1
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Khalili M, Famure O, Minkovich M, Tinckam KJ, Kim SJ. Selective Elimination and Rationalization of Cell-based Assays in Deceased Donor Kidney Transplant Crossmatching. Transplant Direct 2024; 10:e1603. [PMID: 38464424 PMCID: PMC10923350 DOI: 10.1097/txd.0000000000001603] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/30/2023] [Accepted: 01/24/2024] [Indexed: 03/12/2024] Open
Abstract
Background While there is increasing reliance on a negative virtual crossmatch to proceed with deceased donor kidney transplantation, a flow cytometry crossmatch (FCXM) is still usually performed after the transplant has already occurred. Our center has eliminated pretransplant physical crossmatches for most patients, and since 2018, we have eliminated the systematic performance of posttransplant FCXMs. Methods We studied all deceased donor kidney transplants in our program between June 1, 2018, and March 31, 2021, to evaluate the impact of eliminating retrospective FCXMs on resource utilization and graft outcomes (ie, the occurrence of antibody-mediated rejection [AMR] in the first 3-mo posttransplant). Results A total of 358 kidney transplants occurred during the study period, and approximately 70% of these transplants proceeded without the performance of any FCXM. Incidence rates of AMR were low (9.63 per 1000 person-months), which compared favorably with the incidence rate of AMR during the 3-y period preceding the policy (4.82 per 1000 person-months, P = 0.21). Conclusions Our results suggest that moving away from retrospective FCXM and relying exclusively on the virtual crossmatch is safe and efficient for kidney allocation.
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Affiliation(s)
- Myriam Khalili
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Olusegun Famure
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Michelle Minkovich
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Kathryn J Tinckam
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Sang Joseph Kim
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
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2
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Mimouni M, Cole E, Kim SJ, Schiff J, Cardella C, Tinckam KJ, Slomovic AR, Chan CC. Outcomes of keratolimbal allograft from ABO compatible donors for severe bilateral limbal stem cell deficiency. Ocul Surf 2023; 27:48-53. [PMID: 36371055 DOI: 10.1016/j.jtos.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/05/2022] [Accepted: 11/08/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE To report outcomes of keratolimbal allograft (KLAL) compatible for both human leukocyte (HLA) and/or blood type using oral prednisone, mycophenolate, and tacrolimus, with basiliximab if panel reactive antibodies (PRA) are present. Intravenous immunoglobulin (IVIG) was used post-operatively if donor-specific anti-HLA antibodies (DSA) were present. METHODS Retrospective interventional series of consecutive patients with KLAL for limbal stem cell deficiency (LSCD) from HLA and/or blood type compatible deceased donors with a minimum follow-up time of 12 months. Main outcome measures were ocular surface stability, visual acuity and systemic immunosuppression (SI) adverse events. RESULTS Eight eyes of eight patients with mean age of 48.6 ± 10.1 years (range 34-65 years) were included. Mean follow-up time was 37.3 ± 22.7 months (range 12-71 months) following KLAL; four (50%) had combined LR-CLAL surgery. The etiologies of LSCD were Stevens-Johnson Syndrome (n = 4/8), aniridia (n = 2/8), chemical injury (n = 1/8) and atopic eye disease (n = 1/8). All patients had PRA present and received basiliximab infusions. 5/8 patients received IVIG based on DSA identified pre-operatively. At last follow-up, 7 eyes (87.5%) had a stable ocular surface; 1 eye (12.5%) developed failure and had keratoprosthesis implantation. There was a significant improvement in visual acuity from 1.65 ± 0.48 to 0.68 ± 0.34 logMAR (p = 0.01). SI was tolerated well with minimal adverse events. CONCLUSIONS Preliminary outcomes of KLAL with ABO compatible tissue using the Cincinnati protocol, preoperative basiliximab (when PRA present) and post-operative IVIG (when DSA present) are encouraging. This protocol may allow for utilization of deceased donor tissue with results approximating those of living donor tissue transplanted for severe bilateral LSCD.
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Affiliation(s)
- Michael Mimouni
- University of Toronto, Department of Ophthalmology and Vision Sciences, Toronto, Ontario, Canada; Department of Ophthalmology, Rambam Health Care Campus affiliated with the Bruce and Ruth Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Edward Cole
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - S Joseph Kim
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Jeffrey Schiff
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Carl Cardella
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Kathryn J Tinckam
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Allan R Slomovic
- University of Toronto, Department of Ophthalmology and Vision Sciences, Toronto, Ontario, Canada
| | - Clara C Chan
- University of Toronto, Department of Ophthalmology and Vision Sciences, Toronto, Ontario, Canada.
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3
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Murray KR, Foroutan F, Amadio JM, Posada JD, Kozuszko S, Duhamel J, Tsang K, Farkouh ME, McDonald M, Billia F, Barber E, Hershman SG, Bhat M, Tinckam KJ, Ross HJ, McIntosh C, Moayedi Y. Remote Mobile Outpatient Monitoring in Transplant (Reboot) 2.0: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2021; 10:e26816. [PMID: 34528885 PMCID: PMC8571683 DOI: 10.2196/26816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 04/02/2021] [Accepted: 04/19/2021] [Indexed: 01/19/2023] Open
Abstract
Background The number of solid organ transplants in Canada has increased 33% over the past decade. Hospital readmissions are common within the first year after transplant and are linked to increased morbidity and mortality. Nearly half of these admissions to the hospital appear to be preventable. Mobile health (mHealth) technologies hold promise to reduce admission to the hospital and improve patient outcomes, as they allow real-time monitoring and timely clinical intervention. Objective This study aims to determine whether an innovative mHealth intervention can reduce hospital readmission and unscheduled visits to the emergency department or transplant clinic. Our second objective is to assess the use of clinical and continuous ambulatory physiologic data to develop machine learning algorithms to predict the risk of infection, organ rejection, and early mortality in adult heart, kidney, and liver transplant recipients. Methods Remote Mobile Outpatient Monitoring in Transplant (Reboot) 2.0 is a two-phased single-center study to be conducted at the University Health Network in Toronto, Canada. Phase one will consist of a 1-year concealed randomized controlled trial of 400 adult heart, kidney, and liver transplant recipients. Participants will be randomized to receive either personalized communication using an mHealth app in addition to standard of care phone communication (intervention group) or standard of care communication only (control group). In phase two, the prior collected data set will be used to develop machine learning algorithms to identify early markers of rejection, infection, and graft dysfunction posttransplantation. The primary outcome will be a composite of any unscheduled hospital admission, visits to the emergency department or transplant clinic, following discharge from the index admission. Secondary outcomes will include patient-reported outcomes using validated self-administered questionnaires, 1-year graft survival rate, 1-year patient survival rate, and the number of standard of care phone voice messages. Results At the time of this paper’s completion, no results are available. Conclusions Building from previous work, this project will aim to leverage an innovative mHealth app to improve outcomes and reduce hospital readmission in adult solid organ transplant recipients. Additionally, the development of machine learning algorithms to better predict adverse health outcomes will allow for personalized medicine to tailor clinician-patient interactions and mitigate the health care burden of a growing patient population. Trial Registration ClinicalTrials.gov NCT04721288; https://www.clinicaltrials.gov/ct2/show/NCT04721288 International Registered Report Identifier (IRRID) PRR1-10.2196/26816
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Affiliation(s)
- Kevin R Murray
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Farid Foroutan
- Ted Rogers Computational Program, University Health Network, Toronto, ON, Canada
| | - Jennifer M Amadio
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.,Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Juan Duero Posada
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.,Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Stella Kozuszko
- Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Joseph Duhamel
- Ted Rogers Computational Program, University Health Network, Toronto, ON, Canada
| | - Katherine Tsang
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Michael E Farkouh
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Michael McDonald
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.,Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Filio Billia
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.,Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | | | - Steven G Hershman
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Mamatha Bhat
- Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada.,Division of Gastroenterology & Hepatology, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Kathryn J Tinckam
- Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada.,Division of Nephrology, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Heather J Ross
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.,Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Christopher McIntosh
- Ted Rogers Computational Program, University Health Network, Toronto, ON, Canada
| | - Yasbanoo Moayedi
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.,Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
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4
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Chadban SJ, Ahn C, Axelrod DA, Foster BJ, Kasiske BL, Kher V, Kumar D, Oberbauer R, Pascual J, Pilmore HL, Rodrigue JR, Segev DL, Sheerin NS, Tinckam KJ, Wong G, Balk EM, Gordon CE, Earley A, Rofeberg V, Knoll GA. Summary of the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation 2020; 104:708-714. [PMID: 32224812 PMCID: PMC7147399 DOI: 10.1097/tp.0000000000003137] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Indexed: 11/25/2022]
Abstract
The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence. The strengths of recommendations are provided in the full report. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.
