1
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Jaure A, Vastani RT, Teixeira-Pinto A, Ju A, Craig JC, Viecelli AK, Scholes-Robertson N, Josephson MA, Ahn C, Butt Z, Caskey FJ, Dobbels F, Fowler K, Jowsey-Gregoire S, Jha V, Tan JC, Sautenet B, Howell M. Validation of a Core Patient-Reported Outcome Measure for Life Participation in Kidney Transplant Recipients: the SONG Life Participation Instrument. Kidney Int Rep 2024; 9:87-95. [PMID: 38312789 PMCID: PMC10831350 DOI: 10.1016/j.ekir.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 10/04/2023] [Accepted: 10/23/2023] [Indexed: 02/06/2024] Open
Abstract
Introduction Life participation has been established as a critically important core for trials in kidney transplantation. We aimed to validate a patient-reported outcome measure for life participation in kidney transplant recipients. Methods A psychometric evaluation of the Standardized Outcomes in Nephrology life participation (SONG-LP) measure was conducted in adult kidney transplant recipients. The measure includes 4 items of life participation (leisure, family, work, and social) each with a 5-point Likert scale. Each item is scored from 0 (never) to 4 (always) and the summary measure score the average of each item. Results A total of 249 adult kidney transplant recipients from 20 countries participated. The SONG-LP instrument demonstrated internal consistency (Cronbach's α = 0.87; 95% confidence intervals [CI]: 0.83-0.90, baseline) and test-retest reliability over 1 week (intraclass correlation coefficient of 0.62; 95% CI: 0.54-0.70). There was moderate to high correlation (0.65; 95% CI: 0.57-0.72) with the PROMIS Ability to Participate in Social Roles and Activities Short Form 8a that assessed a similar construct, and moderate correlation with measures that assessed related concepts (i.e., EQ5D 0.57; 95% CI: 0.49-0.65), PROMIS Cognitive Functional Abilities Subset Short Form 4a (0.40; 95% CI: 0.29-0.50). Conclusion The SONG-LP instrument is a simple, internally consistent, reliable measure for kidney transplant recipients and correlates with similar measures. Routine incorporation in clinical trials will ensure consistent and appropriate assessment of life participation for informed patient-centered decision-making.
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Affiliation(s)
- Allison Jaure
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Rahim T. Vastani
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Angela Ju
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Jonathan C. Craig
- College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Andrea K. Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Nicole Scholes-Robertson
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Michelle A. Josephson
- Department of Medicine (Section of Nephrology), The University of Chicago, Chicago, Illinois, USA
| | - Curie Ahn
- Transplantation Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Transplantation Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Zeeshan Butt
- Departments of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Phreesia, Inc., Wilmington, Delaware, USA
| | - Fergus J. Caskey
- Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Fabienne Dobbels
- Department of Public Health and Primary Care, KU Leuven, Belgium
| | - Kevin Fowler
- The Voice of the Patient, Saint Louis, Missouri, USA
| | | | - Vivekanand Jha
- George Institute for Global Health, University of New South Wales, New Delhi, India
- School of Public Health, Imperial College, London, UK
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Jane C. Tan
- Department of Medicine, Stanford University, Stanford, California, USA
| | | | - Martin Howell
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
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Josephson MA, Zeier M. The authors reply. Kidney Int 2023; 104:1227. [PMID: 37981433 DOI: 10.1016/j.kint.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 09/06/2023] [Indexed: 11/21/2023]
Affiliation(s)
- Michelle A Josephson
- Section of Nephrology, Department of Medicine, and Transplant Institute, University of Chicago, Chicago, Illinois, USA.
| | - Martin Zeier
- Division of Nephrology, University of Heidelberg, Heidelberg, Germany.
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Josephson MA, Becker Y, Budde K, Kasiske BL, Kiberd BA, Loupy A, Małyszko J, Mannon RB, Tönshoff B, Cheung M, Jadoul M, Winkelmayer WC, Zeier M. Challenges in the management of the kidney allograft: from decline to failure: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2023; 104:1076-1091. [PMID: 37236423 DOI: 10.1016/j.kint.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023]
Abstract
In March 2022, Kidney Disease: Improving Global Outcomes (KDIGO) held a virtual Controversies Conference to address the important but rarely examined phase during which the kidney transplant is failing or has failed. In addition to discussing the definition of a failing allograft, 4 broad areas were considered in the context of a declining functioning graft: prognosis and kidney failure trajectory; immunosuppression strategies; management of medical and psychological complications, and patient factors; and choice of kidney replacement therapy or supportive care following graft loss. Identifying and paying special attention to individuals with failing allografts was felt to be important in order to prepare patients psychologically, manage immunosuppression, address complications, prepare for dialysis and/or retransplantation, and transition to supportive care. Accurate prognostication tools, although not yet widely available, were embraced as necessary to define allograft survival trajectories and the likelihood of allograft failure. The decision of whether to withdraw or continue immunosuppression after allograft failure was deemed to be based most appropriately on risk-benefit analysis and likelihood of retransplantation within a few months. Psychological preparation and support was identified as a critical factor in patient adjustment to graft failure, as was early communication. Several models of care were noted that enabled a medically supportive transition back to dialysis or retransplantation. Emphasis was placed on the importance of dialysis-access readiness before initiation of dialysis, in order to avoid use of central venous catheters. The centrality of the patient to all management decisions and discussions was deemed to be paramount. Patient "activation," which can be defined as engaged agency, was seen as the most effective way to achieve success. Unresolved controversies, gaps in knowledge, and areas for research were also stressed in the conference deliberations.
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Affiliation(s)
- Michelle A Josephson
- Section of Nephrology, Department of Medicine, and Transplant Institute, University of Chicago, Chicago, Illinois, USA.
| | - Yolanda Becker
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Bertram L Kasiske
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Bryce A Kiberd
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Alexandre Loupy
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, F-75015 Paris, France; Department of Kidney Transplantation, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Roslyn B Mannon
- Division of Nephrology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes (KDIGO), Brussels, Belgium
| | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Martin Zeier
- Division of Nephrology, University of Heidelberg, Heidelberg, Germany.
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4
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Josephson MA, Meyer RN. Transforming Transplant in the United States. Clin J Am Soc Nephrol 2023; 19:01277230-990000000-00197. [PMID: 37494013 PMCID: PMC10861102 DOI: 10.2215/cjn.0000000000000271] [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: 05/18/2023] [Accepted: 07/21/2023] [Indexed: 07/27/2023]
Affiliation(s)
- Michelle A. Josephson
- University of Chicago, Section of Nephrology, Department of Medicine, and Transplant Institute, Chicago, Illinois
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5
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Al Sayyab M, Josephson MA. Double Jeopardy: The Complicated Interplay of Preeclampsia Risks to Mom, Baby, and Allograft in Kidney Transplant Recipients. Clin J Am Soc Nephrol 2023; 18:01277230-990000000-00166. [PMID: 37294696 PMCID: PMC10356116 DOI: 10.2215/cjn.0000000000000210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Mina Al Sayyab
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois
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6
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Kumar V, Leigh KA, Kliger AS, Roberts G, Mohan S, Leca N, Sawinski DL, Josephson MA, Mannon RB, Lentine KL. Kidney Transplant Practice in Pandemic Times: Lessons Learned for the Future. Clin J Am Soc Nephrol 2023; 18:01277230-990000000-00062. [PMID: 36795033 PMCID: PMC10356143 DOI: 10.2215/cjn.0000000000000092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Vineeta Kumar
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Alan S. Kliger
- Section of Nephrology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Glenda Roberts
- External Relations and Patient Engagement, Division of Nephrology, Department of Medicine, Kidney Research Institute and Center for Dialysis Innovation, University of Washington, Seattle, Washington
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Mailman School of Public Health, Vagelos College of Physicians and Surgeons and Department of Epidemiology, Columbia University, New York, New York
| | - Nicolae Leca
- Department of Medicine, University of Washington Medical Center, Seattle, Washington
| | - Deidre L. Sawinski
- Department of Nephrology and Hypertension, Weill Cornell Medical College, New York, New York
| | - Michelle A. Josephson
- Section of Nephrology, Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | | | - Krista L. Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri
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7
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Moe SM, Brennan DC, Doshi MD, Gaston RS, Gurley SB, Mujtaba MA, Schmidt RJ, Segal MS, Tucker JK, Wiseman AC, Josephson MA. The Importance of Transplant Nephrology to a Successful Kidney Transplant Program. Clin J Am Soc Nephrol 2022; 17:1403-1406. [PMID: 35914794 PMCID: PMC9625111 DOI: 10.2215/cjn.02000222] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Sharon M. Moe
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Daniel C. Brennan
- Department of Medicine, Comprehensive Transplant Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mona D. Doshi
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | | | - Susan B. Gurley
- Division of Nephrology and Hypertension, Department of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Muhammad A. Mujtaba
- Division of Nephrology, Department of Medicine and Kidney/Pancreas Transplant Program, University of Texas Medical Branch School of Medicine, Galveston, Texas
| | - Rebecca J. Schmidt
- Nephrology, Department of Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Mark S. Segal
- Nephrology, Department of Medicine, Central Florida Kidney Center, Inc., Gainesville, Florida
- Nephrology and Hypertension, Department of Medicine, University of Florida, Gainesville, Florida
- Renal Section, Nephrology, Department of Medicine, North Florida/South Georgia Veteran Healthcare System, Gainesville, Florida
| | - J. Kevin Tucker
- Renal Medicine, Department of Medicine, Brigham & Women’s Faulkner Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Michelle A. Josephson
- Section of Nephrology, Department of Medicine, University of Chicago School of Medicine, Chicago, Illinois
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8
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Josephson MA, Wiseman AC, Tucker JK, Segal MS, Schmidt RJ, Mujtaba MA, Gurley SB, Gaston RS, Doshi MD, Brennan DC, Moe SM. Existing Transplant Nephrology Compensation Models and Opportunities for Equitable Pay. Clin J Am Soc Nephrol 2022; 17:1407-1409. [PMID: 35914793 PMCID: PMC9625105 DOI: 10.2215/cjn.02010222] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
| | | | - J. Kevin Tucker
- Renal Medicine, Brigham and Women’s Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts
| | - Mark S. Segal
- Division of Nephrology, Hypertension & Transplantation, University of Florida, Gainesville, Florida
- Renal Section, North Florida/South Georgia Veteran Healthcare System, Gainesville, Florida
| | - Rebecca J. Schmidt
- Section of Nephrology, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Muhammad A. Mujtaba
- Nephrology, Kidney and Pancreas Transplants, University of Texas Medical Branch School of Medicine, Galveston, Texas
| | - Susan B. Gurley
- Division of Nephrology and Hypertension, Oregon Health and Science University, Portland, Oregon
| | - Robert S. Gaston
- CTI Clinical Trial and Consulting, Inc., Covington, Kentucky
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Mona D. Doshi
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Daniel C. Brennan
- Nephrology, Comprehensive Transplant Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sharon M. Moe
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana
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9
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Abstract
Placed in a historical context, this overview focuses on post-transpant pregnancy, fatherhood, and contraception in women and men. The critical importance of early reproductive counseling because of improved sexual function and the early return of ovulation and menses post-transplant is emphasized. We explain the decision making regarding contraception choices. The available data on the safety of immunosuppressive drugs in pregnancy, and for men desiring fatherhood, are detailed. The risk of maternal ingestion of mycophenolate products on the in utero fetus is considered and contrasted with the lack of concern for their use by men fathering children. Pregnancy risks to the allograft, baby, and mother are discussed. An infant's exposure to specific immunosuppressant medications through breastfeeding is reviewed. The ethics and realities of post-transplant parenthood are explored.
