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Bath NM, Sarna A, Palettas M, Monsour C, Stevens L, Santry H, Ejaz A, Kim A, Pawlik T, Cloyd JM. Characterizing treatment burden during neoadjuvant therapy for patients with gastrointestinal cancer: A mixed methods analysis. J Surg Oncol 2023. [PMID: 37079430 DOI: 10.1002/jso.27288] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 04/08/2023] [Indexed: 04/21/2023]
Abstract
INTRODUCTION Neoadjuvant therapy (NT) is increasingly used before surgery for patients with gastrointestinal (GI) cancers. Treatment burden is a patient-centered measure defined as the work of being a patient and characterizes the impact of medical treatment on one's functioning and well-being. While treatment burden has previously been studied in chronic diseases and cancer survivorship, the treatment burden of undergoing NT is unknown. METHODS All patients enrolled in a prospective cohort study evaluating the real-time experience of NT for GI cancers completed either the Patient Experience with Treatment and Self-management (PETS) survey, a 46-item validated measure of treatment burden, or the mini-PETS questionnaire. PETS subsections were scored on a 5-point Likert scale and then standardized on a 100-point scale (a higher number means more treatment burden). Semistructured interviews were conducted among a convenience sample of patients (n = 5); qualitative data were coded and then analyzed using an integrated approach. RESULTS Among 126 participants, the mean age was 59 years old, 61% were male, and the mean number of comorbidities was 1.57. The most common cancers were colorectal (46%) and pancreatic (28%). The mean length of NT treatment was 3.7 months and 80.2% of patients underwent surgical resection following NT. The highest standardized treatment burden scores were observed in healthcare services (44 ± 15), social limitations (44 ± 26), exhaustion (41 ± 23), and medical expenses (40 ± 18) whereas the lowest scores were reported in medication use (19 ± 16) and interpersonal challenges (19 ± 17). Commonly experienced emotional symptoms were feeling worn out (43%) or frustrated (32%). No significant differences were observed in mean treatment burden subscores between patients who underwent surgery versus those who did not. Qualitative analysis of treatment burden during NT identified common themes of impact on normal life activities, challenges with healthcare access, impact on relationships, and significant physical and emotional symptoms. CONCLUSIONS NT is associated with a significant treatment burden, particularly in the domains of accessing healthcare services, social limitations, and exhaustion. Given the increasing use of NT for GI cancers, novel patient-centered approaches are needed to improve quality of life and ensure the completion of multimodality therapy.
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Affiliation(s)
- Natalie M Bath
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Angela Sarna
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Marilly Palettas
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Christina Monsour
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Lena Stevens
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Heena Santry
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Aslam Ejaz
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alex Kim
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Timothy Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jordan M Cloyd
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Klos CL, Bath NM, Carchman E, Leverson G, Lawson E, Sanger CB, King R, Heise C. Treating acute diverticulitis in pre- and post-solid-organ transplant patients: a single-institution cohort study. Colorectal Dis 2023. [PMID: 36945080 DOI: 10.1111/codi.16544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 03/23/2023]
Abstract
AIM Immunosuppressed patients are more likely to fail nonoperative management of acute diverticulitis and have more postoperative complications than the immunocompetent. Transplant recipients form a subcategory among the immunosuppressed with unique challenges. The aim of this work is to report 30-day postoperative complications after colectomy for acute diverticulitis and success rates of nonoperative management in pre- and post-transplant patients. METHOD This is a retrospective cohort study at a single-institution tertiary referral centre. Patients with a history of acute diverticulitis were extracted from a database of 6152 recipients of solid-organ abdominal transplant between 2000 and 2015 and stratified by the index episode of diverticulitis: before or after solid-organ transplant surgery. Outcomes included 30-day postoperative complications and failure of nonoperative management. RESULTS Acute diverticulitis occurred in 93 patients, 69 (74%) posttransplant. Postcolectomy complications were higher posttransplant than pretransplant (43% vs. 13%, p = 0.04). Posttransplant status was not an independent risk factor for complications (odds ratio 3.59, 95% CI 0.79-16.31) when adjusting for sex and surgical acuity. Immediate urgent colectomy (29% vs. 31%, p = 0.84) and failure of nonoperative management (7% vs. 9%, p = 0.82) were similar. Complications occurred equally in those requiring urgent colectomy after nonoperative management and those undergoing immediate urgent colectomy. CONCLUSION Urgent colectomy rates are similar in solid-organ abdominal transplant recipients pre- and posttransplant. Posttransplant complication rates appear to be increased but transplant status as an independent factor is not significantly associated with an increased risk in this study cohort. These findings should be considered when counselling patients on the relative risks and benefits of surgical intervention for diverticulitis before versus after solid-organ transplantation.
