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Gordon EJ, Gacki-Smith J, Gooden MJ, Waite P, Yacat R, Abubakari ZR, Duquette D, Agrawal A, Friedewald J, Savage SK, Cooper M, Gilbert A, Muhammad LN, Wicklund C. Development of a culturally targeted chatbot to inform living kidney donor candidates of African ancestry about APOL1 genetic testing: a mixed methods study. J Community Genet 2024; 15:205-216. [PMID: 38349598 PMCID: PMC11031529 DOI: 10.1007/s12687-024-00698-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 01/22/2024] [Indexed: 02/25/2024] Open
Abstract
Clinical chatbots are increasingly used to help integrate genetic testing into clinical contexts, but no chatbot exists for Apolipoprotein L1 (APOL1) genetic testing of living kidney donor (LKD) candidates of African ancestry. Our study aimed to culturally adapt and assess perceptions of the Gia® chatbot to help integrate APOL1 testing into LKD evaluation. Ten focus groups and post-focus group surveys were conducted with 54 LKDs, community members, and kidney transplant recipients of African ancestry. Data were analyzed through thematic analysis and descriptive statistics. Key themes about making Gia culturally targeted included ensuring: (1) transparency by providing Black LKDs' testimonials, explaining patient privacy and confidentiality protections, and explaining how genetic testing can help LKD evaluation; (2) content is informative by educating Black LKDs about APOL1 testing instead of aiming to convince them to undergo testing, presenting statistics, and describing how genetic discrimination is legally prevented; and (3) content avoids stigma about living donation in the Black community. Most agreed Gia was neutral and unbiased (82%), trustworthy (82%), and words, phrases, and expressions were familiar to the intended audience (85%). Our culturally adapted APOL1 Gia chatbot was well regarded. Future research should assess how this chatbot could supplement provider discussion prior to genetic testing to scale APOL1 counseling and testing for LKD candidate clinical evaluation.
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Affiliation(s)
- Elisa J Gordon
- Department of Surgery, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, 1161 21St Avenue South, D-4314 Medical Center North Nashville, Nashville, TN, 37232-2730, USA.
| | - Jessica Gacki-Smith
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Matthew J Gooden
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Preeya Waite
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rochell Yacat
- Medstar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, USA
| | - Zenab R Abubakari
- Medstar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, USA
| | - Debra Duquette
- Medicine, Cardiology Division, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Akansha Agrawal
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John Friedewald
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Matthew Cooper
- Froedtert Hospital Center for Advanced Care, Froedtert Memorial Lutheran Hospital Children's Hospital of Wisconsin Medical College of Wisconsin, Milwaukee, WI, USA
- Children's Hospital of Wisconsin, Milwaukee, WI, USA
- Medical College of Wisconsin, Milwaukee, WI, USA
- Froedtert Hospital Center for Advanced Care, Milwaukee, WI, USA
| | - Alexander Gilbert
- Medstar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, USA
| | - Lutfiyya N Muhammad
- Department of Preventive Medicine, Division of Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Catherine Wicklund
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Roufosse C, Naesens M, Haas M, Lefaucheur C, Mannon RB, Afrouzian M, Alachkar N, Aubert O, Bagnasco SM, Batal I, Bellamy COC, Broecker V, Budde K, Clahsen-Van Groningen M, Coley SM, Cornell LD, Dadhania D, Demetris AJ, Einecke G, Farris AB, Fogo AB, Friedewald J, Gibson IW, Horsfield C, Huang E, Husain SA, Jackson AM, Kers J, Kikić Ž, Klein A, Kozakowski N, Liapis H, Mangiola M, Montgomery RA, Nankinvell B, Neil DAH, Nickerson P, Rabant M, Randhawa P, Riella LV, Rosales I, Royal V, Sapir-Pichhadze R, Sarder P, Sarwal M, Schinstock C, Stegall M, Solez K, van der Laak J, Wiebe C, Colvin RB, Loupy A, Mengel M. The Banff 2022 Kidney Meeting Work Plan: Data-driven refinement of the Banff Classification for renal allografts. Am J Transplant 2024; 24:350-361. [PMID: 37931753 DOI: 10.1016/j.ajt.2023.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 10/11/2023] [Indexed: 11/08/2023]
Abstract
The XVIth Banff Meeting for Allograft Pathology was held in Banff, Alberta, Canada, from September 19 to 23, 2022, as a joint meeting with the Canadian Society of Transplantation. In addition to a key focus on the impact of microvascular inflammation and biopsy-based transcript analysis on the Banff Classification, further sessions were devoted to other aspects of kidney transplant pathology, in particular T cell-mediated rejection, activity and chronicity indices, digital pathology, xenotransplantation, clinical trials, and surrogate endpoints. Although the output of these sessions has not led to any changes in the classification, the key role of Banff Working Groups in phrasing unanswered questions, and coordinating and disseminating results of investigations addressing these unanswered questions was emphasized. This paper summarizes the key Banff Meeting 2022 sessions not covered in the Banff Kidney Meeting 2022 Report paper and also provides an update on other Banff Working Group activities relevant to kidney allografts.
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Affiliation(s)
- Candice Roufosse
- Department of Immunology and Inflammation, Faculty Medicine, Imperial College London, London, UK.
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.
| | - Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Carmen Lefaucheur
- Université Paris Cité, INSERM, PARCC, Paris Institute for Transplantation and Organ Regeneration, France & Department of Nephrology and Transplantation, Saint-Louis Hospital, Paris, France
| | - Roslyn B Mannon
- Department of Internal Medicine, Division of Nephrology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Marjan Afrouzian
- Department of Pathology, University of Texas Medical Branch at Galveston, Texas, USA
| | - Nada Alachkar
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Olivier Aubert
- Université Paris Cité, INSERM, PARCC, Paris Institute for Transplantation and Organ Regeneration, France & Department of Transplantation, Necker Hospital, Paris, France
| | - Serena M Bagnasco
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ibrahim Batal
- Pathology & Cell Biology, Columbia University Irving Medical Center, New York, USA
| | | | - Verena Broecker
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin, Berlin, Germany
| | - Marian Clahsen-Van Groningen
- Department of Pathology and Clinical Bioinformatics, Erasmus University Center Rotterdam, Rotterdam, Netherlands; Institute of Experimental Medicine and Systems Biology, RWTH Aachen University, Aachen, Germany
| | - Shana M Coley
- Transplant Translational Research, Arkana Laboratories, Arkansas, USA
| | - Lynn D Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Darshana Dadhania
- Department Medicine, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Anthony J Demetris
- UPMC Hepatic and Transplantation Pathology, Pittsburg, Pennsylvania, USA
| | - Gunilla Einecke
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Germany
| | - Alton B Farris
- Department of Pathology and Laboratory Medicine, Emory University, USA
| | - Agnes B Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - John Friedewald
- Comprehensive Transplant Center, Northwestern University, USA
| | - Ian W Gibson
- Department of Pathology, University of Manitoba, Winnipeg, Canada
| | | | - Edmund Huang
- Department of Medicine, Division of Nephrology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Syed A Husain
- Division of Nephrology, Columbia University, New York, New York, USA
| | | | - Jesper Kers
- Department of Pathology, Leiden University Medical Center, Netherlands; Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Željko Kikić
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | | | | | - Helen Liapis
- Ludwig Maximillian University Munich, Nephrology Center, Germany
| | | | | | - Brian Nankinvell
- Department of Renal Medicine, Westmead Hospital, Westmead, New South Wales, Australia
| | - Desley A H Neil
- Department of Cellular Pathology, Queen Elizabeth Hospital Birmingham and Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Peter Nickerson
- Department of Medicine and Department of Immunology, University of Manitoba, Winnipeg, Canada
| | - Marion Rabant
- Pathology department, Necker-Enfants Malades Hospital, Paris, France
| | - Parmjeet Randhawa
- Pathology, Thomas E. Starzl Transplant Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Leonardo V Riella
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ivy Rosales
- Immunopathology Research Laboratory, Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Virginie Royal
- Maisonneuve-Rosemont Hospital, University of Montreal, Quebec, Canada
| | - Ruth Sapir-Pichhadze
- Division of Nephrology & Multiorgan Transplant Program, McGill University, Montreal, Quebec, Canada
| | - Pinaki Sarder
- Department of Medicine-Quantitative Health, University of Florida College of Medicine, Florida, USA
| | - Minnie Sarwal
- Division of MultiOrgan Transplantation, UCSF, San Francisco, California, USA
| | - Carrie Schinstock
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark Stegall
- Department Transplantation Surgery, Mayo Clinic, Rochester, Massachusetts, USA
| | - Kim Solez
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Canada
| | | | - Chris Wiebe
- Department of Medicine and Department of Immunology, University of Manitoba, Winnipeg, Canada
| | - Robert B Colvin
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexandre Loupy
- Université Paris Cité, INSERM, PARCC, Paris Institute for Transplantation and Organ Regeneration, France & Department of Transplantation, Necker Hospital, Paris, France
| | - Michael Mengel
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Canada
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3
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Singh N, Anand PM, Gupta G, Sawinski D, Fix O, Adey D, Akalin E, Zayas C, Dadhania D, Doshi M, Cibrik D, Gupta M, Parsons R, Leca N, Santos RD, Concepcion BP, Nishio Lucar AG, Ong S, Sridhar VS, Parajuli S, Zachariah M, Mehta S, Soliman K, Shawar S, Husain SA, Preczewski L, Friedewald J, Mohan S, Wiseman A, Samaniego M, Kumar V, Tanriover B, Bloom R. Should Transplant Nephrology pursue recognition from the Accreditation Council for Graduate Medical Education (ACGME)? Clin J Am Soc Nephrol 2024:01277230-990000000-00352. [PMID: 38319649 DOI: 10.2215/cjn.0000000000000441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/31/2024] [Indexed: 02/07/2024]
Abstract
Kidney transplant is not only the best treatment for patients with advanced kidney disease, but it also reduces health-care expenditure. The management of transplant patients is complex as they require special care by transplant nephrologists who have expertise in assessing transplant candidates, understand immunology and organ rejection, have familiarity with peri-operative complications, and have the ability to manage the long-term effects of chronic immunosuppression. This skill set at the intersection of multiple disciplines necessitates additional training in Transplant Nephrology. Currently, there are more than 250,000 patients with a functioning kidney allograft and over 100,000 waitlisted patients awaiting kidney transplant, with a burgeoning number added to the kidney transplant wait list every year. In 2022, more than 40,000 patients were added to the kidney wait list and more than 25,000 received a kidney transplant. The Advancing American Kidney Health Initiative (AAKHI), passed in 2019, is aiming to double the number of kidney transplants by 2030 creating a need for additional transplant nephrologists to help care for them. Over the last decade there has been a decline in the Nephrology- as well Transplant Nephrology- workforce due to a multitude of reasons. The American Society of Transplantation (AST) Kidney Pancreas Community of Practice (KPCOP) created a workgroup to discuss the Transplant Nephrology workforce shortage. In this paper, we discuss the scope of the problem and how ACGME accreditation of Transplant Nephrology Fellowship could at least partly mitigate the Transplant Nephrology work-force crisis.
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Affiliation(s)
| | - Prince M Anand
- Medical University of South Carolina, Lancaster Medical Center, Lancaster, SC
| | | | - Deirdre Sawinski
- Weill Cornell Medical College/New York-Presbyterian Hospital, New York, NY
| | - Oren Fix
- University of North Carolina, Chapel Hill, NC
| | - Deborah Adey
- University of California San Francisco, San Francisco, CA
| | | | | | - Darshana Dadhania
- Weill Cornell Medical College/New York-Presbyterian Hospital, New York, NY
| | | | | | | | | | | | | | | | | | - Song Ong
- University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | - Shikha Mehta
- University of Alabama at Birmingham, Birmingham, AL
| | - Karim Soliman
- Medical University of South Carolina, Charleston, SC
- Medical Services, Ralph H. Johnson VA Medical Center, Charleston, SC
| | - Saed Shawar
- Vanderbilt University Medical Center, Nashville, TN
| | | | | | | | | | | | | | | | - Bekir Tanriover
- University of Arizona, College of Medicine-Tucson, Tucson, AZ
| | - Roy Bloom
- University of Pennsylvania, Philadelphia, PA
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Garg N, Thiessen C, Reese PP, Cooper M, Leishman R, Friedewald J, Sharfuddin AA, Nishio Lucar AG, Dadhania DM, Kumar V, Waterman AD, Mandelbrot DA. Temporal trends in kidney paired donation in the United States: 2006-2021 UNOS/OPTN database analysis. Am J Transplant 2024; 24:46-56. [PMID: 37739347 DOI: 10.1016/j.ajt.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/08/2023] [Accepted: 09/11/2023] [Indexed: 09/24/2023]
Abstract
Kidney paired donation (KPD) is a major innovation that is changing the landscape of kidney transplantation in the United States. We used the 2006-2021 United Network for Organ Sharing data to examine trends over time. KPD is increasing, with 1 in 5 living donor kidney transplants (LDKTs) in 2021 facilitated by KPD. The proportion of LDKT performed via KPD was comparable for non-Whites and Whites. An increasing proportion of KPD transplants are going to non-Whites. End-chain recipients are not identified in the database. To what extent these trends reflect how end-chain kidneys are allocated, as opposed to increase in living donation among minorities, remains unclear. Half the LDKT in 2021 in sensitized (panel reactive antibody ≥ 80%) and highly sensitized (panel reactive antibody ≥ 98%) groups occurred via KPD. Yet, the proportion of KPD transplants performed in sensitized recipients has declined since 2013, likely due to changes in the deceased donor allocation policies and newer KPD strategies such as compatible KPD. In 2021, 40% of the programs reported not performing any KPD transplants. Our study highlights the need for understanding barriers to pursuing and expanding KPD at the center level and the need for more detailed and accurate data collection at the national level.