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Affiliation(s)
- Christina L. Klein
- Piedmont Transplant Institute, Piedmont Healthcare Inc., Atlanta, Georgia
| | - Michelle A. Josephson
- Section of Nephrology, Division of Biological Sciences, University of Chicago, Chicago, Illinois
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10
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Kapp ME, Fogo AB, Roufouse C, Najafian B, Radhakrishnan J, Mohan S, Miller SE, D’Agati VD, Silberzweig J, Barbar T, Gopalan T, Srivatana V, Mokrzycki MH, Benstein JA, Ng YH, Lentine KL, Aggarwal V, Perl J, Salenger P, Koyner JL, Josephson MA, Heung M, Velez JC, Ikizler A, Vijayan A, William P, Thajudeen B, Slepian MJ. Renal Considerations in COVID-19: Biology, Pathology, and Pathophysiology. ASAIO J 2021; 67:1087-1096. [PMID: 34191753 PMCID: PMC8478105 DOI: 10.1097/mat.0000000000001530] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has emerged into a worldwide pandemic of epic proportion. Beyond pulmonary involvement in coronavirus disease 2019 (COVID-19), a significant subset of patients experiences acute kidney injury. Patients who die from severe disease most notably show diffuse acute tubular injury on postmortem examination with a possible contribution of focal macro- and microvascular thrombi. Renal biopsies in patients with proteinuria and hematuria have demonstrated a glomerular dominant pattern of injury, most notably a collapsing glomerulopathy reminiscent of findings seen in human immunodeficiency virus (HIV) in individuals with apolipoprotein L-1 (APOL1) risk allele variants. Although various mechanisms have been proposed for the pathogenesis of acute kidney injury in SARS-CoV-2 infection, direct renal cell infection has not been definitively demonstrated and our understanding of the spectrum of renal involvement remains incomplete. Herein we discuss the biology, pathology, and pathogenesis of SARS-CoV-2 infection and associated renal involvement. We discuss the molecular biology, risk factors, and pathophysiology of renal injury associated with SARS-CoV-2 infection. We highlight the characteristics of specific renal pathologies based on native kidney biopsy and autopsy. Additionally, a brief discussion on ancillary studies and challenges in the diagnosis of SARS-CoV-2 is presented.
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Affiliation(s)
- Meghan E. Kapp
- From the Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Agnes B. Fogo
- From the Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Candice Roufouse
- Department of Immunology and Inflammation, Centre for Inflammatory Diseases, Imperial College, London, UK
| | - Behzad Najafian
- Department of Laboratory Medicine & Pathology, University of Washington Medicine, Seattle, Washington
| | - Jai Radhakrishnan
- Division of Nephrology, Columbia University Medical Center, New York, New York
| | - Sumit Mohan
- Division of Nephrology, Columbia University Medical Center, New York, New York
| | - Sara E. Miller
- Department of Pathology, Duke University School of Medicine, Durham, North Carolina
| | - Vivette D. D’Agati
- Department of Pathology and Cell Biology, Columbia University, New York, New York
| | | | - Tarek Barbar
- Division of Nephrology, Weill Cornell Medical College, New York, New York
| | - Tulasi Gopalan
- Division of Nephrology, Weill Cornell Medical College, New York, New York
| | - Vesh Srivatana
- Division of Nephrology, Weill Cornell Medical College, New York, New York
| | - Michele H. Mokrzycki
- Division of Nephrology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Judith A. Benstein
- Department of Medicine, New York University Tisch Hospital, New York, New York
| | - Yue-Harn Ng
- Division of Nephrology, University of Washington, Seattle, Washington
| | - Krista L. Lentine
- Division of Nephrology (9-FDT), Center for Abdominal Transplantation, St. Louis, Missouri
| | - Vikram Aggarwal
- Division of Nephrology, Northwestern Medicine, Chicago, Illinois
| | - Jeffrey Perl
- Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | | | - Jay L. Koyner
- Department of Nephrology, University of Chicago, Chicago, Illinois
| | | | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Juan Carlos Velez
- Department of Nephrology, Ochsner Health System, New Orleans, Louisiana
| | - Alp Ikizler
- Division of Nephrology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anitha Vijayan
- Department of Medicine – Nephrology, Washington University School of Medicine in St Louis, St. Louis, Missouri
| | - Preethi William
- Division of Cardiology, Banner University of Arizona, Tucson, Arizona
| | - Bijin Thajudeen
- Division of Nephrology, Banner University of Arizona, Tucson, Arizona
| | - Marvin J. Slepian
- Departments of Medicine and Biomedical Engineering, Sarver Heart Center, University of Arizona, Tucson, Arizona
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11
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Axelrod DA, Ince D, Harhay MN, Mannon RB, Alhamad T, Cooper M, Josephson MA, Caliskan Y, Sharfuddin A, Kumar V, Guenette A, Schnitzler MA, Ainapurapu S, Lentine KL. Operational challenges in the COVID era: Asymptomatic infections and vaccination timing. Clin Transplant 2021; 35:e14437. [PMID: 34297878 PMCID: PMC8420523 DOI: 10.1111/ctr.14437] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/23/2021] [Accepted: 07/08/2021] [Indexed: 11/28/2022]
Abstract
The coronavirus disease 2019 (COVID‐19) pandemic has created unprecedented challenges for solid organ transplant programs. While transplant activity has largely recovered, appropriate management of deceased donor candidates who are asymptomatic but have positive nucleic acid testing (NAT) for SARS‐CoV‐2 is unclear, as this result may reflect active infection or prolonged viral shedding. Furthermore, candidates who are unvaccinated or partially vaccinated continue to receive donor offers. In the absence of robust outcomes data, transplant professionals at US adult kidney transplant centers were surveyed (February 13, 2021 to April 29, 2021) to determine community practice (N: 92 centers, capturing 41% of centers and 57% of transplants performed). The majority (97%) of responding centers declined organs for asymptomatic NAT+ patients without documented prior infection. However, 32% of centers proceed with kidney transplant in NAT+ patients who were at least 30 days from initial diagnosis with negative chest imaging. Less than 7% of programs reported inactivating patients who were unvaccinated or partially vaccinated. In conclusion, despite national recommendations to wait for negative testing, many centers are proceeding with kidney transplant in patients with positive SARS‐CoV‐2 NAT results due to presumed viral shedding. Furthermore, few centers are requiring COVID‐19 vaccination prior to transplantation at this time.
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Affiliation(s)
| | - Dilek Ince
- University of Iowa/Transplant Institute, Iowa City, IA, USA
| | - Meera N Harhay
- Drexel University Tower Health Transplant Institute, Philadelphia, USA
| | | | | | - Matthew Cooper
- Medstar Georgetown Transplant Institute, Washington, DC, USA
| | | | - Yasar Caliskan
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO, USA
| | | | - Vineeta Kumar
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alexis Guenette
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO, USA
| | - Mark A Schnitzler
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO, USA
| | - Sruthi Ainapurapu
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO, USA
| | - Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO, USA
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12
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Witkowski P, Odorico J, Pyda J, Anteby R, Stratta RJ, Schrope BA, Hardy MA, Buse J, Leventhal JR, Cui W, Hussein S, Niederhaus S, Gaglia J, Desai CS, Wijkstrom M, Kandeel F, Bachul PJ, Becker YT, Wang LJ, Robertson RP, Olaitan OK, Kozlowski T, Abrams PL, Josephson MA, Andreoni KA, Harland RC, Kandaswamy R, Posselt AM, Szot GL, Ricordi C. Arguments against the Requirement of a Biological License Application for Human Pancreatic Islets: The Position Statement of the Islets for US Collaborative Presented during the FDA Advisory Committee Meeting. J Clin Med 2021; 10:jcm10132878. [PMID: 34209541 PMCID: PMC8269003 DOI: 10.3390/jcm10132878] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/14/2021] [Accepted: 06/16/2021] [Indexed: 12/25/2022] Open
Abstract
The Food and Drug Administration (FDA) has been regulating human islets for allotransplantation as a biologic drug in the US. Consequently, the requirement of a biological license application (BLA) approval before clinical use of islet transplantation as a standard of care procedure has stalled the development of the field for the last 20 years. Herein, we provide our commentary to the multiple FDA’s position papers and guidance for industry arguing that BLA requirement has been inappropriately applied to allogeneic islets, which was delivered to the FDA Cellular, Tissue and Gene Therapies Advisory Committee on 15 April 2021. We provided evidence that BLA requirement and drug related regulations are inadequate in reassuring islet product quality and potency as well as patient safety and clinical outcomes. As leaders in the field of transplantation and endocrinology under the “Islets for US Collaborative” designation, we examined the current regulatory status of islet transplantation in the US and identified several anticipated negative consequences of the BLA approval. In our commentary we also offer an alternative pathway for islet transplantation under the regulatory framework for organ transplantation, which would address deficiencies of in current system.
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Affiliation(s)
- Piotr Witkowski
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (P.J.B.); (Y.T.B.); (L.-J.W.)