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Affiliation(s)
- Coen L Klos
- Division of Colorectal Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Natalie M Bath
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Evie Carchman
- Division of Colorectal Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Glen Leverson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Elise Lawson
- Division of Colorectal Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Cristina B Sanger
- Division of Colorectal Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- University of Wisconsin-Madison, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
| | - Ray King
- Division of Colorectal Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Charles Heise
- Division of Colorectal Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Bath NM, Pawlik TM. Narrative review: current management and novel targeted therapies in intrahepatic cholangiocarcinoma. Chin Clin Oncol 2023; 12:5. [PMID: 36922354 DOI: 10.21037/cco-22-109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/16/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND AND OBJECTIVE Intrahepatic cholangiocarcinoma (iCCA) is a rare hepatic malignancy with poor prognosis, which has seen an increased incidence over the last decade. Most patients present with advanced disease that is not amenable to surgical resection, and those who are able to undergo resection, frequently develop recurrent disease. With the rise of precision medicine, several targetable mutations have been described for iCCA and are currently under investigations. The development of improved targeted therapies is critical to prolonged overall survival (OS), and the use of targeted agents for iCCA is currently the focus of several ongoing randomized controlled trials. The objective of this review is to summarize current guidelines for diagnosis, surgical resection, and systemic treatment, which includes ongoing clinical trials investigated targeted therapies. METHODS A comprehensive review was performed using MEDLINE/PubMed with the end search date of October 1, 2022. In PubMed the terms "intrahepatic cholangiocarcinoma," "bile duct cancer", "targeted therapies", and "clinical trials" were searched. KEY CONTENT AND FINDINGS The mainstay of treatment for iCCA is R0 resection with lymphadenectomy. Following surgical resection, new guidelines recommend 6 months of adjuvant capecitabine. Among patients with advanced or metastatic disease, systemic chemotherapy plays a significant role in prolonging survival for these patients. CONCLUSIONS Surgical resection represents the mainstay of treatment followed by 6 months of adjuvant capecitabine. While additional data is needed through randomized controlled trials, targeted therapies including fibroblast growth factor receptor (FGFR), isocitrate dehydrogenase (IDH), and erythroblastic oncogene B2 (ErbB2) inhibitors offer promising results as adjuncts to current standard of care in iCCA, particularly among individuals with unresectable disease. Future recommendations regarding the use of targeted therapy will emerge as clinical trial data become available.
