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Wiseman A, Alhamad T, Alloway RR, Concepcion BP, Cooper M, Formica R, Klein CL, Kumar V, Leca N, Shihab F, Taber DJ, Mulnick S, Bushnell DM, Hadi M, Bunnapradist S. Use of LCP-Tacrolimus (LCPT) in Kidney Transplantation: A Delphi Consensus Survey of Expert Clinicians. Ann Transplant 2024; 29:e943498. [PMID: 38526543 PMCID: PMC10944009 DOI: 10.12659/aot.943498] [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: 12/14/2023] [Accepted: 02/06/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND LCPT (Envarsus XR®) is a common once-daily, extended-release oral tacrolimus formulation used in kidney transplantation. However, there are minimal evidence-based recommendations regarding optimal dosing and treatment in the de novo and conversion settings. MATERIAL AND METHODS Using Delphi methodology, 12 kidney transplantation experts with LCPT experience reviewed available data to determine potential consensus topics. Key statements regarding LCPT use were generated and disseminated to the panel in an online Delphi survey. Statements were either accepted, revised, or rejected based on the level of consensus, perceived strength of evidence, and alignment with clinical practice. Consensus was defined a priori as ≥75% agreement. RESULTS Twenty-three statements were generated: 14 focused on de novo LCPT use and 9 on general administration or LCPT conversion use. After 2 rounds, consensus was achieved for 11/14 of the former and 7/9 of the latter statements. In a de novo setting, LCPT was recognized as a first-line option based on its safety and efficacy compared to immediate-release tacrolimus. In particular, African Americans and rapid metabolizer populations were identified as preferred for first-line LCPT therapy. In a conversion setting, full consensus was achieved for converting to LCPT to address neurological adverse effects related to immediate-release tacrolimus and for the time required (approximately 7 days) for steady-state LCPT trough levels to be reached. CONCLUSIONS When randomized clinical trials do not replicate current utilization patterns, the Delphi process can successfully generate consensus statements by expert clinicians to inform clinical decision-making for the use of LCPT in kidney transplant recipients.
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Affiliation(s)
- Alexander Wiseman
- AdventHealth Transplant Institute, Porter Adventist Hospital, Denver, CO, USA
| | - Tarek Alhamad
- Division of Nephrology, Washington University School of Medicine in St. Louis, Saint Louis, MO, USA
| | - Rita R. Alloway
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Matthew Cooper
- Transplant Center – Center for Advanced Care – Froedtert Hospital, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Richard Formica
- Yale New Haven Transplantation Center, Yale University School of Medicine, New Haven, CT, USA
| | - Christina L. Klein
- Department of Transplant Nephrology, Piedmont Transplant Institute, Atlanta, GA, USA
| | - Vineeta Kumar
- Renal Transplant Program, University of Alabama at Birmingham Hospital, Birmingham, AL, USA
| | - Nicolae Leca
- Kidney Care and Transplantation Services, University of Washington, Seattle, WA, USA
| | - Fuad Shihab
- Kidney and Liver Clinic, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - David J. Taber
- Transplant Immunobiology Laboratory, Medical University of South Carolina, Charleston, SC, USA
| | - Sarah Mulnick
- Patient-Centered Research, Evidera, Bethesda, MD, USA
| | | | - Monica Hadi
- Patient-Centered Research, Evidera, London, United Kingdom
| | - Suphamai Bunnapradist
- Division of Nephrology and Department of Medicine, David Geffen School of Medicine, Los Angeles, CA, USA
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Bestard O, Augustine J, Wee A, Poggio E, Mannon RB, Ansari MJ, Bhati C, Maluf D, Benken S, Leca N, La Manna G, Samaniego-Picota M, Shawar S, Concepcion BP, Rostaing L, Alberici F, O'Connell P, Chang A, Salem F, Kattan MW, Gallon L, Donovan MJ. Prospective observational study to validate a next-generation sequencing blood RNA signature to predict early kidney transplant rejection. Am J Transplant 2024; 24:436-447. [PMID: 38152017 DOI: 10.1016/j.ajt.2023.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 09/20/2023] [Accepted: 09/30/2023] [Indexed: 12/29/2023]
Abstract
The objective of this study was to validate the performance of Tutivia, a peripheral blood gene expression signature, in predicting early acute rejection (AR) post-kidney transplant. Recipients of living or deceased donor kidney transplants were enrolled in a nonrandomized, prospective, global, and observational study (NCT04727788). The main outcome was validation of the area under the curve (AUC) of Tutivia vs serum creatinine at biopsy alone, or Tutivia + serum creatinine at biopsy. Of the 151 kidney transplant recipients, the mean cohort age was 53 years old, and 64% were male. There were 71% (107/151) surveillance/protocol biopsies and 29% (44/151) for-cause biopsies, with a 31% (47/151) overall rejection rate. Tutivia (AUC 0.69 [95% CI: 0.59-0.77]) and AUC of Tutivia + creatinine at biopsy (0.68 [95% CI: 0.59-0.77]) were greater than the AUC of creatinine at biopsy alone (0.51.4 [95% CI: 0.43-0.60]). Applying a model cut-off of 50 (scale 0-100) generated a high- and low-risk category for AR with a negative predictive value of 0.79 (95% CI: 0.71-0.86), a positive predictive value of 0.60 (95% CI: 0.45-0.74), and an odds ratio of 5.74 (95% CI: 2.63-12.54). Tutivia represents a validated noninvasive approach for clinicians to accurately predict early AR, beyond the current standard of care.