- Correspondence: ; Tel.: +1-773-834-3524
| | - Jon Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, WI 53792, USA;
| | - Jordan Pyda
- Beth Israel Deaconess Medical Center, Department of Surgery, Harvard Medical School, Boston, MA 02115, USA;
| | - Roi Anteby
- Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA;
- Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Robert J. Stratta
- Section of Transplantation, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA;
| | - Beth A. Schrope
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA; (B.A.S.); (M.A.H.)
| | - Mark A. Hardy
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA; (B.A.S.); (M.A.H.)
| | - John Buse
- Division of Endocrinology, Department of Medicine, University of NC, Chapel Hill, NC 27516, USA;
| | - Joseph R. Leventhal
- Department of Surgery, Northwestern University School of Medicine, Chicago, IL 60611, USA;
| | - Wanxing Cui
- Cell Therapy Manufacturing Facility, Georgetown University Hospital, Washington, DC 20007, USA;
| | - Shakir Hussein
- Detroit Medical Center, Department of Surgery, Wayne State School of Medicine, Detroit, MI 48201, USA;
| | - Silke Niederhaus
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Jason Gaglia
- Joslin Diabetes Center, Harvard Medical School, Boston, MA 02215, USA;
| | - Chirag S. Desai
- Department of Surgery, Section of Transplantation, University of NC, Chapel Hill, NC 27516, USA;
| | - Martin Wijkstrom
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15260, USA;
| | - Fouad Kandeel
- Department of Translational Research and Cellular Therapeutics, Diabetes and Metabolism Research Institute, Beckman Research Institute of City of Hope, Duarte, CA 91010, USA;
| | - Piotr J. Bachul
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (P.J.B.); (Y.T.B.); (L.-J.W.)
| | - Yolanda Tai Becker
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (P.J.B.); (Y.T.B.); (L.-J.W.)
| | - Ling-Jia Wang
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (P.J.B.); (Y.T.B.); (L.-J.W.)
| | - R. Paul Robertson
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Washington, Seattle, WA 98133, USA;
| | | | - Tomasz Kozlowski
- Division of Transplantation, Department of Surgery, The University of Oklahoma College of Medicine, Oklahoma City, OK 73104, USA;
| | - Peter L. Abrams
- MedStar Georgetown Transplant Institute, Washington, DC 20007, USA;
| | | | - Kenneth A. Andreoni
- Department of Surgery, University of Florida, College of Medicine, Gainesville, FL 32610-0118, USA;
- Case Western Reserve University, Cleveland, OH 44106-5047, USA
| | - Robert C. Harland
- Department of Surgery, University of Arizona, Tucson, AZ 85711, USA;
| | - Raja Kandaswamy
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Andrew M. Posselt
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA; (A.M.P.); (G.L.S.)
| | - Gregory L. Szot
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA; (A.M.P.); (G.L.S.)
| | - Camillo Ricordi
- Diabetes Research Institute and Cell Transplant Center, University of Miami, Miami, FL 33136, USA;
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13
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Sureshkumar KK, Chopra B, Josephson MA, Shah PB, McGill RL. Recipient Obesity and Kidney Transplant Outcomes: A Mate-Kidney Analysis. Am J Kidney Dis 2021; 78:501-510.e1. [PMID: 33872689 DOI: 10.1053/j.ajkd.2021.02.332] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 02/04/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE The impact of extreme recipient obesity on long-term kidney transplant outcomes has been controversial. This study sought to evaluate the association of various levels of recipient obesity on kidney transplantation outcomes by comparing mate-kidney recipient pairs to address possible confounding effects of donor characteristics on posttransplant outcomes. STUDY DESIGN Nationwide observational cohort study using mate-kidney models. SETTING & PARTICIPANTS In analysis based on the Organ Procurement and Transplant Network/United Network of Organ Sharing database, 44,560 adult recipients of first-time deceased-donor kidney transplants from 2001 through 2016 were paired by donor. PREDICTORS Recipient body mass index (BMI) categorized as 18-25 (n = 12,446), >25-30 (n = 15,477), >30-35 (n = 11,144; obese), and >35 (n = 5,493; extreme obesity) kg/m2. OUTCOMES Outcomes included patient survival, graft survival, death-censored graft survival, delayed graft function (DGF), and hospital length of stay. ANALYTICAL APPROACH Conditional logistic regression and stratified proportional hazards models were used to compare outcomes as odds ratios and hazard ratios (HRs), adjusted for recipient and transplant factors, using recipients with a BMI >35 kg/m2 as a reference. RESULTS At a median follow-up of 3.9 years, adjusted odds ratios for DGF were 0.42 (95% CI, 0.36-0.48), 0.55 (95% CI, 0.48-0.62), and 0.73 (95% CI, 0.64-0.83) for BMI 18-25, >25-30, and >30-35 kg/m2, respectively (P < 0.001 for all). Death-censored graft failure was less frequent for BMI ≤25 and >25-30 kg/m2 (HRs of 0.66 [95% CI, 0.59-0.74] and 0.79 [95% CI, 0.70-0.88], respectively; P < 0.001 for both), but not for BMI >30-35 kg/m2 (HR, 0.91 [95% CI, 0.81-1.02]; P = 0.09). Length of stay and patient survival did not differ by recipient BMI. LIMITATIONS Observational study with limited detail regarding potential confounders. CONCLUSIONS Despite an increased risk of DGF likely unrelated to donor organ quality, long-term transplant outcomes among recipients with a BMI >35 kg/m2 are similar to those among recipients with a BMI >30-35 kg/m2, supporting a flexible approach to kidney transplantation candidacy in candidates with extreme obesity.
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Affiliation(s)
- Kalathil K Sureshkumar
- Division of Nephrology and Hypertension, Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA
| | - Bhavna Chopra
- Division of Nephrology and Hypertension, Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA
| | - Michelle A Josephson
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL
| | - Pratik B Shah
- Division of Nephrology, University of California, Davis, Sacramento, CA
| | - Rita L McGill
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL.
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14
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Witkowski P, Philipson LH, Kaufman DB, Ratner LE, Abouljoud MS, Bellin MD, Buse JB, Kandeel F, Stock PG, Mulligan DC, Markmann JF, Kozlowski T, Andreoni KA, Alejandro R, Baidal DA, Hardy MA, Wickrema A, Mirmira RG, Fung J, Becker YT, Josephson MA, Bachul PJ, Pyda JS, Charlton M, Millis JM, Gaglia JL, Stratta RJ, Fridell JA, Niederhaus SV, Forbes RC, Jayant K, Robertson RP, Odorico JS, Levy MF, Harland RC, Abrams PL, Olaitan OK, Kandaswamy R, Wellen JR, Japour AJ, Desai CS, Naziruddin B, Balamurugan AN, Barth RN, Ricordi C. The demise of islet allotransplantation in the United States: A call for an urgent regulatory update. Am J Transplant 2021; 21:1365-1375. [PMID: 33251712 PMCID: PMC8016716 DOI: 10.1111/ajt.16397] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [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: 07/17/2020] [Revised: 10/14/2020] [Accepted: 11/02/2020] [Indexed: 02/06/2023]
Abstract
Islet allotransplantation in the United States (US) is facing an imminent demise. Despite nearly three decades of progress in the field, an archaic regulatory framework has stymied US clinical practice. Current regulations do not reflect the state-of-the-art in clinical or technical practices. In the US, islets are considered biologic drugs and "more than minimally manipulated" human cell and tissue products (HCT/Ps). In contrast, across the world, human islets are appropriately defined as "minimally manipulated tissue" and not regulated as a drug, which has led to islet allotransplantation (allo-ITx) becoming a standard-of-care procedure for selected patients with type 1 diabetes mellitus. This regulatory distinction impedes patient access to islets for transplantation in the US. As a result only 11 patients underwent allo-ITx in the US between 2016 and 2019, and all as investigational procedures in the settings of a clinical trials. Herein, we describe the current regulations pertaining to islet transplantation in the United States. We explore the progress which has been made in the field and demonstrate why the regulatory framework must be updated to both better reflect our current clinical practice and to deal with upcoming challenges. We propose specific updates to current regulations which are required for the renaissance of ethical, safe, effective, and affordable allo-ITx in the United States.
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Affiliation(s)
- Piotr Witkowski
- Department of Surgery, Transplantation Institute, University of Chicago, Chicago, Illinois, USA
| | | | - Dixon B. Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Lloyd E. Ratner
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Marwan S. Abouljoud
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Melena D. Bellin
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - John B. Buse
- Division of Endocrinology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Fouad Kandeel
- Department of Translational Research and Cellular Therapeutics, Diabetes and Metabolism Research Institute, Beckman Research Institute of City of Hope, Duarte, California, USA
| | - Peter G. Stock
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, California, USA
| | - David C. Mulligan
- Department of Surgery, Transplantation and Immunology, Yale University, New Haven, Connecticut, USA
| | - James F. Markmann
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tomasz Kozlowski
- Division of Transplantation, Department of Surgery, The University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | - Kenneth A. Andreoni
- Department of Surgery, University of Florida, College of Medicine, Gainesville, Florida, USA
| | - Rodolfo Alejandro
- Diabetes Research Institute and Cell Transplant Center, University of Miami, Miami, Florida, USA
| | - David A. Baidal
- Diabetes Research Institute and Cell Transplant Center, University of Miami, Miami, Florida, USA
| | - Mark A. Hardy
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Amittha Wickrema
- Department of Medicine, Section of Hematology and Oncology, University of Chicago, Chicago, Illinois, USA
| | - Raghavendra G. Mirmira
- Department of Medicine, Translational Research Center, University of Chicago, Chicago, Illinois, USA
| | - John Fung
- Department of Surgery, Transplantation Institute, University of Chicago, Chicago, Illinois, USA
| | - Yolanda T. Becker
- Department of Surgery, Transplantation Institute, University of Chicago, Chicago, Illinois, USA
| | - Michelle A. Josephson
- Department of Surgery, Transplantation Institute, University of Chicago, Chicago, Illinois, USA
| | - Piotr J. Bachul
- Department of Surgery, Transplantation Institute, University of Chicago, Chicago, Illinois, USA
| | - Jordan S. Pyda
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Charlton
- Department of Surgery, Transplantation Institute, University of Chicago, Chicago, Illinois, USA
| | - J. Michael Millis
- Department of Surgery, Transplantation Institute, University of Chicago, Chicago, Illinois, USA
| | - Jason L. Gaglia
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert J. Stratta
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jonathan A. Fridell
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Silke V. Niederhaus
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Rachael C. Forbes
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kumar Jayant
- Department of Surgery, Transplantation Institute, University of Chicago, Chicago, Illinois, USA
| | - R. Paul Robertson
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Washington, Seattle, Washington, USA
| | - Jon S. Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Marlon F. Levy
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | | | - Peter L. Abrams
- MedStar Georgetown Transplant Institute, Washington, District of Columbia, USA
| | | | - Raja Kandaswamy
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jason R. Wellen
- Department of Surgery, Washington University, St Louis, Missouri, USA
| | - Anthony J. Japour
- Anthony Japour and Associates, Medical and Scientific Consulting Inc, Miami, FL, USA
| | - Chirag S. Desai
- Department of Surgery, Section of Transplantation, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Bashoo Naziruddin
- Transplantation Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Appakalai N. Balamurugan
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Rolf N. Barth
- Department of Surgery, Transplantation Institute, University of Chicago, Chicago, Illinois, USA
| | - Camillo Ricordi
- Diabetes Research Institute and Cell Transplant Center, University of Miami, Miami, Florida, USA
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15
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Lentine KL, Mannon RB, Josephson MA. Practicing With Uncertainty: Kidney Transplantation During the COVID-19 Pandemic. Am J Kidney Dis 2021; 77:777-785. [PMID: 33388404 PMCID: PMC7946342 DOI: 10.1053/j.ajkd.2020.12.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [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: 09/30/2020] [Accepted: 12/19/2020] [Indexed: 12/21/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic required transplant nephrologists, surgeons, and care teams to make decisions about the full spectrum of transplant program operations and clinical practices in the absence of experience or data. Initially, across the country, there was a reduction in kidney transplant procedures and a striking pause in the conduct of living donation and living-donor transplant surgeries. Aspects of candidate evaluation and follow-up rapidly converted to telehealth. Months into the pandemic, much has been learned from experiences worldwide, yet many questions remain. In this Perspective, we reflect on some of the practice decisions made by the transplant community in the initial response to the pandemic and consider lessons learned, including those related to the risks, benefits, and logistical considerations of proceeding with versus delaying deceased-donor transplantation, living donation, and living-donor transplantation during the pandemic. We review the evolution of therapeutic strategies for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and their use in transplant recipients, current consensus related to immunosuppression management in infected transplant recipients, and emerging information on vaccination against SARS-CoV-2. We share our thoughts on research priorities, discuss the areas in which we are still practicing with uncertainty, and look ahead to the next phase of the pandemic response.