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Affiliation(s)
- Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.
| | - Carrie Thiessen
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, and Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew Cooper
- Division of Transplantation, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - John Friedewald
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Asif A Sharfuddin
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Angie G Nishio Lucar
- Division of Nephrology, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Darshana M Dadhania
- Division of Nephrology, Department of Medicine, Weill Cornell Medicine-New York Presbyterian Hospital, New York, USA
| | - Vineeta Kumar
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Amy D Waterman
- Houston Methodist Transplant Center and Academic Institute, Houston, Texas, USA
| | - Didier A Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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5
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Gonzalez Sepulveda JM, Mehrotra S, Yang JC, Schantz KJ, Becker Y, Formica R, Ladner DP, Kaufman D, Friedewald J. Physician Preferences when Selecting Candidates for Lower-Quality Kidney Offers. Clin J Am Soc Nephrol 2023; 18:1599-1609. [PMID: 37729938 PMCID: PMC10723918 DOI: 10.2215/cjn.0000000000000302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 09/14/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND In the United States, more than 50% of kidneys in the lowest 15% quality range (those with Kidney Donor Profile Index >85) are discarded. Studies suggest that using more of these kidneys could benefit patients waiting for a transplant. This study assesses the trade-offs physicians make when selecting recipients for lower-quality kidneys. METHODS A discrete choice experiment (DCE) was administered to surgeons and nephrologists in the United States who are involved in kidney acceptance decisions. The DCE presented kidneys that varied in terms of Kidney Donor Profile Index, expected cold ischemia time, donor age, pump parameters, serum creatinine levels, glomerulosclerosis, donor diabetes status, and whether donation was made after circulatory death. Candidate characteristics included recipients' age, diabetes history, time on dialysis, ejection fraction, HLA mismatch, calculated panel reactive antibody, and Karnofsky performance score. Regression analysis was used to estimate acceptability weights associated with kidney and recipient characteristics. RESULTS A total of 108 physicians completed the DCE. The likelihood of acceptance was significantly lower with deterioration of kidney quality, expected cold ischemia time at transplantation, and missing biopsy and pump information. Acceptance was prioritized for patients who were higher on the waiting list, younger recipients, those who have spent less time on dialysis, and those without a history of diabetes. Performance status (Karnofsky score) and calculated panel reactive antibody also had a statistically significant but smaller association. Finally, ejection fraction had a marginally significant association, and HLA match had no significant association with the acceptance of marginal kidneys. A group of respondents were found to be primarily concerned about cold ischemia time. CONCLUSIONS In this DCE, physicians considered the recipient characteristics that inform expected post-transplant survival score when they decided whether to accept a marginal kidney for a given recipient.
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Affiliation(s)
- Juan M. Gonzalez Sepulveda
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sanjay Mehrotra
- Industrial Engineering and Management Sciences, McCormick School of Engineering, Northwestern University, Evanston, Illinois
| | - Jui-Chen Yang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - Yolanda Becker
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Richard Formica
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Daniela P. Ladner
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Dixon Kaufman
- University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - John Friedewald
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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6
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Smith JD, Agrawal A, Wicklund C, Duquette D, Friedewald J, Rasmussen LV, Gacki-Smith J, Tandon SD, Muhammad LN, Yancy CW, Dong S, Cooper M, Gilbert A, Shetty A, Gordon EJ. Implementation of a culturally competent APOL1 genetic testing programme into living donor evaluation: A two-site, non-randomised, pre-post trial design. BMJ Open 2023; 13:e067657. [PMID: 37188469 PMCID: PMC10186444 DOI: 10.1136/bmjopen-2022-067657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 04/14/2023] [Indexed: 05/17/2023] Open
Abstract
INTRODUCTION While living donor (LD) kidney transplantation is the optimal treatment for patients with kidney failure, LDs assume a higher risk of future kidney failure themselves. LDs of African ancestry have an even greater risk of kidney failure post-donation than White LDs. Because evidence suggests that Apolipoprotein L1 (APOL1) risk variants contribute to this greater risk, transplant nephrologists are increasingly using APOL1 genetic testing to evaluate LD candidates of African ancestry. However, nephrologists do not consistently perform genetic counselling with LD candidates about APOL1 due to a lack of knowledge and skill in counselling. Without proper counselling, APOL1 testing will magnify LD candidates' decisional conflict about donating, jeopardising their informed consent. Given cultural concerns about genetic testing among people of African ancestry, protecting LD candidates' safety is essential to improve informed decisions about donating. Clinical 'chatbots', mobile apps that provide genetic information to patients, can improve informed treatment decisions. No chatbot on APOL1 is available and no nephrologist training programmes are available to provide culturally competent counselling to LDs about APOL1. Given the shortage of genetic counsellors, increasing nephrologists' genetic literacy is critical to integrating genetic testing into practice. METHODS AND ANALYSIS Using a non-randomised, pre-post trial design in two transplant centres (Chicago, IL, and Washington, DC), we will evaluate the effectiveness of culturally competent APOL1 testing, chatbot and counselling on LD candidates' decisional conflict about donating, preparedness for decision-making, willingness to donate and satisfaction with informed consent and longitudinally evaluate the implementation of this intervention into clinical practice using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework. ETHICS AND DISSEMINATION This study will create a model for APOL1 testing of LDs of African ancestry, which can be implemented nationally via implementation science approaches. APOL1 will serve as a model for integrating culturally competent genetic testing into transplant and other practices to improve informed consent. This study involves human participants and was approved by Northwestern University IRB (STU00214038). Participants gave informed consent to participate in the study before taking part. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04910867. Registered 8 May 2021, https://register. CLINICALTRIALS gov/prs/app/action/SelectProtocol?sid=S000AWZ6&selectaction=Edit&uid=U0001PPF&ts=7&cx=-8jv7m2 ClinicalTrials.gov Identifier: NCT04999436. Registered 5 November 2021, https://register. CLINICALTRIALS gov/prs/app/action/SelectProtocol?sid=S000AYWW&selectaction=Edit&uid=U0001PPF&ts=11&cx=9tny7v.
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Affiliation(s)
- Justin D Smith
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah, USA
- Departments of Psychiatry and Behavioral Sciences and Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Akansha Agrawal
- Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Catherine Wicklund
- Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Debra Duquette
- Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - John Friedewald
- Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Luke V Rasmussen
- Division of Health and Biomedical Informatics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jessica Gacki-Smith
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - S Darius Tandon
- Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lutfiyya N Muhammad
- Department of Preventive Medicine-Division of Biostatistics, Northwestern University, Chicago, Illinois, USA
| | - Clyde W Yancy
- Department of Medicine-Division of Cardiology, Northwestern University, Evanston, Illinois, USA
| | - Siyuan Dong
- Department of Preventive Medicine-Division of Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew Cooper
- Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alexander Gilbert
- Medicine, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Aneesha Shetty
- Medicine, The University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
| | - Elisa J Gordon
- Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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7
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Sawinski D, Lai JC, Pinney S, Gray AL, Jackson AM, Stewart D, Levine DJ, Locke JE, Pomposelli JJ, Hartwig MG, Hall SA, Dadhania DM, Cogswell R, Perez RV, Schold JD, Turgeon NA, Kobashigawa J, Kukreja J, Magee JC, Friedewald J, Gill JS, Loor G, Heimbach JK, Verna EC, Walsh MN, Terrault N, Testa G, Diamond JM, Reese PP, Brown K, Orloff S, Farr MA, Olthoff KM, Siegler M, Ascher N, Feng S, Kaplan B, Pomfret E. Addressing sex-based disparities in solid organ transplantation in the United States - a conference report. Am J Transplant 2023; 23:316-325. [PMID: 36906294 DOI: 10.1016/j.ajt.2022.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 10/17/2022] [Accepted: 11/04/2022] [Indexed: 01/15/2023]
Abstract
Solid organ transplantation provides the best treatment for end-stage organ failure, but significant sex-based disparities in transplant access exist. On June 25, 2021, a virtual multidisciplinary conference was convened to address sex-based disparities in transplantation. Common themes contributing to sex-based disparities were noted across kidney, liver, heart, and lung transplantation, specifically the existence of barriers to referral and wait listing for women, the pitfalls of using serum creatinine, the issue of donor/recipient size mismatch, approaches to frailty and a higher prevalence of allosensitization among women. In addition, actionable solutions to improve access to transplantation were identified, including alterations to the current allocation system, surgical interventions on donor organs, and the incorporation of objective frailty metrics into the evaluation process. Key knowledge gaps and high-priority areas for future investigation were also discussed.
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Affiliation(s)
- Deirdre Sawinski
- Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York, USA.
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| | - Sean Pinney
- University of Chicago Medicine, Chicago, Illinois, USA
| | - Alice L Gray
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Annette M Jackson
- Department of Surgery, Duke University, Department of Surgery, Durham, Carolina, USA
| | - Darren Stewart
- United Network for Organ Sharing, Richmond, Virginia, USA
| | | | - Jayme E Locke
- University of Alabama at Birmingham, Heersink School of Medicine, Birmingham, Alabama, USA
| | - James J Pomposelli
- Department of Surgery University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
| | | | | | - Darshana M Dadhania
- Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York, USA
| | - Rebecca Cogswell
- University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Richard V Perez
- Department of Surgery, University of California, Davis, School of Medicine, Sacramento, California, USA
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Jon Kobashigawa
- Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco, California, USA
| | - John C Magee
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - John Friedewald
- Northwestern University Feinberg School of Medicine, Chicago, Illinois USA
| | - John S Gill
- Division of Nephrology, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Gabriel Loor
- Baylor College of Medicine Lung Institute, Houston, Texas, USA
| | | | - Elizabeth C Verna
- Center for Liver Disease and Transplantation, Columbia University, Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Mary Norine Walsh
- Ascension St Vincent Heart Center, Indianapolis, Indianapolis, Indiana, USA
| | - Norah Terrault
- Keck Medicine of University of Southern California, Los Angeles, California, USA
| | - Guiliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Joshua M Diamond
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter P Reese
- Division of Renal, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Susan Orloff
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Portland, Oregon, USA
| | - Maryjane A Farr
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kim M Olthoff
- Department of Surgery, Penn Transplant Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark Siegler
- University of Chicago Medicine, Chicago, Illinois, USA; MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA
| | - Nancy Ascher
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Sandy Feng
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Bruce Kaplan
- Department of Surgery University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
| | - Elizabeth Pomfret
- Department of Surgery University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
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8
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Xiao N, Riopelle D, Agrawal A, Friedewald J, Resnick S. Transplant Renal Vein Stenosis: Diagnosis and Intervention. J Vasc Interv Radiol 2022; 34:723-726. [PMID: 36584808 DOI: 10.1016/j.jvir.2022.12.473] [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] [Received: 12/22/2021] [Revised: 12/15/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022] Open
Affiliation(s)
- Nicholas Xiao
- Division of Interventional Radiology, Department of Radiology, Northwestern University, 676 N. St. Clair St., Suite 800, Chicago, IL 60611
| | - David Riopelle
- Division of Interventional Radiology, Department of Radiology, Northwestern University, 676 N. St. Clair St., Suite 800, Chicago, IL 60611
| | - Akansha Agrawal
- Division of Nephrology and Hypertension, Department of Medicine, Northwestern University, Chicago, IL
| | - John Friedewald
- Division of Nephrology and Hypertension, Department of Medicine, Northwestern University, Chicago, IL
| | - Scott Resnick
- Division of Interventional Radiology, Department of Radiology, Northwestern University, 676 N. St. Clair St., Suite 800, Chicago, IL 60611.
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9
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Cillo U, Weissenbacher A, Pengel L, Jochmans I, Roppolo D, Amarelli C, Belli LS, Berenguer M, De Vries A, Ferrer J, Friedewald J, Furian L, Greenwood S, Monbaliu D, Nadalin S, Neyrinck A, Strazzabosco M, Toso C, Zaza G, Thuraisingham R, Berney T, Potena L, Montserrat N, Selzner N. ESOT Consensus Platform for Organ Transplantation: Setting the Stage for a Rigorous, Regularly Updated Development Process. Transpl Int 2022; 35:10915. [PMID: 36406781 PMCID: PMC9667481 DOI: 10.3389/ti.2022.10915] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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: 10/07/2022] [Accepted: 10/10/2022] [Indexed: 11/23/2022]
Abstract
The European Society for Organ Transplantation (ESOT) has created a platform for the development of rigorous and regularly updated evidence based guidelines for clinical practice in the transplantation field. A dedicated Guideline Taskforce, including ESOT-council members, a representative from the Centre for Evidence in Transplantation, editors of the journal Transplant International has developed transparent procedures to guide the development of guidelines, recommendations, and consensus statements. During ESOT’s first Consensus Conference in November 2022, leading experts will present in-depth evidence based reviews of nine themes and will propose recommendations aimed at reaching a consensus after public discussion and assessment by an independent jury. All recommendations and consensus statements produced for the nine selected topics will be published including the entire evidence-based consensus-finding process. An extensive literature review of each topic was conducted to provide final evidence and/or expert opinion.