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Affiliation(s)
- Steven J Chadban
- Royal Prince Alfred Hospital and Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Curie Ahn
- Seoul National University, Seoul, South Korea
| | | | - Bethany J Foster
- The Montreal Children's Hospital, McGill University Health Centre, Montreal, Canada
| | | | - Vijah Kher
- Medanta Kidney and Urology Institute, Haryana, India
| | - Deepali Kumar
- University Health Network, University of Toronto, Toronto, Canada
| | | | | | | | | | - Dorry L Segev
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | | | - Ethan M Balk
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI, USA
| | | | | | - Valerie Rofeberg
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI, USA
| | - Gregory A Knoll
- The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Canada
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5
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Sapir-Pichhadze R, Zhang X, Ferradji A, Madbouly A, Tinckam KJ, Gebel HM, Blum D, Marrari M, Kim SJ, Fingerson S, Bashyal P, Cardinal H, Foster BJ. Epitopes as characterized by antibody-verified eplet mismatches determine risk of kidney transplant loss. Kidney Int 2019; 97:778-785. [PMID: 32059998 DOI: 10.1016/j.kint.2019.10.028] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [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: 07/01/2019] [Revised: 09/26/2019] [Accepted: 10/17/2019] [Indexed: 01/01/2023]
Abstract
To optimize strategies that mitigate the risk of graft loss associated with HLA incompatibility, we evaluated whether sequence defined HLA targets (eplets) that result in donor-specific antibodies are associated with transplant outcomes. To define this, we fit multivariable Cox proportional hazard models in a cohort of 118 382 United States first kidney transplant recipients to assess risk of death-censored graft failure by increments of ten antibody-verified eplet mismatches. To verify robustness of our findings, we conducted sensitivity analysis in this United States cohort and assessed the role of antibody-verified eplet mismatches as autonomous predictors of transplant glomerulopathy in an independent Canadian cohort. Antibody-verified eplet mismatches were found to be independent predictors of death-censored graft failure with hazard ratios of 1.231 [95% confidence interval 1.195, 1. 268], 1.268 [1.231, 1.305] and 1.411 [1.331, 1.495] for Class I (HLA-A, B, and C), -DRB1 and -DQB1 loci, respectively. To address linkage disequilibrium between HLA-DRB1 and -DQB1, we fit models in a subcohort without HLA-DQB1 eplet mismatches and found hazard ratios for death-censored graft failure of 1.384 [1.293, 1.480] for each additional antibody-verified HLA-DRB1 eplet mismatch. In a subcohort without HLA-DRB1 mismatches, the hazard ratio was 1.384 [1.072, 1.791] for each additional HLA-DQB1 mismatch. In the Canadian cohort, antibody-verified eplet mismatches were independent predictors of transplant glomerulopathy with hazard ratios of 5.511 [1.442, 21.080] for HLA-DRB1 and 3.640 [1.574, 8.416] for -DRB1/3/4/5. Thus, donor-recipient matching for specific HLA eplets appears to be a feasible and clinically justifiable strategy to mitigate risk of graft loss.
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Affiliation(s)
- Ruth Sapir-Pichhadze
- Division of Nephrology, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada; The Multi Organ Transplant Program, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada; Centre for Outcomes Research and Evaluation (CORE), McGill University Health Centre, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.
| | - Xun Zhang
- Centre for Outcomes Research and Evaluation (CORE), McGill University Health Centre, Montreal, Quebec, Canada
| | - Abdelhakim Ferradji
- Research Institute, McGill University Health Centre, Montreal, Quebec, Canada
| | - Abeer Madbouly
- Bioinformatics Research, Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota, USA
| | - Kathryn J Tinckam
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; The Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Laboratory Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Howard M Gebel
- Department of Pathology, Emory University, Atlanta, Georgia, USA
| | - Daniel Blum
- Division of Nephrology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Marilyn Marrari
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - S Joseph Kim
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; The Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Stephanie Fingerson
- Bioinformatics Research, Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota, USA
| | - Pradeep Bashyal
- Bioinformatics Research, Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota, USA
| | | | - Bethany J Foster
- Centre for Outcomes Research and Evaluation (CORE), McGill University Health Centre, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada; Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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6
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Brar SK, Tinckam KJ. Strategies to offer kidney transplant to highly sensitized patients. Nephrol Dial Transplant 2019. [DOI: 10.1093/ndt/gfy260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sandeep K Brar
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kathryn J Tinckam
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
- HLA Laboratory, Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
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7
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McCaughan JA, Battle RK, Singh SKS, Tikkanen JM, Moayedi Y, Ross HJ, Singer LG, Keshavjee S, Tinckam KJ. Identification of risk epitope mismatches associated with de novo donor-specific HLA antibody development in cardiothoracic transplantation. Am J Transplant 2018; 18:2924-2933. [PMID: 29847022 DOI: 10.1111/ajt.14951] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 04/26/2018] [Accepted: 05/22/2018] [Indexed: 01/25/2023]
Abstract
The development of de novo donor-specific HLA antibodies (dnDSA) after transplantation is associated with graft failure, mortality, and cost. There is no effective therapeutic intervention to prevent dnDSA or ameliorate associated injury. The aims of this study were to identify specific HLA factors associated with dnDSA development and to propose primary prevention strategies that could reduce the incidence of dnDSA without prohibitively limiting access to transplant. The investigation cohort included heart transplant recipients from 2008 to 2015 (n = 265). HLA typing was performed and HLA antibody testing was undertaken before and after transplantation. HLAMatchmaker analysis was performed for persistent dnDSA to identify potentially more immunogenic eplet differences. Validation was performed in recipients of lung transplants from 2008 to 2013 (n = 433). The majority of recipients with dnDSA had antibodies to identical eplet positions on DQ2 and DQ7. A high-risk epitope mismatch (found in DQA1*05 + DQB1*02/DQB1*03:01(7)) was associated with a 4.2- and 4.9-fold increased risk of dnDSA in heart and lung recipients respectively. HLA electrostatic potential modeling provided a plausible explanation for this observed immunogenicity. A theoretical allocation algorithm avoiding high-risk epitope mismatches was generated and predicted to reduce dnDSA by up to 72% without additional testing, eplet analysis, or cost.