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Affiliation(s)
- Krista L Lentine
- Division of Nephrology, Department of Medicine, Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
| | - Roslyn B Mannon
- Division of Nephrology, Department of Medicine, University of Nebraska Medical Center and Medical Service, Nebraska-Western Iowa Veterans Affairs Medical Center, Omaha, NE
| | - Michelle A Josephson
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL.
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16
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Lentine KL, Vest LS, Schnitzler MA, Mannon RB, Kumar V, Doshi MD, Cooper M, Mandelbrot DA, Harhay MN, Josephson MA, Caliskan Y, Sharfuddin A, Kasiske BL, Axelrod DA. Survey of US Living Kidney Donation and Transplantation Practices in the COVID-19 Era. Kidney Int Rep 2020; 5:1894-1905. [PMID: 32864513 PMCID: PMC7445484 DOI: 10.1016/j.ekir.2020.08.017] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/14/2020] [Accepted: 08/17/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The scope of the impact of the coronavirus disease 2019 (COVID-19) pandemic on living donor kidney transplantation (LDKT) practices is not well defined. METHODS We surveyed US transplant programs to assess practices, strategies, and barriers to living LDKT during the COVID-19 pandemic. After institutional review board approval, the survey was distributed from 9 May 2020 to 30 May 2020 by e-mail and postings to professional society list-servs. Responses were stratified based on state COVID-19 cumulative incidence levels. RESULTS Staff at 118 unique centers responded, representing 61% of US living donor recovery programs and 75% of LKDT volume in the prepandemic year. Overall, 66% reported that LDKT surgery was on hold (81% in "high" vs. 49% in "low" COVID-19 cumulative incidence states). A total of 36% reported that evaluation of new donor candidates had paused, 27% reported that evaluations were very much decreased (>0% to <25% typical), and 23% reported that evaluations were moderately decreased (25% to <50% typical). Barriers to LDKT surgery included program concerns for donor (85%) and recipient (75%) safety, patient concerns (56%), elective case restrictions (47%), and hospital administrative restrictions (48%). Programs with higher local COVID-19 cumulative incidence reported more barriers related to staff and resource diversion. Most centers continuing donor evaluations used remote strategies (video, 82%; telephone, 43%). As LDKT resumes, all programs will screen for COVID-19, although timeframe and modalities will vary. Recommendations for presurgical self-quarantine are also variable. CONCLUSION The COVID-19 pandemic has had broad impacts on LDKT practice. Ongoing research and consensus building are needed to reduce barriers, to guide optimal practices, and to support safe restoration of LDKT across centers.
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Affiliation(s)
- Krista L. Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri, USA
| | - Luke S. Vest
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri, USA
| | - Mark A. Schnitzler
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri, USA
| | - Roslyn B. Mannon
- Department of Medicine, University of Nebraska, Omaha, Nebraska, USA
| | - Vineeta Kumar
- University of Alabama Comprehensive Transplant Center, Birmingham, Alabama, USA
| | - Mona D. Doshi
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Matthew Cooper
- Medstar Georgetown Transplant Institute, Washington, DC, USA
| | - Didier A. Mandelbrot
- Comprehensive Transplant Program, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Meera N. Harhay
- Department of Medicine, Drexel University, Philadelphia, Pennsylvania, USA
| | | | - Yasar Caliskan
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri, USA
| | - Asif Sharfuddin
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Bertram L. Kasiske
- Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - David A. Axelrod
- Organ Transplant Center, University of Iowa, Iowa City, Iowa, USA
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17
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Affiliation(s)
- George L Bakris
- Department of Medicine, American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine, Chicago, Illinois
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18
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Gupta V, McGill RL, Sampra M, Hammes M, Reddy B, Stankus N, Josephson MA, Saunders MR. Weight, Weight Perception and Self-reported Access to Transplantation in African American Hemodialysis Patients. Kidney Med 2019; 1:226-227. [PMID: 31754661 PMCID: PMC6870939 DOI: 10.1016/j.xkme.2019.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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19
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Shah PB, Ennis JL, Cunningham PN, Josephson MA, McGill RL. The Epidemiologic Burden of Tacrolimus Variability among Kidney Transplant Recipients in the United States. Am J Nephrol 2019; 50:370-374. [PMID: 31553982 DOI: 10.1159/000503167] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/03/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Within-patient tacrolimus level variability >30% has been shown to be a risk factor for de novo donor-specific antibody formation and death-censored graft failure among kidney transplant recipients. The burden of tacrolimus variability and the correlation between variability and subtherapeutic tacrolimus levels were examined in a large national data set. METHODS All tacrolimus levels drawn at LabCorp® facilities in the United States with a diagnosis code for kidney transplant between November 2011 and September 2017 were examined, excluding values that could represent new allografts. Tacrolimus variability was calculated if at least 3 levels were available. The percentage of subtherapeutic (<4.0 ng/dL) tacrolimus levels (%subT) was also calculated. Interdependence between %subT and tacrolimus variability was assessed with correlation analysis and linear regression. RESULTS There were 410,257 tacrolimus levels among 27,375 patients, who had 11 (interquartile range [IQR] 6-20) tacrolimus levels over a median follow-up of 26.5 (IQR 12.8-46.1) months. Median tacrolimus variability was 30.6%, and 51.6% of patients exceeded 30% variability. Median %subT was 11.1% (IQR 0-30.8%), and 34.3% of patients had no subtherapeutic levels. The correlation coefficient between tacrolimus variability and %subT was 0.253 (p< 0.001). In linear regression, tacrolimus variability increased 1.86% for each 10% increase in %subT (p < 0.001), but R-squared for this model was only 0.06. CONCLUSION More than half of established kidney transplant patients from a large national sample exhibited levels of tacrolimus variability that have been associated with inferior transplant outcomes. Tacrolimus variability has a weak association with subtherapeutic levels, but represents a more complicated constellation of clinical factors.
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Affiliation(s)
- Pratik B Shah
- Section of Nephrology, University of Chicago, Chicago, Illinois, USA,
| | | | | | | | - Rita L McGill
- Section of Nephrology, University of Chicago, Chicago, Illinois, USA
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20
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Ju A, Chow BY, Ralph AF, Howell M, Josephson MA, Ahn C, Butt Z, Dobbels F, Fowler K, Jowsey-Gregoire S, Jha V, Locke JE, Tan JC, Taylor Q, Rutherford C, Craig JC, Tong A. Patient-reported outcome measures for life participation in kidney transplantation: A systematic review. Am J Transplant 2019; 19:2306-2317. [PMID: 30664327 DOI: 10.1111/ajt.15267] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/07/2019] [Accepted: 01/13/2019] [Indexed: 01/25/2023]
Abstract
For many patients with end-stage kidney disease, transplantation improves survival and quality of life compared with dialysis. However, complications and side effects in kidney transplant recipients can limit their ability to participate in activities of daily living including work, study, and recreational activities. The aim of this study was to identify the characteristics, content, and psychometric properties of the outcome measures used to assess life participation in kidney transplant recipients. We searched MEDLINE, Embase, PsycINFO, and CINAHL from inception to July 2018 for all studies that reported life participation in kidney transplant recipients. Two authors identified instruments measuring life participation and reviewed for characteristics. In total, 230 studies were included: 19 (8%) randomized trials, 17 (7%) nonrandomized trials, and 194 (85%) observational studies. Across these studies, we identified 29 different measures that were used to assess life participation. Twelve (41%) measures specifically assessed aspects of life participation (eg, disability assessment, daily activities of living), while 17 (59%) assessed other constructs (eg, quality of life) that included questions on life participation. Validation data to support the use of these measures in kidney transplant recipients were available for only 7 measures. A wide range of measures have been used to assess life participation in kidney transplant recipients, but validation data supporting the use of these measures in this population are sparse. A content relevant and validated measure to improve the consistency and accuracy of measuring life participation in research may inform strategies for transplant recipients to be better able to engage in their life activities.
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Affiliation(s)
- Angela Ju
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Bi Yang Chow
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Angelique F Ralph
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Martin Howell
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | | | - Curie Ahn
- Transplantation Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.,Transplantation Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Zeeshan Butt
- Departments of Medical Social Sciences and Surgery (Division of Organ Transplantation), Northwestern University, Chicago, Illinois
| | | | - Kevin Fowler
- Kidney Health Initiative, Patient Family Partnership Council, The Voice of the Patient, Elmhurst, Illinois
| | | | | | - Jayme E Locke
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Jane C Tan
- Department of Medicine, Stanford University, Stanford, California
| | | | - Claudia Rutherford
- School of Psychology, University of Sydney, Sydney, New South Wales, Australia.,Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Allison Tong
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
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21
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Abstract
PURPOSE OF REVIEW To review the studies and practice guidelines on the preeclampsia risks in kidney donors and recipients. RECENT FINDINGS There is a small increased risk of gestational hypertension and preeclampsia in pregnancies that follow kidney donation. Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guideline (2017) and the 2015 American Society of Transplantation (AST) consensus conference statement recommends counseling kidney donors about this increased risk. There is no observed increase in fetal complications or eclampsia post-kidney donation. Preeclampsia is more commonly observed in kidney transplant recipients than the general population and these patients should be co-managed with an obstetrician with experience in managing high risk pregnancies. Although preeclampsia has not been found to have a deleterious effect on renal graft function, it can cause premature delivery. Risk calculators have been proposed and an elevated pre-pregnancy creatinine seems to be an important risk. KDIGO Clinical Practice Guidelines (2009) recommends attempting pregnancy when kidney function is stable with proteinuria of less than 1 g per day. The use of novel biomarkers for preeclampsia has not been published in this population. Preeclampsia is an important concern for female kidney donors and recipients of child-bearing age. These individuals should be appropriately counseled.
