, p = 0.25). Forty-one percent of patients who were treated with angioplasty plus stenting or bypass graft prior to transplantation had post-transplant cardiac events, as compared with 28% of those without intervention in the high-risk group and 6.5% of patients in the low-risk group (p = 0.001). Age, pre-transplant cardiac disease, arrhythmias, and low-ejection fraction (< or = 40%) were significant independent predictors of post-transplant cardiac events. CONCLUSION Post-transplant survival of high-CV risk patients (with known CAD) is lower than that of low-risk recipients but remains acceptable. Cardiac interventions may reduce perioperative risk but do not reduce the probability of post-transplant cardiac events to that of low-risk group.
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Affiliation(s)
- Tarun K Jeloka
- Renal Transplant Programme, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
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Abstract
The calcineurin inhibitors (CNI) cyclosporine and tacrolimus remain the backbone of immunosuppression for most kidney transplant recipients. Despite many years of experience, protocols that optimize efficacy with minimal toxicity remain a subject of debate. Nevertheless, studies of the pharmacokinetic properties of the CNI, particularly cyclosporine, have led to improved dosing strategies. The purpose of this article is to review the current understanding of CNI pharmacokinetics and its relevance to proper dosing and monitoring of these medications. This article also reviews the trials that have helped to define the optimal dosages and discusses the effect of adjunctive immunosuppressive agents on CNI pharmacokinetics and dosing.
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Affiliation(s)
- Jeffrey Schiff
- Division of Nephrology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
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Monoski M, Schiff J, Li P, Chan P, Goldstein M. P-640. Fertil Steril 2006. [DOI: 10.1016/j.fertnstert.2006.07.1015] [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: 11/29/2022]
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Schiff J, Duke M, Copperman A, Devenuta A, Valluzzo L, Bar-Chama N. P-598. Fertil Steril 2006. [DOI: 10.1016/j.fertnstert.2006.07.970] [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: 11/27/2022]
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