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Affiliation(s)
- Umberto Cillo
- Chirurgia Generale 2, Epato-Bilio-Pancreatica e Centro Trapianto di Fegato, Azienda Ospedale Università Padova, Padova, Italy
- *Correspondence: Umberto Cillo,
| | - Annemarie Weissenbacher
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Liset Pengel
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Ina Jochmans
- Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Luca S. Belli
- Hepatology and Gastroenterology Unit, ASST GOM Niguarda, Milan, Italy
| | - Marina Berenguer
- Liver Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Aiko De Vries
- Division of Nephrology, Department of Medicine, Leiden Transplant Center, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Joana Ferrer
- Hepatobiliopancreatic Surgery and Liver and Pancreatic Transplantation Unit, Department of Surgery, Institute Clínic of Digestive and Metabolic Diseases (ICMDiM), Hospital Clínic, University of Barcelona, Barcelona, Spain
- Barcelona Clínic Liver Cancer Group (BCLC), University of Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical, Research Institute (IDIBAPS), University of Barcelona, Barcelona, Spain
- Network for Biomedical Research in Hepatic and Digestive Diseases (CIBERehd), Barcelona, Spain
| | - John Friedewald
- Division of Medicine and Surgery, Northwestern University, Chicago, IL, United States
| | - Lucrezia Furian
- Kidney and Pancreas Transplantation Unit, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Sharlene Greenwood
- King’s College Hospital NHS Trust, London, UK King’s College London, London, United Kingdom
| | - Diethard Monbaliu
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Catholic University Leuven, Leuven, Belgium
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Arne Neyrinck
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Mario Strazzabosco
- Liver Center, Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, United States
| | - Christian Toso
- Division of Abdominal Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Gianluigi Zaza
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | | | - Thierry Berney
- School of Medicine, University of Geneva, Geneva, Switzerland
- Ilia State University, Tbilisi, Georgia
| | - Luciano Potena
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Nuria Montserrat
- Pluripotency for Organ Regeneration, Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, Barcelona, Spain
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Nazia Selzner
- Ajmera Transplant Center, University of Toronto, Toronto, ON, Canada
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10
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Singh N, Doshi MD, Schold JD, Preczewski L, Klein C, Akalin E, Leca N, Nicoll K, Pesavento T, Dadhania DM, Friedewald J, Samaniego-Picota M, Bloom RD, Wiseman AC. Survey of Salary and Job Satisfaction of Transplant Nephrologists in the United States. Clin J Am Soc Nephrol 2022; 17:1372-1381. [PMID: 35914792 PMCID: PMC9625100 DOI: 10.2215/cjn.03490322] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/09/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVES There are no standardized benchmarks to measure productivity and compensation of transplant nephrologists in the United States, and consequently, criteria set for general nephrologists are often used. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A web-based survey was sent to 809 nephrologists who were members of the American Society of Transplantation to gather data on measures of productivity, compensation, and job satisfaction. Factors associated with higher total compensation and job satisfaction were examined. RESULTS Of 365 respondents, 260 were actively practicing in the United States and provided data on compensation. Clinical productivity was assessed variably, and although 194 (76%) had their work relative value units (wRVUs) reported to them, only 107 (44%) had an established RVU target. Two hundred thirty-four respondents (90%) had fixed base compensation, and 172 (66%) received a bonus on the basis of clinical workload (68%), academic productivity (31%), service (32%), and/or teaching responsibility (31%). Only 127 respondents (49%) filled out time studies, and 92 (35%) received some compensation for nonbillable transplant activity. Mean total compensation (base salary and bonus) was $274,460±$91,509. The unadjusted mean total compensation was higher with older age and was higher for men; Hispanic and White respondents; adult care transplant nephrologists; residents of the western United States; US medical school graduates; nonuniversity hospital employees; and those with an administrative title, higher academic rank, and a higher number of years in practice. Two hundred and nine respondents (80%) thought their compensation was unfair, and 180 (70%) lacked a clear understanding of how they were compensated. One hundred forty-five respondents (55%) reported being satisfied or highly satisfied with their job. Job satisfaction was greater among those with higher amounts of compensation and US medical school graduates. CONCLUSIONS We report significant heterogeneity in the assessment of productivity and compensation for transplant nephrologists and the association of compensation with job satisfaction.
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Affiliation(s)
- Neeraj Singh
- John C. McDonald Regional Transplant Center, Willis Knighton Health System, Shreveport, Louisiana
| | - Mona D. Doshi
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Jesse D. Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Luke Preczewski
- Jackson Health System, Miami Transplant Institute, Miami, Florida
| | - Christina Klein
- Piedmont Healthcare, Piedmont Transplant Institute, Atlanta, Georgia
| | - Enver Akalin
- Renal Transplantation, Albert Einstein College of Medicine, Montefiore Medical Center, New York
| | - Nicolae Leca
- Division of Nephrology, University of Washington, Seattle, Washington
| | - Kimberly Nicoll
- US Transplant Reimbursement, TransMedics, Inc., Andover, Massachusetts
| | - Todd Pesavento
- Division of Nephrology, Ohio State University Medical Center, Columbus, Ohio
| | - Darshana M. Dadhania
- Division of Nephrology, Weill Cornell Medical College, Cornell University, New York, New York
| | - John Friedewald
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Roy D. Bloom
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Kurian S, Friedewald J. Comparing Plasma Donor-Derived Cell-free DNA to Indication Kidney Biopsy Tissue Gene Expression: Toward Understanding the Molecular Equivalents of Non-Invasive Tests. J Am Soc Nephrol 2022; 33:256-258. [PMID: 35058353 PMCID: PMC8819994 DOI: 10.1681/asn.2021121595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Sunil Kurian
- The Scripps Research Institute, Department of Molecular and Experimental Medicine, La Jolla, California
| | - John Friedewald
- Northwestern University Feinberg School of Medicine, Comprehensive Transplant Center, Chicago, Illinois
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12
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Alhamad T, Lubetzky M, Lentine KL, Edusei E, Parsons R, Pavlakis M, Woodside KJ, Adey D, Blosser CD, Concepcion BP, Friedewald J, Wiseman A, Singh N, Chang SH, Gupta G, Molnar MZ, Basu A, Kraus E, Ong S, Faravardeh A, Tantisattamo E, Riella L, Rice J, Dadhania DM. Kidney recipients with allograft failure, transition of kidney care (KRAFT): A survey of contemporary practices of transplant providers. Am J Transplant 2021; 21:3034-3042. [PMID: 33559315 DOI: 10.1111/ajt.16523] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/13/2021] [Accepted: 01/20/2021] [Indexed: 01/25/2023]
Abstract
Kidney allograft failure and return to dialysis carry a high risk of morbidity. A practice survey was developed by the AST Kidney Pancreas Community of Practice workgroup and distributed electronically to the AST members. There were 104 respondents who represented 92 kidney transplant centers. Most survey respondents were transplant nephrologists at academic centers. The most common approach to immunosuppression management was to withdraw the antimetabolite first (73%), while only 12% responded they would withdraw calcineurin inhibitor (CNI) first. More than 60% reported that the availability of a living donor is the most important factor in their decision to taper immunosuppression, followed by risk of infection, risk of sensitization, frailty, and side effects of medications. More than half of respondents reported that embolization was either not available or offered to less than 10% as an option for surgical intervention. Majority reported that ≤50% of failed allograft patients were re-listed before dialysis, and less than a quarter of transplant nephrologists performed frequent visits with their patients with failed kidney allograft after they return to dialysis. This survey demonstrates heterogeneity in the care of patients with a failing allograft and the need for more evidence to guide improvements in clinical practice related to transition of care.
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Affiliation(s)
- Tarek Alhamad
- Washington University in St. Louis, Saint Louis, Missouri, USA
| | - Michelle Lubetzky
- New York Presbyterian Hospital- Weill Cornell Medicine, New York, New York, USA
| | | | - Emmanuel Edusei
- New York Presbyterian Hospital- Weill Cornell Medicine, New York, New York, USA
| | | | - Martha Pavlakis
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Deborah Adey
- University of California San Francisco, San Francisco, California, USA
| | | | | | | | | | - Neeraj Singh
- Willis Knighton Health System, Shreveport, Louisiana, USA
| | - Su-Hsin Chang
- Washington University in St. Louis, Saint Louis, Missouri, USA
| | - Gaurav Gupta
- Virginia Commonwealth University, Richmond, Virginia, USA
| | | | | | | | - Song Ong
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Arman Faravardeh
- SHARP Kidney and Pancreas Transplant Center, San Diego, California, USA
| | | | | | - Jim Rice
- Scripps Heath, San Diego, California, USA
| | - Darshana M Dadhania
- New York Presbyterian Hospital- Weill Cornell Medicine, New York, New York, USA
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13
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Lubetzky M, Tantisattamo E, Molnar MZ, Lentine KL, Basu A, Parsons RF, Woodside KJ, Pavlakis M, Blosser CD, Singh N, Concepcion BP, Adey D, Gupta G, Faravardeh A, Kraus E, Ong S, Riella LV, Friedewald J, Wiseman A, Aala A, Dadhania DM, Alhamad T. The failing kidney allograft: A review and recommendations for the care and management of a complex group of patients. Am J Transplant 2021; 21:2937-2949. [PMID: 34115439 DOI: 10.1111/ajt.16717] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/23/2021] [Accepted: 05/20/2021] [Indexed: 01/25/2023]
Abstract
The return to dialysis after allograft failure is associated with increased morbidity and mortality. This transition is made more complex by the rising numbers of patients who seek repeat transplantation and therefore may have indications for remaining on low levels of immunosuppression, despite the potential increased morbidity. Management strategies vary across providers, driven by limited data on how to transition off immunosuppression as the allograft fails and a paucity of randomized controlled trials to support one approach over another. In this review, we summarize the current data available for management and care of the failing allograft. Additionally, we discuss a suggested plan for immunosuppression weaning based upon the availability of re-transplantation and residual allograft function. We propose a shared-care model in which there is improved coordination between transplant providers and general nephrologists so that immunosuppression management and preparation for renal replacement therapy and/or repeat transplantation can be conducted with the goal of improved outcomes and decreased morbidity in this vulnerable patient group.
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Affiliation(s)
- Michelle Lubetzky
- Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Ekamol Tantisattamo
- Division of Nephrology, University of California Irvine, Orange, California, USA
| | - Miklos Z Molnar
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah, USA
| | - Krista L Lentine
- Internal Medicine-Nephrology, Saint Louis University, St. Louis, Missouri, USA
| | - Arpita Basu
- Division of Transplantation, Emory University, Atlanta, Georgia, USA
| | - Ronald F Parsons
- Division of Transplantation, Emory University, Atlanta, Georgia, USA
| | - Kenneth J Woodside
- Department of Surgery, Section of Transplantation, University of Michigan, Ann Arbor, Michigan, USA
| | - Martha Pavlakis
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christopher D Blosser
- Division of Nephrology, University of Washington and Seattle Children's Hospital, Seattle, Washington, USA
| | - Neeraj Singh
- Division of Nephrology, Willis Knighton Health System, Shreveport, Louisiana, USA
| | | | - Deborah Adey
- Division of Nephrology, University of California San Francisco, San Francisco, California, USA
| | - Gaurav Gupta
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Arman Faravardeh
- SHARP Kidney and Pancreas Transplant Center, San Diego, California, USA
| | - Edward Kraus
- Department of Medicine, Johns Hopkins, Baltimore, Maryland, USA
| | - Song Ong
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Leonardo V Riella
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John Friedewald
- Division of Medicine and Surgery, Northwestern University, Chicago, Illinois, USA
| | - Alex Wiseman
- Division of Nephrology, University of Colorado, Denver, Colorado, USA
| | - Amtul Aala
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Darshana M Dadhania
- Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Tarek Alhamad
- Division of Nephrology, Washington University in St. Louis, St. Louis, Michigan, USA
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14
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Singh N, Friedewald J, Bloom R, Dadhania D, Parsons RF, Kaplan B, Samaniego M, Qazi Y, Doshi M, McNatt G, Naseer MS, Pesavento T, Wiseman A. Transplant administration-A survey of the roles and responsibilities of kidney and pancreas medical directors of US transplant centers. Clin Transplant 2021; 35:e14305. [PMID: 33797134 DOI: 10.1111/ctr.14305] [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: 01/25/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 11/28/2022]
Abstract
The current American Society of Transplantation (AST) accredited transplant fellowship programs in the United States provide no structured formal training in leadership and administration which is essential for successfully running a transplant program. We conducted a survey of medical directors of active adult kidney and kidney-pancreas transplant programs in the United States about their demographics, training pathways, and roles and responsibilities. The survey was emailed to 183 medical directors, and 123 (67.2%) completed the survey. A majority of respondents were older than 50 years (61%), males (80%), and holding that position for more than 10 years (47%). Only 51% of current medical directors had taken that position after completing a one-year transplant fellowship, and 58% took on the role with no prior administrative or leadership experience. The medical directors reported spending a median 50%-75% of time in clinical responsibilities, 25%-50% of time in administration, and 0%-25% time in research. The survey also captured various administrative roles of medical directors vis-à-vis other transplant leaders. The study, designed to be the starting point of an improvement initiative of the AST, provided important insight into the demographics, training pathways, roles and responsibilities, job satisfaction, education needs, and training gaps of current medical directors.
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Affiliation(s)
- Neeraj Singh
- John C McDonald Regional Transplant Center, Willis-Knighton Health System, Shreveport, LA, USA
| | - John Friedewald
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Roy Bloom
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Darshana Dadhania
- Division of Nephrology, Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Ronald F Parsons
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Bruce Kaplan
- Central Division, Baylor Scott and White Health, Temple, TX, USA
| | - Millie Samaniego
- Division of Nephrology, Department of Internal Medicine, Henry Ford Health System, Detroit, MI, USA
| | - Yasir Qazi
- Division of Nephrology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Mona Doshi
- Division of Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - Gwen McNatt
- Organ Transplant Center, University of Iowa, Iowa City, IA, USA
| | - Muhammad Saad Naseer
- John C McDonald Regional Transplant Center, Willis-Knighton Health System, Shreveport, LA, USA
| | - Todd Pesavento
- Division of Nephrology, Ohio State University Medical Center, Columbus, OH, USA
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15
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C Wiseman A, Akalin E, M Dadhania D, DeMattos A, Doshi M, Friedewald J, Klein C, Leca N, Nicoll K, Pesavento T, Preczewski L, Samaniego M, Singh N, Bloom R. Defining the roles and responsibilities of the kidney transplant medical director: A necessary step for future training, mentoring, and professional development. Am J Transplant 2021; 21:1556-1563. [PMID: 33021008 DOI: 10.1111/ajt.16332] [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] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 01/25/2023]
Abstract
The management of a kidney transplant program has evolved significantly in the last decades to become a highly specialized, multidisciplinary standard of care for end-stage kidney disease. Transplant center job descriptions have similarly morphed with increasing responsibilities to address a more complex patient mix, increasing medical and surgical therapeutic options, and increasing regulatory burden in the face of an ever-increasing organ shortage. Within this evolution, the role of the Kidney Transplant Medical Director (KTMD) has expanded beyond the basic requirements described in the United Network for Organ Sharing bylaws. Without a clear job description, transplant nephrology trainees may be inadequately trained and practicing transplant nephrologists may face opaque expectations for the roles and responsibilities of Medical Director. To address this gap and clarify the key areas in which the KTMD interfaces with the kidney transplant program, American Society of Transplantation (AST) formed a Task Force of 14 AST KTMDs to review and define the role of the KTMD in key aspects of administrative, regulatory, budgetary, and educational oversight of a kidney transplant program.