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Affiliation(s)
- Pratik B Shah
- Section of Nephrology, University of Chicago Medicine, Chicago, IL, USA
| | - Manpreet Samra
- Division of Nephrology, University of Illinois at Chicago, Chicago, IL, USA
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22
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Saunders MR, Josephson MA. Donor Outcomes: Why We Need to Listen. Clin J Am Soc Nephrol 2018; 13:831-832. [PMID: 29853615 PMCID: PMC5989681 DOI: 10.2215/cjn.05000418] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Milda R. Saunders
- Section of General Internal Medicine, University of Chicago Medicine, Chicago, Illinois; and
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23
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Ju A, Unruh M, Davison S, Dapueto J, Dew MA, Fluck R, Germain M, Jassal SV, Obrador G, O'Donoghue D, Josephson MA, Craig JC, Viecelli A, O'Lone E, Hanson CS, Manns B, Sautenet B, Howell M, Reddy B, Wilkie C, Rutherford C, Tong A. Establishing a Core Outcome Measure for Fatigue in Patients on Hemodialysis: A Standardized Outcomes in Nephrology-Hemodialysis (SONG-HD) Consensus Workshop Report. Am J Kidney Dis 2018; 72:104-112. [PMID: 29551585 DOI: 10.1053/j.ajkd.2017.12.018] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [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: 09/27/2017] [Accepted: 12/23/2017] [Indexed: 11/11/2022]
Abstract
Fatigue is one of the most highly prioritized outcomes for patients and clinicians, but remains infrequently and inconsistently reported across trials in hemodialysis. We convened an international Standardized Outcomes in Nephrology-Hemodialysis (SONG-HD) consensus workshop with stakeholders to discuss the development and implementation of a core outcome measure for fatigue. 15 patients/caregivers and 42 health professionals (clinicians, researchers, policy makers, and industry representatives) from 9 countries participated in breakout discussions. Transcripts were analyzed thematically. 4 themes for a core outcome measure emerged. Drawing attention to a distinct and all-encompassing symptom was explicitly recognizing fatigue as a multifaceted symptom unique to hemodialysis. Emphasizing the pervasive impact of fatigue on life participation justified the focus on how fatigue severely impaired the patient's ability to do usual activities. Ensuring relevance and accuracy in measuring fatigue would facilitate shared decision making about treatment. Minimizing burden of administration meant avoiding the cognitive burden, additional time, and resources required to use the measure. A core outcome measure that is simple, is short, and includes a focus on the severity of the impact of fatigue on life participation may facilitate consistent and meaningful measurement of fatigue in all trials to inform decision making and care of patients receiving hemodialysis.
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Affiliation(s)
- Angela Ju
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia.
| | - Mark Unruh
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, NM
| | - Sara Davison
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Juan Dapueto
- Departamento de Psicología Médica, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Mary Amanda Dew
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Richard Fluck
- Department of Renal Medicine, Royal Derby Hospital, Derby, United Kingdom
| | - Michael Germain
- Renal and Transplant Associates of New England, Division of Nephrology, Baystate Medical Center, Tufts University School of Medicine, Boston, MA
| | - Sarbjit V Jassal
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Gregorio Obrador
- Universidad Panamericana School of Medicine, Mexico City, Mexico
| | - Donal O'Donoghue
- Department of Renal Medicine, Salford Royal Hospital, Salford, United Kingdom
| | | | - Jonathan C Craig
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Andrea Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Emma O'Lone
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Camilla S Hanson
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Braden Manns
- Department of Medicine and Community Health Sciences, Libin Cardiovascular Institute and O'Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Benedicte Sautenet
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia; Department of Nephrology and Clinical Immunology, University Francois Rabelais, Tours Hospital; INSERUM, U1246, Tours, Franc Tours, France
| | - Martin Howell
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Bharathi Reddy
- Department of Medicine, University of Chicago, Chicago, IL
| | - Caroline Wilkie
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia; University of North Carolina at Charlotte, Charlotte, NC
| | - Claudia Rutherford
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Allison Tong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
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Gallan AJ, Chon WJ, Josephson MA, Cunningham PN, Henriksen KJ, Chang A. Bowman capsulitis predicts poor kidney allograft outcome in T cell-mediated rejection. Hum Pathol 2018; 76:47-51. [PMID: 29501487 DOI: 10.1016/j.humpath.2018.02.016] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 02/08/2018] [Accepted: 02/14/2018] [Indexed: 11/17/2022]
Abstract
Acute T cell-mediated rejection (TCMR) is an important cause of renal allograft loss. The Banff classification for tubulointerstitial (type I) rejection is based on the extent of both interstitial inflammation and tubulitis. Lymphocytes may also be present between parietal epithelial cells and Bowman capsules in this setting, which we have termed "capsulitis." We conducted this study to determine the clinical significance of capsulitis. We identified 42 patients from the pathology archives at The University of Chicago with isolated Banff type I TCMR from 2010 to 2015. Patient demographic data, Banff classification, and graft outcome measurements were compared between capsulitis and noncapsulitis groups using Mann-Whitney U test. Capsulitis was present in 26 (62%) and was more frequently seen in Banff IB than in IA TCMR (88% versus 44%, P = .01). Patients with capsulitis had a higher serum creatinine at biopsy (4.6 versus 2.9 mg/dL, P = .04) and were more likely to progress to dialysis (42% versus 13%, P = .06), with fewer recovering their baseline serum creatinine (12% versus 38%, P = .08). Patients with both Banff IA TCMR and capsulitis have clinical outcomes similar to or possibly worse than Banff IB TCMR compared with those with Banff IA and an absence of capsulitis. Capsulitis is an important pathologic parameter in the evaluation of kidney transplant biopsies with potential diagnostic, prognostic, and therapeutic implications in the setting of TCMR.
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Affiliation(s)
- Alexander J Gallan
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA.
| | - Woojin James Chon
- Department of Medicine, The University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Michelle A Josephson
- Department of Medicine, Section of Nephrology, The University of Chicago, Chicago, IL 60637, USA
| | - Patrick N Cunningham
- Department of Medicine, Section of Nephrology, The University of Chicago, Chicago, IL 60637, USA
| | - Kammi J Henriksen
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA
| | - Anthony Chang
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA
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25
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Agrawal N, Echenique IA, Meehan SM, Limaye AP, Cook L, Chang A, Harland RC, Javaid B, Kadambi PV, Matushek S, Williams J, Josephson MA. Variability in assessing for BK viremia: whole blood is not reliable and plasma is not above reproach - a retrospective analysis. Transpl Int 2017; 30:670-678. [PMID: 28295760 DOI: 10.1111/tri.12951] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 12/31/2016] [Accepted: 03/08/2017] [Indexed: 12/22/2022]
Abstract
Polyomavirus nephropathy (PVN) is a major complication of kidney transplantation. Most reports describe polyomavirus viremia either precedes or is detectable at the time of diagnosis of PVN. This association is the basis of current screening recommendations. We retrospectively reviewed the PCR results of blood and urine samples from 29 kidney transplant recipients with biopsy-proven PVN. Biopsies were performed for a rise in serum creatinine or persistent high-level BK viruria. All biopsies showed polyoma virus large T-antigen expression in tubular epithelium using immunohistochemistry. All had viruria preceding or at the time of biopsy (range, 5.2 × 104 to >25 × 106 BKV DNA copies/ml). Twenty (69%) had viremia ranging from 2.5 × 103 to 4.3 × 106 copies/ml at the time of the biopsy. Via blood BK PCR assay, nine (31%) had no BK viremia detected either preceding or at the time of the biopsy. In five recipients where sufficient specimen permitted, additional plasma BK assessment revealed positive detection of viremia. A comparative analysis of assays from two centres was performed with spiked samples. BK DNA may not be detected in the blood of some kidney transplant recipients with histologically confirmed PVN. This may reflect limitation of whole blood as opposed to plasma-based BK DNA assessment.
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Affiliation(s)
- Neerja Agrawal
- Department of Transplant Nephrology, Cleveland Clinic Florida, Weston, FL, USA
| | | | | | - Ajit P Limaye
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Linda Cook
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - Anthony Chang
- Department of Pathology, University of Chicago, Chicago, IL, USA
| | | | - Basit Javaid
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Georgetown, DC, USA
| | | | - Scott Matushek
- Department of Clinical Microbiology, University of Chicago, Chicago, IL, USA
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26
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Lockwood MB, Saunders MR, Nass R, McGivern CL, Cunningham PN, Chon WJ, Josephson MA, Becker YT, Lee CS. Patient-Reported Barriers to the Prekidney Transplant Evaluation in an At-Risk Population in the United States. Prog Transplant 2017; 27:131-138. [DOI: 10.1177/1526924817699957] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Despite our knowledge of barriers to the early stages of the transplant process, we have limited insight into patient-reported barriers to the prekidney transplant medical evaluation in populations largely at-risk for evaluation failure. Methods: One-hundred consecutive adults were enrolled at an urban, Midwestern transplant center. Demographic, clinical, and quality of life data were collected prior to patients visit with a transplant surgeon/nephrologist (evaluation begins). Patient-reported barriers to evaluation completion were collected using the Subjective Barriers Questionnaire 90-days after the initial medical evaluation appointment (evaluation ends), our center targeted goal for transplant work-up completion. Results: At 90 days, 40% of participants had not completed the transplant evaluation. Five barrier categories were created from the 85 responses to the Subjective Barriers Questionnaire. Patient-reported barriers included poor communication, physical health, socioeconomics, psychosocial influences, and access to care. In addition, determinants for successful evaluation completion included being of white race, higher income, free of dialysis, a lower comorbid burden, and reporting higher scores on the Kidney Disease Quality of Life subscale role-emotional. Conclusion: Poor communication between patients and providers, and among providers, was the most prominent patient-reported barrier identified. Barriers were more prominent in marginalized groups such as ethnic minorities and people with low income. Understanding the prevalence of patient-reported barriers may aid in the development of patient-centered interventions to improve completion rates.
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Affiliation(s)
- Mark B. Lockwood
- University of Illinois at Chicago College of Nursing, Department of Biobehavioral Science
| | - Milda R. Saunders
- University of Chicago Medicine, Hospital Medicine and MacLean Center for Clinical Medical Ethics
| | - Rachel Nass
- University of Chicago Medicine, Department of Medicine
| | | | | | - W. James Chon
- University of Arkansas for Medical Sciences, Department of Medicine
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Chisholm-Burns MA, Spivey CA, Hagemann T, Josephson MA. Women in leadership and the bewildering glass ceiling. Am J Health Syst Pharm 2017; 74:312-324. [DOI: 10.2146/ajhp160930] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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28
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Webster P, Lightstone L, McKay DB, Josephson MA. Pregnancy in chronic kidney disease and kidney transplantation. Kidney Int 2017; 91:1047-1056. [PMID: 28209334 DOI: 10.1016/j.kint.2016.10.045] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [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: 07/13/2016] [Revised: 09/28/2016] [Accepted: 10/06/2016] [Indexed: 12/20/2022]
Abstract
Chronic kidney disease (CKD) affects up to 6% of women of childbearing age in high income countries, and is estimated to affect 3% of pregnant women. Advanced renal dysfunction, proteinuria, hypertension, and poorly controlled underlying primary renal disease are all significant risks for adverse maternal, fetal, and renal outcomes. In order to achieve the best outcomes, it is therefore of paramount importance that these pregnancies are planned, where possible, to allow the opportunity to counsel women and their partners in advance and to optimize these risks. These pregnancies should be deemed high risk and they require close antenatal monitoring from an expert multidisciplinary team. We discuss the effect of pregnancy on CKD, and also current guidelines and literature with specific reference to transplantation, autoimmune disease, and medication use in pregnancy. We also discuss the benefits of prepregnancy counseling and give practical recommendations to advise pregnant women with renal disease.