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Affiliation(s)
- J A McCaughan
- HLA Laboratory, Laboratory Medicine Program, University Health Network, Toronto, Canada
| | - R K Battle
- Histocompatibility & Immunogenetics Laboratory, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - S K S Singh
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Canada
| | - J M Tikkanen
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Y Moayedi
- Toronto Heart Transplant Program, University Health Network, Toronto, Canada
| | - H J Ross
- Toronto Heart Transplant Program, University Health Network, Toronto, Canada
| | - L G Singer
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - S Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - K J Tinckam
- HLA Laboratory, Laboratory Medicine Program, University Health Network, Toronto, Canada.,Division of Nephrology, Department of Medicine, University Health Network, Toronto, Canada
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8
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Moayedi Y, Fan CPS, Tinckam KJ, Ross HJ, McCaughan JA. De novo donor-specific HLA antibodies in heart transplantation: Do transient de novo DSA confer the same risk as persistent de novo DSA? Clin Transplant 2018; 32:e13416. [DOI: 10.1111/ctr.13416] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/24/2018] [Accepted: 09/24/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Yasbanoo Moayedi
- Ted Rogers Centre of Excellence in Heart Function; University Health Network; Toronto Ontario Canada
- Cardiovascular Medicine, Heart Transplantation; Stanford University; Stanford California
| | - Chun-Po S. Fan
- Department of Pediatrics, The Labatt Family Heart Centre; The Hospital for Sick Children, University of Toronto; Toronto Ontario Canada
| | - Kathryn J. Tinckam
- HLA Laboratory, Laboratory Medicine Program; University Health Network; Toronto Ontario Canada
- Division of Nephrology, Department of Medicine; University Health Network; Toronto Ontario Canada
| | - Heather J. Ross
- Ted Rogers Centre of Excellence in Heart Function; University Health Network; Toronto Ontario Canada
| | - Jennifer A. McCaughan
- HLA Laboratory, Laboratory Medicine Program; University Health Network; Toronto Ontario Canada
- Division of Nephrology, Department of Medicine; University Health Network; Toronto Ontario Canada
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9
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McCaughan JA, Tinckam KJ. Donor specific HLA antibodies & allograft injury: mechanisms, methods of detection, manifestations and management. Transpl Int 2018; 31:1059-1070. [DOI: 10.1111/tri.13324] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/11/2018] [Accepted: 07/27/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Jennifer A. McCaughan
- HLA Laboratory; Laboratory Medicine Program; University Health Network; Toronto ON Canada
- Department of Nephrology and Transplantation; Belfast City Hospital; Belfast UK
| | - Kathryn J. Tinckam
- HLA Laboratory; Laboratory Medicine Program; University Health Network; Toronto ON Canada
- Division of Nephrology; Department of Medicine; University Health Network; Toronto ON Canada
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10
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Snyder LD, Tinckam KJ. Another piece of the antibody puzzle: Observations from the HALT study. Am J Transplant 2018; 18:2111-2112. [PMID: 29862642 DOI: 10.1111/ajt.14959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 05/09/2018] [Accepted: 05/28/2018] [Indexed: 01/25/2023]
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11
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Ballios BG, Weisbrod M, Chan CC, Borovik A, Schiff JR, Tinckam KJ, Humar A, Kim SJ, Cole EH, Slomovic AR. Systemic immunosuppression in limbal stem cell transplantation: best practices and future challenges. Can J Ophthalmol 2018; 53:314-323. [PMID: 30119783 DOI: 10.1016/j.jcjo.2017.10.040] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 10/17/2017] [Accepted: 10/19/2017] [Indexed: 02/01/2023]
Abstract
The objective of this study was to evaluate systemic immunosuppression regimens used for patients undergoing ocular surface stem cell transplantation, including their benefits and adverse effects in the adjunctive management of limbal stem cell deficiency (LSCD). A systematic literature review was conducted using the MEDLINE and EMBASE databases (1980-2015). Data were collected on surgical intervention(s), type of immunosuppressive agent(s), duration of immunosuppression, percentage with stable ocular surface at last follow-up, mean follow-up time, and demographics. Data were also collected on adverse ocular and systemic outcomes. Sixteen reports met the inclusion criteria. There were no randomized controlled studies. Three studies were noncomparative prospective case series, whereas the majority were retrospective case series. Bilateral severe LSCD was the most common disease (50%), and keratolimbal allograft was the most common intervention (80%). Immunosuppressive regimens showed a progression from early studies using oral cyclosporine to later studies using combinations of mycophenolate mofetil and tacrolimus. Most studies included a course of high-dose systemic corticosteroids. For patients adherent to long-term systemic immunosuppression, stable ocular surface rates of 70%-80% at last follow-up were reported. Adverse effects included hypertension, diabetes mellitus, and biochemical abnormalities managed with pharmacotherapy or discontinuation of offending agents. There were no cases of mortality related to immunosuppression. However, the current literature does not elucidate which immunosuppressive regimen is most efficacious for different categories of LSCD or graft types. Evidence-based guidelines for systemic immunosuppression in limbal allograft therapy would benefit from randomized controlled and/or additional prospective studies. Long-term immunosuppression would benefit from close collaboration between ophthalmologists and transplant specialists to individualize treatments.
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Affiliation(s)
- Brian G Ballios
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ont
| | - Maxwell Weisbrod
- Department of Family and Community Medicine, University of Toronto, Toronto, Ont
| | - Clara C Chan
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ont
| | - Armand Borovik
- Department of Ophthalmology, Toronto Western Hospital, University of Toronto, Toronto, Ont
| | - Jeffrey R Schiff
- Toronto Transplant Institute, University Health Network, Toronto, Ont.; Department of Medicine (Nephrology), Toronto General Hospital, University of Toronto, Toronto, Ont
| | - Kathryn J Tinckam
- Toronto Transplant Institute, University Health Network, Toronto, Ont.; Department of Medicine (Nephrology), Toronto General Hospital, University of Toronto, Toronto, Ont
| | - Atul Humar
- Toronto Transplant Institute, University Health Network, Toronto, Ont
| | - S Joseph Kim
- Toronto Transplant Institute, University Health Network, Toronto, Ont.; Department of Medicine (Nephrology), Toronto General Hospital, University of Toronto, Toronto, Ont
| | - Edward H Cole
- Toronto Transplant Institute, University Health Network, Toronto, Ont.; Department of Medicine (Nephrology), Toronto General Hospital, University of Toronto, Toronto, Ont.; University Health Network, Toronto General Hospital, Toronto, Ont
| | - Allan R Slomovic
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ont.; Toronto Transplant Institute, University Health Network, Toronto, Ont..