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Affiliation(s)
- Natalie M Bath
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Bath NM, Verhoven BM, Wilson NA, Zeng W, Zhong W, Coons L, Djamali A, Redfield RR. APRIL/BLyS deficient rats prevent donor specific antibody (DSA) production and cell proliferation in rodent kidney transplant model. PLoS One 2022; 17:e0275564. [PMID: 36227902 PMCID: PMC9562156 DOI: 10.1371/journal.pone.0275564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 09/19/2022] [Indexed: 11/18/2022] Open
Abstract
APRIL (A proliferation inducing ligand) and BLyS (B Lymphocyte Stimulator) are two critical survival factors for B lymphocytes and plasma cells, the main source of alloantibody. We sought to characterize the specific effects of these cytokines in a kidney transplant model of antibody mediated rejection (AMR). We engineered APRIL-/- and BLyS-/- Lewis rats using CRISPR/Cas9. APRIL-/- and BLyS-/- rats were sensitized with Brown Norway (BN) blood (complete MHC mismatch). Twenty-one days following sensitization, animals were harvested and collected tissues were analyzed using flow cytometry, ELISPOT, and immunohistochemistry. Flow cross match and a 3 day mixed lymphocyte reaction (MLR) was performed to assess donor specific antibody (DSA) production and T-cell proliferation, respectively. Sensitized dual knock out Lewis rats (APRIL-/-/BLyS-/-) underwent kidney transplantation and were sacrificed on day 7 post-transplant. Sensitized BLyS-/- had significant decreases in DSA and cell proliferation compared to WT and APRIL-/- (p<0.02). Additionally, BLyS-/- rats had a significant reduction in IgG secreting cells in splenic marginal zone B lymphocytes, and in cell proliferation when challenged with alloantigen compared to WT and APRIL-/-. Transplanted APRIL-/-/BLyS-/- rodents had significantly less DSA and antibody secreting cells compared to WT (p<0.05); however, this did not translate into a significant difference in AMR seen between groups. In summary, our studies suggest that APRIL and BLyS play a greater role in DSA generation rather than AMR, highlighting the role of cellular pathways that regulate AMR.
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Affiliation(s)
- Natalie M. Bath
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
- * E-mail:
| | - Bret M. Verhoven
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Nancy A. Wilson
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Weifeng Zeng
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Lauren Coons
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Arjang Djamali
- Department of Medicine, Maine Medical Center, Portland, Maine, United States of America
| | - Robert R. Redfield
- Division of Transplant, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
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Parajuli S, Bath NM, Hidalgo L, Leverson G, Garg N, R Redfield R, Mandelbrot DA. Impact of low-level pretransplant donor-specific antibodies on outcomes after kidney transplantation. Immun Inflamm Dis 2021; 9:1508-1519. [PMID: 34407300 PMCID: PMC8589373 DOI: 10.1002/iid3.504] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/09/2021] [Accepted: 07/29/2021] [Indexed: 01/23/2023]
Abstract
Background The effect of low‐level pretransplant donor‐specific antibody (DSA) on kidney transplant outcomes is not well described. The goal of this study was to compare outcomes among patients of varying immunologic risk, based on the level of pretransplant DSA. Methods We retrospectively reviewed all adult kidney transplant recipients who had undergone a transplant at our center between January 2013 and May 2017. Patients were grouped as negative DSA (mean fluorescence intensity, [MFISUM < 100]), low‐level DSA (MFISUM 100–1000), and positive DSA (MFISUM > 1000). Rejection, infection, graft, and patient survival were outcomes measured. Results Of 952 patients, 82.1% had negative DSA, 10.7% had low‐level DSA, and 7.1% had positive DSA. The positive DSA group had the highest rate of antibody‐mediated rejection (10.3%), followed by low‐level DSA (7.8%) and the negative DSA group (4.5%) (p = .034). The rate of BK viremia was highest in the positive DSA group (39.7%), followed by the low‐level group (30.4%) and the negative DSA group (25.6%), (p = .025). None of the other outcomes, including graft or patient survival, were different between the groups. Conclusion While low‐level DSA should not prevent proceeding with kidney transplantation, it should not be ignored. Future studies are needed to investigate the long‐term effects of varying levels of pre‐transplant DSA on outcomes.