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Affiliation(s)
- Philip Webster
- Section of Renal Medicine and Vascular Inflammation, Department of Medicine, Imperial College London, United Kingdom
| | - Liz Lightstone
- Section of Renal Medicine and Vascular Inflammation, Department of Medicine, Imperial College London, United Kingdom
| | - Dianne B McKay
- Division of Nephrology, Department of Medicine, University of California, San Diego, California, USA
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McKay DB, Adams PL, Bumgardner GL, Davis CL, Fine RN, Krams SM, Martinez OM, Murphy B, Pavlakis M, Tolkoff-Rubin N, Sherman MS, Josephson MA. Reproduction and Pregnancy in Transplant Recipients: Current Practices. Prog Transplant 2016; 16:127-32. [PMID: 16789701 DOI: 10.1177/152692480601600206] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Many transplant physicians are faced with questions from their patients about the safety and long-term consequences of pregnancy following transplantation. To better understand how pregnancies are managed and to clarify the outcome of pregnancy after transplantation, a survey questionnaire was developed and mailed to all medical and surgical directors of transplant centers throughout the United States; responses were obtained from 59.1% of the transplant centers. Although many opinions were collected, most respondents conceded that their opinions were based on personal experience rather than evidence-based. The underutilization of existing information was revealing and highlighted a need for an evidence-based approach to care of the pregnant transplant recipient and her offspring. The survey results, reported in this article, led to formation of a consensus conference to determine the optimal approach to pregnant transplant recipients and to define what is currently known and unknown about reproduction and transplantation.
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Affiliation(s)
- Dianne B McKay
- Scripps Clinic and The Scripps Research Institute, La Jolla, Calif, USA
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30
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Chon WJ, Aggarwal N, Kocherginsky M, Kane B, Sutor J, Josephson MA. High-level viruria as a screening tool for BK virus nephropathy in renal transplant recipients. Kidney Res Clin Pract 2016; 35:176-81. [PMID: 27668162 PMCID: PMC5025461 DOI: 10.1016/j.krcp.2016.05.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 05/10/2016] [Accepted: 05/25/2016] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Although early monitoring of BK virus infection in renal transplant patients has led to improved outcomes over the past decade, it remains unclear whether monitoring for viremia is the best screening tool for BK virus nephropathy (BKVN). METHODS We conducted a retrospective review of the medical records of 368 renal transplant recipients who had a minimum of 18 months of posttransplantation follow-up. The relationship between the presence of BK viruria and a composite end point of BK viremia/BKVN was established, and the predictive value of high-grade BK viruria for development of viremia/BKVN was determined. RESULTS High grade of BK viruria was present in 110 (30.1%) of the renal transplant recipients. BK viremia/BKVN was present in 64 (17.4%) patients and was 50 times more likely to be present in patients with high-grade BK viruria. The risk of developing BK viremia/BKVN was 3 times higher in high-grade viruria patients, and viruria preceded viremia by nearly 7 weeks. CONCLUSION The presence of high-grade viruria is an early marker for developing BK viremia/BKVN. Detection of high-grade viruria should prompt early allograft biopsy and/or preemptive reduction in immunosuppression.
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Affiliation(s)
- W James Chon
- Division of Nephrology & Hypertension, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Nidhi Aggarwal
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Brenna Kane
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Jozefa Sutor
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Michelle A Josephson
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL, USA
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Josephson MA, Perazella MA, Choi MJ. American Society of Nephrology Quiz and Questionnaire 2015: Transplantation. Clin J Am Soc Nephrol 2016; 11:1114-1122. [PMID: 26915914 PMCID: PMC4891764 DOI: 10.2215/cjn.13451215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The Nephrology Quiz and Questionnaire remains an extremely popular session for attendees of the Annual Kidney Week Meeting of the American Society of Nephrology. Once again, the conference hall was overflowing with audience members and eager quiz participants. Topics covered by the expert discussants included electrolyte and acid-base disorders, glomerular disease, ESRD/dialysis, and kidney transplantation. Complex cases representing each of these categories along with single best answer questions were prepared and submitted by the panel of experts. Before the meeting, training program directors of US nephrology fellowship programs and nephrology fellows answered the questions through an internet-based questionnaire. During the live session, members of the audience tested their knowledge and judgment on a series of case-oriented questions prepared and discussed by the experts. They compared their answers in real time using their cell phones with a special application with the answers of the nephrology fellows and training program directors. The correct and incorrect answers were then discussed after the results of the questionnaire were displayed. As always, the audience, lecturers, and moderators enjoyed this highly educational session. This article recapitulates the session and reproduces its educational value for the Clinical Journal of the American Society of Nephrology readers. Enjoy the clinical cases and expert discussions.
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Affiliation(s)
| | - Mark A. Perazella
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
- Section of Nephrology, Veterans Affairs Connecticut, West Haven, Connecticut; and
| | - Michael J. Choi
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland
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Han Z, Kane BM, Petty LA, Josephson MA, Sutor J, Pursell KJ. Cobicistat Significantly Increases Tacrolimus Serum Concentrations in a Renal Transplant Recipient with Human Immunodeficiency Virus Infection. Pharmacotherapy 2016; 36:e50-e53. [DOI: 10.1002/phar.1752] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Zhe Han
- Department of Pharmacy Services; The University of Chicago Medicine; Chicago Illinois
| | - Brenna M. Kane
- Department of Pharmacy Services; The University of Chicago Medicine; Chicago Illinois
| | - Lindsay A. Petty
- Department of Medicine; Section of Infectious Diseases and Global Health; The University of Chicago Medicine; Chicago Illinois
| | - Michelle A. Josephson
- Department of Medicine; Section of Nephrology; The University of Chicago Medicine; Chicago Illinois
| | - Jozefa Sutor
- The University of Chicago Medicine Transplant Center; Chicago Illinois
| | - Kenneth J. Pursell
- Department of Medicine; Section of Infectious Diseases and Global Health; The University of Chicago Medicine; Chicago Illinois
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Jamieson NJ, Hanson CS, Josephson MA, Gordon EJ, Craig JC, Halleck F, Budde K, Tong A. Motivations, Challenges, and Attitudes to Self-management in Kidney Transplant Recipients: A Systematic Review of Qualitative Studies. Am J Kidney Dis 2016; 67:461-78. [DOI: 10.1053/j.ajkd.2015.07.030] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 07/19/2015] [Indexed: 12/20/2022]
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Chon WJ, Desai A, Wing C, Arwindekar D, Tang IYS, Josephson MA, Akkina S. Impact of Maintenance Steroids versus Rapid Steroid Withdrawal in African-American Kidney Transplant Recipients: Comparison of Two Urban Centers. ACTA ACUST UNITED AC 2016; 7:204-216. [PMID: 27088051 PMCID: PMC4829964 DOI: 10.4236/ijcm.2016.73021] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Rapid steroid withdrawal (RSW) is used increasingly in kidney transplantation but long-term outcomes in African-American (AA) recipients are not well known. We compared 1 and 5 year transplant outcomes in a large cohort of AA patients who were maintained on continued steroid therapy (CST) to those who underwent RSW. Methods Post-transplant courses of A as receiving kidney allografts from 2003–2011 at two urban transplant centers in Chicago were followed. Prior to outcome analysis, we used Inverse Probability of Treatment Weights (IPTW) to match the two groups on a set of baseline risk factors. Graft and patient survival, GFR at 1 and 5 years, incidence and type of rejection, incidence of post-transplant diabetes mellitus (PTDM), delayed graft function, CMV and BK viremia were compared. Results There were 150 AA recipients in the CST analytic group and 157 in the RSW analytic group. Graft and patient survival was similar between the two groups. Rates of CMV viremia were higher in the RSW compared to the CST analytic group at 1 year. Biopsy-proven acute rejection and PTDM were similar between the RSW and CST groups. Conclusions In AA recipients, RSW has similar long-term outcomes to CST.
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Affiliation(s)
- W James Chon
- Department of Medicine, Division of Nephrology, University of Chicago Medicine, Chicago, IL, USA
| | - Amishi Desai
- Department of Medicine, Division of Nephrology, Loyola University Medical Center, Maywood, IL, USA
| | - Coady Wing
- School of Public and Environmental Affairs, Indiana University, Bloomington, IN, USA
| | - Divya Arwindekar
- Department of Medicine, Division of Nephrology, University of Illinois Hospital & Health Sciences System, Chicago, IL, USA
| | - Ignatius Y S Tang
- Department of Medicine, Division of Nephrology, University of Illinois Hospital & Health Sciences System, Chicago, IL, USA; Department of Medicine, Division of Nephrology, Jesse Brown VA Medical Center, Chicago, IL, USA
| | - Michelle A Josephson
- Department of Medicine, Division of Nephrology, University of Chicago Medicine, Chicago, IL, USA
| | - Sanjeev Akkina
- Department of Medicine, Division of Nephrology, Loyola University Medical Center, Maywood, IL, USA
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Lockwood M, Saunders M, Josephson MA, Becker YT, Lee C. Determinants of frequent Internet use in an urban kidney transplant population in the United States: characterizing the digital divide. Prog Transplant 2015; 25:9-17. [PMID: 25758795 DOI: 10.7182/pit2015957] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
CONTEXT The Internet is a staple of electronic communication and is essential to the emerging telemonitoring and health information technology interventions for adults with chronic diseases. OBJECTIVE To identify determinants of frequent Internet use in an urban kidney transplant population in the United States. DESIGN A single center, cross-sectional survey study. SETTING An urban Midwestern transplant center. PARTICIPANTS 78 pretransplant and 177 posttransplant patients. MAIN OUTCOME MEASURES Frequent Internet use, defined as using the Internet more than 5 hours per week. RESULTS Only 38% of participants reported being frequent Internet users. Non-Hispanic blacks and participants who reported their race/ethnicity as "other" were significantly less likely than whites to report being frequent Internet users. Women were 59% less likely than men to be frequent users of the Internet. Those who reported having kidney disease for more than 3 years were more likely to report being frequent Internet users. As education increased, Internet use increased. As age increased, Internet use decreased. CONCLUSION Alternatives to electronic information sources and/or additional resources should be considered for those who may fall in the so-called digital divide.