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12
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Reynolds BC, Tinckam KJ. Sensitization assessment before kidney transplantation. Transplant Rev (Orlando) 2017; 31:18-28. [DOI: 10.1016/j.trre.2016.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 10/05/2016] [Indexed: 01/28/2023]
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13
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Sapir-Pichhadze R, Pintilie M, Tinckam KJ, Laupacis A, Logan AG, Beyene J, Kim SJ. Survival Analysis in the Presence of Competing Risks: The Example of Waitlisted Kidney Transplant Candidates. Am J Transplant 2016; 16:1958-66. [PMID: 26751409 DOI: 10.1111/ajt.13717] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 12/30/2015] [Accepted: 01/03/2016] [Indexed: 01/25/2023]
Abstract
Competing events (or risks) preclude the observation of an event of interest or alter the probability of the event's occurrence and are commonly encountered in transplant outcomes research. Transplantation, for example, is a competing event for death on the waiting list because receiving a transplant may significantly decrease the risk of long-term mortality. In a typical analysis of time-to-event data, competing events may be censored or incorporated into composite end points; however, the presence of competing events violates the assumption of "independent censoring," which is the basis of standard survival analysis techniques. The use of composite end points disregards the possibility that competing events may be related to the exposure in a way that is different from the other components of the composite. Using data from the Scientific Registry of Transplant Recipients, this paper reviews the principles of competing risks analysis; outlines approaches for analyzing data with competing events (cause-specific and subdistribution hazards models); compares the estimates obtained from standard survival analysis, which handle competing events as censoring events; discusses the appropriate settings in which each of the two approaches could be used; and contrasts their interpretation.
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Affiliation(s)
- R Sapir-Pichhadze
- Division of Nephrology and the Multi Organ Transplant Program, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada.,Centre for Outcomes Research and Evaluation (CORE), McGill University Health Centre, Montreal, Quebec, Canada.,Division of Nephrology, Department of Medicine, McGill University, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - M Pintilie
- Division of Biostatistics, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - K J Tinckam
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Departments of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - A Laupacis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Departments of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - A G Logan
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - J Beyene
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Population Health Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - S J Kim
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology and the Renal Transplant Program, St. Michael's Hospital, Toronto, Ontario, Canada
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14
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Chruscinski A, Huang FYY, Nguyen A, Lioe J, Tumiati LC, Kozuszko S, Tinckam KJ, Rao V, Dunn SE, Persinger MA, Levy GA, Ross HJ. Generation of Antigen Microarrays to Screen for Autoantibodies in Heart Failure and Heart Transplantation. PLoS One 2016; 11:e0151224. [PMID: 26967734 PMCID: PMC4788148 DOI: 10.1371/journal.pone.0151224] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 02/23/2016] [Indexed: 11/19/2022] Open
Abstract
Autoantibodies directed against endogenous proteins including contractile proteins and endothelial antigens are frequently detected in patients with heart failure and after heart transplantation. There is evidence that these autoantibodies contribute to cardiac dysfunction and correlate with clinical outcomes. Currently, autoantibodies are detected in patient sera using individual ELISA assays (one for each antigen). Thus, screening for many individual autoantibodies is laborious and consumes a large amount of patient sample. To better capture the broad-scale antibody reactivities that occur in heart failure and post-transplant, we developed a custom antigen microarray technique that can simultaneously measure IgM and IgG reactivities against 64 unique antigens using just five microliters of patient serum. We first demonstrated that our antigen microarray technique displayed enhanced sensitivity to detect autoantibodies compared to the traditional ELISA method. We then piloted this technique using two sets of samples that were obtained at our institution. In the first retrospective study, we profiled pre-transplant sera from 24 heart failure patients who subsequently received heart transplants. We identified 8 antibody reactivities that were higher in patients who developed cellular rejection (2 or more episodes of grade 2R rejection in first year after transplant as defined by revised criteria from the International Society for Heart and Lung Transplantation) compared with those who did have not have rejection episodes. In a second retrospective study with 31 patients, we identified 7 IgM reactivities that were higher in heart transplant recipients who developed antibody-mediated rejection (AMR) compared with control recipients, and in time course studies, these reactivities appeared prior to overt graft dysfunction. In conclusion, we demonstrated that the autoantibody microarray technique outperforms traditional ELISAs as it uses less patient sample, has increased sensitivity, and can detect autoantibodies in a multiplex fashion. Furthermore, our results suggest that this autoantibody array technology may help to identify patients at risk of rejection following heart transplantation and identify heart transplant recipients with AMR.
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Affiliation(s)
- Andrzej Chruscinski
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
- * E-mail:
| | - Flora Y. Y. Huang
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Albert Nguyen
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Jocelyn Lioe
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Laura C. Tumiati
- Division of Cardiac Surgery, University Health Network, Toronto, Ontario, Canada
| | - Stella Kozuszko
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Kathryn J. Tinckam
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Vivek Rao
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
- Division of Cardiac Surgery, University Health Network, Toronto, Ontario, Canada
| | - Shannon E. Dunn
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada
- Toronto General Research Institute, Toronto, Ontario, Canada
- Women’s College Research Institute, Toronto, Ontario, Canada
| | - Michael A. Persinger
- Behavioral Neuroscience, Biomolecular Sciences and Human Studies Programs, Laurentian University, Sudbury, Ontario, Canada
| | - Gary A. Levy
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Heather J. Ross
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
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15
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Tinckam KJ, Rose C, Hariharan S, Gill J. Re-Examining Risk of Repeated HLA Mismatch in Kidney Transplantation. J Am Soc Nephrol 2016; 27:2833-41. [PMID: 26888475 DOI: 10.1681/asn.2015060626] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [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: 06/08/2015] [Accepted: 12/19/2015] [Indexed: 11/03/2022] Open
Abstract
Kidney retransplantation is a risk factor for decreased allograft survival. Repeated mismatched HLA antigens between first and second transplant may be a stimulus for immune memory responses and increased risk of alloimmune damage to the second allograft. Historical data identified a role of repeated HLA mismatches in allograft loss. However, evolution of HLA testing methods and a modern transplant era necessitate re-examination of this role to more accurately risk-stratify recipients. We conducted a contemporary registry analysis of data from 13,789 patients who received a second kidney transplant from 1995 to 2011, of which 3868 had one or more repeated mismatches. Multivariable Cox proportional hazards modeling revealed no effect of repeated mismatches on all-cause or death-censored graft loss. Analysis of predefined subgroups, however, showed that any class 2 repeated mismatch increased the hazard of death-censored graft loss, particularly in patients with detectable panel-reactive antibody before second transplant (hazard ratio [HR], 1.15; 95% confidence interval [95% CI], 1.02 to 1.29). Furthermore, in those who had nephrectomy of the first allograft, class 2 repeated mismatches specifically associated with all-cause (HR, 1.30; 95% CI, 1.07 to 1.58) and death-censored graft loss (HR, 1.41; 95% CI, 1.12 to 1.78). These updated data redefine the effect of repeated mismatches in retransplantation and challenge the paradigm that repeated mismatches in isolation confer increased immunologic risk. We also defined clear recipient categories for which repeated mismatches may be of greater concern in a contemporary cohort. Additional studies are needed to determine appropriate interventions for these recipients.