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Affiliation(s)
- Alexander C Wiseman
- Kidney Transplantation, Centura Transplant at Porter Hospital, Denver, Colorado
| | - Enver Akalin
- Montefiore Medical Center - Renal Transplantation, Albert Einstein College of Medicine,, Bronx, New York
| | | | - Angelo DeMattos
- Transplant Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon
| | - Mona Doshi
- Medicine, University of Michigan Hospital, Ann Arbor, Michigan
| | | | - Christina Klein
- Piedmont Healthcare - Piedmont Transplant Institute, Atlanta, Georgia
| | - Nicolae Leca
- Department of Medicine, Division of Nephrology, University of Washington Medical Center, Seattle, Washington
| | - Kim Nicoll
- US Transplant Reimbursement, TransMedics Inc, Andover, Massachusetts
| | - Todd Pesavento
- Ohio State Univ - Nephrology-Internal Medicine, Columbus, Ohio
| | - Luke Preczewski
- Transplant, Jackson Health System - Miami Transplant Institute, Miami, Florida
| | | | - Neeraj Singh
- Nephrology, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana
| | - Roy Bloom
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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16
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Mandelbrot DA, Reese PP, Garg N, Thomas CP, Rodrigue JR, Schinstock C, Doshi M, Cooper M, Friedewald J, Naik AS, Kaul DR, Ison MG, Rocco MV, Verbesey J, Hladunewich MA, Ibrahim HN, Poggio ED. KDOQI US Commentary on the 2017 KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Am J Kidney Dis 2020; 75:299-316. [PMID: 32007233 DOI: 10.1053/j.ajkd.2019.10.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/02/2019] [Indexed: 12/27/2022]
Abstract
Living kidney donation is widely practiced throughout the world. During the past 2 decades, various groups have provided guidance about the evaluation and care of living donors. However, during this time, our knowledge in the field has advanced substantially and many agreed on the need for a comprehensive, unifying document. KDIGO (Kidney Disease: Improving Global Outcomes) addressed this issue at an international level with the publication of its clinical practice guideline on the evaluation and care of living kidney donors. The KDIGO work group extensively reviewed the available literature and wrote a series of guideline recommendations using various degrees of evidence when available. As has become recent practice, NKF-KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) convened a work group to provide a commentary on the KDIGO guideline, with a focus on how these recommendations apply in the context of the United States. In the United States, the United Network for Organ Sharing (UNOS) guides and regulates the practice of living kidney donation. While the KDIGO guideline for the care of living kidney donors and UNOS policy are similar in most aspects of the care of living kidney donors, several important areas are not consistent or do not align with common practice by US transplantation programs in areas in which UNOS has not set specific policy. For the time being, and recognizing the value of the KDIGO guidelines, US transplantation programs should continue to follow UNOS policy.
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Affiliation(s)
| | - Peter P Reese
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Neetika Garg
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | - Carrie Schinstock
- Division of Nephrology and Hypertension, William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Mona Doshi
- Division of Nephrology, University of Michigan, Ann Arbor, MI
| | - Matthew Cooper
- Georgetown University School of Medicine, MedStar Georgetown Transplant Institute, Washington, DC
| | - John Friedewald
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Abhijit S Naik
- Division of Nephrology, University of Michigan, Ann Arbor, MI
| | | | - Michael G Ison
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Jennifer Verbesey
- MedStar Georgetown Transplant Institute and Children's National Health System, Washington, DC
| | - Michelle A Hladunewich
- Division of Nephrology, Department of Medicine, Nanji Family Kidney Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | - Emilio D Poggio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
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17
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Friedewald J, Abecassis M. Clinical implications for the use of a biomarker for subclinical rejection - Conflating arguments cause a disconnection between the premise and the conclusion. Am J Transplant 2019; 19:2141-2142. [PMID: 30809931 DOI: 10.1111/ajt.15327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- John Friedewald
- Division of Transplantation, Northwestern University Medical Center, Chicago, Illinois
| | - Michael Abecassis
- Division of Transplantation, Northwestern University Medical Center, Chicago, Illinois
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18
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Gordon EJ, Amórtegui D, Blancas I, Wicklund C, Friedewald J, Sharp RR. A Focus Group Study on African American Living Donors’ Treatment Preferences, Sociocultural Factors, and Health Beliefs About Apolipoprotein L1 Genetic Testing. Prog Transplant 2019; 29:239-247. [DOI: 10.1177/1526924819854485] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Because apolipoprotein L1 ( APOL1) risk variants may contribute to live donors’ kidney failure postdonation, professional guidelines suggest informing potential donors with African ancestry about the availability of APOL1 genotyping. This study assessed African American (AA) donors’ perceptions of APOL1 genetic testing and how APOL1 may affect ethnic identity. Methods/Approach: Four focus groups were conducted with AA donors about their decision-making for and perceptions of APOL1 genetic testing and donation to inform a new culturally targeted educational brochure on APOL1 genetic testing. Qualitative data were analyzed by thematic analysis. Findings: Seventeen donors participated (47% participation rate). Four major themes emerged. (1) In hypothetical scenarios, most participants would have undergone APOL1 testing during donor evaluation to make a more informed decision, but many would have still donated. (2) Participants desired information about how having 2 APOL1 risk variants affects the donor’s and the recipient’s health. (3) Participants referred to diversity of genetic ancestry and cultural constructions of racial/ethnic identity to question the population at risk for APOL1 risk variants and recommended that all potential donors undergo genetic testing and receive education about APOL1. (4) Participants worried that out-of-pocket costs would deter APOL1 testing and that APOL1 could become a preexisting condition and discriminate against AAs. Discussion: Our findings suggest that AA donors desire APOL1 testing to foster informed consent. Transplant clinicians should be aware of these responses to APOL1 testing and be sensitive to historical issues of distrust and discrimination.
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Affiliation(s)
- Elisa J. Gordon
- Division of Transplantation, Department of Surgery, Center for Healthcare Studies, Center for Bioethics and Medical Humanities, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Daniela Amórtegui
- Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Isaac Blancas
- Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Catherine Wicklund
- Center for Genetic Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John Friedewald
- Division of Transplantation, Department of Surgery, Division of Nephrology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Richard R. Sharp
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, USA
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19
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Toby TK, Fornelli L, Srzentić K, DeHart CJ, Levitsky J, Friedewald J, Kelleher NL. A comprehensive pipeline for translational top-down proteomics from a single blood draw. Nat Protoc 2019; 14:119-152. [PMID: 30518910 DOI: 10.1038/s41596-018-0085-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Top-down proteomics (TDP) by mass spectrometry (MS) is a technique by which intact proteins are analyzed. It has become increasingly popDesalting and concentrating GELFrEEular in translational research because of the value of characterizing distinct proteoforms of intact proteins. Compared to bottom-up proteomics (BUP) strategies, which measure digested peptide mixtures, TDP provides highly specific molecular information that avoids the bioinformatic challenge of protein inference. However, the technique has been difficult to implement widely because of inherent limitations of existing sample preparation methods and instrumentation. Recent improvements in proteoform pre-fractionation and the availability of high-resolution benchtop mass spectrometers have made it possible to use high-throughput TDP for the analysis of complex clinical samples. Here, we provide a comprehensive protocol for analysis of a common sample type in translational research: human peripheral blood mononuclear cells (PBMCs). The pipeline comprises multiple workflows that can be treated as modular by the reader and used for various applications. First, sample collection and cell preservation are described for two clinical biorepository storage schemes. Cell lysis and proteoform pre-fractionation by gel-eluted liquid fractionation entrapment electrophoresis are then described. Importantly, instrument setup and liquid chromatography-tandem MS are described for TDP analyses, which rely on high-resolution Fourier-transform MS. Finally, data processing and analysis are described using two different, application-dependent software tools: ProSight Lite for targeted analyses of one or a few proteoforms and TDPortal for high-throughput TDP in discovery mode. For a single sample, the minimum completion time of the entire experiment is 72 h.
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Affiliation(s)
- Timothy K Toby
- Departments of Chemistry and of Molecular Biosciences, Northwestern University, Evanston, IL, USA
| | - Luca Fornelli
- Departments of Chemistry and of Molecular Biosciences, Northwestern University, Evanston, IL, USA
| | - Kristina Srzentić
- Departments of Chemistry and of Molecular Biosciences, Northwestern University, Evanston, IL, USA
| | - Caroline J DeHart
- National Resource for Translational and Developmental Proteomics, Northwestern University, Evanston, IL, USA
| | - Josh Levitsky
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John Friedewald
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Neil L Kelleher
- Departments of Chemistry and of Molecular Biosciences, Northwestern University, Evanston, IL, USA. .,National Resource for Translational and Developmental Proteomics, Northwestern University, Evanston, IL, USA.
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20
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Friedewald J, Abecassis M, Kurian S. Gene expression biomarkers for kidney transplant rejection - The entire landscape. EBioMedicine 2019; 42:41. [PMID: 30910482 PMCID: PMC6491954 DOI: 10.1016/j.ebiom.2019.03.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 03/20/2019] [Indexed: 12/17/2022] Open
Affiliation(s)
- John Friedewald
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Michael Abecassis
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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21
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Gordon EJ, Wicklund C, Lee J, Sharp RR, Friedewald J. A National Survey of Transplant Surgeons and Nephrologists on Implementing Apolipoprotein L1 (APOL1) Genetic Testing Into Clinical Practice. Prog Transplant 2018; 29:26-35. [DOI: 10.1177/1526924818817048] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: There is debate over whether Apolipoprotein L1 (APOL1) gene risk variants contribute to African American (AA) live donors’ (LD) increased risk of kidney failure. Little is known about factors influencing physicians’ integration of APOL1 genetic testing of AA LDs into donor evaluation. Design: We conducted a cross-sectional survey, informed by Roger’s Diffusion of Innovations theory, among nephrology and surgeon members of the American Society of Nephrology, American Society of Transplantation, and American Society of Transplant Surgeons about their practices of and attitudes about APOL1 genetic testing of AA potential LDs. Descriptive statistics and bivariate analyses were performed. Results: Of 383 completed surveys, most physicians believed that APOL1 testing can help AA LDs make more informed donation decisions (87%), and the addition of APOL1 testing offers better clinical information about AA LD’s eligibility for donation than existing evaluation approaches (74%). Among respondents who evaluate LDs (n = 345), 63% would definitely or probably begin or continue using APOL1 testing in the next year, however, few use APOL1 testing routinely (4%) or on a case-by-case basis (14%). Most did not know the right clinical scenario to order APOL1 testing (59%), but would use educational materials to counsel AA LDs about APOL1 testing (97%). Discussion: Although physicians were highly supportive of APOL1 genetic testing for AA LDs, few physicians use APOL1 testing. As more physicians intend to use APOL1 testing, an ethical framework and clinical decision support are needed presently to assist clinicians in clarifying the proper indication of APOL1 genetic testing.
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Affiliation(s)
- Elisa J. Gordon
- Division of Transplantation, Department of Surgery, Center for Healthcare Studies, Center for Bioethics and Medical Humanities, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Catherine Wicklund
- Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jungwha Lee
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Richard R. Sharp
- Biomedical Ethics Research Program Mayo Clinic, Rochester, MN, USA
| | - John Friedewald
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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22
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Gordon EJ, Amόrtegui D, Blancas I, Wicklund C, Friedewald J, Sharp RR. African American Living Donors' Attitudes About APOL1 Genetic Testing: A Mixed Methods Study. Am J Kidney Dis 2018; 72:819-833. [PMID: 30360961 PMCID: PMC6252162 DOI: 10.1053/j.ajkd.2018.07.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 07/24/2018] [Indexed: 12/16/2022]
Abstract
RATIONALE & OBJECTIVE African American live kidney donors ("donors") have a greater risk for kidney failure than European American donors. Apolipoprotein L1 gene (APOL1) variants in African Americans may be associated with this disparity. STUDY DESIGN Cross-sectional mixed-methods design. SETTING & PARTICIPANTS African American donors at 1 transplantation center. ANALYTICAL APPROACH Semistructured interviews assessed attitudes about APOL1 genetic testing, willingness to undergo APOL1 testing, hypothetical decisions about donating with 2 APOL1 variants, and demographics. Surveys assessed perceptions of ethnic identity and genetics knowledge. Interview transcriptions were analyzed using thematic analysis. Survey data were analyzed using descriptive statistics. RESULTS 23 donors participated in semistructured interviews. Most (96%) reported that transplantation centers should routinely offer APOL1 genetic testing to all African American potential donors. Most (87%) would have been willing to undergo APOL1 testing before donating. Although study participants noted that APOL1 testing may deter African American potential donors from donating, most (61%) would have donated even if they had 2 high-risk APOL1 variants. Several themes emerged. Study participants believed that APOL1 testing was beneficial for providing information to help donors make informed donation decisions. Participants expressed concern about APOL1 variants placing donors at harm for kidney failure, and therefore valued taking preventive health measures. Participants believed that potential donors would experience psychological distress from learning that they have 2 gene variants and could harm their recipients. Participants were apprehensive about insurance coverage and costs of APOL1 testing and feared that APOL1 genetic test results could discriminate against African Americans. LIMITATIONS Findings may not be generalizable to African American potential donors. CONCLUSIONS Findings suggest that African American donors support APOL1 genetic testing yet fear that APOL1 variants and genetic testing could adversely affect donors' health and ethnic identity. Transplantation centers using APOL1 genetic testing should address African American donors' concerns about APOL1 genetic testing to optimize future donors' informed consent practices.