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Affiliation(s)
- Mark Lockwood
- University of Chicago Medical Center, Chicago, Illinois
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36
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Tong A, Ralph AF, Chapman JR, Wong G, Gill JS, Josephson MA, Craig JC. Focus group study of public opinion about paying living kidney donors in Australia. Clin J Am Soc Nephrol 2015; 10:1217-26. [PMID: 25908793 PMCID: PMC4491296 DOI: 10.2215/cjn.10821014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 02/26/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The unmet demand for kidney transplantation has generated intense controversy about introducing incentives for living kidney donors to increase donation rates. Such debates may affect public perception and acceptance of living kidney donation. This study aims to describe the range and depth of public opinion on financial reimbursement, compensation, and incentives for living kidney donors. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Twelve focus groups were conducted with 113 participants recruited from the general public in three Australian states in February 2013. Thematic analysis was used to analyze the transcripts. RESULTS Five themes were identified: creating ethical impasses (commodification of the body, quandary of kidney valuation, pushing moral boundaries), corrupting motivations (exposing the vulnerable, inevitable abuse, supplanting altruism), determining justifiable risk (compromising kidney quality, undue harm, accepting a confined risk, trusting protective mechanisms, right to autonomy), driving access (urgency of organ shortage, minimizing disadvantage, guaranteeing cost-efficiency, providing impetus, counteracting black markets), and honoring donor deservingness (fairness and reason, reassurance and rewards, merited recompense). Reimbursement and justifiable recompense are considered by the Australian public as a legitimate way of supporting donors and reducing disadvantage. Financial payment beyond reimbursement is regarded as morally reprehensible, with the potential for exploitative commercialism. Some contend that regulated compensation could be a defensible strategy to increased donation rates provided that mechanisms are in place to protect donors. CONCLUSIONS The perceived threat to community values of human dignity, goodwill, and fairness suggests that there could be strong public resistance to any form of financial inducements for living kidney donors. Policy priorities addressing the removal of disincentives may be more acceptable to the public.
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Affiliation(s)
- Allison Tong
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia; The Centre for Kidney Research, Children's Hospital at Westmead, Westmead, New South Wales, Australia;
| | - Angelique F Ralph
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia; The Centre for Kidney Research, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Jeremy R Chapman
- The Centre for Kidney Research, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia; The Centre for Kidney Research, Children's Hospital at Westmead, Westmead, New South Wales, Australia; Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia
| | - John S Gill
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada; and
| | | | - Jonathan C Craig
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia; The Centre for Kidney Research, Children's Hospital at Westmead, Westmead, New South Wales, Australia
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Abstract
The Nephrology Quiz and Questionnaire remains an extremely popular session for attendees of the Annual Kidney Week Meeting of the American Society of Nephrology. Once again, the conference hall was overflowing with audience members and eager quiz participants. Topics covered by the expert discussants included electrolyte and acid-base disorders, glomerular disease, ESRD/dialysis, and transplantation. Complex cases representing each of these categories along with single best answer questions were prepared and submitted by the panel of experts. Before the meeting, program directors of United States nephrology training programs and nephrology fellows answered the questions through an internet-based questionnaire. During the live session, members of the audience tested their knowledge and judgment on a series of case-oriented questions prepared and discussed by experts. They compared their answers in real time using audience response devices with the answers of the nephrology fellows and training program directors. The correct and incorrect answers were then discussed after the audience responses and the results of the questionnaire were displayed. As always, the audience, lecturers, and moderators enjoyed this educational session. This article recapitulates the session and reproduces its educational value for the readers of CJASN. Enjoy the clinical cases and expert discussions.
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Affiliation(s)
| | - Mark A Perazella
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; and
| | - Michael J Choi
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Tong A, Hanson CS, Chapman JR, Halleck F, Budde K, Josephson MA, Craig JC. 'Suspended in a paradox'-patient attitudes to wait-listing for kidney transplantation: systematic review and thematic synthesis of qualitative studies. Transpl Int 2015; 28:771-87. [PMID: 25847569 DOI: 10.1111/tri.12575] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [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: 01/25/2015] [Revised: 02/23/2015] [Accepted: 03/31/2015] [Indexed: 12/21/2022]
Abstract
Patients on waiting lists for kidney transplantation have higher mortality rates and have specific anxieties about their eligibility, process, and outcomes of wait-listing. We aimed to describe patient experiences and attitudes to wait-listing for kidney transplantation. Electronic databases were searched to September 2014. Thematic synthesis was used to analyze the findings. From 22 studies (n = 795 patients), we identified six themes: accepting the only option (chance to regain normality, avoiding guilt, impulsive decision-making); maintaining hope (determined optimism, appreciating a fortuitous gift, enduring for optimal outcomes, trust in clinical judgment); burden of testing (strenuous commitment, losing the battle, medical mistrust); permeating vulnerability (eligibility enigma, being threatened, angst of timing uncertainty, desperate urgency, living in limbo, spiraling doubt and disappointment, residual ambivalence); deprived of opportunity (unfairly dismissed, unexpected disqualification, self-resignation and acceptance, jealousy, suspicious of inequity); and moral guilt (awaiting someone's death, questioning deservingness). The waiting list offered hope of restored normality. However, the demands of workup, uncertainty about eligibility, and waiting times that exceeded expectations impelled patients to disillusionment, despair, and suspicion of inequity. Managing patient expectations and ensuring transparency of wait-listing and allocation decisions may allay patient disappointment and skepticism, to improve patient satisfaction and treatment outcomes.
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Affiliation(s)
- Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Camilla S Hanson
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Jeremy R Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Fabian Halleck
- Department of Nephrology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
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Chon WJ, Kadambi PV, Xu C, Becker YT, Witkowski P, Pursell K, Kane B, Josephson MA. Use of leflunomide in renal transplant recipients with ganciclovir-resistant/refractory cytomegalovirus infection: a case series from the University of Chicago. Case Rep Nephrol Dial 2015; 5:96-105. [PMID: 26000278 PMCID: PMC4427155 DOI: 10.1159/000381470] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Introduction Although antiviral prophylaxis for cytomegalovirus (CMV) is widely used, CMV infection remains common in renal transplant recipients with adverse consequences. Methods We report 5 cases of renal transplant recipients with resistant CMV infection who were successfully managed with leflunomide at the University of Chicago Medical Center. Results Five renal transplant recipients (2 simultaneous pancreas/kidney transplants, 3 deceased donor kidney transplants) were diagnosed with GCV-resistant CMV infection from 2003 to 2011. Of the 4 patients who had resistance genotype testing, 3 showed a UL97 mutation and 1 patient had a clinically resistant CMV infection. All patients received CMV prophylaxis with valganciclovir for 3 months. The number of days from the date of transplant to viremia ranged from 38 to 458 days (median 219). All 5 patients received other antiviral agents (e.g. ganciclovir, foscarnet), and in 4 patients, viremia was cleared before leflunomide was initiated as consolidation (or maintenance) therapy. Conclusion Leflunomide was well tolerated and successful in preventing recurrence of viremia in renal transplant recipients with resistant CMV infection. The beneficial effect of leflunomide in this setting warrants further investigation.
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Affiliation(s)
- W James Chon
- Section of Nephrology, University of Chicago, Chicago, Ill., USA
| | - Pradeep V Kadambi
- Division of Nephrology and Transplant Medicine, University of Arizona, Tucson, Ariz., USA
| | - Chang Xu
- Section of Nephrology, University of Chicago, Chicago, Ill., USA
| | - Yolanda T Becker
- Section of Transplant Surgery, University of Chicago, Chicago, Ill., USA
| | - Piotr Witkowski
- Section of Transplant Surgery, University of Chicago, Chicago, Ill., USA
| | - Kenneth Pursell
- Section of Infectious Disease, University of Chicago, Chicago, Ill., USA
| | - Brenna Kane
- Department of Pharmacy Services, University of Chicago, Chicago, Ill., USA
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40
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Abstract
The nephrology quiz and questionnaire remains an extremely popular session for attendees of the Annual Meeting of the American Society of Nephrology. As in past years, the conference hall was overflowing with interested audience members. Topics covered by expert discussants included electrolyte and acid-base disorders, glomerular disease, ESRD/dialysis, and transplantation. Complex cases representing each of these categories along with single best answer questions were prepared by a panel of experts. Before the meeting, program directors of United States nephrology training programs answered questions through an Internet-based questionnaire. A new addition to the nephrology quiz and questionnaire was participation in the questionnaire by nephrology fellows. To review the process, members of the audience test their knowledge and judgment on a series of case-oriented questions prepared and discussed by experts. Their answers are compared in real time using audience response devices with the answers of nephrology fellows and training program directors. The correct and incorrect answers are then briefly discussed after the audience responds, and the results of the questionnaire are displayed. This article recapitulates the session and reproduces its educational value for the readers of CJASN. Enjoy the clinical cases and expert discussions.
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Affiliation(s)
| | - Mark A Perazella
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; and
| | - Michael J Choi
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
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Chon WJ, Josephson MA, Gordon EJ, Becker YT, Witkowski P, Arwindekar DJ, Naik A, Thistlethwaite JR, Liao C, Ross LF. When the living and the deceased cannot agree on organ donation: a survey of US organ procurement organizations (OPOs). Am J Transplant 2014; 14:172-7. [PMID: 24369025 DOI: 10.1111/ajt.12519] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The legal concept of first person authorization (FPA) is based on the principle that a decision by a person with decision-making capacity should be respected even after he or she dies. Although the transplant community largely supports this concept, its implementation has not been universal. We conducted a web-based survey of all 58 Organ Procurement Organization (OPO)executive directors in the United States to assess OPOs' procurement policies and practices in the context of family objections. All 58 respondents(100%) responded to our survey. All OPOs except one have an online donor registration website. Most OPOs(89%) (51 of 57 respondents) estimated that the frequency of family objecting to organ donation in cases of registered donors was <10%. No OPOs reported the frequency to be higher than 25%. Only 50% (27 of 54) of the OPOs have a written policy on handling family objections. Approximately 80% of the OPOs reported honoring FPA. However, in the past 5 years, 20 OPOs (35%) have not yet participated in organ procurement from a registered deceased donor over family objection. Further research to identify the barriers and possible solutions to implementing FPA is warranted.
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Abstract
Late kidney transplant dysfunction may be a harbinger of graft failure. For many years, calcineurin inhibitor toxicity was felt to be the main cause for graft dysfunction with fibrosis and transplant loss. Recently this idea has come into question. With the observation that peritubular capillary C4d staining in kidney allografts may indicate antibody-mediated injury in conjunction with biopsy study findings, an appreciation for antibody-mediated rejection as a major cause of late graft dysfunction and loss has emerged. Twenty percent to 30% of patients develop de novo donor-specific antibodies after kidney transplantation. There are no US Food and Drug Administration-approved treatments for antibody-mediated rejection, nor have any randomized controlled trials assessed efficacy. Off-label treatment strategies include some combination of plasma exchange, intravenous immunoglobulin, and rituximab. Other approaches, including splenectomy, bortezomib, and eculizumab, have also been tried.