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Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Natalie M Bath
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Luis Hidalgo
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Glen Leverson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Robert R Redfield
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,Department of Surgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Didier A Mandelbrot
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Bath NM, Djamali A, Parajuli S, Mandelbrot D, Leverson G, Hidalgo L, Ellis T, Descourouez JL, Jorgenson MR, Hager D, Kaufman DB, Redfield RR. Induction and Donor Specific Antibodies in Low Immunologic Risk Kidney Transplant Recipients. Kidney360 2020; 1:1407-1418. [PMID: 35372884 DOI: 10.34067/kid.0000122020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 10/01/2020] [Indexed: 12/20/2022]
Abstract
Background Optimal induction for patients without pretransplant donor-specific antibodies (DSAs) is poorly defined. The goal of this study was to compare the incidence of de novo DSA (dnDSA) and graft outcomes between induction therapies in patients with a negative virtual crossmatch (VXM). Methods A retrospective chart review was performed, identifying 782 patients with a negative VXM who underwent kidney transplantation at a single, high-volume institution between January 2013 and May 2017. Kaplan-Meier analysis was used to assess the incidence of dnDSA and allograft survival between induction therapies in this group. dnDSA is defined as the development of new post-transplant DSA, at any MFI level. Results Induction therapy included alemtuzumab (N=87, 11%), basiliximab (N=522, 67%), and anti-thymocyte globulin (ATG; N=173, 22%). One-year graft survival was similar between groups (alemtuzumab, 100%; basiliximab, 98%; ATG, 99%). Incidence of acute rejection at 1 year was <2% and not different between the three groups. Alemtuzumab was associated with the highest incidence of dnDSA at 14%, compared with 5% and 8% in basiliximab and ATG groups, respectively, at 1 year (P=0.009). In multivariate regression analyses, alemtuzumab retained its significant association with a dnDSA HR of 2.5 (95% CI, 1.51 to 4.25; P=0.0004). Conclusions In summary, alemtuzumab was associated with a higher rate of dnDSA development in patients with a negative VXM; however, this finding was not associated with rejection or graft failure.
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Affiliation(s)
- Natalie M Bath
- Division of Transplant, Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Didier Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Glen Leverson
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Luis Hidalgo
- Division of Transplant, Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Thomas Ellis
- Department of Pathology and Laboratory Medicine, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Jillian L Descourouez
- Division of Transplant, Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Margaret R Jorgenson
- Division of Transplant, Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Dave Hager
- Division of Transplant, Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Dixon B Kaufman
- Division of Transplant, Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Robert R Redfield
- Division of Transplant, Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
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Bath NM, Leverson G, Al-Adra D, D’Alessandro A, Mezrich J, Foley DP. Microsteatosis in Livers From Donation After Circulatory Death Donors Is Associated With Inferior Outcomes Following Liver Transplantation. Liver Transpl 2020; 26:1127-1137. [PMID: 32453905 PMCID: PMC8860344 DOI: 10.1002/lt.25803] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/20/2020] [Accepted: 04/05/2020] [Indexed: 12/20/2022]
Abstract
The acceptable threshold remains unknown for the percentage of macrosteatosis (MaS) and microsteatosis (MiS) to yield optimal outcomes after donation after circulatory death (DCD) liver transplantation (LT). The purpose of this analysis was to determine the impact of donor liver MaS and MiS on DCD LT outcomes. Using the Organ Procurement and Transplantation Network database, we analyzed pretransplant biopsy results from adult, solitary, DCD livers transplanted between January 1, 2006, and December 31, 2017. Kaplan-Meier analysis was used to assess graft and patient survival based on MaS and MiS severity. MiS was divided into the groups MiS ≤10% and >10%. MaS was divided into the groups MaS ≤15% and >15%. Of 7757 recovered DCD livers, 11.4% (n = 885) were biopsied and transplanted. Patients who received DCD livers with MaS >15% had significantly worse patient survival (P < 0.04), and those with MiS >10% demonstrated inferior graft and patient survival (P < 0.02). In multivariate analyses including known risk factors, both MaS >15% and MiS >10% were associated with increased risk of graft failure and patient mortality (P < 0.03). Recipient and donor age >60 years were also associated with increased risk of graft failure and patient death. This analysis demonstrates that MaS >15% and MiS >10% are additional risk factors for graft loss and patient mortality in DCD LT.