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Affiliation(s)
- Elisa J Gordon
- Division of Transplantation, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL; Center for Bioethics and Medical Humanities, Feinberg School of Medicine, Northwestern University, Chicago, IL.
| | - Daniela Amόrtegui
- Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Isaac Blancas
- Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Catherine Wicklund
- Center for Genetic Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - John Friedewald
- Division of Transplantation, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Internal Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
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23
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Cooper M, Formica R, Friedewald J, Hirose R, O’Connor K, Mohan S, Schold J, Axelrod D, Pastan S. Report of National Kidney Foundation Consensus Conference to Decrease Kidney Discards. Clin Transplant 2018; 33:e13419. [DOI: 10.1111/ctr.13419] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 09/29/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Matthew Cooper
- Medstar Georgetown Transplant Institute; Georgetown University; Washington District of Columbia
| | - Richard Formica
- Department of Medicine, Section of Nephrology; Yale School of Medicine; New Haven Connecticut
| | - John Friedewald
- Northwestern University Comprehensive Transplant Center; Chicago Illinois
| | - Ryutaro Hirose
- Department of Surgery; University of California San Francisco; San Francisco California
| | | | - Sumit Mohan
- Division of Nephrology, Department of Medicine; Vagelos College of Physicians & Surgeons, Columbia University; New York New York
- Department of Epidemiology, Mailman School of Public Health; Columbia University; New York New York
| | - Jesse Schold
- Department of Quantitative Health Sciences; Cleveland Clinic; Cleveland Ohio
| | - David Axelrod
- Department of Surgery; Lahey Hospital and Medical Center; Burlington Massachusetts
| | - Stephen Pastan
- Renal Division, Department of Medicine; Emory University School of Medicine; Atlanta Georgia
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24
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Tambur AR, Campbell P, Claas FH, Feng S, Gebel HM, Jackson AM, Mannon RB, Reed EF, Tinckam K, Askar M, Chandraker A, Chang PP, Colvin M, Demetris AJ, Diamond JM, Dipchand AI, Fairchild RL, Ford ML, Friedewald J, Gill RG, Glotz D, Goldberg H, Hachem R, Knechtle S, Kobashigawa J, Levine DJ, Levitsky J, Mengel M, Milford E, Newell KA, O'Leary JG, Palmer S, Randhawa P, Smith J, Snyder L, Starling RC, Sweet S, Taner T, Taylor CJ, Woodle S, Zeevi A, Nickerson P. Sensitization in Transplantation: Assessment of Risk (STAR) 2017 Working Group Meeting Report. Am J Transplant 2018; 18:1604-1614. [PMID: 29603613 DOI: 10.1111/ajt.14752] [Citation(s) in RCA: 183] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 02/25/2018] [Accepted: 03/20/2018] [Indexed: 02/06/2023]
Abstract
The presence of preexisting (memory) or de novo donor-specific HLA antibodies (DSAs) is a known barrier to successful long-term organ transplantation. Yet, despite the fact that laboratory tools and our understanding of histocompatibility have advanced significantly in recent years, the criteria to define presence of a DSA and assign a level of risk for a given DSA vary markedly between centers. A collaborative effort between the American Society for Histocompatibility and Immunogenetics and the American Society of Transplantation provided the logistical support for generating a dedicated multidisciplinary working group, which included experts in histocompatibility as well as kidney, liver, heart, and lung transplantation. The goals were to perform a critical review of biologically driven, state-of-the-art, clinical diagnostics literature and to provide clinical practice recommendations based on expert assessment of quality and strength of evidence. The results of the Sensitization in Transplantation: Assessment of Risk (STAR) meeting are summarized here, providing recommendations on the definition and utilization of HLA diagnostic testing, and a framework for clinical assessment of risk for a memory or a primary alloimmune response. The definitions, recommendations, risk framework, and highlighted gaps in knowledge are intended to spur research that will inform the next STAR Working Group meeting in 2019.
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Affiliation(s)
| | | | - Frans H Claas
- Leiden University Medical Center, Leiden, Netherlands
| | - Sandy Feng
- UCSF Medical Center, San Francisco, California
| | | | | | | | - Elaine F Reed
- UCLA Pathology & Laboratory Medicine, Los Angeles, California
| | | | | | | | | | | | | | | | | | | | - Mandy L Ford
- Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | | | - Ramsey Hachem
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | | | | | | | - Edgar Milford
- Brigham and Women's' Hospital, Boston, Massachusetts
| | | | | | - Scott Palmer
- Duke University School of Medicine, Durham, North Carolina
| | | | - John Smith
- Royal Brompton & Harefield NHS Foundation Trust, Harefield, UK
| | - Laurie Snyder
- Duke University School of Medicine, Durham, North Carolina
| | | | - Stuart Sweet
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | | | - Adriana Zeevi
- University of Pittsburg Medical Center, Pittsburgh, Pennsylvania
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25
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Leventhal JR, Miller J, Mathew JM, Kurian S, Tambur AR, Friedewald J, Charrette J, Abecassis MM. Updated follow-up of a tolerance protocol in HLA-identical renal transplant pairs given donor hematopoietic stem cells. Hum Immunol 2018; 79:277-282. [PMID: 29408689 DOI: 10.1016/j.humimm.2018.01.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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: 08/29/2017] [Revised: 01/23/2018] [Accepted: 01/23/2018] [Indexed: 12/14/2022]
Abstract
Kidney transplant recipients given donor hematopoietic stem cells from their HLA-identical living related donors have now been followed between 5 and 9½ years post-operatively. Recipients who were designated as tolerant (Tol) have remained so since the last report when the 5 year (biopsy associated) milestone was reached. There has been 1 mortality of a Tol patient, unrelated to the study protocol, while 5 (of 15) have remained Tol between 7 and 8½ years post-operatively. There has been continuing elevated T-regulatory (CD4+CD25HighCD127-FOXP3+) cells in PBMC previously reported on. Ten year renal transplant biopsies are tentatively planned.
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Affiliation(s)
- Joseph R Leventhal
- Comprehensive Transplant Center, Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Joshua Miller
- Comprehensive Transplant Center, Department of Surgery, Northwestern University, Chicago, IL, USA
| | - James M Mathew
- Comprehensive Transplant Center, Department of Surgery, Northwestern University, Chicago, IL, USA; Department of Microbiology-Immunology, Northwestern University, Chicago, IL, USA.
| | - Sunil Kurian
- Department of Molecular and Experimental Medicine, The Scripps Research Institute and Scripps Center for Organ Transplantation, La Jolla, CA, USA
| | - Anat R Tambur
- Comprehensive Transplant Center, Department of Surgery, Northwestern University, Chicago, IL, USA
| | - John Friedewald
- Comprehensive Transplant Center, Department of Surgery, Northwestern University, Chicago, IL, USA; Division of Nephrology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jane Charrette
- Comprehensive Transplant Center, Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Michael M Abecassis
- Comprehensive Transplant Center, Department of Surgery, Northwestern University, Chicago, IL, USA; Department of Microbiology-Immunology, Northwestern University, Chicago, IL, USA
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26
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Levitsky J, Formica RN, Bloom RD, Charlton M, Curry M, Friedewald J, Friedman J, Goldberg D, Hall S, Ison M, Kaiser T, Klassen D, Klintmalm G, Kobashigawa J, Liapakis A, O'Conner K, Reese P, Stewart D, Terrault N, Theodoropoulos N, Trotter J, Verna E, Volk M. The American Society of Transplantation Consensus Conference on the Use of Hepatitis C Viremic Donors in Solid Organ Transplantation. Am J Transplant 2017; 17:2790-2802. [PMID: 28556422 DOI: 10.1111/ajt.14381] [Citation(s) in RCA: 236] [Impact Index Per Article: 33.7] [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: 04/11/2017] [Revised: 05/12/2017] [Accepted: 05/18/2017] [Indexed: 01/25/2023]
Abstract
The availability of direct-acting antiviral agents for the treatment of hepatitis C virus (HCV) infection has resulted in a profound shift in the approach to the management of this infection. These changes have affected the practice of solid organ transplantation by altering the framework by which patients with end-stage organ disease are managed and receive organ transplants. The high level of safety and efficacy of these medications in patients with chronic HCV infection provides the opportunity to explore their use in the setting of transplanting organs from HCV-viremic patients into non-HCV-viremic recipients. Because these organs are frequently discarded and typically come from younger donors, this approach has the potential to save lives on the solid organ transplant waitlist. Therefore, an urgent need exists for prospective research protocols that study the risk versus benefit of using organs for hepatitis C-infected donors. In response to this rapidly changing practice and the need for scientific study and consensus, the American Society of Transplantation convened a meeting of experts to review current data and develop the framework for the study of using HCV viremic organs in solid organ transplantation.
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Affiliation(s)
| | | | - R D Bloom
- University of Pennsylvania, Philadelphia, PA
| | - M Charlton
- Intermountain Medical Center, Salt Lake City, UT
| | - M Curry
- Beth Israel Deaconess Medical Center, Boston, MA
| | | | - J Friedman
- Optum Population Health Solutions, Minneapolis, MN
| | - D Goldberg
- University of Pennsylvania, Philadelphia, PA
| | - S Hall
- Baylor University Medical Center, Dallas, TX
| | - M Ison
- Northwestern University, Chicago, IL
| | - T Kaiser
- University of Cincinnati, Cincinnati, OH
| | - D Klassen
- United Network of Organ Sharing, Richmond, VA
| | - G Klintmalm
- Baylor University Medical Center, Dallas, TX
| | | | | | | | - P Reese
- University of Pennsylvania, Philadelphia, PA
| | - D Stewart
- United Network of Organ Sharing, Richmond, VA
| | - N Terrault
- University of California San Francisco, San Francisco, CA
| | | | - J Trotter
- Baylor University Medical Center, Dallas, TX
| | - E Verna
- Columbia University, New York, NY
| | - M Volk
- Loma Linda University, San Diego, CA
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27
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Asare A, Kanaparthi S, Lim N, Phippard D, Vincenti F, Friedewald J, Pavlakis M, Poggio E, Heeger P, Mannon R, Burrell BE, Morrison Y, Bridges N, Sanz I, Chandraker A, Newell KA, Turka LA. B Cell Receptor Genes Associated With Tolerance Identify a Cohort of Immunosuppressed Patients With Improved Renal Allograft Graft Function. Am J Transplant 2017; 17:2627-2639. [PMID: 28371372 PMCID: PMC5620117 DOI: 10.1111/ajt.14283] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 02/16/2017] [Accepted: 03/15/2017] [Indexed: 01/25/2023]
Abstract
We previously reported that two B cell receptor genes, IGKV1D-13 and IGKV4-1, were associated with tolerance following kidney transplantation. To assess the potential utility of this "signature," we conducted a prospective, multicenter study to determine the frequency of patients predicted tolerant within a cohort of patients deemed to be candidates for immunosuppressive minimization. At any single time point, 25-30% of patients were predicted to be tolerant, while 13.7% consistently displayed the tolerance "signature" over the 2-year study. We also examined the relationship of the presence of the tolerance "signature" on drug use and graft function. Contrary to expectations, the frequency of predicted tolerance was increased in patients receiving tacrolimus and reduced in those receiving corticosteroids, mycophenolate mofetil, or Thymoglobulin as induction. Surprisingly, patients consistently predicted to be tolerant displayed a statistically and clinically significant improvement in estimated glomerular filtration rate that increased over time following transplantation. These findings indicate that the frequency of patients consistently predicted to be tolerant is sufficiently high to be clinically relevant and confirm recent findings by others that immunosuppressive agents impact putative biomarkers of tolerance. The association of a B cell-based "signature" with graft function suggests that B cells may contribute to the function/survival of transplanted kidneys.
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Affiliation(s)
- Adam Asare
- Immune Tolerance Network, Massachusetts General Hospital, Bethesda, MD 20814
| | - Sai Kanaparthi
- Immune Tolerance Network, Massachusetts General Hospital, Bethesda, MD 20814
| | - Noha Lim
- Immune Tolerance Network, Massachusetts General Hospital, Bethesda, MD 20814
| | - Deborah Phippard
- Immune Tolerance Network, Massachusetts General Hospital, Bethesda, MD 20814
| | - Flavio Vincenti
- Departments of Medicine and Surgery, University of California - San Francisco, CA 94143
| | - John Friedewald
- Northwestern Memorial Hospital, Northwestern University, Chicago, IL 60611
| | | | | | - Peter Heeger
- Recanati Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Roslyn Mannon
- University of Alabama School of Medicine, Birmingham, AL 35233
| | - Bryna E. Burrell
- Immune Tolerance Network, Massachusetts General Hospital, Bethesda, MD 20814
| | - Yvonne Morrison
- Division of Allergy, Immunology, and Transplantation (DAIT), NIAID, Rockville, MD 20852
| | - Nancy Bridges
- Division of Allergy, Immunology, and Transplantation (DAIT), NIAID, Rockville, MD 20852
| | - Inaki Sanz
- Department of Surgery, Emory University School of Medicine, Emory University, Atlanta, GA 30322
| | | | - Kenneth A. Newell
- Department of Surgery, Emory University School of Medicine, Emory University, Atlanta, GA 30322
| | - Laurence A. Turka
- Center for Transplantation Sciences and Immune Tolerance Network, Massachusetts General Hospital, Boston, MA 02129
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Gandolfini I, Harris C, Abecassis M, Anderson L, Bestard O, Comai G, Cravedi P, Cremaschi E, Duty JA, Florman S, Friedewald J, La Manna G, Maggiore U, Moran T, Piotti G, Purroy C, Jarque M, Nair V, Shapiro R, Reid-Adam J, Heeger PS. Rapid Biolayer Interferometry Measurements of Urinary CXCL9 to Detect Cellular Infiltrates Noninvasively After Kidney Transplantation. Kidney Int Rep 2017; 2:1186-1193. [PMID: 29270527 PMCID: PMC5733675 DOI: 10.1016/j.ekir.2017.06.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [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: 05/13/2017] [Revised: 06/08/2017] [Accepted: 06/15/2017] [Indexed: 10/31/2022] Open
Abstract
Introduction Measuring the chemokine CXCL9 in urine by enzyme-linked immunosorbent assay (ELISA) can diagnose acute cellular rejection (ACR) noninvasively after kidney transplantation, but the required 12- to 24-hour turnaround time is not ideal for rapid, clinical decision-making. Methods We developed a biolayer interferometry (BLI)-based assay to rapidly measure urinary CXCL9 in <1 hour. We validated this new assay versus standard ELISA in 86 urine samples from kidney transplantation recipients with various diagnoses. We then used BLI to analyze samples from 56 kidney transplantation recipients, including 46 subjects who experienced an acute rise in serum creatinine associated with biopsy-proven ACR (n = 22), subclinical rejection (n = 15), or no infiltrates (n = 9), and 10 stable kidney transplantation recipients with surveillance biopsies. To assess its usefulness in detecting adequacy of therapy we serially measured serum creatinine and urinary CXCL9 in 6 subjects after treatment for ACR, and correlated the results with histological diagnoses on follow-up biopsies. Results BLI accurately and reproducibly detected urinary CXCL9 in <1 hour. BLI-based results showed that urinary CXCL9 was >200 pg/ml in subjects with ACR and ≤100 pg/ml in subjects with stable kidney function without cellular infiltrates. In samples obtained after treatment for ACR, BLI CXCL9 measurements detected biopsy-proven intragraft infiltrates despite treatment-induced reduction in serum creatinine. Discussion Together, our proof-of-principle results demonstrate that BLI-based urinary CXCL9 detection has potential as a point-of-care noninvasive biomarker to diagnose and guide therapy for ACR in kidney transplantation recipients.
