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Cullinan DR, Ahmed O, Scalea JR, Chapman WC. An Evolution of Organ Allocation: Principles, Processes, and Innovations (Con). Transplantation 2023; 107:2302-2310. [PMID: 37644653 DOI: 10.1097/tp.0000000000004513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Affiliation(s)
- Darren R Cullinan
- Department of Surgery, Division of Abdominal Transplantation, Washington University School of Medicine, St. Louis, MO
| | - Ola Ahmed
- Department of Surgery, Division of Abdominal Transplantation, Washington University School of Medicine, St. Louis, MO
| | - Joseph R Scalea
- Department of Surgery, Division of Transplantation, Medical University of South Carolina, SC
| | - William C Chapman
- Department of Surgery, Division of Abdominal Transplantation, Washington University School of Medicine, St. Louis, MO
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Lee YS, Cheng IT, Raquel GR, Weber DJ, Scalea JR. Initial exploration of a novel fusion protein, IL-4/IL-34/IL-10, which promotes cardiac allograft survival mice through alloregulation. Innate Immun 2023; 29:150-158. [PMID: 37800911 PMCID: PMC10559875 DOI: 10.1177/17534259231186239] [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: 09/16/2022] [Revised: 05/24/2023] [Accepted: 06/14/2023] [Indexed: 10/07/2023] Open
Abstract
Immune mediated graft loss still represents a major risk to transplant recipients. Creative approaches to immunosuppression that exploit the recipient's own alloregulatory mechanisms could reduce the need for pharmacologic immunosuppression and potentially induce immune tolerance. In the process of studying recipient derived myeloid derived suppressor cells (MDSCs), we identified key alloregulatory MDSC mechanisms, mediated by isolatable proteins IL-4, IL-34, and IL-10. We sought to purify these proteins and fuse them for subsequent infusion into transplant recipients as a means of inducing an alloregulatory response. In this introductory investigation, we leveraged molecular engineering technology to create a fusion protein (FP) of three cytokine coding sequences of IL-4, IL-34, and IL-10 and demonstrated their expressions by Western Blot analysis. Following purification, we tested whether FP IL-4/IL-34/IL-10 (FP1) can protect heart transplant allografts. Injection of FP1 significantly prolonged allogeneic cardiac graft survival in a dose-dependent fashion and the increase of graft survival time exceeded survival attributable to IL-34 alone. In vitro, MDSCs cells were expanded by FP1 treatment. However, FP1 did not directly inhibit T cell proliferation in vitro. In conclusion, newly developed FP1 improves the graft survival in cardiac transplantation mouse model. Significant additional work to optimize FP1 or include other novel proteins could supplement current treatment options for transplant patients.
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Affiliation(s)
- Young S. Lee
- Department of Surgery, University of Maryland School of Medicine, Baltimore, USA
- Center for Vascular and Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, USA
| | - I-Ting Cheng
- Department of Biochemistry and Molecular Biology, University of Maryland School of Medicine, Baltimore, USA
- Institute for Bioscience and Biotechnology Research, Rockville, USA
- The Center for Biomolecular Therapeutics, University of Maryland School of Medicine, Baltimore, USA
| | - Godoy-Ruiz Raquel
- Department of Biochemistry and Molecular Biology, University of Maryland School of Medicine, Baltimore, USA
- Institute for Bioscience and Biotechnology Research, Rockville, USA
- The Center for Biomolecular Therapeutics, University of Maryland School of Medicine, Baltimore, USA
| | - David J. Weber
- Department of Biochemistry and Molecular Biology, University of Maryland School of Medicine, Baltimore, USA
- Institute for Bioscience and Biotechnology Research, Rockville, USA
- The Center for Biomolecular Therapeutics, University of Maryland School of Medicine, Baltimore, USA
| | - Joseph R. Scalea
- Medical University of South Carolina, Department of Surgery and Immunology, Charleston, SC, USA
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Kwon JH, Blanding WM, Shorbaji K, Scalea JR, Gibney BC, Baliga PK, Kilic A. Waitlist and Transplant Outcomes in Organ Donation After Circulatory Death: Trends in the United States. Ann Surg 2023; 278:609-620. [PMID: 37334722 DOI: 10.1097/sla.0000000000005947] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
OBJECTIVES To summarize waitlist and transplant outcomes in kidney, liver, lung, and heart transplantation using organ donation after circulatory death (DCD). BACKGROUND DCD has expanded the donor pool for solid organ transplantation, most recently for heart transplantation. METHODS The United Network for Organ Sharing registry was used to identify adult transplant candidates and recipients in the most recent allocation policy eras for kidney, liver, lung, and heart transplantation. Transplant candidates and recipients were grouped by acceptance criteria for DCD versus brain-dead donors [donation after brain death (DBD)] only and DCD versus DBD transplant, respectively. Propensity matching and competing-risks regression was used to model waitlist outcomes. Survival was modeled using propensity matching and Kaplan-Meier and Cox regression analysis. RESULTS DCD transplant volumes have increased significantly across all organs. Liver candidates listed for DCD organs were more likely to undergo transplantation compared with propensity-matched candidates listed for DBD only, and heart and liver transplant candidates listed for DCD were less likely to experience death or clinical deterioration requiring waitlist inactivation. Propensity-matched DCD recipients demonstrated an increased mortality risk up to 5 years after liver and kidney transplantation and up to 3 years after lung transplantation compared with DBD. There was no difference in 1-year mortality between DCD and DBD heart transplantation. CONCLUSIONS DCD continues to expand access to transplantation and improves waitlist outcomes for liver and heart transplant candidates. Despite an increased risk for mortality with DCD kidney, liver, and lung transplantation, survival with DCD transplant remains acceptable.
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Affiliation(s)
- Jennie H Kwon
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Walker M Blanding
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Khaled Shorbaji
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Joseph R Scalea
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC
| | - Barry C Gibney
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Prabhakar K Baliga
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
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Taber DJ, Su Z, Gebregziabher M, Mauldin PD, Morinelli TA, Mahmood AO, Magwood GS, Casey MJ, Scalea JR, Kavarana SM, Baliga PK, Rodrigue JR, DuBay DA. Multilevel Intervention to Improve Racial Equity in Access to Kidney Transplant. J Am Coll Surg 2023; 236:721-727. [PMID: 36728400 DOI: 10.1097/xcs.0000000000000542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND African Americans (AAs) have reduced access to kidney transplant (KTX). Our center undertook a multilevel quality improvement endeavor to address KTX access barriers, focused on vulnerable populations. This program included dialysis center patient/staff education, embedding telehealth services across South Carolina, partnering with community providers to facilitate testing/procedures, and increased use of high-risk donors. STUDY DESIGN This was a time series analysis from 2017 to 2021 using autoregression to assess trends in equitable access to KTX for AAs. Equity was measured using a modified version of the Kidney Transplant Equity Index (KTEI), defined as the proportion of AAs in South Carolina with end-stage kidney disease (ESKD) vs the proportion of AAs initiating evaluation, completing evaluation, waitlisting, and undergoing KTX. A KTEI of 1.00 is considered complete equity; a KTEI of <1.00 is indicative of disparity. RESULTS From January 2017 to September 2021, 11,487 ESKD patients (64.7% AA) were referred, 6,748 initiated an evaluation (62.8% AA), 4,109 completed evaluation (59.7% AA), 2,762 were waitlisted (60.0% AA), and 1,229 underwent KTX (55.3% AA). The KTEI for KTX demonstrated significant improvements in equity. The KTEI for initiated evaluations was 0.89 in 2017, improving to 1.00 in 2021 (p = 0.0045). Completed evaluation KTEI improved from 0.85 to 0.95 (p = 0.0230), while waitlist addition KTEI improved from 0.83 to 0.96 (p = 0.0072). The KTEI for KTX also improved from 0.76 to 0.91, which did not reach statistical significance (p = 0.0657). CONCLUSIONS A multilevel intervention focused on improving access to vulnerable populations was significantly associated with reduced disparities for AAs.
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Affiliation(s)
- David J Taber
- From the Medical University of South Carolina, Division of Transplant Surgery (Taber, Morinelli, Mahmood, Scalea, Kavarana, Baliga, DuBay), Charleston, SC
| | - Zemin Su
- Division of General Internal Medicine and Geriatrics (Su, Mauldin), Charleston, SC
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, College of Medicine (Gebregziabher), Charleston, SC
| | - Patrick D Mauldin
- Division of General Internal Medicine and Geriatrics (Su, Mauldin), Charleston, SC
| | - Thomas A Morinelli
- From the Medical University of South Carolina, Division of Transplant Surgery (Taber, Morinelli, Mahmood, Scalea, Kavarana, Baliga, DuBay), Charleston, SC
| | - Ammar O Mahmood
- From the Medical University of South Carolina, Division of Transplant Surgery (Taber, Morinelli, Mahmood, Scalea, Kavarana, Baliga, DuBay), Charleston, SC
| | - Gayenell S Magwood
- the University of South Carolina, College of Nursing, Columbia, SC (Magwood)
| | | | - Joseph R Scalea
- From the Medical University of South Carolina, Division of Transplant Surgery (Taber, Morinelli, Mahmood, Scalea, Kavarana, Baliga, DuBay), Charleston, SC
| | - Sam M Kavarana
- From the Medical University of South Carolina, Division of Transplant Surgery (Taber, Morinelli, Mahmood, Scalea, Kavarana, Baliga, DuBay), Charleston, SC
| | - Prabhakar K Baliga
- From the Medical University of South Carolina, Division of Transplant Surgery (Taber, Morinelli, Mahmood, Scalea, Kavarana, Baliga, DuBay), Charleston, SC
| | - James R Rodrigue
- the Beth Israel Deaconess Medical Center, Department of Surgery, Boston, MA (Rodrigue)
| | - Derek A DuBay
- From the Medical University of South Carolina, Division of Transplant Surgery (Taber, Morinelli, Mahmood, Scalea, Kavarana, Baliga, DuBay), Charleston, SC
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Yoo A, Riedel A, Qian I, Bartosic A, Soltani R, Kibria G, Haririan A, Drachenberg CB, Abrams PL, Odorico JS, Cooper M, Bromberg JS, Scalea JR. An Initial Analysis of the Baseline Levels of Dd-cfDNA After Pancreas Transplantation: A Prospective Study From High-volume Centers in the United States. Transplant Direct 2023; 9:e1459. [PMID: 36935870 PMCID: PMC10019258 DOI: 10.1097/txd.0000000000001459] [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: 09/16/2022] [Revised: 01/19/2023] [Accepted: 01/22/2023] [Indexed: 03/17/2023] Open
Abstract
Pancreas transplantation offers patients with diabetes an opportunity for glucose homeostasis. Current blood tests to surveil for rejection have poor sensitivity and specificity for identifying rejection, and pancreas biopsies are challenging and associated with morbidity and graft loss. Donor-derived cell-free DNA (dd-cfDNA) is shed from transplanted organs and detectable in peripheral blood. Thus, a potential dd-cfDNA blood test assessing rejection would be clinically advantageous. Methods One hundred eighty-one dd-cfDNA samples (n) were collected from 77 patients (N) up to 132 mo posttransplant. Results The median dd-cfDNA level among all subjects was 0.28% (0.13%, 0.71%). In simultaneous pancreas-kidney (SPK) transplant recipients, the median dd-cfDNA level was 0.29% (0.13%, 0.71%), and it was 0.23% (0.08%, 0.71%) in pancreas transplant alone (PTA) recipients. When isolating for when without infection or rejection, the median dd-cfDNA level was 0.28% (0.13%, 0.64%) for SPK and 0.20% (0.00%, 0.32%) for PTA. Both transplant types approached 1.0% ≤1 mo posttransplant followed by a decrease in median dd-cfDNA. During episodes of rejection or infection, median dd-cfDNA levels were greater among all transplant types. Conclusions The mean dd-cfDNA level for all pancreas transplant recipients is <1.0%, consistent with the published kidney transplant rejection threshold (>1.0%), regardless of SPK or PTA. Early posttransplant dd-cfDNA levels are transiently higher than later measurements. Dd-cfDNA elevation also correlates with rejection and infection and thus is a promising biomarker for surveilling pancreas transplant dysfunction.