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Affiliation(s)
- Natalie M. Bath
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Glen Leverson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - David Al-Adra
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Anthony D’Alessandro
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Joshua Mezrich
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - David P. Foley
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Abstract
Brazilian-born British biologist Dr. Peter Medawar played an integral role in developing the concepts of immunologic rejection and tolerance, which led to him receiving the Nobel Prize "for the discovery of acquired immunologic tolerance" and eventually made organ transplantation a reality. However, at the time of his early work in tolerance, a paradox to his theories was brought to his attention; how was pregnancy possible? Pregnancy resembles organ transplantation in that the fetus, possessing paternal antigens, is a semi-allogeneic graft that can survive without immunosuppression for 9 months. To answer this question, Medawar proposed three hypotheses of how a mother supports her fetus in utero, now known as "Medawar's Paradox." The mechanisms that govern fetomaternal tolerance are still incompletely understood but may provide critical insight into how to achieve immune tolerance in organ transplantation. Here, we review current understanding of the immune factors responsible for fetomaternal tolerance during pregnancy and discuss the potential implications for advances in transplantation science.
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Affiliation(s)
- Victoria Rendell
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Natalie M Bath
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Todd V Brennan
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Bath NM, Ding X, Verhoven BM, Wilson NA, Coons L, Sukhwal A, Zhong W, Redfield III RR. Autoantibody production significantly decreased with APRIL/BLyS blockade in murine chronic rejection kidney transplant model. PLoS One 2019; 14:e0223889. [PMID: 31647850 PMCID: PMC6812745 DOI: 10.1371/journal.pone.0223889] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 10/01/2019] [Indexed: 12/28/2022] Open
Abstract
Chronic antibody mediated rejection (cAMR) remains a significant barrier to achieving long-term graft survival in kidney transplantation, which results from alloantibody production from B lymphocytes and plasma cells. APRIL (A proliferation-inducing ligand) and BLyS (B lymphocyte stimulator) are critical survival factors for B lymphocytes and plasma cells. Here we describe the results of APRIL/BLyS blockade in a murine cAMR kidney transplant model. c57/B6 mice underwent kidney transplantation with Bm12 kidneys (minor MHC mismatch), a well-described model for chronic rejection where animals cannot make donor specific antibody but rather make antinuclear antibody (ANA). Following transplantation, animals received TACI-Ig (to block APRIL and BLyS) or no treatment. Animals were continued on treatment until harvest 4 weeks following transplant. Serum was analyzed for circulating anti-nuclear autoantibodies using HEp-2 indirect immunofluorescence. Spleen and transplanted kidneys were analyzed via H&E. ANA production was significantly decreased in APRIL/BLyS blockade treated animals (p<0.0001). No significant difference in autoantibody production was found between syngeneic transplant control (B6 to B6) and APRIL/BLyS blockade treated animals (p = 0.90). Additionally, disruption of splenic germinal center architecture was noted in the APRIL/BLyS blockade treated animals. Despite the significant decrease in autoantibody production and germinal center disruption, no significant difference in lymphocyte infiltration was noted in the transplanted kidney. APRIL/BLyS blockade resulted in a significant decrease of autoantibody production and disrupted splenic germinal center formation in a chronic kidney transplant model, however in this model no difference in kidney transplant pathology was seen, which may have to do with the absence of any T cell centric immunosuppression. Regardless, these findings suggest that APRIL/BLyS blockade may play a role in decreasing antibody formation long-term in kidney transplantation. Future investigations will use APRIL/BLyS blockade in conjunction with T lymphocyte depleting agents to determine its efficacy in chronic rejection.