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Affiliation(s)
- Kathryn J Tinckam
- Division of Nephrology and Multiorgan Transplant Program, Department of Medicine and HLA Laboratory, Laboratory Medicine Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Caren Rose
- Division of Nephrology, Department of Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada; and
| | - Sundaram Hariharan
- Department of Medicine and Surgery, Thomas E. Starzl Transplant Institute, University of Pittsburgh Medical Center and Kidney Transplant Program, Pittsburgh, Pennsylvania
| | - John Gill
- Division of Nephrology, Department of Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada; and
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16
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Tinckam KJ, Liwski R, Pochinco D, Mousseau M, Grattan A, Nickerson P, Campbell P. cPRA Increases With DQA, DPA, and DPB Unacceptable Antigens in the Canadian cPRA Calculator. Am J Transplant 2015; 15:3194-201. [PMID: 26080906 PMCID: PMC4744749 DOI: 10.1111/ajt.13355] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 03/26/2015] [Accepted: 04/15/2015] [Indexed: 01/25/2023]
Abstract
A calculated panel reactive antibody (cPRA) estimates the percentage of donors with unacceptable antigens (UA) for a recipient. cPRA may be underestimated in transplant candidates with UA to DQA, DPA, and DPB if these are not included in the calculation program. To serve the National Canadian Transplant Programs, a cPRA calculator was developed with complete molecular typing for all donors at HLA-A, B, C, DRB1, DRB3/4/5, DQA1, DQB1, DPA1, and DPB1, all resolved to serologic equivalents. The prevalence of UA at DQA, DPA and DPB was evaluated in a sensitized regional population. The impact of adding these additional UA to cPRA was calculated alone and in combination, and compared to the baseline cPRA for UA at A, B, C, DR, DR51/52/53, and DQ. Of 740 sensitized transplant candidates, 18% of total and 32% with cPRA≥95% had DQA UA. Twenty-seven percent of total and 54% with cPRA≥95% had DPB UA. Of 280/740 subjects with these UA, 36/280 (13%) had cPRA increase of >20% when they were included, 7% increased cPRA to ≥80% and 6% to ≥95%. Inclusion of DQA, DPA, and DPB UA in Canadian cPRA calculations improves the accuracy of cPRA where these are relevant in allocation.
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Affiliation(s)
- K J Tinckam
- Division of Nephrology, Department of Medicine and HLA Laboratory, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Canadian Blood Services, Organ and Tissue Donation and Transplantation, Ottawa, Ontario, Canada
| | - R Liwski
- Department of Pathology and Laboratory Medicine, Dalhousie University, Nova Scotia, Canada
| | - D Pochinco
- Transplant Immunology Laboratory, Diagnostic Services Manitoba, Winnipeg, Manitoba, Canada
| | - M Mousseau
- Canadian Blood Services, Organ and Tissue Donation and Transplantation, Ottawa, Ontario, Canada
| | - A Grattan
- Canadian Blood Services, Organ and Tissue Donation and Transplantation, Ottawa, Ontario, Canada
| | - P Nickerson
- Canadian Blood Services, Organ and Tissue Donation and Transplantation, Ottawa, Ontario, Canada
- Transplant Immunology Laboratory, Diagnostic Services Manitoba, Winnipeg, Manitoba, Canada
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - P Campbell
- Division of Medicine and Laboratory Medicine, University of Alberta, Edmonton, Alberta, Canada
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17
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Ferrari P, Weimar W, Johnson RJ, Lim WH, Tinckam KJ. Kidney paired donation: principles, protocols and programs. Nephrol Dial Transplant 2015; 30:1276-85. [PMID: 25294848 DOI: 10.1093/ndt/gfu309] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 08/30/2014] [Indexed: 02/07/2023] Open
Abstract
Due to the ongoing shortage of deceased-donor organs, novel strategies to augment kidney transplantation rates through expanded living donation strategies have become essential. These include desensitization in antibody-incompatible transplants and kidney paired donation (KPD) programs. KPD enables kidney transplant candidates with willing but incompatible living donors to join a registry of other incompatible pairs in order to find potentially compatible transplant solutions. Given the significant immunologic barriers with fewer donor options, single-center or small KPD programs may be less successful in transplanting the more sensitized patients; the optimal solution for the difficult-to-match patient is access to more potential donors and large multicenter or national registries are essential. Multicenter KPD programs have become common in the last decade, and now represent one of the most promising opportunities to improve transplant rates. To maximize donor-recipient matching, and minimize immunologic risk, these multicenter KPD programs use sophisticated algorithms to identify optimal match potential, with simultaneous two-, three- or more complex multiway exchanges. The article focuses on the recent progresses in KPD and it also reviews some of the differences and commonalities across four different national KPD programs.
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Affiliation(s)
- Paolo Ferrari
- Department of Nephrology, Fremantle Hospital, Fremantle, WA, Australia School of Medicine and Pharmacology, University of Western Australia, Perth, Australia Organ and Tissue Authority, Canberra, ACT, Australia
| | - Willem Weimar
- Department of Internal Medicine and Transplantation, Erasmus MC, University Medical Center, Rotterdam, The Netherlands Dutch Transplant Foundation, Leiden, The Netherlands
| | | | - Wai H Lim
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia Department of Nephrology, Sir Charles Gairdner Hospital, Perth, Australia
| | - Kathryn J Tinckam
- Division of Nephrology, Department of Medicine and HLA Laboratory, Laboratory Medicine Program, University Health Network, Toronto, ON, Canada Canadian Blood Services, Organ Donation and Transplantation, Toronto, ON, Canada
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18
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Sapir-Pichhadze R, Tinckam KJ, Laupacis A, Logan AG, Beyene J, Kim SJ. Immune Sensitization and Mortality in Wait-Listed Kidney Transplant Candidates. J Am Soc Nephrol 2015; 27:570-8. [PMID: 26054537 DOI: 10.1681/asn.2014090894] [Citation(s) in RCA: 43] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 04/27/2015] [Indexed: 11/03/2022] Open
Abstract
Cardiovascular mortality is the leading cause of death in ESRD. Whereas innate and adaptive immunity have established roles in cardiovascular disease, the role of humoral immunity is unknown. We conducted a retrospective cohort study in first-time adult kidney transplant candidates (N=161,308) using data from the Scientific Registry of Transplant Recipients and the Centers for Medicare and Medicaid Services to evaluate whether anti-human leukocyte antigen antibodies, measured as panel reactive antibodies (PRAs), are related to mortality in ESRD. Relationships between time-varying PRAs and all-cause or cardiovascular mortality were assessed using Cox proportional hazards models. The analysis was repeated in subcohorts of candidates at lower risk for significant comorbidities, activated on the waiting list after 2007, or unsensitized at activation. Competing risks analyses were also conducted. Fully adjusted models showed increased hazard ratios (HRs [95% confidence intervals]) for all-cause mortality (HR, 1.02 [95% CI, 0.99 to 1.06]; HR, 1.11 [95% CI,1.07 to 1.16]; and HR,1.21 [95% CI,1.15 to 1.27]) and cardiovascular mortality (HR, 1.05 [95% CI,1.00 to 1.10]; HR,1.11 [95% CI,1.05 to 1.18]; and HR,1.21 [95% CI,1.12 to 1.31]) in PRA 1%-19%, PRA 20%-79%, and PRA 80%-100% categories compared with PRA 0%, respectively. Associations between PRA and the study outcomes were accentuated in competing risks models and in lower-risk patients and persisted in other subcohorts. Our findings suggest that PRA is an independent predictor of mortality in wait-listed kidney transplant candidates. The mechanisms by which PRA confers an incremental mortality risk in sensitized patients, and the role of transplantation in modifying this risk, warrant further study.