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Affiliation(s)
- Ashley Yoo
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Alexandria Riedel
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Ian Qian
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Amanda Bartosic
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Rudi Soltani
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Gulam Kibria
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Abdolreza Haririan
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Cinthia B. Drachenberg
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | | | - Jon S. Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Jonathan S. Bromberg
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Joseph R. Scalea
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
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Lee YS, Gavzy SJ, Jang J, Kamberi S, Zhang T, Sands L, Scalea JR. Transport-Associated Vibrational Stress Triggers Drug-Reversible Apoptosis and Cardiac Allograft Failure in Mice. IEEE J Transl Eng Health Med 2023; 11:145-150. [PMID: 36816099 PMCID: PMC9904449 DOI: 10.1109/jtehm.2023.3239790] [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] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/14/2023] [Accepted: 01/18/2023] [Indexed: 01/26/2023]
Abstract
Increasingly complex and long-range donor organ allocation routes coupled with implementation of unmanned aerial vehicles (UAVs) have prompted investigations of the conditions affecting organs once packaged for shipment. Our group has previously demonstrated that different modes of organ transport exert unique environmental stressors, in particular vibration. Using a mouse heart transplant model, we demonstrated that vibrational forces exert tangible, cellular effects in the form of cardiomyocyte apoptosis and cytoskeletal derangement. Functionally, these changes translated into accelerated allograft loss. Notably, administration of an apoptosis inhibitor, Z-VAD-FMK, helped to ameliorate the detrimental cellular and functional effects of mechanical vibration in a dose-dependent manner. These findings constitute one of the first reports of the negative impact of transit environment on transplant outcomes, a contributing mechanism underpinning this effect, and a potential agent to prophylax against this process. Given current limitations in measuring donor organ transit environments in situ, further study is required to better characterize the impact of transport environment and to potentially improve the care of donor organs during shipment. Clinical and Translational Impact Statement: We show that apoptosis inhibitor, Z-VAD-FMK, ameliorated transport-related vibrational stress in murine heart transplants, which presents a potential therapeutic or preservation solution additive for future use in transporting donor organs.
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Affiliation(s)
- Young S. Lee
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMD21201USA
- Center for Vascular and Inflammatory DiseasesUniversity of Maryland School of MedicineBaltimoreMD21201USA
| | - Samuel J. Gavzy
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMD21201USA
- Center for Vascular and Inflammatory DiseasesUniversity of Maryland School of MedicineBaltimoreMD21201USA
| | - Jihyun Jang
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMD21201USA
- Center for Vascular and Inflammatory DiseasesUniversity of Maryland School of MedicineBaltimoreMD21201USA
| | - Shani Kamberi
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMD21201USA
| | - Tianshu Zhang
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMD21201USA
- Center for Vascular and Inflammatory DiseasesUniversity of Maryland School of MedicineBaltimoreMD21201USA
| | - Lauren Sands
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMD21201USA
| | - Joseph R. Scalea
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMD21201USA
- Center for Vascular and Inflammatory DiseasesUniversity of Maryland School of MedicineBaltimoreMD21201USA
- Department of Microbiology and ImmunologyUniversity of Maryland School of MedicineBaltimoreMD21201USA
- Department of SurgeryMedical University of South CarolinaCharlestonSC29425USA
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Lin MS, Carrier A, Toursavadkohi S, Meier RPH, Sarkar R, Bromberg J, Cox SR, Scalea JR. Can remote endarterectomy expand access to kidney transplantation in patients with severe iliac calcification? Am J Transplant 2023; 23:108-110. [PMID: 36148600 DOI: 10.1111/ajt.17200] [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: 04/03/2022] [Revised: 09/14/2022] [Accepted: 09/17/2022] [Indexed: 02/04/2023]
Abstract
Severe iliac artery calcification in patients with end-stage renal disease is a common barrier to listing for kidney transplant. While few surgical solutions to iliac calcification have been reported, improving treatment may thus improve access to transplant care. Here we present two cases of a novel application of remote endarterectomy of the external iliac artery to facilitate listing for renal transplant. Both patients were listed following remote endarterectomy, followed by successful renal transplants using the treated vessels.
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Affiliation(s)
- Mary S Lin
- University of Maryland Medical Center, Baltimore, Maryland, USA.
| | - Amber Carrier
- University of Maryland Medical Center, Baltimore, Maryland, USA
| | | | | | | | | | - Samantha R Cox
- University of South Carolina School of Medicine, Columbia, South Carolina, USA
| | - Joseph R Scalea
- University of Maryland Medical Center, Baltimore, Maryland, USA
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Strauss AT, Sidoti CN, Purnell TS, Sung HC, Jackson JW, Levin S, Jain VS, Malinsky D, Segev DL, Hamilton JP, Garonzik‐Wang J, Gray SH, Levan ML, Scalea JR, Cameron AM, Gurakar A, Gurses AP. Multicenter study of racial and ethnic inequities in liver transplantation evaluation: Understanding mechanisms and identifying solutions. Liver Transpl 2022; 28:1841-1856. [PMID: 35726679 PMCID: PMC9796377 DOI: 10.1002/lt.26532] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/15/2022] [Accepted: 06/06/2022] [Indexed: 01/02/2023]
Abstract
Racial and ethnic disparities persist in access to the liver transplantation (LT) waiting list; however, there is limited knowledge about underlying system-level factors that may be responsible for these disparities. Given the complex nature of LT candidate evaluation, a human factors and systems engineering approach may provide insights. We recruited participants from the LT teams (coordinators, advanced practice providers, physicians, social workers, dieticians, pharmacists, leadership) at two major LT centers. From December 2020 to July 2021, we performed ethnographic observations (participant-patient appointments, committee meetings) and semistructured interviews (N = 54 interviews, 49 observation hours). Based on findings from this multicenter, multimethod qualitative study combined with the Systems Engineering Initiative for Patient Safety 2.0 (a human factors and systems engineering model for health care), we created a conceptual framework describing how transplant work system characteristics and other external factors may improve equity in the LT evaluation process. Participant perceptions about listing disparities described external factors (e.g., structural racism, ambiguous national guidelines, national quality metrics) that permeate the LT evaluation process. Mechanisms identified included minimal transplant team diversity, implicit bias, and interpersonal racism. A lack of resources was a common theme, such as social workers, transportation assistance, non-English-language materials, and time (e.g., more time for education for patients with health literacy concerns). Because of the minimal data collection or center feedback about disparities, participants felt uncomfortable with and unadaptable to unwanted outcomes, which perpetuate disparities. We proposed transplant center-level solutions (i.e., including but not limited to training of staff on health equity) to modifiable barriers in the clinical work system that could help patient navigation, reduce disparities, and improve access to care. Our findings call for an urgent need for transplant centers, national societies, and policy makers to focus efforts on improving equity (tailored, patient-centered resources) using the science of human factors and systems engineering.
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Affiliation(s)
- Alexandra T. Strauss
- Department of MedicineSchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA,Malone Center for Engineering in HealthcareWhiting School of Engineering, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Carolyn N. Sidoti
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Tanjala S. Purnell
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA,Department of EpidemiologyBloomberg School of Public, Health Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Hannah C. Sung
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - John W. Jackson
- Department of EpidemiologyBloomberg School of Public, Health Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Scott Levin
- Malone Center for Engineering in HealthcareWhiting School of Engineering, Johns Hopkins UniversityBaltimoreMarylandUSA,Department of Emergency MedicineSchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Vedant S. Jain
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Daniel Malinsky
- Department of BiostatisticsColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | - Dorry L. Segev
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA,Department of EpidemiologyBloomberg School of Public, Health Johns Hopkins UniversityBaltimoreMarylandUSA
| | - James P. Hamilton
- Department of MedicineSchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | | | - Stephen H. Gray
- Department of SurgerySchool of Medicine, University of MarylandBaltimoreMarylandUSA
| | - Macey L. Levan
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Joseph R. Scalea
- Department of SurgerySchool of Medicine, University of MarylandBaltimoreMarylandUSA
| | - Andrew M. Cameron
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Ahmet Gurakar
- Department of MedicineSchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Ayse P. Gurses
- Department of Emergency MedicineSchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA,Center for Health Care Human FactorsArmstrong Institute for Patient Safety and Quality, Johns Hopkins MedicineBaltimoreMarylandUSA,Anesthesiology and Critical Care Medicine, Biomedical Informatics and Data Science (General Internal Medicine)School of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA,Department of Health Policy and ManagementBloomberg School of Public Health, Johns Hopkins UniversityBaltimoreMarylandUSA
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Goussous N, Talaie T, St. Michel DP, Mcdade H, Gaines S, Borth A, Dawany N, Xie W, Scalea JR. Readmission After Pancreas Transplantation: Timing of Surgery Matters. EXP CLIN TRANSPLANT 2022; 20:77-82. [DOI: 10.6002/ect.2021.0319] [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: 11/05/2022]
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10
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Boggi U, Vistoli F, Andres A, Arbogast HP, Badet L, Baronti W, Bartlett ST, Benedetti E, Branchereau J, Burke GW, Buron F, Caldara R, Cardillo M, Casanova D, Cipriani F, Cooper M, Cupisti A, Davide J, Drachenberg C, de Koning EJP, Ettorre GM, Fernandez Cruz L, Fridell JA, Friend PJ, Furian L, Gaber OA, Gruessner AC, Gruessner RW, Gunton JE, Han D, Iacopi S, Kauffmann EF, Kaufman D, Kenmochi T, Khambalia HA, Lai Q, Langer RM, Maffi P, Marselli L, Menichetti F, Miccoli M, Mittal S, Morelon E, Napoli N, Neri F, Oberholzer J, Odorico JS, Öllinger R, Oniscu G, Orlando G, Ortenzi M, Perosa M, Perrone VG, Pleass H, Redfield RR, Ricci C, Rigotti P, Paul Robertson R, Ross LF, Rossi M, Saudek F, Scalea JR, Schenker P, Secchi A, Socci C, Sousa Silva D, Squifflet JP, Stock PG, Stratta RJ, Terrenzio C, Uva P, Watson CJ, White SA, Marchetti P, Kandaswamy R, Berney T. First World Consensus Conference on pancreas transplantation: Part II - recommendations. Am J Transplant 2021; 21 Suppl 3:17-59. [PMID: 34245223 PMCID: PMC8518376 DOI: 10.1111/ajt.16750] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [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: 02/19/2021] [Revised: 06/25/2021] [Accepted: 06/26/2021] [Indexed: 02/07/2023]
Abstract
The First World Consensus Conference on Pancreas Transplantation provided 49 jury deliberations regarding the impact of pancreas transplantation on the treatment of diabetic patients, and 110 experts' recommendations for the practice of pancreas transplantation. The main message from this consensus conference is that both simultaneous pancreas-kidney transplantation (SPK) and pancreas transplantation alone can improve long-term patient survival, and all types of pancreas transplantation dramatically improve the quality of life of recipients. Pancreas transplantation may also improve the course of chronic complications of diabetes, depending on their severity. Therefore, the advantages of pancreas transplantation appear to clearly surpass potential disadvantages. Pancreas after kidney transplantation increases the risk of mortality only in the early period after transplantation, but is associated with improved life expectancy thereafter. Additionally, preemptive SPK, when compared to SPK performed in patients undergoing dialysis, appears to be associated with improved outcomes. Time on dialysis has negative prognostic implications in SPK recipients. Increased long-term survival, improvement in the course of diabetic complications, and amelioration of quality of life justify preferential allocation of kidney grafts to SPK recipients. Audience discussions and live voting are available online at the following URL address: http://mediaeventi.unipi.it/category/1st-world-consensus-conference-of-pancreas-transplantation/246.