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Affiliation(s)
- Ilaria Gandolfini
- Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Kidney and Kidney-Pancreas Unit, Department of Nephrology, Parma University Hospital, Parma, Italy
| | - Cynthia Harris
- Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Michael Abecassis
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Lisa Anderson
- Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Oriol Bestard
- Kidney Transplant Unit, Bellvitge University Hospital, IDIBELL, UB, Barcelona, Spain
| | - Giorgia Comai
- Department of Experimental, Diagnostic, Specialty Medicine, Nephrology, Dialysis, and Renal Transplant Unit, S. Orsola University Hospital, Bologna, Italy
| | - Paolo Cravedi
- Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Elena Cremaschi
- Kidney and Kidney-Pancreas Unit, Department of Nephrology, Parma University Hospital, Parma, Italy
| | - J Andrew Duty
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sander Florman
- Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Friedewald
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Gaetano La Manna
- Department of Experimental, Diagnostic, Specialty Medicine, Nephrology, Dialysis, and Renal Transplant Unit, S. Orsola University Hospital, Bologna, Italy
| | - Umberto Maggiore
- Kidney and Kidney-Pancreas Unit, Department of Nephrology, Parma University Hospital, Parma, Italy
| | - Thomas Moran
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Giovanni Piotti
- Kidney and Kidney-Pancreas Unit, Department of Nephrology, Parma University Hospital, Parma, Italy
| | - Carolina Purroy
- Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marta Jarque
- Kidney Transplant Unit, Bellvitge University Hospital, IDIBELL, UB, Barcelona, Spain
| | - Vinay Nair
- Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ron Shapiro
- Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jessica Reid-Adam
- Division of Pediatric Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter S Heeger
- Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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29
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Modena BD, Milam R, Harrison F, Cheeseman JA, Abecassis MM, Friedewald J, Kirk AD, Salomon DR. Changes in Urinary Microbiome Populations Correlate in Kidney Transplants With Interstitial Fibrosis and Tubular Atrophy Documented in Early Surveillance Biopsies. Am J Transplant 2017; 17:712-723. [PMID: 27597148 PMCID: PMC5328852 DOI: 10.1111/ajt.14038] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 08/19/2016] [Accepted: 08/22/2016] [Indexed: 01/25/2023]
Abstract
An unbalanced microbiome may lead to disease by creating aberrant immune responses. A recent association of cellular rejection with the development of interstitial fibrosis and tubular atrophy (IFTA) suggests the role of immune-mediated tissue injury. We hypothesized that developing IFTA correlates with altered urinary tract microbiomes (UMBs). UMBs at two serial time points, 1 and 6-8 months posttransplant, were assessed by 16S microbial ribosomal gene sequencing in 25 patients developing biopsy-proven IFTA compared to 23 transplant patients with normal biopsies and excellent function (TX) and 20 healthy nontransplant controls (HC). Streptococcus, the dominant genera in HC males, was lower in IFTA and TX males at 1 month compared to HCs. At 6-8 months, Streptococcus was further decreased in IFTA males, but normalized in TX. IFTA males and females had increases in number of genera per sample at 6-8 months. UMB composition varied substantially between individuals in all groups. Despite the wide variation in UMBs between individuals, IFTA was associated with a loss in dominant resident urinary microbes in males, and a parallel increase in nonresident, pathogenic bacteria in males and females. UMB changes may contribute to IFTA development by alteration of the host immune response.
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Affiliation(s)
- Brian D Modena
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| | - Rachel Milam
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| | - Frank Harrison
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| | | | - Michael M Abecassis
- Northwestern Comprehensive Transplant Center, Northwestern University, Chicago, IL
| | - John Friedewald
- Northwestern Comprehensive Transplant Center, Northwestern University, Chicago, IL
| | | | - Daniel R Salomon
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA, Scripps Center for Organ Transplantation, Scripps Health, La Jolla, CA
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30
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Robinson JK, Friedewald J, Gordon EJ. Perceptions of Risk of Developing Skin Cancer for Diverse Audiences: Enhancing Relevance of Sun Protection to Reduce the Risk. J Cancer Educ 2016; 31:153-157. [PMID: 26209181 PMCID: PMC4881419 DOI: 10.1007/s13187-015-0885-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Sixty-five percent of kidney transplant recipients (KTRs) develop squamous cell carcinoma (SCC). Perceptions of risk of developing skin cancer, amelioration of this risk with sun protection, and having choices among sun protection strategies may enhance sun protection use by KTRS, who are at greater risk than the general population. Thirty KTRs stratified among non-Hispanic Whites, non-Hispanic Blacks, and Hispanic/Latinos evaluated three versions of the interactive, web-based, electronic sun protection program and suggested refinements. The sequence of content presentation prepared the participant to accept the credibility, accuracy, and relevance of the message. Beginning with informing participants that using sun protection reduces the chance of developing skin cancer made the information credible to KTRs. Showing skin cancer on all skin types and patient testimonials enhanced participants' awareness of their susceptibility to develop skin cancer and primed patients to receive their personal risk of developing skin cancer. Coupling presentation of knowledge about the benefits of sun protection in reducing the risk of developing skin cancer with the personal risk of getting the disease was essential to KTRs believing that they could influence their health outcome.
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Affiliation(s)
- June K Robinson
- Department of Dermatology, Northwestern University Feinberg School of Medicine, 676 St. Clair Street, Suite 1260, Chicago, IL, 60611, USA.
| | - John Friedewald
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Elisa J Gordon
- Center for Healthcare Studies and Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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31
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Cusick M, Haarberg K, Friedewald J, Tambur AR. Assessing the correlation between C3d-binding de novo donor specific HLA antibodies and rejection in kidney transplant recipients. Hum Immunol 2015. [DOI: 10.1016/j.humimm.2015.07.197] [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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32
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Suhre K, Schwartz JE, Sharma VK, Chen Q, Lee JR, Muthukumar T, Dadhania DM, Ding R, Ikle DN, Bridges ND, Williams NM, Kastenmüller G, Karoly ED, Mohney RP, Abecassis M, Friedewald J, Knechtle SJ, Becker YT, Samstein B, Shaked A, Gross SS, Suthanthiran M. Urine Metabolite Profiles Predictive of Human Kidney Allograft Status. J Am Soc Nephrol 2015; 27:626-36. [PMID: 26047788 DOI: 10.1681/asn.2015010107] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [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: 01/29/2015] [Accepted: 04/15/2015] [Indexed: 12/29/2022] Open
Abstract
Noninvasive diagnosis and prognostication of acute cellular rejection in the kidney allograft may help realize the full benefits of kidney transplantation. To investigate whether urine metabolites predict kidney allograft status, we determined levels of 749 metabolites in 1516 urine samples from 241 kidney graft recipients enrolled in the prospective multicenter Clinical Trials in Organ Transplantation-04 study. A metabolite signature of the ratio of 3-sialyllactose to xanthosine in biopsy specimen-matched urine supernatants best discriminated acute cellular rejection biopsy specimens from specimens without rejection. For clinical application, we developed a high-throughput mass spectrometry-based assay that enabled absolute and rapid quantification of the 3-sialyllactose-to-xanthosine ratio in urine samples. A composite signature of ratios of 3-sialyllactose to xanthosine and quinolinate to X-16397 and our previously reported urinary cell mRNA signature of 18S ribosomal RNA, CD3ε mRNA, and interferon-inducible protein-10 mRNA outperformed the metabolite signatures and the mRNA signature. The area under the receiver operating characteristics curve for the composite metabolite-mRNA signature was 0.93, and the signature was diagnostic of acute cellular rejection with a specificity of 84% and a sensitivity of 90%. The composite signature, developed using solely biopsy specimen-matched urine samples, predicted future acute cellular rejection when applied to pristine samples taken days to weeks before biopsy. We conclude that metabolite profiling of urine offers a noninvasive means of diagnosing and prognosticating acute cellular rejection in the human kidney allograft, and that the combined metabolite and mRNA signature is diagnostic and prognostic of acute cellular rejection with very high accuracy.
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Affiliation(s)
- Karsten Suhre
- Department of Physiology and Biophysics, Weill Cornell Medical College in Qatar, Doha, Qatar; Institute of Bioinformatics and Systems Biology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | - Joseph E Schwartz
- Department of Psychiatry, Stony Brook University, Stony Brook, New York; Division of Nephrology and Hypertension, Departments of Medicine and Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Vijay K Sharma
- Division of Nephrology and Hypertension, Departments of Medicine and Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Qiuying Chen
- Department of Pharmacology, Weill Cornell College of Medicine, New York, New York
| | - John R Lee
- Division of Nephrology and Hypertension, Departments of Medicine and Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Thangamani Muthukumar
- Division of Nephrology and Hypertension, Departments of Medicine and Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Darshana M Dadhania
- Division of Nephrology and Hypertension, Departments of Medicine and Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Ruchuang Ding
- Division of Nephrology and Hypertension, Departments of Medicine and Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - David N Ikle
- Rho Federal Systems, Chapel Hill, North Carolina
| | - Nancy D Bridges
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Nikki M Williams
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Gabi Kastenmüller
- Institute of Bioinformatics and Systems Biology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | | | | | - Michael Abecassis
- Division of Surgery-Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John Friedewald
- Division of Nephrology-Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stuart J Knechtle
- Division of Surgery, Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Yolanda T Becker
- Division of Surgery, Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Benjamin Samstein
- Division of Transplantation, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York; and
| | - Abraham Shaked
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Steven S Gross
- Department of Pharmacology, Weill Cornell College of Medicine, New York, New York
| | - Manikkam Suthanthiran
- Division of Nephrology and Hypertension, Departments of Medicine and Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York;
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Fisher JS, Butt Z, Friedewald J, Fry-Revere S, Hanneman J, Henderson ML, Ladin K, Mysel H, Preczewski L, Sherman LA, Thiessen C, Gordon EJ. Between Scylla and Charybdis: charting an ethical course for research into financial incentives for living kidney donation. Am J Transplant 2015; 15:1180-6. [PMID: 25833728 DOI: 10.1111/ajt.13234] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 12/15/2014] [Accepted: 12/25/2015] [Indexed: 01/25/2023]
Abstract
New approaches to address the kidney scarcity in the United States are urgently needed. The greatest potential source of kidneys is from living donors. Proposals to offer financial incentives to increase living kidney donation rates remain highly controversial. Despite repeated calls for a pilot study to assess the impact of financial compensation on living kidney donation rates, many fear that financial incentives will exploit vulnerable individuals and cast the field of transplantation in a negative public light, ultimately reducing donation rates. This paper provides an ethical justification for conducting a pilot study of a federally regulated approach to providing financial incentives to living kidney donors, with the goal of assessing donors' perceptions.
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Affiliation(s)
- J S Fisher
- Scripps Center for Organ and Cell Transplantation, Scripps Clinic/Green Hospital, La Jolla, CA
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Guevara Y, Gaber R, Clayman ML, Gordon EJ, Friedewald J, Robinson JK. Sun protection education for diverse audiences: need for skin cancer pictures. J Cancer Educ 2015; 30:187-189. [PMID: 24788983 PMCID: PMC4216777 DOI: 10.1007/s13187-014-0661-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Sun protection education is needed for kidney transplant recipients, whose increased risk of skin cancer could be ameliorated with sun protection. Cognitive interviews with 24 participants equally stratified among non-Hispanic White, non-Hispanic Black, and Hispanic/Latino kidney transplant recipients were performed to evaluate a sun protection education workbook. Study participants were recruited over the phone using a registry of 700 kidney transplant recipients. Participants included 12 women and 12 men with a median age of 52. In 16 of the cognitive interviews with non-Hispanic Blacks and Hispanic/Latinos, pictures of skin cancer were requested by the participants in order to see the appearance of skin cancer. Kidney transplant recipients with skin of color did not consider themselves at risk to develop skin cancer and wanted to see examples of skin cancer occurring on people with skin of color. Based on these results, the workbook was modified to include pictures of squamous cell carcinoma on varying skin tones. Then, 8 participants evaluated the revised workbook in cognitive interviews and found the photographs acceptable and necessary to demonstrate the severity of skin cancer and personalize their risk of developing skin cancer. The participants progressed from having knowledge of skin cancer to believing that they could develop skin cancer because they observed skin cancers on people with their skin tone. Using pictures of skin cancers occurring on people with similar skin tone may heighten a kidney transplant recipients' sense of vulnerability and possibly improve the use of sun protection.