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Affiliation(s)
- Ruth Sapir-Pichhadze
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, and Division of Nephrology, Departments of Medicine and
| | - Kathryn J Tinckam
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Division of Nephrology, Departments of Medicine and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Andreas Laupacis
- Institute of Health Policy, Management, and Evaluation, and Li Ka Shing Knowledge Institute, and
| | - Alexander G Logan
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, and Division of Nephrology, Departments of Medicine and
| | - Joseph Beyene
- Institute of Health Policy, Management, and Evaluation, and Population Health Sciences Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada; and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - S Joseph Kim
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, and Division of Nephrology, Departments of Medicine and Division of Nephrology and the Renal Transplant Program, St. Michael's Hospital, Toronto, Ontario, Canada;
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19
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Tinckam KJ, Keshavjee S, Chaparro C, Barth D, Azad S, Binnie M, Chow CW, de Perrot M, Pierre AF, Waddell TK, Yasufuku K, Cypel M, Singer LG. Survival in sensitized lung transplant recipients with perioperative desensitization. Am J Transplant 2015; 15:417-26. [PMID: 25612494 DOI: 10.1111/ajt.13076] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 08/19/2014] [Accepted: 09/06/2014] [Indexed: 01/25/2023]
Abstract
Donor-specific HLA antibodies (DSA) have an adverse effect on short-term and long-term lung transplant outcomes. We implemented a perioperative strategy to treat DSA-positive recipients, leading to equivalent rejection and graft survival outcomes. Pretransplant DSA were identified to HLA-A, B, C, DR and DQ antigens. DSA-positive patients were transplanted if panel reactive antibody (PRA) ≥30% or medically urgent and desensitized with perioperative plasma exchange, intravenous immune globulin, antithymocyte globulin (ATG), and mycophenolic acid (MPA). PRA-positive/DSA-negative recipients received MPA. Unsensitized patients received routine cyclosporine, azathioprine and prednisone without ATG. From 2008-2011, 340 lung-only first transplants were performed: 53 DSA-positive, 93 PRA-positive/DSA-negative and 194 unsensitized. Thirty-day survival was 96 %/99%/96% in the three groups, respectively. One-year graft survival was 89%/88%/86% (p = 0.47). DSA-positive and PRA-positive/DSA-negative patients were less likely to experience any ≥ grade 2 acute rejection (9% and 9% vs. 18% unsensitized p = 0.04). Maximum predicted forced expiratory volume (1 s) (81%/74%/76%, p = NS) and predicted forced vital capacity (81%/77%/78%, respectively, p = NS) were equivalent between groups. With the application of this perioperative treatment protocol, lung transplantation can be safely performed in DSA/PRA-positive patients, with similar outcomes to unsensitized recipients.
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Affiliation(s)
- K J Tinckam
- Laboratory Medicine Program and Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
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Cole E, Tinckam KJ. Desensitization outcomes: quantifying and questioning. Am J Transplant 2014; 14:1475-6. [PMID: 24912411 DOI: 10.1111/ajt.12789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 04/14/2014] [Accepted: 04/16/2014] [Indexed: 01/25/2023]
Affiliation(s)
- E Cole
- Renal Transplant Programme, University Health Network/University of Toronto, Toronto, ON, Canada
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Chih S, Tinckam KJ, Ross HJ. A survey of current practice for antibody-mediated rejection in heart transplantation. Am J Transplant 2013; 13:1069-1074. [PMID: 23414257 DOI: 10.1111/ajt.12162] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 12/11/2012] [Accepted: 12/23/2012] [Indexed: 01/25/2023]
Abstract
No evidence based management guidelines exist for antibody mediated rejection (AMR) in heart transplantation. The International Society for Heart and Lung Transplantation (ISHLT) recently introduced standardized pathologic based diagnostic criteria for AMR (pAMR 0-3). We evaluated international practice for the management of AMR focusing on pAMR grade, donor specific antibody (DSA) and allograft function. On-line survey data were analyzed from 184 ISHLT members (physicians-78%, surgeons-20%). The majority were from adult-transplant (84%), medium-large volume centres (transplants/year: 10-25, 61%; 25-50, 19%) across North America (60%) and Europe (26%). Irrespective of pAMR grade and DSA, 83-90% treated a drop in ejection fraction (EF≤45% or >25% decrease). In the presence of stable EF, an increasing number elected treatment for progressively severe pAMR grade (p<0.001) and for accompanying DSA (p<0.05, pAMR 1-3). Intravenous steroid was the most commonly used therapy followed by intravenous immunoglobulin (IVIG) or plasmapheresis, rituximab and thymoglobulin. Plasmapheresis and rituximab were favored for positive versus negative DSA (p<0.05). Using a threshold of ≥70% consensus among respondents, treatment for AMR may be considered for a drop in EF, asymptomatic pAMR 3 or asymptomatic pAMR 2 with DSA. Combination steroid, IVIG and plasmapheresis are suggested as initial therapies.