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Lee YS, Saxena V, Bromberg JS, Scalea JR. G-CSF promotes alloregulatory function of MDSCs through a c-Kit dependent mechanism. Cell Immunol 2021; 364:104346. [PMID: 33848847 DOI: 10.1016/j.cellimm.2021.104346] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/04/2021] [Accepted: 03/21/2021] [Indexed: 12/30/2022]
Abstract
Myeloid-derived suppressor cells (MDSC) are a heterogeneous population of immature myeloid cells that expand in inflammatory conditions including transplantation. MDSCs may be capable of controlling rejection. The critical mechanisms underlying MDSC mediated alloregulation remain unexplored. G-CSF potently stimulates MDSC expansion. We hypothesized that G-CSF-induced MDSCs use a novel mechanism to suppress T cell responses. G-CSF promoted expansion of MDSCs and enhanced their suppressive function against T cell proliferation. Gene expression analysis revealed MDSCs expanded with G-CSF upregulated immune-related genes, but downregulated proliferation-related genes when compared to naïve control MDSCs. The KIT oncogene, encoding the c-Kit (CD117) transmembrane tyrosine kinase receptor, was the most significantly increased in MDSCs expanded with G-CSF. c-Kit inhibition with both imatinib and monoclonal blocking antibody reduced expression of ARG-1, iNOS, PD-L1, and SAA3. Further, imatinib also reduced MDSC-mediated T cell suppression in vitro. Modulation of c-Kit activity may represent a therapeutic target for alloregulatory MDSCs.
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Affiliation(s)
- Young S Lee
- Department of Surgery, University of Maryland School of Medicine, Baltimore, United States; Center for Vascular and Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, United States
| | - Vikas Saxena
- Center for Vascular and Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, United States
| | - Jonathan S Bromberg
- Department of Surgery, University of Maryland School of Medicine, Baltimore, United States; Center for Vascular and Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, United States; Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, United States
| | - Joseph R Scalea
- Department of Surgery, University of Maryland School of Medicine, Baltimore, United States; Center for Vascular and Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, United States; Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, United States.
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12
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Knighton BJ, Ngaage LM, Calvert C, Niederhaus SV, Scalea JR, Rasko YM. Post-Abdominal Transplant Hernia: Can We Predict Size and Onset? Transplant Proc 2021; 53:730-736. [PMID: 33541717 DOI: 10.1016/j.transproceed.2020.10.028] [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: 04/17/2020] [Revised: 09/03/2020] [Accepted: 10/01/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Abdominal organ transplant is a life-saving treatment. However, the resultant weakening of abdominal muscles leaves patients susceptible to incisional hernia. Obesity, smoking, and diabetes mellitus are common risk factors for post-transplant hernia. However, the literature is void on the impact these risk factors have on timing and size of hernia. METHODS We performed a retrospective review of all post-abdominal transplant patients who underwent hernia repair in 2010-2017 at a single institution. Primary outcomes were hernia size and time from transplant to hernia repair. RESULTS We identified 31 patients. The majority of patients were female (15 male, 16 female), and the average patient was 56 ± 8.7 years old and obese (body mass index 30.6). Smoking (26.7%, n = 8) and diabetes mellitus (51.6%, n = 16) were prevalent. Transplant types represented were renal (n = 24), simultaneous pancreas-kidney (n = 5), liver (n = 1), and liver with subsequent kidney (n = 1). The median size of hernia was 100.0 cm2 (interquartile range [IQR]: 78.5-234.0), and median time to hernia repair was 53.0 months (IQR: 12.5-110.0). Risk factors (obesity, smoking, and diabetes) did not influence hernia size, nor alter time to hernia repair. CONCLUSION Obesity, smoking, and diabetes mellitus are not prognostic of size or onset of post-transplant incisional hernia. Large cohort studies are needed to determine predictive factors of size and onset of hernia.
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Affiliation(s)
| | - Ledibabari M Ngaage
- Division of Plastic Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore
| | - Catherine Calvert
- Department of Surgery, University of Maryland Medical Center, Baltimore
| | - Silke V Niederhaus
- Division of Transplantation, Department of Surgery, University of Maryland Medical Center, Baltimore
| | - Joseph R Scalea
- Division of Transplantation, Department of Surgery, University of Maryland Medical Center, Baltimore
| | - Yvonne M Rasko
- Division of Plastic Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore.
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13
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Affiliation(s)
- Joseph R Scalea
- University of Maryland, School of Medicine and University of Maryland Medical Center, United States.
| | - Wen Xie
- University of Maryland, School of Medicine and University of Maryland Medical Center, United States.
| | - Georgios Vrakas
- University of Maryland, School of Medicine and University of Maryland Medical Center, United States.
| | - Stephen H Gray
- University of Maryland, School of Medicine and University of Maryland Medical Center, United States.
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14
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Goussous N, St Michel DP, Mcdade H, Gaines S, Borth A, Dawany N, Al-Qaoud T, Bromberg JS, Barth RN, Scalea JR. Is Prophylactic Drainage After Pancreas Transplant Associated With Reduced Reoperation Rate? EXP CLIN TRANSPLANT 2020; 19:64-71. [PMID: 33272163 DOI: 10.6002/ect.2020.0010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Advances in surgery and perioperative care have contributed to improved outcomes after pancreas transplant. However, the development of peripancreatic infections carries a poor prognosis. It is not clear whether abdominal drainage is helpful in collection prevention. MATERIALS AND METHODS A retrospective review of adult consecutive pancreas transplants at a single institution between January 2017 and December 2018 was undertaken. Postoperative outcomes were compared between patients in whom prophylactic intraoperative drains were placed and patients with no drains. RESULTS We identified 83 patients who underwent pancreas transplant with a median age of 45 years; 54.2% were males, and median body mass index was 25.8. Thirty patients had 1 or 2 drains placed (36.1%). There was no difference in the readmission rate (70.0% vs 60.4%; P = .48), reoperation (20.0% vs 30.2%; P = .44), or percutaneous drainage of peripancreatic infections (20.0% vs 15.1%; P = .56) between patients with drains and no drains, respectively. However, prophylactic drainage was associated with a lower rate of reoperation for peripancreatic infections compared with those who were not drained (0.0% vs 13.2%; P < .05). No graft loss occurred in the drain group. CONCLUSIONS Prophylactic drainage after pancreas transplant may be helpful for reduction in the infection rate after reoperation. The risks of drain placement should be weighed against those of drain avoidance.
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Affiliation(s)
- Naeem Goussous
- From the Division of Transplantation, Department of Surgery, University of Maryland School of Medicine Baltimore, Maryland, USA
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15
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Lee YS, Zhang T, Saxena V, Li L, Piao W, Bromberg JS, Scalea JR. Myeloid-derived suppressor cells expand after transplantation and their augmentation increases graft survival. Am J Transplant 2020; 20:2343-2355. [PMID: 32282980 DOI: 10.1111/ajt.15879] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 03/05/2020] [Accepted: 03/10/2020] [Indexed: 01/25/2023]
Abstract
Myeloid-derived suppressor cells (MDSCs) expand in an inflammatory microenvironment such as cancer and autoimmunity. To study if transplantation induces MDSCs and these cells regulate allograft survival, C57BL/6 donor hearts were transplanted into BALB/c recipients and endogenous MDSCs were characterized. The effects of adoptive transfer of transplant (tx), tumor (tm), and granulocyte-colony stimulating factor (g-csf)-expanded MDSCs or depletion of MDSC were assessed. MDSCs expanded after transplantation (1.7-4.6-fold) in the absence of immunosuppression, homed to allografts, and suppressed proliferation of CD4 T cells in vitro. Tx-MDSCs differed phenotypically from tm-MDSCs and g-csf-MDSCs. Among various surface markers, Rae-1 expression was notably low and TGF-β receptor II was high in tx-MDSCs when compared to tm-MDSCs and g-csf-MDSCs. Adoptive transfer of these three MDSCs led to differential graft survival: control (6 days), tx-MDSCs (7.5 days), tm-MDSCs (9.5 days), and g-csf-MDSCs (19.5 days). In combination with anti-CD154 mAb, MDSCs synergistically extended graft survival from 40 days (anti-CD154 alone) to 86 days with tm-MDSCs and 132 days with g-csf-MDSCs. Early MDSC depletion (day 0 or 20), however, abrogated graft survival, but late depletion (day 25) did not. In conclusion, MDSCs expanded following transplantation, migrated to cardiac allografts, prolonged graft survival, and were synergistic with anti-CD154 mAb.