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Lockwood MB, Saunders MR, Lee CS, Becker YT, Josephson MA, Chon WJ. Kidney Transplant and the Digital Divide: Is Information and Communication Technology a Barrier or a Bridge to Transplant for African Americans? Prog Transplant 2013; 23:302-9. [DOI: 10.7182/pit2013869] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Context Barriers to kidney transplant for African Americans are well documented in the literature. Little information on ownership of information and communication technology and use of such technology in transplant populations has been published. Objective To characterize racial differences related to ownership and use of information and communication technology in kidney transplant patients. Design A single-center, cross-sectional survey study. Setting An urban Midwestern transplant center. Participants 78 pretransplant patients and 177 transplant recipients. Main Outcomes Measures The survey consisted of 6 demographic questions, 3 disease-related questions, and 9 technology-related questions. Dichotomous (yes/no) and Likert-scale items were the basis for the survey. Results Cell phone use was high and comparable between groups (94% in African Americans, 90% in whites, P = .22). A vast majority (75% of African Americans and 74% of whites) reported being “comfortable” sending and receiving text messages. Computer ownership (94.3% vs 79.3%) and Internet access (97.7% vs 80.7%) were greater among whites than African Americans (both P < .01). Fewer African Americans were frequent users of the Internet (27.1% vs 56.3%) and e-mail (61.6% vs 79.3%) than whites (both P < .01). More African Americans than whites preferred education in a classroom setting (77% vs 60%; P < .005) and educational DVDs (66% vs 46%; P < .002). Conclusion The use of cell phone technology and text messaging was ubiquitous and comparable between groups, but computer and Internet access and frequency of use were not. Reaching out to the African American community may best be accomplished by using cell phone/text messaging as opposed to Internet-based platforms.
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Affiliation(s)
- Mark B. Lockwood
- University of Chicago Medical Center, Chicago, Illinois (MBL, MRS, YTB, MAJ, WJC), Oregon Health and Science University School of Nursing, Portland, Oregon (MBL, CSL)
| | - Milda R. Saunders
- University of Chicago Medical Center, Chicago, Illinois (MBL, MRS, YTB, MAJ, WJC), Oregon Health and Science University School of Nursing, Portland, Oregon (MBL, CSL)
| | - Christopher S. Lee
- University of Chicago Medical Center, Chicago, Illinois (MBL, MRS, YTB, MAJ, WJC), Oregon Health and Science University School of Nursing, Portland, Oregon (MBL, CSL)
| | - Yolanda T. Becker
- University of Chicago Medical Center, Chicago, Illinois (MBL, MRS, YTB, MAJ, WJC), Oregon Health and Science University School of Nursing, Portland, Oregon (MBL, CSL)
| | - Michelle A. Josephson
- University of Chicago Medical Center, Chicago, Illinois (MBL, MRS, YTB, MAJ, WJC), Oregon Health and Science University School of Nursing, Portland, Oregon (MBL, CSL)
| | - W. James Chon
- University of Chicago Medical Center, Chicago, Illinois (MBL, MRS, YTB, MAJ, WJC), Oregon Health and Science University School of Nursing, Portland, Oregon (MBL, CSL)
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Josephson MA, McKay DB. Women and transplantation: fertility, sexuality, pregnancy, contraception. Adv Chronic Kidney Dis 2013; 20:433-40. [PMID: 23978550 DOI: 10.1053/j.ackd.2013.06.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 06/14/2013] [Accepted: 06/17/2013] [Indexed: 01/23/2023]
Abstract
Since 1958, thousands of women with kidney transplants have become pregnant. Although most pregnancies in kidney transplant recipients are successful, they are high-risk endeavors. This seems more a function of the associated issues and comorbidities that often affect individuals with kidney transplants (eg, hypertension) or immunosuppression side effects rather than the kidney transplant per se. Regardless of the underlying pathophysiology, these pregnancies are associated with a high rate of preeclampsia diagnoses, preterm deliveries, Cesarean sections, and small-for-gestational-age babies. Given these risks, it is critical to counsel and inform transplant recipients and prospective transplant recipients of childbearing age and their partners regarding many aspects of pregnancy, including the need for contraception to prevent pregnancy after transplant, immunosuppression concerns, and the potential effect of pregnancy on the outcome of the mother, baby, and kidney transplant.
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Mullane KM, Cornely OA, Crook DW, Golan Y, Louie TJ, Miller MA, Josephson MA, Gorbach SL. Renal impairment and clinical outcomes of Clostridium difficile infection in two randomized trials. Am J Nephrol 2013; 38:1-11. [PMID: 23796582 DOI: 10.1159/000351757] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [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: 11/30/2012] [Accepted: 05/02/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Patients with chronic kidney disease (CKD) have increased risk for Clostridium difficile infection (CDI) and for subsequent mortality. We determined the effect of CKD on response to treatment for CDI. METHODS This is a post hoc analysis of two randomized controlled phase 3 trials that enrolled patients with CDI. Patients received either fidaxomicin 200 mg b.i.d. or vancomycin 125 mg q.i.d. for 10 days. Univariate and multivariate analyses compared end points by treatment received and CKD stage. RESULTS At baseline, 27, 21, and 9% of the patients had stage 2 (60-89 ml/min/1.73 m(2)), stage 3 (30-59), and stage 4 or higher (<30) CKD. Cure rates were similar for normal (91%) and stage 2 CKD (92%), but declined to 80% for stage 3 and to 75% for stage 4 CKD (p < 0.001 for trend). Time to resolution of diarrhea (TTROD) increased with stage 3 and stage 4 CKD. CDI recurrence rates 4 weeks after treatment were 16, 20, 27, and 24% for normal, stage 2, stage 3, and stage 4 or higher CKD, respectively. Mortality increased with CKD stage. In multivariate analyses, stage 3 or higher CKD correlated with lower odds of cure, greater chance of recurrence, and lower odds of sustained response 28 days after treatment. Initial cure rates were similar in the vancomycin or fidaxomicin groups; however, the rate of recurrence was higher following vancomycin treatment independent of renal function. The presence of immunosuppression did not alter this effect. CONCLUSION Progressive CKD is associated with increased TTROD, lower cure rates, and higher recurrence rates with treatment of CDI.
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Alshayeb HM, Josephson MA, Sprague SM. CKD-mineral and bone disorder management in kidney transplant recipients. Am J Kidney Dis 2012; 61:310-25. [PMID: 23102732 DOI: 10.1053/j.ajkd.2012.07.022] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 07/09/2012] [Indexed: 12/11/2022]
Abstract
Kidney transplantation, the most effective treatment for the metabolic abnormalities of chronic kidney disease (CKD), only partially corrects CKD-mineral and bone disorders. Posttransplantation bone disease, one of the major complications of kidney transplantation, is characterized by accelerated loss of bone mineral density and increased risk of fractures and osteonecrosis. The pathogenesis of posttransplantation bone disease is multifactorial and includes the persistent manifestations of pretransplantation CKD-mineral and bone disorder, peritransplantation changes in the fibroblast growth factor 23-parathyroid hormone-vitamin D axis, metabolic perturbations such as persistent hypophosphatemia and hypercalcemia, and the effects of immunosuppressive therapies. Posttransplantation fractures occur more commonly at peripheral than central sites. Although there is significant loss of bone density after transplantation, the evidence linking posttransplantation bone loss and subsequent fracture risk is circumstantial. Presently, there are no prospective clinical trials that define the optimal therapy for posttransplantation bone disease. Combined pharmacologic therapy that targets multiple components of the disordered pathways has been used. Although bisphosphonate or calcitriol therapy can preserve bone mineral density after transplantation, there is no evidence that these agents decrease fracture risk. Moreover, bisphosphonates pose potential risks for adynamic bone disease.
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Affiliation(s)
- Hala M Alshayeb
- Department of Medicine, Section of Nephrology, University of Chicago, Chicago, IL, USA
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Kadambi PV, Chon WJ, Josephson MA, Desai A, Thistlethwaite JR, Harland RC, Meehan SM, Garfinkel MR. Reuse of a previously transplanted kidney: does success come with a price? Clin Kidney J 2012; 5:434-437. [PMID: 23986860 PMCID: PMC3755571 DOI: 10.1093/ckj/sfs086] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2011] [Accepted: 06/21/2012] [Indexed: 11/13/2022] Open
Abstract
Longer wait times for deceased donor kidney transplant have prompted newer initiatives to expedite the process. Reuse of a previously transplanted kidney might be appropriate in certain circumstances. However, one must also consider the unique issues that may arise after such transplants. We describe our experience in one such case where the donor kidney had lesions of focal and segmental glomerulosclerosis and signs of alloreactivity (positive C4d staining) prior to transplantation and the recipient developed ganciclovir-resistant cytomegalovirus (CMV) infection, which was perhaps transmitted from the donor. Despite the challenges, the allograft function remained stable 5 years after reuse.
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Affiliation(s)
- Pradeep V Kadambi
- Division of Nephrology and Hypertension, Department of Medicine , University of Texas Medical Branch , Galveston, TX , USA
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Chang A, Moore JM, Cowan ML, Josephson MA, Chon WJ, Sciammas R, Du Z, Marino SR, Meehan SM, Millis M, David MZ, Williams JW, Chong AS. Plasma cell densities and glomerular filtration rates predict renal allograft outcomes following acute rejection. Transpl Int 2012; 25:1050-8. [PMID: 22805456 DOI: 10.1111/j.1432-2277.2012.01531.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The contribution of T cells and graft-reactive antibodies to acute allograft rejection is widely accepted, but the role of graft-infiltrating B and plasma cells is controversial. We examined 56 consecutive human renal transplant biopsies classified by Banff schema into T-cell-mediated (N = 21), antibody-mediated (N = 18), and mixed (N = 17) acute rejection, using standard immunohistochemistry for CD3, CD20, CD138, and CD45. In a predominantly African-American population (75%), neither Banff classification nor C4d deposition predicted the return to dialysis. Immunohistochemical analysis revealed CD3(+) T cells as the dominant cell type, followed by CD20(+) B cells and CD138(+) plasma cells in all acute rejection types. Using univariate Cox Proportional Hazard analysis, plasma cell density significantly predicted graft failure while B-cell density trended toward significance. Surprisingly T-cell density did not predict graft failure. The estimated glomerular filtration rate (eGFR) at diagnosis of acute rejection also predicted graft failure, while baseline eGFR ≥6 months prior to biopsy did not. Using multivariate analysis, a model including eGFR at biopsy and plasma cell density was most predictive of graft loss. These observations suggest that plasma cells may be a critical mediator and/or an independently sensitive marker of steroid-resistant acute rejection.
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Affiliation(s)
- Anthony Chang
- Departments of Pathology, University of Chicago Medical Center, Chicago, IL 60637, USA.
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