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Affiliation(s)
- S Chih
- Advanced Heart Failure and Cardiac Transplant Service, Royal Perth Hospital, Perth, Western Australia, Australia
| | | | - H J Ross
- Division of Cardiology and Cardiac Transplant, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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Cole EH, Prasad GVR, Cardella CJ, Kim JS, Tinckam KJ, Cattran DC, Schiff JR, Landsberg DN, Zaltzman JS, Gill JS. A pilot study of reduced dose cyclosporine and corticosteroids to reduce new onset diabetes mellitus and acute rejection in kidney transplant recipients. Transplant Res 2013; 2:1. [PMID: 23369458 PMCID: PMC3599918 DOI: 10.1186/2047-1440-2-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 12/15/2012] [Indexed: 01/14/2023] Open
Abstract
Background New onset diabetes mellitus (NODM) and acute rejection (AR) are important causes of morbidity and risk factors for allograft failure after kidney transplantation. Methods In this multi-center, open label, single-arm pilot study, 49 adult (≥18 years of age), low immunologic risk, non-diabetic recipients of a first deceased or living donor kidney transplant received early steroid reduction to 5 mg/day combined with Thymoglobulin® (Genzyme Transplant, Cambridge, MA, USA) induction, low dose cyclosporine (2-hour post-dose (C2) target of 600 to 800 ng/ml) and mycophenolic acid (MPA) therapy. Results Six months after transplantation, two patients (4%) developed NODM and one patient (2%) developed AR. Four patients had impaired fasting glucose tolerance based on 75-g oral glucose tolerance testing (OGTT). There was one patient death. There were no episodes of cytomegalovirus (CMV) infection or BK virus nephritis. In contrast, in a historical cohort of n = 27 patients treated with Thymoglobulin induction, and conventional doses of cyclosporine and corticosteroids, the incidence of NODM and AR was 18% and 15%. Conclusions The pilot study results suggest that Thymoglobulin induction combined with early steroid reduction, reduced cyclosporine exposure and MPA, may reduce the incidence of both NODM and AR in low immunological risk patients. A future controlled study enriched for patients at high risk for NODM is under consideration. Trial registration ClinicalTrials.gov: http://NCT00706680
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Affiliation(s)
- Edward H Cole
- Toronto General Hospital, 190 Elizabeth Street, M5G 2C4, Toronto, ON, Canada.
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Narayanan R, Cardella CJ, Cattran DC, Cole EH, Tinckam KJ, Schiff J, Kim SJ. Delayed graft function and the risk of death with graft function in living donor kidney transplant recipients. Am J Kidney Dis 2010; 56:961-70. [PMID: 20870331 DOI: 10.1053/j.ajkd.2010.06.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2010] [Accepted: 06/25/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND The link between delayed graft function (DGF) and death with graft function (DWGF) in living donor kidney transplant recipients presently is unknown. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS 44,630 adult living donor kidney recipients (first transplants only) in the US Renal Data System from January 1, 1994, to December 31, 2004. PREDICTOR DGF, defined as the need for dialysis therapy in the first week after transplant. OUTCOME Time to DWGF. MEASUREMENTS Kaplan-Meier curves were constructed to assess the impact of DGF on DWGF. Recipients with DGF were 1:1 propensity score matched to those without DGF, and time-dependent Cox proportional hazards models were used to examine factors associated with DWGF. Subgroup and sensitivity analyses also were conducted. RESULTS DWGF occurred in 3,878 patients during 3.9 years' (median) follow-up. In patients with DGF, survival with graft function at 1, 3, 5, and 10 years was 91.9%, 86.8%, 81.6%, and 61.7%, respectively (in patients without DGF, these values were 98.0%, 95.2%, 91.6%, and 80.1%, respectively; P < 0.001 compared with the DGF group). In a fully adjusted time-dependent Cox model, HRs for DWGF in patients with DGF (vs without DGF) were 6.55 (95% CI, 4.78-8.97), 3.55 (95% CI, 2.46-5.11), 2.07 (95% CI, 1.53-2.81), and 1.48 (95% CI, 1.26-1.73) at 0-1, 1-3, 3-12, and longer than 12 months posttransplant, respectively. Propensity score analysis showed similar results. Inferences were unchanged after adjustment for kidney function and acute rejection at 6 months and 1 year posttransplant. Cardiovascular and infectious causes of DWGF were more prevalent in patients with DGF. The association was more marked in female recipients and robust to various sensitivity analyses. LIMITATIONS The impact of lesser decreases in early graft function could not be evaluated. CONCLUSIONS DGF is associated with an increased risk of DWGF in living donor kidney recipients. The mechanisms underlying this relation require further study.
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Affiliation(s)
- Ranjit Narayanan
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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Tapiawala SN, Tinckam KJ, Cardella CJ, Schiff J, Cattran DC, Cole EH, Kim SJ. Delayed graft function and the risk for death with a functioning graft. J Am Soc Nephrol 2009; 21:153-61. [PMID: 19875806 DOI: 10.1681/asn.2009040412] [Citation(s) in RCA: 138] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Delayed graft function (DGF) associates with an increased risk for graft failure, but its link with death with graft function (DWGF) is unknown. We used the US Renal Data System to assemble a cohort of all first, adult, deceased-donor kidney transplant recipients from January 1, 1998, through December 31, 2004. In total, 11,542 (23%) of 50,246 recipients required at least one dialysis session in the first week after transplantation. Compared with patients without DGF, patients with DGF were significantly more likely to die with a functioning graft (relative hazard 1.83 [95% confidence interval 1.73 to 1.93] and 1.53 [95% CI 1.45 to 1.63] for unadjusted and fully adjusted models, respectively). The risk for DWGF was slightly higher among women with DGF than among men. There was no significant heterogeneity among other subgroups, and the results were robust to sensitivity analyses. Acute rejection within the first year attenuated the DGF-DWGF association. Cardiovascular and infectious deaths were slightly more prevalent in the DGF group, but the relative hazards of cause-specific death were similar between DWGF and deaths during total follow-up. In summary, DGF associates with an increased risk for DWGF; the mechanisms underlying the negative impact of DGF require further study.
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Affiliation(s)
- Shruti N Tapiawala
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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Abstract
The role of alloantibodies against HLA and non-HLA targets is becoming increasingly recognized as critical in the pathogenesis of acute and chronic renal allograft outcomes. This review discusses the antigenic targets, the mechanisms of T and B cell activation that result in the production of antibody, the complement cascade, methods of antibody detection, and the evidence that alloantibody-mediated mechanisms are active in acute and chronic rejection.
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Affiliation(s)
- Kathryn J Tinckam
- Transplantation Research Center, Brigham and Women's Hospital, Boston, MA 02115, USA.
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26
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Abstract
BACKGROUND Diffuse peritubular capillary (PTC) C4d deposition has been shown to be associated with relatively poor graft outcome. The significance of focal PTC C4d staining in the early post-transplant period is uncertain. METHODS Sixty-five biopsies from 53 patients with acute rejection were graded (Banff '97 criteria), stained for C4d, monocytes and T cells, and divided into three groups according to PTC C4d: (i) focal C4d (F) (14 biopsies, 14 patients), (ii) diffuse C4d (D) (23 biopsies, 15 patients) and (iii) no C4d (N) (28 biopsies, 24 patients). The three groups were compared with respect to a variety of biopsy and clinical parameters including outcome. RESULTS The incidence of transplant glomerulitis and glomerular monocyte infiltration were significantly greater in F (64% and 2.0+/-2.0) and D (57% and 3.4+/-2.0) than in N (11% and 0.2+/-0.2). A significantly higher proportion of F (93%) demonstrated acute cellular rejection (Banff '97 grade > or = 1A) than did D (35%). The F and D groups included significantly more females (50 and 67%, respectively) than did N (21%). The percentage of patients with a second or third transplant was higher in F (29%) and D (40%) than in N (8%) (P = 0.0589). The proportion of patients with glomerular filtration rate < 30 ml/min at 12, 24 and 48 months was higher in the D and F groups than in the N, and there was a statistically significant increasing trend in odds of this outcome occurring at 48 months across the three groups (D > F > N group) (P = 0.0416). CONCLUSION The results suggest that the biopsy findings and clinical course in patients with focal PTC C4d staining are similar to those associated with diffuse C4d.