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Affiliation(s)
- Young S Lee
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Center for Vascular and Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Tianshu Zhang
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Vikas Saxena
- Center for Vascular and Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Lushen Li
- Center for Vascular and Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Wenji Piao
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Center for Vascular and Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jonathan S Bromberg
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Center for Vascular and Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joseph R Scalea
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Center for Vascular and Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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16
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Chow JH, Wallis M, Lankford AS, Chancer Z, Barth RN, Scalea JR, LaMattina JC, Mazzeffi MA, McCurdy MT. Treatment of Renin-Angiotensin-Aldosterone System Dysfunction With Angiotensin II in High-Renin Septic Shock. Semin Cardiothorac Vasc Anesth 2020; 25:67-73. [DOI: 10.1177/1089253220949070] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Endothelial dysfunction is common in septic shock and has been shown to impair angiotensin converting enzyme and the renin-angiotensin-aldosterone system (RAAS). Dysregulation of this pathway, which can be measured with plasma renin activity (PRA), is important not only because RAAS dysfunction is associated with increased mortality but also because treatment with angiotensin II (Ang-2) has been shown to decrease mortality. In this case series of 2 patients, serial PRA levels identified septic shock patients with RAAS dysfunction. The patients were treated with Ang-2, an angiotensin type 1 receptor agonist, which resulted in significant improvements in hemodynamics and PRA levels during treatment.
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Affiliation(s)
| | - Marianne Wallis
- University of Maryland, School of Medicine, Baltimore, MD, USA
| | | | - Zackary Chancer
- University of Maryland, School of Medicine, Baltimore, MD, USA
| | - Rolf N. Barth
- University of Maryland, School of Medicine, Baltimore, MD, USA
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17
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18
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Baglien B, Ngaage LM, Elegbede A, Gebran SG, Nam AJ, Niederhaus S, Scalea JR, Bromberg JS, Bartlett ST, Rasko YM. Teamwork Makes the Dream Work: Maximizing Surgical Intervention at the Time of Living Donor Renal Transplantation. Transplant Proc 2020; 52:731-736. [DOI: 10.1016/j.transproceed.2020.01.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/02/2020] [Indexed: 01/06/2023]
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19
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Suk Lee Y, Davila E, Zhang T, Milmoe HP, Vogel SN, Bromberg JS, Scalea JR. Myeloid-derived suppressor cells are bound and inhibited by anti-thymocyte globulin. Innate Immun 2019; 25:46-59. [PMID: 30782043 PMCID: PMC6830891 DOI: 10.1177/1753425918820427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Myeloid-derived suppressor cells (MDSCs) inhibit T cell responses and are
relevant to cancer, autoimmunity and transplant biology. Anti-thymocyte globulin
(ATG) is a commonly used T cell depletion agent, yet the effect of ATG on MDSCs
has not been investigated. MDSCs were generated in Lewis Lung Carcinoma 1
tumor-bearing mice. MDSC development and function were assessed in
vivo and in vitro with and without ATG
administration. T cell suppression assays, RT-PCR, flow cytometry and arginase
activity assays were used to assess MDSC phenotype and function. MDSCs increased
dramatically in tumor-bearing mice and the majority of splenic MDSCs were of the
polymorphonuclear subset. MDSCs potently suppressed T cell proliferation.
ATG-treated mice developed 50% fewer MDSCs and these MDSCs were significantly
less suppressive of T cell proliferation. In vitro, ATG
directly bound 99.6% of MDSCs. CCR7, L-selectin and LFA-1 were expressed by both
T cells and MDSCs, and binding of LFA-1 was inhibited by ATG pre-treatment.
Arg-1 and PD-L1 transcript expression were reduced 30–40% and arginase activity
decreased in ATG-pretreated MDSCs. MDSCs were bound and functionally inhibited
by ATG. T cells and MDSCs expressed common Ags which were also targets of ATG.
ATG may be helpful in tumor models seeking to suppress MDSCs. Alternatively, ATG
may inadvertently inhibit important T cell regulatory events in autoimmunity and
transplantation.
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Affiliation(s)
- Young Suk Lee
- 1 Department of Surgery, University of Maryland, Baltimore, USA
| | - Eduardo Davila
- 2 Department of Microbiology and Immunology, University of Maryland, Baltimore, USA
| | - Tianshu Zhang
- 1 Department of Surgery, University of Maryland, Baltimore, USA
| | - Hugh P Milmoe
- 1 Department of Surgery, University of Maryland, Baltimore, USA
| | - Stefanie N Vogel
- 2 Department of Microbiology and Immunology, University of Maryland, Baltimore, USA
| | - Jonathan S Bromberg
- 1 Department of Surgery, University of Maryland, Baltimore, USA.,2 Department of Microbiology and Immunology, University of Maryland, Baltimore, USA
| | - Joseph R Scalea
- 1 Department of Surgery, University of Maryland, Baltimore, USA.,2 Department of Microbiology and Immunology, University of Maryland, Baltimore, USA
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20
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St Michel D, Donnelly T, Jackson T, Taylor B, Barth RN, Bromberg JS, Scalea JR. Assessing Pancreas Transplant Candidate Cardiac Disease: Preoperative Protocol Development at a Rapidly Growing Transplant Program. Methods Protoc 2019; 2:mps2040082. [PMID: 31627355 PMCID: PMC6960608 DOI: 10.3390/mps2040082] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/01/2019] [Accepted: 10/11/2019] [Indexed: 12/22/2022] Open
Abstract
Pancreas transplant rates, despite improving outcomes, have decreased over the past two decades. This is due, in part, to ageing, increasingly co-morbid pancreas transplant candidates. There is a paucity of published data regarding coronary artery disease (CAD) in this population. To inform peri-operative management strategies, we sought to understand the frequency of CAD among recipients of pancreas transplants at our center. Informed by these data, we sought to develop a standard protocol for evaluation. A retrospective review of pancreas transplants (solitary pancreas and simultaneous pancreas-kidney) was undertaken at the University of Maryland. Transplant outcomes and frequency of cardiac disease were analyzed. Current data were compared with historic controls. Over the study period, 59 patients underwent pancreas transplantation. Coronary architecture was assessed in 38 patients (64.4%). Discrete evidence of CAD was present in 28 of 39 patients (71.7%). All pancreas candidates (n = 21) who underwent left heart catheterization (LHC) demonstrated CAD (100%). No patients experienced myocardial infarction (MI) and no deaths resulted from cardiac disease in the early post-transplant period. Pancreas transplant candidates are at high risk for CAD. At a center in which pancreas transplant rates are increasing, a rigorous cardiac work up revealed that 71.7% of assessed recipients had CAD. Although asymptomatic, 6.8% required coronary artery bypass graft (CABG). Despite increasing age and co-morbid status, pancreas transplant recipients can enjoy excellent results if protocolized preoperative testing is used.
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Affiliation(s)
- David St Michel
- Department of Surgery, University of Maryland, Baltimore, MD 20742, USA.
| | - Tracy Donnelly
- Department of Surgery, University of Maryland, Baltimore, MD 20742, USA.
| | - Towanda Jackson
- Department of Surgery, University of Maryland, Baltimore, MD 20742, USA.
| | - Bradley Taylor
- Department of Surgery, University of Maryland, Baltimore, MD 20742, USA.
| | - Rolf N Barth
- Department of Surgery, University of Maryland, Baltimore, MD 20742, USA.
| | | | - Joseph R Scalea
- Department of Surgery, University of Maryland, Baltimore, MD 20742, USA.
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21
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Ngaage LM, Elegbede A, Tadisina KK, Gebran SG, Masters BM, Rada EM, Nam AJ, Scalea JR, Niederhaus SV, Singh D, Bromberg JS, Bartlett ST, Rasko YM. Panniculectomy at the time of living donor renal transplantation: An 8-year experience. Am J Transplant 2019; 19:2284-2293. [PMID: 30720924 DOI: 10.1111/ajt.15285] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 01/16/2019] [Accepted: 01/18/2019] [Indexed: 01/25/2023]
Abstract
Panniculectomy can be performed as a prophylactic procedure preceding transplantation to enable obese patients to meet criteria for renal transplantation. No literature exists on combined renal transplant and panniculectomy surgery (LRT-PAN). We describe our 8-year experience performing LRT-PAN. A retrospective chart review of all patients who had undergone LRT-PAN from 2010 to 2018 was conducted. Data were collected on patient demographics, allograft survival and function, and postoperative course. Fifty-eight patients underwent LRT-PAN. All grafts survived, with acceptable function at 1 year. Median length of stay was 4 days with a mean operative duration of 363 minutes. The wound complication rate was 24%. Ninety-day readmission rate was 52%, with medical causes as the most common reason for readmission (45%), followed by wound (32%) and graft-related complications (23%). Body mass index, diabetes status, and previous immunosuppression did not influence wound complication rate or readmission (P = .7720, P = .0818, and P = .4830, respectively). Combining living donor renal transplant and panniculectomy using a multidisciplinary team may improve access to transplantation, particularly for the obese and postobese population. This combined approach yielded shorter-than-expected hospital stays and similar wound complication rates, and thus should be considered for patients in whom transplantation might otherwise be withheld on the basis of obesity.
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Affiliation(s)
- Ledibabari M Ngaage
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Adekunle Elegbede
- Department of Plastic & Reconstructive Surgery, Johns Hopkins Hospital/University of Maryland Medical Center, Baltimore, Maryland
| | - Kashyap K Tadisina
- Division of Plastic Surgery, Saint Louis University School of Medicine, St Louis, Missouri
| | - Selim G Gebran
- Division of Plastic & Reconstructive Surgery, R Adams Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Brian M Masters
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland
| | - Erin M Rada
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Arthur J Nam
- Division of Plastic & Reconstructive Surgery, R Adams Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joseph R Scalea
- Division of Transplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Silke V Niederhaus
- Division of Transplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Devinder Singh
- Division of Plastic Surgery, Anne Arundel Medical Center, Annapolis, Maryland
| | - Jonathan S Bromberg
- Division of Transplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Stephen T Bartlett
- Division of Transplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Yvonne M Rasko
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
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22
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Bromberg JS, Scalea JR, Mongodin EF. De-bugging the system: could antibiotics improve liver transplant outcomes? J Clin Invest 2019; 129:3054-3057. [PMID: 31329161 PMCID: PMC6668694 DOI: 10.1172/jci130314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Organ transplantation is now a preferred treatment for end-stage organ failure. Among the challenges for ensuring excellent clinical outcomes for transplant recipients is good initial allograft function at the time of organ implantation. This is determined in part by the functional status of the donor and donor organ, functional status of the recipient, and conduct of the operative procedure. Despite optimization of these variables, organ transplantation is still often plagued by substantial initial dysfunction, variably referred to as slow or delayed graft function, or in the most extreme cases, primary graft nonfunction necessitating urgent regrafting. In this issue of the JCI, Nakamura, Kageyama, Ito, Hirao, and colleagues investigate a potential role for the recipient's microbiome in determining graft function after liver transplantation and demonstrate the benefits of antibiotic pretreatment in both a mouse model and in human patients.