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Affiliation(s)
- Yanina Guevara
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Rikki Gaber
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Marla L. Clayman
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Elisa J. Gordon
- Center for Healthcare Studies & Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - John Friedewald
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - June K. Robinson
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL
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35
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Levitsky J, Baker TB, Jie C, Ahya S, Levin M, Friedewald J, Al-Saden P, Salomon DR, Abecassis MM. Plasma protein biomarkers enhance the clinical prediction of kidney injury recovery in patients undergoing liver transplantation. Hepatology 2014; 60:2017-26. [PMID: 25078558 DOI: 10.1002/hep.27346] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 07/28/2014] [Indexed: 12/23/2022]
Abstract
UNLABELLED Biomarkers predictive of recovery from acute kidney injury (AKI) after liver transplantation (LT) could enhance decision algorithms regarding the need for liver-kidney transplantation or renal sparing regimens. Multianalyte plasma/urine kidney injury protein panels were performed immediately before and 1 month post-LT in an initial test group divided by reversible pre-LT AKI (rAKI = post-LT renal recovery) versus no AKI (nAKI). This was followed by a larger validation set that included an additional group: irreversible pre-LT AKI (iAKI = no post-LT renal recovery). In the test group (n = 16), six pre-LT plasma (not urine) kidney injury proteins (osteopontin [OPN], neutrophil gelatinase-associated lipocalin, cystatin C, trefoil factor 3, tissue inhibitor of metalloproteinase [TIMP]-1, and β-2-microglobulin) were higher in rAKI versus nAKI (P < 0.05) and returned to normal values with renal recovery post-LT. In the validation set (n = 46), a number of proteins were significantly higher in both rAKI and iAKI versus nAKI. However, only pre-LT plasma OPN (P = 0.009) and TIMP-1 (P = 0.019) levels were significantly higher in rAKI versus iAKI. Logistic regression modeling was used to correlate the probability of post-LT rAKI, factoring in both pre-LT protein markers and clinical variables. A combined model including elevated OPN and TIMP-1 levels, age <57, and absence of diabetes had the highest area under the curve of 0.82, compared to protein-only and clinical variable-only models. CONCLUSION These data suggest that plasma protein profiles might improve the prediction of pre-LT kidney injury recovery after LT. However, multicenter, prospective studies are needed to validate these findings and ultimately test the value of such protein panels in perioperative management and decision making.
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Affiliation(s)
- Josh Levitsky
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL
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Rastrou MV, Li Y, Liu WM, Kurian SM, Gelbart T, Mondala T, Abecassis MM, Friedewald J, Salomon DR, Erlich HA, Holcomb CL. OR37. Hum Immunol 2014. [DOI: 10.1016/j.humimm.2014.08.040] [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: 10/24/2022]
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37
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Chang Y, Gallon L, Jay C, Shetty K, Ho B, Levitsky J, Baker T, Ladner D, Friedewald J, Abecassis M, Hazen G, Skaro AI. Comparative effectiveness of liver transplant strategies for end-stage liver disease patients on renal replacement therapy. Liver Transpl 2014; 20:1034-44. [PMID: 24777647 PMCID: PMC4146665 DOI: 10.1002/lt.23899] [Citation(s) in RCA: 15] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 04/09/2014] [Indexed: 01/12/2023]
Abstract
There are complex risk-benefit tradeoffs with different transplantation strategies for end-stage liver disease patients on renal support. Using a Markov discrete-time state transition model, we compared survival for this group with 3 strategies: simultaneous liver-kidney (SLK) transplantation, liver transplantation alone (LTA) followed by immediate kidney transplantation if renal function did not recover, and LTA followed by placement on the kidney transplant wait list. Patients were followed for 30 years from the age of 50 years. The probabilities of events were synthesized from population data and clinical trials according to Model for End-Stage Liver Disease (MELD) scores (21-30 and >30) to estimate input parameters. Sensitivity analyses tested the impact of uncertainty on survival. Overall, the highest survival rates were seen with SLK transplantation for both MELD score groups (82.8% for MELD scores of 21-30 and 82.5% for MELD scores > 30 at 1 year), albeit at the cost of using kidneys that might not be needed. Liver transplantation followed by kidney transplantation led to higher survival rates (77.3% and 76.4%, respectively, at 1 year) than placement on the kidney transplant wait list (75.1% and 74.3%, respectively, at 1 year). When uncertainty was considered, the results indicated that the waiting time and renal recovery affected conclusions about survival after SLK transplantation and liver transplantation, respectively. The subgroups with the longest durations of pretransplant renal replacement therapy and highest MELD scores had the largest absolute increases in survival with SLK transplantation versus sequential transplantation. In conclusion, the findings demonstrate the inherent tension in choices about the use of available kidneys and suggest that performing liver transplantation and using renal transplantation only for those who fail to recover their native renal function could free up available donor kidneys. These results could inform discussions about transplantation policy.
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Affiliation(s)
- Yaojen Chang
- Lombardi Comprehensive Cancer Center, Department of Oncology, Cancer Prevention and Control Program, Georgetown University School of Medicine, Washington, DC
| | - Lorenzo Gallon
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago IL
| | - Colleen Jay
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago IL
| | - Kirti Shetty
- Division of Gastroenterology & Hepatology, Sibley Memorial Hospital, Johns Hopkins Medicine, Washington, DC
| | - Bing Ho
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago IL
| | - Josh Levitsky
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago IL
| | - Talia Baker
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago IL
| | - Daniela Ladner
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago IL
| | - John Friedewald
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago IL
| | - Michael Abecassis
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago IL
| | - Gordon Hazen
- Department of Industrial Engineering and Management Sciences, Northwestern University, McCormick School of Engineering, Evanston IL
| | - Anton I. Skaro
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago IL
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Leventhal J, Mathew J, Salomon D, Kurian S, Friedewald J, Gallon L, Tambur A, Levitsky J, Kanwar Y, Abecassis M, Miller J. HLA Identical Renal Transplant Tolerance Using Donor Hematopoietic Stems Cells and Immunoregulation. Transplantation 2014. [DOI: 10.1097/00007890-201407151-00251] [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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Radhakrishnan S, Shah S, Haarberg K, Safdi A, Wegner W, Tambur A, Friedewald J. A Prospective Study Analyzing the Role of Donor-Specific Endothelial Cell Antibodies in Kidney Graft Outcome: A 3-Year Follow-Up. Transplantation 2014. [DOI: 10.1097/00007890-201407151-00805] [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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40
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Kurian SM, Williams AN, Gelbart T, Campbell D, Mondala TS, Head SR, Horvath S, Gaber L, Thompson R, Whisenant T, Lin W, Langfelder P, Robison EH, Schaffer RL, Fisher JS, Friedewald J, Flechner SM, Chan LK, Wiseman AC, Shidban H, Mendez R, Heilman R, Abecassis MM, Marsh CL, Salomon DR. Molecular classifiers for acute kidney transplant rejection in peripheral blood by whole genome gene expression profiling. Am J Transplant 2014; 14:1164-72. [PMID: 24725967 PMCID: PMC4439107 DOI: 10.1111/ajt.12671] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [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: 09/09/2013] [Revised: 12/30/2013] [Accepted: 01/15/2014] [Indexed: 01/25/2023]
Abstract
There are no minimally invasive diagnostic metrics for acute kidney transplant rejection (AR), especially in the setting of the common confounding diagnosis, acute dysfunction with no rejection (ADNR). Thus, though kidney transplant biopsies remain the gold standard, they are invasive, have substantial risks, sampling error issues and significant costs and are not suitable for serial monitoring. Global gene expression profiles of 148 peripheral blood samples from transplant patients with excellent function and normal histology (TX; n = 46), AR (n = 63) and ADNR (n = 39), from two independent cohorts were analyzed with DNA microarrays. We applied a new normalization tool, frozen robust multi-array analysis, particularly suitable for clinical diagnostics, multiple prediction tools to discover, refine and validate robust molecular classifiers and we tested a novel one-by-one analysis strategy to model the real clinical application of this test. Multiple three-way classifier tools identified 200 highest value probesets with sensitivity, specificity, positive predictive value, negative predictive value and area under the curve for the validation cohort ranging from 82% to 100%, 76% to 95%, 76% to 95%, 79% to 100%, 84% to 100% and 0.817 to 0.968, respectively. We conclude that peripheral blood gene expression profiling can be used as a minimally invasive tool to accurately reveal TX, AR and ADNR in the setting of acute kidney transplant dysfunction.
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Affiliation(s)
- S. M. Kurian
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| | - A. N. Williams
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| | - T. Gelbart
- DNA Array Core, The Scripps Research Institute, La Jolla, CA
| | - D. Campbell
- DNA Array Core, The Scripps Research Institute, La Jolla, CA
| | - T. S. Mondala
- DNA Array Core, The Scripps Research Institute, La Jolla, CA
| | - S. R. Head
- DNA Array Core, The Scripps Research Institute, La Jolla, CA
| | - S. Horvath
- Department of Biostatistics, University of California, Los Angeles, CA
| | - L. Gaber
- The Texas Medical Center, Houston, TX
| | - R. Thompson
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| | - T. Whisenant
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| | - W. Lin
- Department of Biostatistics, University of California, Los Angeles, CA
| | - P. Langfelder
- Department of Biostatistics, University of California, Los Angeles, CA
| | - E. H. Robison
- DNA Array Core, The Scripps Research Institute, La Jolla, CA
| | - R. L. Schaffer
- Scripps Center for Organ Transplantation, Scripps Health, La Jolla, CA
| | - J. S. Fisher
- Scripps Center for Organ Transplantation, Scripps Health, La Jolla, CA
| | - J. Friedewald
- Northwestern Comprehensive Transplant Center, Northwestern University, Chicago, IL
| | - S. M. Flechner
- Glickman Urological Institute, The Cleveland Clinic, Cleveland, OH
| | - L. K. Chan
- University of Colorado Hospital, Transplant Services, Aurora, CO
| | - A. C. Wiseman
- University of Colorado Hospital, Transplant Services, Aurora, CO
| | - H. Shidban
- St. Vincent Medical Center, Kidney Transplantation, Los Angeles, CA
| | - R. Mendez
- St. Vincent Medical Center, Kidney Transplantation, Los Angeles, CA
| | - R. Heilman
- Department of Medicine, Mayo Clinic Arizona and Mayo Clinic College of Medicine, Phoenix, AZ
| | - M. M. Abecassis
- Northwestern Comprehensive Transplant Center, Northwestern University, Chicago, IL
| | - C. L. Marsh
- Scripps Center for Organ Transplantation, Scripps Health, La Jolla, CA
| | - D. R. Salomon
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA,Scripps Center for Organ Transplantation, Scripps Health, La Jolla, CA,Corresponding author: Daniel R. Salomon,
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Suthanthiran M, Schwartz JE, Ding R, Abecassis M, Dadhania D, Samstein B, Knechtle SJ, Friedewald J, Becker YT, Sharma VK, Williams NM, Chang CS, Hoang C, Muthukumar T, August P, Keslar KS, Fairchild RL, Hricik DE, Heeger PS, Han L, Liu J, Riggs M, Ikle DN, Bridges ND, Shaked A. Urinary-cell mRNA profile and acute cellular rejection in kidney allografts. N Engl J Med 2013; 369:20-31. [PMID: 23822777 PMCID: PMC3786188 DOI: 10.1056/nejmoa1215555] [Citation(s) in RCA: 254] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The standard test for the diagnosis of acute rejection in kidney transplants is the renal biopsy. Noninvasive tests would be preferable. METHODS We prospectively collected 4300 urine specimens from 485 kidney-graft recipients from day 3 through month 12 after transplantation. Messenger RNA (mRNA) levels were measured in urinary cells and correlated with allograft-rejection status with the use of logistic regression. RESULTS A three-gene signature of 18S ribosomal (rRNA)-normalized measures of CD3ε mRNA and interferon-inducible protein 10 (IP-10) mRNA, and 18S rRNA discriminated between biopsy specimens showing acute cellular rejection and those not showing rejection (area under the curve [AUC], 0.85; 95% confidence interval [CI], 0.78 to 0.91; P<0.001 by receiver-operating-characteristic curve analysis). The cross-validation estimate of the AUC was 0.83 by bootstrap resampling, and the Hosmer-Lemeshow test indicated good fit (P=0.77). In an external-validation data set, the AUC was 0.74 (95% CI, 0.61 to 0.86; P<0.001) and did not differ significantly from the AUC in our primary data set (P=0.13). The signature distinguished acute cellular rejection from acute antibody-mediated rejection and borderline rejection (AUC, 0.78; 95% CI, 0.68 to 0.89; P<0.001). It also distinguished patients who received anti-interleukin-2 receptor antibodies from those who received T-cell-depleting antibodies (P<0.001) and was diagnostic of acute cellular rejection in both groups. Urinary tract infection did not affect the signature (P=0.69). The average trajectory of the signature in repeated urine samples remained below the diagnostic threshold for acute cellular rejection in the group of patients with no rejection, but in the group with rejection, there was a sharp rise during the weeks before the biopsy showing rejection (P<0.001). CONCLUSIONS A molecular signature of CD3ε mRNA, IP-10 mRNA, and 18S rRNA levels in urinary cells appears to be diagnostic and prognostic of acute cellular rejection in kidney allografts. (Funded by the National Institutes of Health and others.).