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Affiliation(s)
- Alexander B Magil
- Department of Pathology and Laboratory Medicine, St.Paul's Hospital, 1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6.
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27
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Abstract
BACKGROUND Both peritubular capillary (PTC) C4d deposition and macrophage/monocyte (MO) infiltration in acute rejection (AR) have separately been shown to be associated with reduced graft survival and recently were demonstrated to be closely correlated in AR. Whether MO infiltration is an independent predictor of graft outcome is uncertain. METHODS All patients with biopsy-proven AR (over a 3-year period) were included (N= 96). All biopsies (N= 121) were graded according to the Banff 97 criteria and immunohistochemically stained for C4d and MO (CD68). The primary outcome was glomerular filtration rate (GFR) <30 mL/min 1-year posttransplant as estimated by the Modified Diet in Renal Disease (MDRD) Formula. Secondary outcomes at 2 and 4 years' posttransplant were also explored. A variety of clinical and biopsy variables were statistically analyzed to establish univariate predictors of graft outcome. Stepwise multivariate logistic regression modeling was applied to determine independent predictors of outcomes. RESULTS There was a close correlation between PTC C4d and glomerular MO infiltration (P < 0.001). Univariate predictors of primary outcome (GFR <30 mL/min 1-year posttransplant) included mean glomerular MO count > or =1.0 MO/glomerulus (P= 0.014), female sex (P= 0.02), higher peak (P= 0.005), and pretransplant (P= 0.003) panel-reactive antibody levels, cadaveric donor (P= 0.006), transplant glomerulitis (P= 0.004), and longer cold ischemic time (CIT) (P= 0.002). Mean MO/glomerulus > or =1.0 [OR 10.3 (1.23, 87.1)], female sex [OR 5.27(1.31, 21.1)], and CIT [OR 1.14 (1.06, 1.25)] were identified as independent predictors of adverse graft outcome. Furthermore, mean MO/glomerulus > or =1.0 independently predicted poor renal function at 2 years [OR 3.89 (1.19, 12.70)] and 4 years [OR 4.03 (1.22, 13.28)] posttransplant. CONCLUSION The results demonstrate that glomerular MO infiltration is an independent predictor of worse outcomes posttransplant following acute renal allograft rejection.
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Affiliation(s)
- Kathryn J Tinckam
- Division of Nephrology, Department of Medicine, Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada
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28
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Abstract
Clinical transplantation tolerance has remained an elusive goal in the 50 yr since it was first described in experimental animals. Greater understanding of the molecular mechanisms responsible for allorecognition have allowed for the development of promising immunosuppressive strategies that may bring us closer to reproducible induction of tolerance; consideration of past successes and failures from both clinical and basic science is required to define future challenges facing this field. This article reviews mechanisms of self and transplantation tolerance, translation of basic science research to clinical protocols in animals and human beings, the changing role of immunosuppression, complications following tolerance induction and controversies surrounding the choice of patients for tolerance trials with a focus on issues relevant to pediatric patients. The role of the Immune Tolerance Network is discussed along with realistic goals for tolerance induction in human beings over the next decade.
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Affiliation(s)
- Kathryn J Tinckam
- Transplantation Research Center, Brigham and Women's Hospital and Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA
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Tinckam KJ, Wood IG, Ji F, Milford EL. ATG induction is associated with an increase in anti-HLA antibodies after kidney transplantation. Hum Immunol 2004; 65:1281-7. [PMID: 15556678 DOI: 10.1016/j.humimm.2004.09.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [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] [Received: 08/10/2004] [Revised: 09/15/2004] [Accepted: 09/16/2004] [Indexed: 10/26/2022]
Abstract
Anti-human histocompatibility antigen antibodies (HLA-Ab) are deleterious after kidney transplant and may be increased after T-cell depleting agents are given. A retrospective case control study was conducted to evaluate increase in HLA-Ab in 27 kidney transplant recipients who had received antithymocyte globulin (ATG) induction compared with 27 control subjects. A greater than 10% increase in class I or class II HLA-Ab was found in 6 (22.2%) of ATG subjects versus only 1 (3.7%) of non-ATG subjects (p = 0.05). In females, 6/14 ATG subjects developed increased HLA-Ab > or =10% compared with none of the control subjects (p = 0.016). In sensitized subjects, 4/10 in the ATG group developed increased HLA-Ab > or =10% versus none of the controls (p = 0.043). There was no difference in number or severity of acute rejection episodes or estimated glomerular filtration rate 6 months after transplant between the two treatment groups. We conclude that ATG induction may result in increased posttransplant HLA-Ab, particularly in subjects at higher immunologic risk. Further studies are necessary to determine the natural history, clinical consequences, appropriate therapy, and mechanisms responsible for HLA-Ab in this setting.
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Affiliation(s)
- Kathryn J Tinckam
- Renal Division, Brigham and Women's Hospital, Harvard University, Boston, MA 02115, USA.
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Buller CE, Nogareda JG, Ramanathan K, Ricci DR, Djurdjev O, Tinckam KJ, Penn IM, Fox RS, Stevens LA, Duncan JA, Levin A. The profile of cardiac patients with renal artery stenosis. J Am Coll Cardiol 2004; 43:1606-13. [PMID: 15120819 DOI: 10.1016/j.jacc.2003.11.050] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2003] [Revised: 11/07/2003] [Accepted: 11/13/2003] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We examined the prevalence and severity of renal artery stenosis (RAS) in patients undergoing cardiac catheterization who were deemed at risk for RAS based on clinical or laboratory criteria for study entry, but who had not previously been suspected of having RAS. BACKGROUND The diagnosis of atherosclerotic RAS remains problematic because its clinical manifestations are nonspecific. METHODS Consecutive patients undergoing non-emergent cardiac catheterization at a single institution during a 12-month period were evaluated using standardized clinical, laboratory, and angiographic criteria. Patients exhibiting at least one of four predefined selection criteria (severe hypertension, unexplained renal dysfunction, acute pulmonary edema with hypertension, or severe atherosclerosis) were prospectively registered and underwent coincident diagnostic renal angiography. RESULTS Renal angiography was performed in 851 patients and was diagnostic in 837. Angiographically evident renal atherosclerosis was present in 39% of the population, with RAS > or =50% in 120 (14.3%) and severe stenosis (> or =70%) in 61 (7.3%). Severe stenosis was present in 48 (7%) patients with severe atherosclerosis, 38 (16%) with renal dysfunction, 25 (9%) with hypertension, and 2 (22%) with acute pulmonary edema with hypertension. The prevalence was higher in those exhibiting multiple selection criteria. In a multivariate model, severe RAS was associated with age, female gender, reduced creatinine clearance, increased systolic blood pressure, and peripheral or carotid artery disease. CONCLUSIONS In a population at risk of, but not previously suspected of having RAS, severe RAS is associated with simple and readily determined clinical and laboratory patient characteristics. These data facilitate focused application of diagnostic renal angiography.
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Affiliation(s)
- Christopher E Buller
- Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, Canada.
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