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Affiliation(s)
- Natalie M. Bath
- Department of Surgery, Division of Transplant, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Xiang Ding
- Department of Surgery, Division of Transplant, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Bret M. Verhoven
- Department of Surgery, Division of Transplant, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Nancy A. Wilson
- Department of Medicine, Division of Nephrology, University of Wisconsin-Madison, Madison, Wisconsin, Unites States of America
| | - Lauren Coons
- Department of Surgery, Division of Transplant, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Adarsh Sukhwal
- Department of Surgery, Division of Transplant, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin–Madison, Madison, Wisconsin, United States of America
| | - Robert R. Redfield III
- Department of Surgery, Division of Transplant, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
- * E-mail:
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10
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Wilson NA, Bath NM, Verhoven BM, Ding X, Boldt BA, Sukhwal A, Zhong W, Panzer SE, Redfield RR. APRIL/BLyS Blockade Reduces Donor-specific Antibodies in Allosensitized Mice. Transplantation 2019; 103:1372-1384. [PMID: 30830041 PMCID: PMC6594891 DOI: 10.1097/tp.0000000000002686] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Highly sensitized candidates on the transplant waitlist remain a significant challenge, as current desensitization protocols have variable success rates of donor-specific antibody (DSA) reduction. Therefore, improved therapies are needed. A proliferation-inducing ligand (APRIL) and B-lymphocyte stimulator (BLyS) are critical survival factors for B-lymphocytes and plasma cells, which are the primary sources of alloantibody production. We examined the effect of APRIL/BLyS blockade on DSA in a murine kidney transplant model as a possible novel desensitization strategy. METHODS C57BL/6 mice were sensitized with intraperitoneal (IP) injections of 2 × 10 BALB/c splenocytes. Twenty-one days following sensitization, animals were treated with 100 μg of BLyS blockade (B-cell activating factor receptor-immunoglobulin) or APRIL/BLyS blockade (transmembrane activator and calcium modulator and cyclophilin ligand interactor-immunoglobulin), administered thrice weekly for an additional 21 days. Animals were then euthanized or randomized to kidney transplant with Control Ig, BLyS blockade, or APRIL/BLyS blockade. Animals were euthanized 7 days posttransplant. B-lymphocytes and DSA of BLyS blockade only or APRIL/BLyS blockade-treated mice were assessed by flow cytometry, immunohistochemistry, and enzyme-linked immunospot. RESULTS APRIL/BLyS inhibition resulted in a significant reduction of DSA by flow crossmatch compared with controls (P < 0.01). APRIL/BLyS blockade also significantly depleted IgM- and IgG-secreting cells and B-lymphocyte populations compared to controls (P < 0.0001). APRIL/BLyS blockade in transplanted mice also resulted in decreased B-lymphocyte populations; however, no difference in rejection rates were seen between groups. CONCLUSIONS APRIL/BLyS blockade with transmembrane activator and calcium modulator and cyclophilin ligand interactor-immunoglobulin significantly depleted B-lymphocytes and reduced DSA in this sensitized murine model. APRIL/BLyS inhibition may be a clinically useful desensitization strategy for sensitized transplant candidates.
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Affiliation(s)
- Nancy A Wilson
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison, Madison, WI
| | - Natalie M Bath
- Division of Transplant, Department of Surgery, University of Wisconsin-Madison, Madison, WI
| | - Bret M Verhoven
- Division of Transplant, Department of Surgery, University of Wisconsin-Madison, Madison, WI
| | - Xiang Ding
- Department of Organ Transplantation, Xiangya Hospital, Central South University, Changsha, China
| | - Brittney A Boldt
- Division of Transplant, Department of Surgery, University of Wisconsin-Madison, Madison, WI
| | - Adarsh Sukhwal
- Department of Organ Transplantation, Xiangya Hospital, Central South University, Changsha, China
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin-Madison, Madison, WI
| | - Sarah E Panzer
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison, Madison, WI
| | - Robert R Redfield
- Division of Transplant, Department of Surgery, University of Wisconsin-Madison, Madison, WI
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Bath NM, Ding X, Wilson NA, Verhoven BM, Boldt BA, Sukhwal A, Reese SR, Panzer SE, Djamali A, Redfield RR. Desensitization and treatment with APRIL/BLyS blockade in rodent kidney transplant model. PLoS One 2019; 14:e0211865. [PMID: 30735519 PMCID: PMC6368307 DOI: 10.1371/journal.pone.0211865] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 01/23/2019] [Indexed: 11/19/2022] Open
Abstract