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Affiliation(s)
- Jonathan S. Bromberg
- Department of Surgery
- Department of Microbiology and Immunology
- Center for Vascular and Inflammatory Diseases, and
| | - Joseph R. Scalea
- Department of Surgery
- Department of Microbiology and Immunology
- Center for Vascular and Inflammatory Diseases, and
| | - Emmanuel F. Mongodin
- Department of Surgery
- Department of Microbiology and Immunology
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
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23
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Affiliation(s)
- Joseph R Scalea
- Division of Transplantation, Department of Surgery, University of Maryland, Baltimore, MD, USA
| | | | | | - Stephen T Bartlett
- Division of Transplantation, Department of Surgery, University of Maryland, Baltimore, MD, USA
| | - Norman Wereley
- Department of Aerospace Engineering, University of Maryland, College Park, MD, USA
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24
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Scalea JR, Restaino S, Scassero M, Blankenship G, Bartlett ST, Wereley N. An Initial Investigation of Unmanned Aircraft Systems (UAS) and Real-Time Organ Status Measurement for Transporting Human Organs. IEEE J Transl Eng Health Med 2018; 6:4000107. [PMID: 30464862 PMCID: PMC6242697 DOI: 10.1109/jtehm.2018.2875704] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 09/10/2018] [Accepted: 09/26/2018] [Indexed: 11/09/2022]
Abstract
Organ transportation has yet to be substantially innovated. If organs could be moved by drone, instead of ill-timed commercial aircraft or expensive charter flights, lifesaving organs could be transplanted more quickly. A modified, six-rotor UAS was used to model situations relevant to organ transportation. To monitor the organ, we developed novel technologies that provided the real-time organ status using a wireless biosensor combined with an organ global positioning system. Fourteen drone organ missions were performed. Temperatures remained stable and low (2.5 °C). Pressure changes (0.37-0.86 kPa) correlated with increased altitude. Drone travel was associated with less vibration (<0.5 G) than was observed with fixed-wing flight (>2.0 G). Peak velocity was 67.6 km/h (42 m/h). Biopsies of the kidney taken prior to and after organ shipment revealed no damage resulting from drone travel. The longest flight was 3.0 miles, modeling an organ flight between two inner city hospitals. Organ transportation may be an ideal use-case for drones. With the development of faster, larger drones, long-distance drone organ shipment may result in substantially reduced cold ischemia times, subsequently improved organ quality, and thousands of lives saved.
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Affiliation(s)
| | | | | | | | - Stephen T. Bartlett
- University of Maryland BaltimoreBaltimoreMD21201USA
- University of Maryland Medical SystemBaltimoreMD21207USA
| | - Norman Wereley
- University of Maryland at College ParkCollege ParkMD20742USA
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25
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Cimeno A, Munley J, Drachenberg C, Weir M, Haririan A, Bromberg J, Barth RN, Scalea JR. Diabetic nephropathy after kidney transplantation in patients with pretransplantation type II diabetes: A retrospective case series study from a high-volume center in the United States. Clin Transplant 2018; 32:e13425. [PMID: 30326148 DOI: 10.1111/ctr.13425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/31/2018] [Accepted: 09/18/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with type II diabetes mellitus (DM) undergoing renal transplantation are at risk of diabetic nephropathy (DN) in the transplanted kidney. The true risk of developing post-transplantation DN is unknown, and post-transplantation DN is poorly characterized in the literature. METHODS The biopsy database at the University of Maryland Medical Center was queried for kidney transplant biopsies which demonstrated evidence of DN. The time from transplantation to biopsy-proven DN (time to diagnosis, TTD) was calculated and analyzed in the context of demographics, serum creatinine, and onset of diabetes. By extrapolating the total number of patients who developed DN in the last 2 years, we estimated the recurrence rate of DN. RESULTS Sixty patients whose renal biopsies met criteria were identified. The mean age was 56.6 (±1.58) years, and the mean creatinine level at time of biopsy was 1.65 (±0.12) mg/dL. Simultaneous pathological diagnoses were frequent on kidney biopsy; rejection was present at variable rates: classes I, IIA, IIB, and III were 5.0%, 66.7%, 18.4%, and 10%, respectively. The mean TTD was 1456 (±206) days. TTD was significantly shorter for patients receiving a cadaveric vs living donor renal transplant (1118 ± 184 vs 2470 ± 547 days, P = 0.004). Older patients (r = 0.378, P = 0.003) and patients with higher serum creatinine (r = 0.282, P = 0.029) had shorter TTDs. Extrapolations showed that 74.7% of patients would be free of DN 10 years after renal transplantation. CONCLUSIONS Diabetic nephropathy occurs after transplantation, and this appears to be due to both donor and recipient-derived factors. Encouragingly, our estimates suggest that as many as 75% of patients may be free of DN at 10 years following kidney transplantation.
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Affiliation(s)
- Arielle Cimeno
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jennifer Munley
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Cinthia Drachenberg
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Matthew Weir
- Department of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Abdolreza Haririan
- Department of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jonathan Bromberg
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Rolf N Barth
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joseph R Scalea
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
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26
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Hsiao TI, Scalea JR. Hypoglycemia Following Pancreas Transplant: A Diagnostic Challenge in the Immediate Posttransplant Setting. EXP CLIN TRANSPLANT 2018; 18:536-538. [PMID: 29993354 DOI: 10.6002/ect.2017.0252] [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] [Indexed: 11/05/2022]
Abstract
Few studies have described glucose metabolism in the immediate posttransplant period. Here, we report a 37-year-old female patient who had transient hypoglycemia after combined pancreas and kidney transplant for poorly controlled type 1 diabetes and renal failure. Although the patient's blood sugar decreased from 420 to less than 120 mg/dL and the kidney demonstrated graft function immediately posttransplant, at 19 hours after transplant, the patient's blood glucose decreased to below the normal range at a nadir of 59 mg/dL. When treated with intravenous dextrose, her blood glucose levels increased over 7 hours to 119 mg/dL but then again declined, appearing to follow a circadian rhythm, with hypoglycemia shown during early morning hours and then improving during the afternoon. This prompted treatment with a continuous infusion of 5% dextrose on day 2, resulting in blood sugar levels returning to normal by day 4 and discharge on day 6. She has since remained euglycemic. The differential diagnosis of hypoglycemia immediately after kidney-pancreas transplant is wide. Indeed, after we excluded ischemia-reperfusion injury, impaired renal clearance, insulin-associated antibodies, and lack of pancreatic innervation, we believe that cause was most likely due to impairment of early glucose counterregulatory responses or delayed alpha cell function.
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Affiliation(s)
- Tiffany I Hsiao
- From the Division of Transplant Surgery, University of Maryland, Baltimore, Maryland, USA; and the School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
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27
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Butler-Peres K, Scalea JR. Horseshoe kidney in a deceased organ donor: a rare glimpse at an uncommon finding. Lancet 2018; 391:2028. [PMID: 29864019 DOI: 10.1016/s0140-6736(18)30759-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 03/19/2018] [Accepted: 03/20/2018] [Indexed: 10/16/2022]
Affiliation(s)
- Kamilia Butler-Peres
- Division of Transplantation and Department of Surgery, University of Maryland, Baltimore, MA, USA
| | - Joseph R Scalea
- Division of Transplantation and Department of Surgery, University of Maryland, Baltimore, MA, USA.
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28
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Scalea JR, Sultan S, Lamos EM, Bartlett ST, Barth RN. Improvement in pancreas transplant evaluation and surgical volume using a multidisciplinary approach. Am J Transplant 2018; 18:1295-1296. [PMID: 29166550 DOI: 10.1111/ajt.14598] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Joseph R Scalea
- Division of Transplantation, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Samuel Sultan
- Division of Transplantation, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Elizabeth M Lamos
- Division of Transplantation, Department of Endocrinology, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Stephen T Bartlett
- Division of Transplantation, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Rolf N Barth
- Division of Transplantation, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, USA
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29
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Taylor LJ, Buffington A, Scalea JR, Fost N, Croes KD, Mezrich JD, Schwarze ML. Harms of unsuccessful donation after circulatory death: An exploratory study. Am J Transplant 2018; 18:402-409. [PMID: 28805291 PMCID: PMC5790593 DOI: 10.1111/ajt.14464] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 07/23/2017] [Accepted: 08/03/2017] [Indexed: 01/25/2023]
Abstract
While donation after circulatory death (DCD) has expanded options for organ donation, many who wish to donate are still unable to do so. We conducted face-to-face interviews with family members (N = 15) who had direct experience with unsuccessful DCD and 5 focus groups with professionals involved in the donation process. We used qualitative content analysis to characterize the harms of nondonation as perceived by participants. Participants reported a broad spectrum of harms affecting organ recipients, donors, and donor families. Harms included waste of precious life-giving organs and hospital resources, inability to honor the donor's memory and character, and impaired ability for families to make sense of tragedy and cope with loss. Donor families empathized with the initial hope and ultimate despair of potential recipients who must continue their wait on the transplant list. Focus group members reinforced these findings and highlighted the struggle of families to navigate the uncertainty regarding the timing of death during the donation process. While families reported significant harm, many appreciated the donation attempt. These findings highlight the importance of organ donation to donor families and the difficult experiences associated with current processes that could inform development of alternative donation strategies.
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Affiliation(s)
| | | | - Joseph R Scalea
- Department of Surgery, University of Maryland. Baltimore, MD
| | - Norman Fost
- Department of Pediatrics, University of Wisconsin. Madison, WI,Department of Medical History and Bioethics. University of Wisconsin. Madison, WI
| | | | | | - Margaret L Schwarze
- Department of Surgery, University of Wisconsin. Madison, WI,Department of Medical History and Bioethics. University of Wisconsin. Madison, WI
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30
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Scalea JR, Pettinato L, Fiscella B, Bartosic A, Piedmonte A, Paran J, Todi N, Siskind EJ, Bartlett ST. Successful pancreas transplantation alone is associated with excellent self-identified health score and glucose control: A retrospective study from a high-volume center in the United States. Clin Transplant 2018; 32. [PMID: 29226480 DOI: 10.1111/ctr.13177] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND The benefits of pancreas transplantation are often difficult to measure. Here, we sought to determine the difference in quality of life for diabetic patients with and without a functional pancreas transplant alone (PTA). METHODS Pancreas transplant alone cases from 1993 to 2015 were considered. An IRB-approved survey inclusive of 15 questions spanning four domains was employed. Chi-square, Fisher's exact, and the T test were used where appropriate. RESULTS A total of 137 PTAs were performed during the study period. Of those reached (n = 32), 94% responded to the survey. Self-reported health scores were better (2.1 vs 3.0) for those with functioning pancreata (n = 18) vs those with a non-functional pancreas (n = 14), respectively (P = .036). Those with a functional pancreas had a HgbA1c of 5.3, vs 7.7 for a non-functional pancreas (P = .016). Significant hypoglycemia was reported in two of 18 with a functional transplant vs nine of 14 patients with a failed transplant (P = .003). Daily frustration with blood sugar affecting quality of life was significantly higher for patients with non-functional pancreas grafts (P < .001). CONCLUSIONS Pancreas transplantation alone is associated with better glucose control than insulin. In addition, recipients of functional PTAs have improved quality of life and better overall health scores than those with failed grafts.