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Leventhal JR, Mathew JM, Salomon DR, Kurian SM, Suthanthiran M, Tambur A, Friedewald J, Gallon L, Charette J, Levitsky J, Kanwar Y, Abecassis M, Miller J. Genomic biomarkers correlate with HLA-identical renal transplant tolerance. J Am Soc Nephrol 2013; 24:1376-85. [PMID: 23787913 DOI: 10.1681/asn.2013010068] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
The ability to achieve immunologic tolerance after transplantation is a therapeutic goal. Here, we report interim results from an ongoing trial of tolerance in HLA-identical sibling renal transplantation. The immunosuppressive regimen included alemtuzumab induction, donor hematopoietic stem cells, tacrolimus/mycophenolate immunosuppression converted to sirolimus, and complete drug withdrawal by 24 months post-transplantation. Recipients were considered tolerant if they had normal biopsies and renal function after an additional 12 months without immunosuppression. Of the 20 recipients enrolled, 10 had at least 36 months of follow-up after transplantation. Five of these 10 recipients had immunosuppression successfully withdrawn for 16-36 months (tolerant), 2 had disease recurrence, and 3 had subclinical rejection in protocol biopsies (nontolerant). Microchimerism disappeared after 1 year, and CD4(+)CD25(high)CD127(-)FOXP3(+) regulatory T cells and CD19(+)IgD/M(+)CD27(-) B cells were increased through 5 years post-transplantation in both tolerant and nontolerant recipients. Immune/inflammatory gene expression pathways in the peripheral blood and urine, however, were differentially downregulated between tolerant and nontolerant recipients. In summary, interim results from this trial of tolerance in HLA-identical renal transplantation suggest that predictive genomic biomarkers, but not immunoregulatory phenotyping, may be able to discriminate tolerant from nontolerant patients.
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Affiliation(s)
- Joseph R Leventhal
- Comprehensive Transplant Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Theodoropoulos N, Wang E, Penugonda S, Ladner DP, Stosor V, Leventhal J, Friedewald J, Angarone MP, Ison MG. BK virus replication and nephropathy after alemtuzumab-induced kidney transplantation. Am J Transplant 2013; 13:197-206. [PMID: 23136975 DOI: 10.1111/j.1600-6143.2012.04314.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 09/21/2012] [Accepted: 09/21/2012] [Indexed: 01/25/2023]
Abstract
BK virus nephropathy (BKVN) is a recognized cause of graft failure in kidney transplant recipients. There are limited data on the epidemiology of BK virus (BKV) infection after alemtuzumab induction. By clinical protocol, the kidney transplant recipients at our center were screened with BKV plasma PCR monthly for the first 4 months posttransplant then every 2-3 months for 2 years. A single center retrospective cohort study of all kidney transplant recipients from January 2008 to August 2010 was conducted to determine incidence and outcomes of BKV infection. Descriptive statistics and Kaplan-Meier analysis was performed. Of 666 recipients, 250 (37.5%) developed viruria, 80 (12%) developed viremia and 31 (4.7%) developed BKVN at a median of 17, 21 and 30 weeks, respectively. Induction with alemtuzumab did not significantly affect incidence of BKVN. Increased recipient age, African American race, acute graft rejection and CMV infection were significantly associated with the development of BKVN in multivariate analysis. The incidence of BK viruria, viremia and nephropathy was not significantly different among kidney transplant recipients who received alemtuzumab induction compared to patients receiving less potent induction.
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Affiliation(s)
- N Theodoropoulos
- Division of Infectious Diseases, The Ohio State University College of Medicine, Columbus, USA
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44
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Leventhal JR, Mathew JM, Ildstad S, Salomon DR, Kurian SM, Suthanthiran M, Tambur A, Friedewald J, Gallon L, Charette J, Levitsky J, Kanwar Y, Abecassis M, Miller J. HLA identical non-chimeric and HLA disparate chimeric renal transplant tolerance. Clin Transpl 2013:145-156. [PMID: 25095503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
In this chapter, we describe studies on non-chimeric human leukocyte antigen (HLA) identical tolerance and chimeric HLA disparate tolerance brought about by infusions of hematopoietic stem cells from the renal donor (DHSC). In our HLA identical series, 4 DHSC infusions were administered during the first 9 months posttransplant in a highly immunoregulatory environment using alemtuzumab induction and rapid conversion from early tacrolimus to mycophenolate and sirolimus. This resulted in the generation of recipient T regulatory cells accompanied by genomic indicators, but only transient chimerism. Seven of the first 12 recipients have been immunosuppression-free between 1 1/2 - 4 years with transplant biopsies free of rejection one year after immunosuppression withdrawal. The HLAdisparate group was treated by non-myeloablative conditioning consisting of: 200cGy whole body irradiation; fludarabine; cyclophosphamide; and, perioperative infusion of a product termed FCRx that contained DHSC, T cells, and a unique fraction of bone marrow derived CD8+TCR-alphabeta-negative cells. Five of the first 8 subjects became 100% chimeric in the peripheral blood and have been immunosuppression-free for 2 to 4 years without graft-versus-host-disease and with normal function and transplant biopsies. An additional 12 recipients with shorter follow-up have had similar courses. Those with non-durable chimerism have not been able to have immunosuppression withdrawn but maintain normal renal transplant function. We conclude that non-HLA disparities in renal transplants between HLA identical pairs may not need durable chimerism to induce tolerance provided by DHSC and temporary immunosuppression supporting the development of regulatory T cells. However, more intense conditioning and infusion of FCRx leading to durable chimerism in the absence of graft versus host disease is necessary to induce tolerance in HLA disparate pairs.
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45
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Levitsky J, Baker T, Ahya SN, Levin ML, Friedewald J, Gallon L, Ho B, Skaro A, Krupp J, Wang E, Spies SM, Salomon DR, Abecassis MM. Outcomes and native renal recovery following simultaneous liver-kidney transplantation. Am J Transplant 2012; 12:2949-57. [PMID: 22759344 DOI: 10.1111/j.1600-6143.2012.04182.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
With the increase in patients having impaired renal function at liver transplant due to MELD, accurate predictors of posttransplant native renal recovery are needed to select candidates for simultaneous liver-kidney transplantation (SLK). Current UNOS guidelines rely on specific clinical criteria for SLK allocation. To examine these guidelines and other variables predicting nonrecovery, we analyzed 155 SLK recipients, focusing on a subset (n = 78) that had post-SLK native GFR (nGFR) determined by radionuclide renal scans. The 77 patients not having renal scans received a higher number of extended criteria donor organs and had worse posttransplant survival. Of the 78 renal scan patients, 31 met and 47 did not meet pre-SLK UNOS criteria. The UNOS criteria were more predictive than our institutional criteria for all nGFR recovery thresholds (20-40 mL/min), although at the most conservative cut-off (nGFR ≤ 20) it had low sensitivity (55.3%), specificity (75%), PPV (67.6%) and NPV (63.8%) for predicting post-SLK nonrecovery. On multivariate analysis, the only predictor of native renal nonrecovery (nGFR ≤ 20) was abnormal pre-SLK renal imaging (OR 3.85, CI 1.22-12.5). Our data support the need to refine SLK selection utilizing more definitive biomarkers and predictors of native renal recovery than current clinical criteria.
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Affiliation(s)
- J Levitsky
- Comprehensive Transplant Center, Northwestern University, Chicago, IL, USA.
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46
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Abecassis M, Bridges N, Clancy C, Dew M, Eldadah B, Englesbe M, Flessner M, Frank J, Friedewald J, Gill J, Gries C, Halter J, Hartmann E, Hazzard W, Horne F, Hosenpud J, Jacobson P, Kasiske B, Lake J, Loomba R, Malani P, Moore T, Murray A, Nguyen MH, Powe N, Reese P, Reynolds H, Samaniego M, Schmader K, Segev D, Shah A, Singer L, Sosa J, Stewart Z, Tan J, Williams W, Zaas D, High K. Solid-organ transplantation in older adults: current status and future research. Am J Transplant 2012; 12:2608-22. [PMID: 22958872 PMCID: PMC3459231 DOI: 10.1111/j.1600-6143.2012.04245.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
An increasing number of patients older than 65 years are referred for and have access to organ transplantation, and an increasing number of older adults are donating organs. Although short-term outcomes are similar in older versus younger transplant recipients, older donor or recipient age is associated with inferior long-term outcomes. However, age is often a proxy for other factors that might predict poor outcomes more strongly and better identify patients at risk for adverse events. Approaches to transplantation in older adults vary across programs, but despite recent gains in access and the increased use of marginal organs, older patients remain less likely than other groups to receive a transplant, and those who do are highly selected. Moreover, few studies have addressed geriatric issues in transplant patient selection or management, or the implications on health span and disability when patients age to late life with a transplanted organ. This paper summarizes a recent trans-disciplinary workshop held by ASP, in collaboration with NHLBI, NIA, NIAID, NIDDK and AGS, to address issues related to kidney, liver, lung, or heart transplantation in older adults and to propose a research agenda in these areas.
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Affiliation(s)
- M. Abecassis
- Departments of Surgery and Microbiology-Immunology, Northwestern University Feinberg School of Medicine
| | - N.D. Bridges
- Transplantation Immunobiology Branch and Clinical Transplantation Section, National Institute of Allergy and Infectious Diseases
| | | | - M.A. Dew
- Department of Psychiatry, University of Pittsburgh
| | - B. Eldadah
- Division of Geriatrics and Clinical Gerontology, National Institute on Aging
| | - M.J. Englesbe
- Division of Transplantation, Department of Surgery, University of Michigan Medical School
| | - M.F. Flessner
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases
| | - J.C. Frank
- Geffen School of Medicine at the University of California, Los Angeles
| | - J. Friedewald
- Departments of Medicine and Surgery, Northwestern University
| | - J Gill
- Division of Nephrology, University of British Columbia
| | - C. Gries
- University of Pittsburgh School of Medicine
| | - J.B. Halter
- Division of Geriatric and Palliative Medicine, University of Michigan Medical School
| | | | - W.R. Hazzard
- Division of Gerontology and Geriatric Medicine, University of Washington, VA Puget Sound Health Care System
| | | | | | - P. Jacobson
- Department of Experimental and Clinical Pharmacology, University of Minnesota
| | | | - J. Lake
- Liver Transplant Program, University of Minnesota
| | - R. Loomba
- University of California, San Diego School of Medicine
| | - P.N. Malani
- Department of Internal Medicine, University of Michigan Medical School
| | - T.M. Moore
- National Heart, Lung, and Blood Institute
| | - A. Murray
- Division of Geriatrics, University of Minnesota
| | | | - N.R. Powe
- University of California, San Francisco
| | | | | | | | - K.E. Schmader
- GRECC, Durham VA Medical Center and Division of Geriatric Medicine, Duke University School of Medicine
| | - D.L. Segev
- Division of Transplant Surgery, Johns Hopkins University School of Medicine
| | - A.S. Shah
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine
| | - L.G. Singer
- Toronto Lung Transplant Program, University of Toronto
| | - J.A. Sosa
- Divisions of Endocrine Surgery and Surgical Oncology, Department of Surgery, Yale University School of Medicine
| | | | - J.C. Tan
- Adult Kidney and Pancreas Transplant Program, Stanford University
| | - W.W. Williams
- Harvard University and Massachusetts General Hospital
| | - D.W. Zaas
- Department of Medicine, Duke University School of Medicine
| | - K.P. High
- Wake Forest School of Medicine,To Whom Correspondence Should be Sent: Kevin P. High, M.D., M.S., Professor of Medicine and Translational Science, Chief, Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC 27157-1042, Phone: (336) 716-4584, Fax: (336) 716-3825,
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Vincenti F, Tedesco Silva H, Busque S, O'Connell P, Friedewald J, Cibrik D, Budde K, Yoshida A, Cohney S, Weimar W, Kim YS, Lawendy N, Lan SP, Kudlacz E, Krishnaswami S, Chan G. Randomized phase 2b trial of tofacitinib (CP-690,550) in de novo kidney transplant patients: efficacy, renal function and safety at 1 year. Am J Transplant 2012; 12:2446-56. [PMID: 22682022 DOI: 10.1111/j.1600-6143.2012.04127.x] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [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
In this Phase 2b study, 331 low-to-moderate risk de novo kidney transplant patients (approximately 60% deceased donors) were randomized to a more intensive (MI) or less intensive (LI) regimen of tofacitinib (CP-690, 550), an oral Janus kinase inhibitor or cyclosporine (CsA). All patients received basiliximab induction, mycophenolic acid and corticosteroids. Primary endpoints were: incidence of biopsy-proven acute rejection (BPAR) with a serum creatinine increase of ≥0.3 mg/dL and ≥20% (clinical BPAR) at Month 6 and measured GFR at Month 12. Similar 6-month incidences of clinical BPAR (11%, 7% and 9%) were observed for MI, LI and CsA. Measured GFRs were higher (p < 0.01) at Month 12 for MI and LI versus CsA (65 mL/min, 65 mL/min vs. 54 mL/min). Fewer (p < 0.05) patients in MI or LI developed chronic allograft nephropathy at Month 12 compared with CsA (25%, 24% vs. 48%). Serious infections developed in 45%, 37% and 25% of patients in MI, LI and CsA, respectively. Anemia, neutropenia and posttransplant lymphoproliferative disorder occurred more frequently in MI and LI compared with CsA. Tofacitinib was equivalent to CsA in preventing acute rejection, was associated with improved renal function and less chronic allograft histological injury, but had side-effects at the doses evaluated.
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Affiliation(s)
- F Vincenti
- University of California, San Francisco, USA.
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48
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Skaro A, Wang E, Lyuksemburg V, Moges Y, Moklyak M, Schieler A, Ladner D, Friedewald J, Abecassis M, Gallon L. Trends in Immunologic Risk Among Kidney Transplant Recipients in the United States. J Surg Res 2012. [DOI: 10.1016/j.jss.2011.11.397] [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: 10/14/2022]
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50
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Gordon EJ, Reddy E, Ladner DP, Friedewald J, Abecassis MM, Ison MG. Kidney transplant candidates’ understanding of increased risk donor kidneys: a qualitative study. Clin Transplant 2011; 26:359-68. [DOI: 10.1111/j.1399-0012.2011.01536.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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