Alloantibody represents a significant barrier in kidney transplant through the sensitization of patients prior to transplant through antibody mediated rejection (ABMR). APRIL BLyS are critical survival factors for mature B lymphocytes plasma cells, the primary source of alloantibody. We examined the effect of APRIL/BLyS blockade via TACI-Ig (Transmembrane activator calcium modulator cyclophilin lig interactor-Immunoglobulin) in a preclinical rodent model as treatment for both desensitization ABMR. Lewis rats were sensitized with Brown Norway (BN) blood for 21 days. Following sensitization, animals were then sacrificed or romized into kidney transplant (G4, sensitized transplant control); desensitization with TACI-Ig followed by kidney transplant (G5, sensitized + pre-transplant TACI-Ig); kidney transplant with post-transplant TACI-Ig for 21 days (G6, sensitized + post-transplant TACI-Ig); desensitization with TACI-Ig followed by kidney transplant post-transplant TACI-Ig for 21 days (G7, sensitized + pre- post-transplant TACI-Ig). Animals were sacrificed on day 21 post-transplant tissues were analyzed using flow cytometry, IHC, ELISPOT, RT-PCR. Sensitized animals treated with APRIL/BLyS blockade demonstrated a significant decrease in marginal zone non-switched B lymphocyte populations (p<0.01). Antibody secreting cells were also significantly reduced in the sensitized APRIL/BLyS blockade treated group. Post-transplant APRIL/BLyS blockade treated animals were found to have significantly less C4d deposition less ABMR as defined by Banff classification when compared to groups receiving APRIL/BLyS blockade before transplant or both before after transplant (p<0.0001). The finding of worse ABMR in groups receiving APRIL/BLyS blockade before both before after transplant may indicate that B lymphocyte depletion in this setting also resulted in regulatory lymphocyte depletion resulting in a worse rejection. Data presented here demonstrates that the targeting of APRIL BLyS can significantly deplete mature B lymphocytes, antibody secreting cells, effectively decrease ABMR when given post-transplant in a sensitized animal model.
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Affiliation(s)
- Natalie M. Bath
- Department of Surgery, Division of Transplant, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Xiang Ding
- Department of Surgery, Division of Transplant, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Nancy A. Wilson
- Department of Medicine, Division of Nephrology, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Bret M. Verhoven
- Department of Surgery, Division of Transplant, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Brittney A. Boldt
- Department of Medicine, Division of Nephrology, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Adarsh Sukhwal
- Department of Medicine, Division of Nephrology, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Shannon R. Reese
- Department of Medicine, Division of Nephrology, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Sarah E. Panzer
- Department of Medicine, Division of Nephrology, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Arjang Djamali
- Department of Medicine, Division of Nephrology, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Robert R. Redfield
- Department of Surgery, Division of Transplant, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
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Abstract
Loin Pain Hematuria Syndrome (LPHS) remains a rare disease but has a significant impact on those affected by it. Patients diagnosed with LPHS experience severe, constant or intermittent flank pain that radiates to the groin and may be exacerbated even by a gentle touch. These patients often require significant narcotic regimens for pain control and are unable to maintain a functional lifestyle. Previously, diagnosis has been made based on clinical presentation. One treatment for this syndrome is renal autotransplant; however, success rates are varied. Therefore, patient selection for this procedure is important. We have developed the UW-LPHS test as a diagnostic maneuver in order to determine which patients with LPHS would benefit from renal autotransplant. To perform this diagnostic test, bupivacaine is instilled into the ureter on the affected side and left to dwell. Patients who experience pain relief following this test are deemed to benefit from renal autotransplant. Here we describe this novel diagnostic test and initial success rates following renal autotransplant.
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Affiliation(s)
- Natalie M Bath
- Division of Transplant Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Daniel H Williams
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Hans W Sollinger
- Division of Transplant Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Robert R Redfield
- Division of Transplant Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Bath NM, Gregerman RI. Labeled polymeric substrate for renin. Synthesis of N-acetyl-poly(L-glutamyl)-( 125 )tridecapeptide and use for enzyme assay. Biochemistry 1972; 11:2845-53. [PMID: 5041900 DOI: 10.1021/bi00765a017] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Gunnells JC, Bath NM, Sode J, Robinson RR. Prinary aldosteronism. Arch Intern Med 1967; 120:568-74. [PMID: 6054592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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