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Affiliation(s)
- Joseph R Scalea
- Division of Transplantation, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Lauren Pettinato
- Division of Transplantation, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Blythe Fiscella
- Division of Transplantation, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Amanda Bartosic
- Division of Transplantation, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Allison Piedmonte
- Division of Transplantation, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Jastine Paran
- Division of Transplantation, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Niket Todi
- Division of Transplantation, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Eric J Siskind
- Division of Transplantation, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Stephen T Bartlett
- Division of Transplantation, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, USA
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31
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Scalea JR, Redfield RR, Arpali E, Leverson G, Sollinger HW, Kaufman DB, Odorico JS. Pancreas transplantation in older patients is safe, but patient selection is paramount. Transpl Int 2017; 29:810-8. [PMID: 26859581 DOI: 10.1111/tri.12754] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [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: 10/06/2015] [Revised: 11/03/2015] [Accepted: 01/29/2016] [Indexed: 12/13/2022]
Abstract
Pancreas transplant outcomes have progressively improved. Despite this, some centers have continued to employ historical age limits for pancreas transplant candidates. We sought to determine the importance of chronological age in determining patient and graft survival rates after pancreas transplantation. A single-center, retrospective study of adult, deceased donor simultaneous pancreas and kidney (SPK) and solitary pancreas transplants (SP, including pancreas transplant alone and pancreas after kidney transplants) in recipients ≥ 55 years (55 + ), occurring between July 1, 1999, and June 30, 2012, was performed. Seven-hundred and forty patients underwent pancreas transplantation, of which 28 patients were 55 + . Patient survival was comparable for younger and older pancreas transplant recipients. Both non-death-censored and death-censored pancreatic graft survival rates were similar in younger and in older patients. Patients aged 45-54 and those aged 55 + had more frequent cardiovascular events than younger pancreas transplant recipients. There was no difference in renal graft survival for SPK patients when compared with diabetic kidney transplant alone recipients aged 55 years and older. Older pancreas transplant recipients had acceptable long-term patient and graft survival rates, although complications may occur. Chronological age alone should not exclude a patient for pancreas transplant candidacy.
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Affiliation(s)
- Joseph R Scalea
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Robert R Redfield
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Emre Arpali
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Glen Leverson
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Hans W Sollinger
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Dixon B Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Jon S Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
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32
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Scalea JR, Redfield RR, Arpali E, Leverson GE, Bennett RJ, Anderson ME, Kaufman DB, Fernandez LA, D'Alessandro AM, Foley DP, Mezrich JD. Does DCD Donor Time-to-Death Affect Recipient Outcomes? Implications of Time-to-Death at a High-Volume Center in the United States. Am J Transplant 2017; 17:191-200. [PMID: 27375072 DOI: 10.1111/ajt.13948] [Citation(s) in RCA: 23] [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: 03/30/2016] [Revised: 06/02/2016] [Accepted: 06/22/2016] [Indexed: 02/06/2023]
Abstract
For donation after circulatory death (DCD), many centers allow 1 h after treatment withdrawal to donor death for kidneys. Our center has consistently allowed 2 h. We hypothesized that waiting longer would be associated with worse outcome. A single-center, retrospective analysis of DCD kidneys transplanted between 2008 and 2013 as well as a nationwide survey of organ procurement organization DCD practices were conducted. We identified 296 DCD kidneys, of which 247 (83.4%) were transplanted and 49 (16.6%) were discarded. Of the 247 recipients, 225 (group 1; 91.1%) received kidneys with a time to death (TTD) of 0-1 h; 22 (group 2; 8.9%) received grafts with a TTD of 1-2 h. Five-year patient survival was 88.8% for group 1, and 83.9% for group 2 (p = 0.667); Graft survival was also similar, with 5-year survival of 74.1% for group 1, and 83.9% for group 2 (p = 0.507). The delayed graft function rate was the same in both groups (50.2% vs. 50.0%, p = 0.984). TTD was not predictive of graft failure. Nationally, the average maximum wait-time for DCD kidneys was 77.2 min. By waiting 2 h for DCD kidneys, we performed 9.8% more transplants without worse outcomes. Nationally, this practice would allow for hundreds of additional kidney transplants, annually.
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Affiliation(s)
- J R Scalea
- Division of Transplantation, Department of Surgery, University of Wisconsin, Madison, WI
| | - R R Redfield
- Division of Transplantation, Department of Surgery, University of Wisconsin, Madison, WI
| | - E Arpali
- Division of Transplantation, Department of Surgery, University of Wisconsin, Madison, WI
| | - G E Leverson
- Division of Transplantation, Department of Surgery, University of Wisconsin, Madison, WI
| | - R J Bennett
- University of Wisconsin Organ and Tissue Donation, Madison, WI
| | - M E Anderson
- University of Wisconsin Organ and Tissue Donation, Madison, WI
| | - D B Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin, Madison, WI
| | - L A Fernandez
- Division of Transplantation, Department of Surgery, University of Wisconsin, Madison, WI
| | - A M D'Alessandro
- Division of Transplantation, Department of Surgery, University of Wisconsin, Madison, WI
| | - D P Foley
- Division of Transplantation, Department of Surgery, University of Wisconsin, Madison, WI
| | - J D Mezrich
- Division of Transplantation, Department of Surgery, University of Wisconsin, Madison, WI
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33
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Scalea JR, Sollinger HW. Only Time Will Tell: The Future of Donation After Circulatory Death. EXP CLIN TRANSPLANT 2016; 14:27-31. [PMID: 27805506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The rapid rise of transplantation over the past 60 years has been marked by a number of critical milestones. Donation after circulatory death (DCD) has played an important role in the development of this young field. Although early observations by Dr. Tom Starzl touched on the importance of warm ischemic time, new and exciting data may be changing our views of ischemia. Indeed, as we learn more about the importance of time-to-death for DCD donors after circulatory death, the hemodynamic changes experienced by DCD donors, and the other physiologic perturbations surrounding all forms of death, we are beginning to drill down to the factors that drive recipient outcomes after deceased donor transplant. As far as the future? Only time will tell.
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Affiliation(s)
- Joseph R Scalea
- From the Division of Transplantation, Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
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34
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Scalea JR, Hickman JB, Moore DJ, Brayman KL. An overview of the necessary thymic contributions to tolerance in transplantation. Clin Immunol 2016; 173:S1521-6616(16)30382-5. [PMID: 27989896 DOI: 10.1016/j.clim.2016.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 10/04/2016] [Accepted: 10/22/2016] [Indexed: 02/08/2023]
Abstract
The thymus is important for the development of the immune system. However, aging leads to predictable involution of the thymus and immunodeficiency. These immunodeficiencies may be rectified with thymic rejuvenation. Atrophy of the thymus is governed by a complex interplay of molecular, cytokine and hormonal factors. Herein we review the interaction of these factors across age and how they may be targeted for thymic rejuvenation. We further discuss the growing pre-clinical evidence defining the necessary and sufficient contributions of the thymus to successful tolerance induction in transplantation.
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Affiliation(s)
- Joseph R Scalea
- Division of Transplantation, Department of Surgery, University of Maryland, United States.
| | - John B Hickman
- School of Medicine, University of Virginia, United States
| | - Daniel J Moore
- Division of Endocrinology, Department of Pediatrics, Department of Pathology, Microbiology and Immunology, Vanderbilt University, United States
| | - Kenneth L Brayman
- School of Medicine, University of Virginia, United States; Division of Transplantation, Department of Surgery, University of Virginia, United States
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35
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Scalea JR, Redfield RR, Foley DP. Liver transplant outcomes using ideal donation after circulatory death livers are superior to using older donation after brain death donor livers. Liver Transpl 2016; 22:1197-204. [PMID: 27314220 DOI: 10.1002/lt.24494] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 06/03/2016] [Indexed: 02/06/2023]
Abstract
Multiple reports have demonstrated that liver transplantation following donation after circulatory death (DCD) is associated with poorer outcomes when compared with liver transplantation from donation after brain death (DBD) donors. We hypothesized that carefully selected, underutilized DCD livers recovered from younger donors have excellent outcomes. We performed a retrospective study of the United Network for Organ Sharing database to determine graft survivals for patients who received liver transplants from DBD donors of age ≥ 60 years, DBD donors < 60 years, and DCD donors < 50 years of age. Between January 2002 and December 2014, 52,271 liver transplants were performed in the United States. Of these, 41,181 (78.8%) underwent transplantation with livers from DBD donors of age < 60 years, 8905 (17.0%) from DBD donors ≥ 60 years old, and 2195 (4.2%) livers from DCD donors < 50 years of age. DCD livers of age < 50 years with < 6 hours of cold ischemia time (CIT) had superior graft survival when compared with DBD livers ≥ age 60 years (P < 0.001). In 2014, there were 133 discarded DCD livers; of these, 111 (83.4%) were from donors < age 50 years old. Young DCD donor livers (age < 50 years old) with short CITs yield results better than that seen with DBD livers > 60 years old. Careful donor organ and recipient selection can lead to excellent results, despite previous reports suggesting otherwise. Increased acceptance of these DCD livers would lead to shorter wait list times and increased national liver transplant rates. Liver Transplantation 22 1197-1204 2016 AASLD.
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Affiliation(s)
- Joseph R Scalea
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; and
| | - Robert R Redfield
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; and
| | - David P Foley
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; and.,Veterans Administration Surgical Services, William S. Middleton Memorial Veterans Hospital, Madison, WI
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36
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Redfield RR, Scalea JR, Zens TJ, Mandelbrot DA, Leverson G, Kaufman DB, Djamali A. The mode of sensitization and its influence on allograft outcomes in highly sensitized kidney transplant recipients. Nephrol Dial Transplant 2016; 31:1746-53. [DOI: 10.1093/ndt/gfw099] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 04/05/2016] [Indexed: 11/14/2022] Open
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37
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Scalea JR, Tomita Y, Lindholm CR, Burlingham W. Transplantation Tolerance Induction: Cell Therapies and Their Mechanisms. Front Immunol 2016; 7:87. [PMID: 27014267 PMCID: PMC4779899 DOI: 10.3389/fimmu.2016.00087] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 02/22/2016] [Indexed: 12/12/2022] Open
Abstract
Cell-based therapies have been studied extensively in the context of transplantation tolerance induction. The most successful protocols have relied on transfusion of bone marrow prior to the transplantation of a renal allograft. However, it is not clear that stem cells found in bone marrow are required in order to render a transplant candidate immunologically tolerant. Accordingly, mesenchymal stem cells, regulatory myeloid cells, T regulatory cells, and other cell types are being tested as possible routes to tolerance induction, in the absence of donor-derived stem cells. Early data with each of these cell types have been encouraging. However, the induction regimen capable of achieving consistent tolerance, while avoiding unwanted sided effects, and which is scalable to the human patient, has yet to be identified. Here, we present the status of investigations of various tolerogenic cell types and the mechanistic rationale for their use in tolerance induction protocols.
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Affiliation(s)
- Joseph R Scalea
- Department of Surgery, Division of Transplantation, University of Wiconsin , Madison, WI , USA
| | - Yusuke Tomita
- Department of Surgery, Division of Transplantation, University of Wiconsin , Madison, WI , USA
| | | | - William Burlingham
- Department of Surgery, Division of Transplantation, University of Wiconsin , Madison, WI , USA
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38
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Abstract
Since its introduction to the antirejection armamentarium in 1994, tacrolimus has become the workhorse of transplant professionals for avoidance of solid organ transplant rejection. Not only does tacrolimus have potent immunosuppressive qualities that prevent rejection, but dosing is straight forward and it is generally well tolerated. However, in the long term, conditions such as calcineurin inhibitor nephrotoxicity can become a problem. A discussion of the compound, the pharmacokinetics, history, and current approved uses for tacrolimus is described. Indeed, tacrolimus is the most important drug for preventing transplant rejection. However, the increased appreciation for significant side effects, particularly in the long term, has led to building interest in new agents with different mechanisms of action and different metabolism.
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Affiliation(s)
- Joseph R Scalea
- a Division of Transplantation, Department of Surgery , University of Wisconsin , Madison , VA , USA
| | - Shoshana T Levi
- b School of Medicine , University of Virginia , Charlottesville , VA , USA
| | - Winston Ally
- c Department of Pharmacy Services , University of Virginia Health System , Charlottesville , VA , USA
| | - Kenneth L Brayman
- b School of Medicine , University of Virginia , Charlottesville , VA , USA
- d Division of Transplantation, Department of Surgery , University of Virginia , Charlottesville , VA , USA
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39
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Villani V, Yamada K, Scalea JR, Gillon BC, Arn JS, Sekijima M, Tasaki M, Cormack TA, Moran SG, Torabi R, Shimizu A, Sachs DH. Adoptive Transfer of Renal Allograft Tolerance in a Large Animal Model. Am J Transplant 2016; 16:317-24. [PMID: 26260215 PMCID: PMC4718904 DOI: 10.1111/ajt.13424] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 04/01/2015] [Revised: 05/19/2015] [Accepted: 06/11/2015] [Indexed: 01/25/2023]
Abstract
Our recent studies in an inbred swine model demonstrated that both peripheral and intra-graft regulatory cells were required for the adoptive transfer of tolerance to a second, naïve donor-matched kidney. Here, we have asked whether both peripheral and intra-graft regulatory elements are required for adoptive transfer of tolerance when only a long-term tolerant (LTT) kidney is transplanted. Nine highly-inbred swine underwent a tolerance-inducing regimen to prepare LTT kidney grafts which were then transplanted to histocompatible recipients, with or without the peripheral cell populations required for adoptive transfer of tolerance to a naïve kidney. In contrast to our previous studies, tolerance of the LTT kidney transplants alone was achieved without transfer of additional peripheral cells and without strategies to increase the number/potency of regulatory T cells in the donor. This tolerance was systemic, since most subsequent, donor-matched challenge kidney grafts were accepted. These results confirm the presence of a potent tolerance-inducing and/or tolerance-maintaining cell population within LTT renal allografts. They suggest further that additional peripheral tolerance mechanisms, required for adoptive transfer of tolerance to a naïve donor-matched kidney, depend on peripheral cells that, if not transferred with the LTT kidney, require time to develop in the adoptive host.
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Affiliation(s)
- V Villani
- Transplantation Biology Research Center (TBRC) Laboratories, Center for Transplantation Sciences (CTS), Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - K Yamada
- Transplantation Biology Research Center (TBRC) Laboratories, Center for Transplantation Sciences (CTS), Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - J R Scalea
- Transplantation Biology Research Center (TBRC) Laboratories, Center for Transplantation Sciences (CTS), Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - B C Gillon
- Transplantation Biology Research Center (TBRC) Laboratories, Center for Transplantation Sciences (CTS), Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - J S Arn
- Transplantation Biology Research Center (TBRC) Laboratories, Center for Transplantation Sciences (CTS), Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - M Sekijima
- Transplantation Biology Research Center (TBRC) Laboratories, Center for Transplantation Sciences (CTS), Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - M Tasaki
- Transplantation Biology Research Center (TBRC) Laboratories, Center for Transplantation Sciences (CTS), Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - T A Cormack
- Transplantation Biology Research Center (TBRC) Laboratories, Center for Transplantation Sciences (CTS), Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - S G Moran
- Transplantation Biology Research Center (TBRC) Laboratories, Center for Transplantation Sciences (CTS), Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - R Torabi
- Transplantation Biology Research Center (TBRC) Laboratories, Center for Transplantation Sciences (CTS), Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - A Shimizu
- Transplantation Biology Research Center (TBRC) Laboratories, Center for Transplantation Sciences (CTS), Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - D H Sachs
- Transplantation Biology Research Center (TBRC) Laboratories, Center for Transplantation Sciences (CTS), Massachusetts General Hospital, Harvard Medical School, Boston, MA
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40
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Scalea JR, Redfield RR, Muth BL, Mohamed M, Wilson NA, Ellis TM, Kaufman DB, Djamali A. Older kidney transplant patients experience less antibody-mediated rejection: a retrospective study of patients with mild to moderate sensitization. Clin Transplant 2015; 29:1090-7. [DOI: 10.1111/ctr.12632] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2015] [Indexed: 01/30/2023]
Affiliation(s)
- Joseph R. Scalea
- Division of Transplantation; Department of Surgery; University of Wisconsin; Madison WI USA
| | - Robert R. Redfield
- Division of Transplantation; Department of Surgery; University of Wisconsin; Madison WI USA
| | - Brenda L. Muth
- Division of Nephrology; Department of Medicine; University of Wisconsin; Madison WI USA
| | - Maha Mohamed
- Division of Nephrology; Department of Medicine; University of Wisconsin; Madison WI USA
| | - Nancy A. Wilson
- Division of Nephrology; Department of Medicine; University of Wisconsin; Madison WI USA
| | - Thomas M. Ellis
- Department of Surgery; HLA Laboratory; University of Wisconsin; Madison WI USA
| | - Dixon B. Kaufman
- Division of Transplantation; Department of Surgery; University of Wisconsin; Madison WI USA
| | - Arjang Djamali
- Division of Nephrology; Department of Medicine; University of Wisconsin; Madison WI USA
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41
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Redfield RR, Scalea JR, Zens TJ, Muth B, Kaufman DB, Djamali A, Astor BC, Mohamed M. Predictors and outcomes of delayed graft function after living-donor kidney transplantation. Transpl Int 2015; 29:81-7. [DOI: 10.1111/tri.12696] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 09/07/2015] [Accepted: 09/23/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Robert R. Redfield
- Division of Transplant Surgery; University of Wisconsin Hospital and Clinics; Madison WI USA
| | - Joseph R. Scalea
- Division of Transplant Surgery; University of Wisconsin Hospital and Clinics; Madison WI USA
| | - Tiffany J. Zens
- Division of Transplant Surgery; University of Wisconsin Hospital and Clinics; Madison WI USA
| | - Brenda Muth
- Division of Nephrology; Department of Medicine; University of Wisconsin Hospital and Clinics; Madison WI USA
| | - Dixon B. Kaufman
- Division of Transplant Surgery; University of Wisconsin Hospital and Clinics; Madison WI USA
| | - Arjang Djamali
- Division of Transplant Surgery; University of Wisconsin Hospital and Clinics; Madison WI USA
- Division of Nephrology; Department of Medicine; University of Wisconsin Hospital and Clinics; Madison WI USA
| | - Brad C. Astor
- Departments of Medicine and Population Health Sciences; University of Wisconsin School of Medicine and Public Health; Madison WI USA
| | - Maha Mohamed
- Division of Nephrology; Department of Medicine; University of Wisconsin Hospital and Clinics; Madison WI USA
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Scalea JR, Torabi R, Tena A, Tasaki M, Gillon BC, Moran S, Cormack T, Villani V, Shimizu A, Sachs DH, Yamada K. The rejuvenating effects of leuprolide acetate on the aged baboon's thymus. Transpl Immunol 2014; 31:134-9. [PMID: 25240733 DOI: 10.1016/j.trim.2014.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 05/27/2014] [Revised: 09/02/2014] [Accepted: 09/05/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND We have previously demonstrated that the juvenile thymus plays an essential role in tolerance induced by both renal transplantation and a short course of calcineurin inhibitors. Aged thymi have a decreased ability to induce tolerance. Luteinizing hormone-releasing hormone (LHRH) is known to pharmacologically rejuvenate the thymus in rodents. In order to develop a clinically applicable regimen of transplantation tolerance in adults, we sought to determine if thymic rejuvenation would occur with LHRH agonism in non-human primates. METHODS AND RESULTS Thymic rejuvenation was evaluated by magnetic resonance imaging (MRI), histology, as well as in-vitro cellular and molecular tests. Four aged male hamadryas baboons underwent subcutaneous injection of a 3-month depot of Lupron (11.25mg; LI) and were followed for 3 months. Thymi increased volumetrically by MRI. After LI, thymic cellularity markedly increased within the cortical and medullary thymus. Additionally, a significant increase in the CD4(+)/CD45RA(hi+) population in the peripheral blood occurred for 50 days after LI, and flow cytometry of thymic tissue revealed a large increase in the percentage of CD4(+)/CD8(+) cells. TREC assay corroborated enhancement in thymic function. CONCLUSION These data indicate that LI is associated with thymic rejuvenation in baboons, and further confirm that extrinsic factors play an important role in thymic rejuvenation in a non-human primate model.
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Affiliation(s)
- Joseph R Scalea
- Transplantation Biology Research Center, Massachusetts General Hospital, Boston, MA 02129, United States; Harvard Medical School, Boston, MA 02129, United States
| | - Radbeh Torabi
- Transplantation Biology Research Center, Massachusetts General Hospital, Boston, MA 02129, United States; Harvard Medical School, Boston, MA 02129, United States
| | - Aseda Tena
- Transplantation Biology Research Center, Massachusetts General Hospital, Boston, MA 02129, United States; Harvard Medical School, Boston, MA 02129, United States
| | - Masayuki Tasaki
- Transplantation Biology Research Center, Massachusetts General Hospital, Boston, MA 02129, United States; Harvard Medical School, Boston, MA 02129, United States
| | - Bradford C Gillon
- Transplantation Biology Research Center, Massachusetts General Hospital, Boston, MA 02129, United States; Harvard Medical School, Boston, MA 02129, United States
| | - Shannon Moran
- Transplantation Biology Research Center, Massachusetts General Hospital, Boston, MA 02129, United States; Harvard Medical School, Boston, MA 02129, United States
| | - Taylor Cormack
- Transplantation Biology Research Center, Massachusetts General Hospital, Boston, MA 02129, United States; Harvard Medical School, Boston, MA 02129, United States
| | - Vincenzo Villani
- Transplantation Biology Research Center, Massachusetts General Hospital, Boston, MA 02129, United States; Harvard Medical School, Boston, MA 02129, United States
| | - Akira Shimizu
- Transplantation Biology Research Center, Massachusetts General Hospital, Boston, MA 02129, United States; Harvard Medical School, Boston, MA 02129, United States
| | - David H Sachs
- Transplantation Biology Research Center, Massachusetts General Hospital, Boston, MA 02129, United States; Harvard Medical School, Boston, MA 02129, United States
| | - Kazuhiko Yamada
- Transplantation Biology Research Center, Massachusetts General Hospital, Boston, MA 02129, United States; Harvard Medical School, Boston, MA 02129, United States
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Scalea JR, Okumi M, Villani V, Shimizu A, Nishimura H, Gillon BC, Torabi R, Cormack T, Moran S, LeGuern C, Sachs DH, Yamada K. Abrogation of renal allograft tolerance in MGH miniature swine: the role of intra-graft and peripheral factors in long-term tolerance. Am J Transplant 2014; 14:2001-10. [PMID: 25100613 PMCID: PMC4194165 DOI: 10.1111/ajt.12816] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [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: 11/25/2013] [Revised: 04/22/2014] [Accepted: 05/01/2014] [Indexed: 01/25/2023]
Abstract
We have previously demonstrated that long-term tolerance (LTT) of an MHC class-I mismatched renal allograft can be achieved with a short course of cyclosporine. In order to examine regulatory mechanisms underlying tolerance in this model, we assessed the contributions of factors within the graft and in the peripheral blood for their relative roles in the maintenance of stable tolerance. Twelve LTT recipients of MHC class-I mismatched primary kidneys were subjected to a treatment consisting of donor-specific transfusion followed by leukapheresis, in order to remove peripheral leukocytes, including putative regulatory T cells (Tregs). Following treatment, 2 controls were followed clinically and 10 animals had the primary graft removed and received a second, donor-MHC-matched kidney. Neither control animal showed evidence of rejection, while 8 of 10 retransplanted animals developed either rejection crisis or full rejection of the second transplant. In vitro assays confirmed that the removed leukocytes were suppressive and that CD4(+) Foxp3(+) Treg reconstitution in blood and kidney grafts correlated with return to normal renal function in animals experiencing transient rejection crises. These data indicate that components of accepted kidney grafts as well as peripheral regulatory components both contribute to the tolerogenic environment required for tolerance of MHC class-I mismatched allotransplants.
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Abstract
INTRODUCTION Statin use after renal transplantation improves long-term outcome and reduces the incidence of glomerulonephritis. With both anti-inflammatory and cardioprotective effects, statins may also improve outcomes in pancreas transplantation. METHODS A retrospective review at a single institution was undertaken. Patients who underwent solitary pancreas transplantation between 2001 and 2010 were identified. Multiple data points including recipient and donor demographics, patient and graft outcomes, and early use of statins were collected. RESULTS Sixty-eight patients underwent solitary pancreas transplantation within the study period. Eighteen patients (26%) were already on, or were prescribed, a statin at the time of hospital discharge; the 1-year death-censored graft survival was 81.25% for those that were on statins versus 72.9% for those without (P = NS). Excluding patients with early graft loss (<600 days) mean graft survival was 646 days longer for patients receiving statins (P = .02). CONCLUSIONS The use of statins in the solitary pancreas transplant patient may lead to improved outcomes. Whether this is owing to cardiovascular protection or to other factors not associated with lipid lowering remains unclear.
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Affiliation(s)
- J R Scalea
- University of Maryland, Baltimore, Maryland.
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Okumi M, Scalea JR, Gillon BC, Tasaki M, Villani V, Cormack T, Hirakata A, Shimizu A, Sachs DH, Yamada K. The induction of tolerance of renal allografts by adoptive transfer in miniature swine. Am J Transplant 2013; 13:1193-202. [PMID: 23464595 PMCID: PMC3671754 DOI: 10.1111/ajt.12194] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2012] [Revised: 12/17/2012] [Accepted: 01/04/2013] [Indexed: 01/25/2023]
Abstract
Our previous in vitro data have demonstrated that regulatory mechanisms are involved in tolerance of class I-mismatched renal allografts in miniature swine treated with 12 days of high dose Cyclsporin A. In this study, we attempted to induce tolerance of class I-mismatched kidneys by adoptive transfer of cells and/or kidneys from long-term tolerant animals. Fifteen SLA(dd) miniature swine received 1.5 Gy whole body irradiation and class I-mismatched (SLA(gg) ) kidneys from naïve pigs with or without cotransplanted kidneys and/or adoptively transferred cells from long-term tolerant (LTT) SLA(dd) recipients of SLA(gg) grafts. In addition, three SLA(dd) miniature swine received class I mismatched kidney with adoptively transferred cells from LTT SLA(dd) recipients. Naïve kidneys transplanted without a LTT kidney were rejected within 9 days. All recipients of naive kidneys along with cells and kidney grafts from LTT animals showed markedly prolonged survival of the naive renal grafts (day 28, >150 and >150 days). These studies suggest that (1) tolerated kidneys have potent regulatory effects and (2) cells from LTT animals infused in conjunction with kidney grafts augment these regulatory effects. To our knowledge, these studies represent the first demonstration of successful adoptive transfer of tolerance in large animals.
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Affiliation(s)
- Masayoshi Okumi
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard
Medical School, Boston, Massachusetts
| | - Joseph R. Scalea
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard
Medical School, Boston, Massachusetts
| | - Brad C. Gillon
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard
Medical School, Boston, Massachusetts
| | - Masayuki Tasaki
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard
Medical School, Boston, Massachusetts
| | - Vincenzo Villani
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard
Medical School, Boston, Massachusetts
| | - Taylor Cormack
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard
Medical School, Boston, Massachusetts
| | - Atsushi Hirakata
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard
Medical School, Boston, Massachusetts
| | | | - David H Sachs
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard
Medical School, Boston, Massachusetts
| | - Kazuhiko Yamada
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard
Medical School, Boston, Massachusetts,Address for Correspondence: Kazuhiko Yamada, M.D., PhD., Director, Surgical research
and head, Organ Transplantation Tolerance and Xenotransplantation Laboratory, Transplantation
Biology Research Center, Massachusetts General Hospital. MGH-East, Bldg. 149-9014, 13th Street,
Boston, MA, 02129, Tel: 617-726-4065, FAX: 617-726-4067,
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Leto Barone AA, Leonard DA, Torabi R, Mallard C, Glor T, Scalea JR, Randolph MA, Sachs DH, Cetrulo CL. The gracilis myocutaneous free flap in swine: an advantageous preclinical model for vascularized composite allograft transplantation research. Microsurgery 2012; 33:51-5. [PMID: 22707437 DOI: 10.1002/micr.21997] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 04/13/2012] [Indexed: 11/09/2022]
Abstract
Vascularized composite allotransplantation (VCA) has become a clinical reality, prompting research aimed at improving the risk-benefit ratio of such transplants. Here, we report our experience with a gracilis myocutaneous free flap in Massachusetts General Hospital miniature swine as a preclinical VCA model. Fourteen animals underwent free transfer of a gracilis myocutaneous flap comprised of the gracilis muscle and overlying skin, each tissue supplied by independent branches of the femoral vessels. End-to-end anastomoses were performed to the common carotid artery and internal jugular vein, or to the femoral vessels of the recipients. Thirteen of fourteen flaps were successful. A single flap was lost due to compromise of venous outflow. This model allows transplantation of a substantial volume of skin, subcutaneous tissue, and muscle. The anatomy is reliable and easily identified and harvest incurs minimal donor morbidity. We find this gracilis myocutaneous flap an excellent pre-clinical model for the study of vascularized composite allotransplantation.
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Affiliation(s)
- Angelo A Leto Barone
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
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Abstract
Diabetes mellitus type II (or type 2 diabetes; DM2) has multiple definitions but is generally considered to be a disease marked by insulin resistance and loss of β cell function that develops in adulthood. Today, greater than 90% of patients with diabetes have DM2. When uncontrolled, DM2 may result in comorbidities such as cardiovascular disease, retinopathy, neuropathy, immune system dysfunction, and renal failure. Classically, treatment of type 2 diabetes has included dietary and lifestyle changes. Even with behavior modification and oral hypoglycemics, many patients are unable to maintain glycemic control. With a growing understanding of the hormonal signals involved in the pathogenesis of type 2 diabetes, there has been a shift in the therapeutic approach to this growing epidemic. Bariatric surgery has been shown to decrease the progression and potentially reverse the effects of diabetes in 80% to 90% of patients. In addition, bariatric operations are associated with sustained weight loss in contrast to nonsurgical options. The antidiabetic effect of bariatric operations is likely due to the improvement in the hormonal dysregulation associated with the development of diabetes. Many patients with diabetes, however, have irreparably damaged insulin production capabilities as well. In addition, it is well recognized that transplantation may be required for patients with severe loss of islet cell function. Surgery for type 2 diabetes, via bariatric procedures and transplantation, has become an important treatment modality for patients with advanced disease.
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Affiliation(s)
- Joseph R Scalea
- Division of Transplantation, Department of Surgery, University of Maryland, Baltimore, MD, USA.
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Abstract
Diabetes mellitus (DM) represents an enormous health care concern for the United States and other countries. According to the American Diabetes Association in 2007, there were more than 23 million Americans living with diabetes. This is a 13.5% increase from 2005, likely representing increases in Type II DM (DMII). Diabetes mellitus results when the beta cells of the pancreas are unable to produce sufficient insulin to prevent hyperglycemia. Simultaneous pancreas and kidney transplantation, or SPK, may be indicated for patients that have experienced renal failure as a complication of DM (either type I or type II). Until recently, technical failure represented a significant impediment to the success of pancreas transplantation. At the turn of the century, however, both renal and pancreatic graft survival dramatically improved. Immunologic and nonimmunologic causes of graft failure continue to challenge inpatient and outpatient management. With vigilance in the ICU postoperatively and in the clinic, SPK can provide significant benefit both in patient survival and quality of life.
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Affiliation(s)
- Joseph R Scalea
- Division of Transplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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