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Affiliation(s)
- Oriol Bestard
- Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Alvin Wee
- Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | | | | | - Daniel Maluf
- University of Maryland, Baltimore, Maryland, USA
| | - Scott Benken
- University of Illinois at Chicago, Chicago, Illinois, USA
| | - Nicolae Leca
- University of Washington, Seattle, Washington, USA
| | - Gaetano La Manna
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | | | - Saed Shawar
- Vanderbilt University, Nashville, Tennessee, USA
| | | | | | | | | | | | - Fadi Salem
- Mayo Medical, Jacksonville, Florida, USA
| | | | - Lorenzo Gallon
- Northwestern University, Evanston, Illinois, USA; Verici Dx, Franklin, Tennessee, USA.
| | - Michael J Donovan
- Verici Dx, Franklin, Tennessee, USA; Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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Vincenti F, Bromberg J, Kim J, Faravardeh A, Leca N, Alperovich G, Csomor PA, Aslam S, Neylan J. The hepatocyte growth factor mimetic, ANG-3777, in kidney transplant recipients with delayed graft function: Results from a randomized phase 3 trial. Am J Transplant 2024:S1600-6135(24)00156-4. [PMID: 38387622 DOI: 10.1016/j.ajt.2024.02.014] [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: 09/14/2023] [Revised: 01/22/2024] [Accepted: 02/14/2024] [Indexed: 02/24/2024]
Abstract
In kidney transplant recipients, delayed graft function increases the risk of graft failure and mortality. In a phase 3, randomized, double-blind, placebo-controlled trial, we investigated the hepatocyte growth factor mimetic, ANG-3777 (once daily for 3 consecutive days, starting ≤30 hours posttransplant), in 248 patients receiving a first kidney transplant from a deceased donor. At day 360, estimated glomerular filtration rate (primary endpoint) was not significantly different between the ANG-3777 and placebo groups. There were no significant between-group differences in the duration of dialysis through day 30 or in the percentage of patients with an estimated glomerular filtration rate of >30 mL/min/1.73 m2 at day 360. The incidence of both delayed graft function and acute rejection was similar between ANG-3777 and placebo groups (68.5% vs 69.4% and 8.1% vs 6.5%, respectively). ANG-3777 was well tolerated, and there was a numerically lower incidence of graft failure versus placebo (3.2% vs 8.1%). Although there is insufficient evidence to support an indication of ANG-3777 for patients at risk of renal dysfunction after deceased-donor kidney transplantation, these findings indicate potential biological activity that may warrant further investigation.
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Affiliation(s)
- Flavio Vincenti
- Department of Medicine, University of California San Francisco, San Francisco, California, USA.
| | - Jonathan Bromberg
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jim Kim
- Department of Surgery, University of Southern California, Los Angeles, California, USA
| | - Arman Faravardeh
- Sharp HealthCare Kidney and Pancreas Transplant Center, San Diego, California, USA
| | - Nicolae Leca
- Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
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Singh N, Anand PM, Gupta G, Sawinski D, Fix O, Adey D, Akalin E, Zayas C, Dadhania D, Doshi M, Cibrik D, Gupta M, Parsons R, Leca N, Santos RD, Concepcion BP, Nishio Lucar AG, Ong S, Sridhar VS, Parajuli S, Zachariah M, Mehta S, Soliman K, Shawar S, Husain SA, Preczewski L, Friedewald J, Mohan S, Wiseman A, Samaniego M, Kumar V, Tanriover B, Bloom R. Should Transplant Nephrology pursue recognition from the Accreditation Council for Graduate Medical Education (ACGME)? Clin J Am Soc Nephrol 2024:01277230-990000000-00352. [PMID: 38319649 DOI: 10.2215/cjn.0000000000000441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/31/2024] [Indexed: 02/07/2024]
Abstract
Kidney transplant is not only the best treatment for patients with advanced kidney disease, but it also reduces health-care expenditure. The management of transplant patients is complex as they require special care by transplant nephrologists who have expertise in assessing transplant candidates, understand immunology and organ rejection, have familiarity with peri-operative complications, and have the ability to manage the long-term effects of chronic immunosuppression. This skill set at the intersection of multiple disciplines necessitates additional training in Transplant Nephrology. Currently, there are more than 250,000 patients with a functioning kidney allograft and over 100,000 waitlisted patients awaiting kidney transplant, with a burgeoning number added to the kidney transplant wait list every year. In 2022, more than 40,000 patients were added to the kidney wait list and more than 25,000 received a kidney transplant. The Advancing American Kidney Health Initiative (AAKHI), passed in 2019, is aiming to double the number of kidney transplants by 2030 creating a need for additional transplant nephrologists to help care for them. Over the last decade there has been a decline in the Nephrology- as well Transplant Nephrology- workforce due to a multitude of reasons. The American Society of Transplantation (AST) Kidney Pancreas Community of Practice (KPCOP) created a workgroup to discuss the Transplant Nephrology workforce shortage. In this paper, we discuss the scope of the problem and how ACGME accreditation of Transplant Nephrology Fellowship could at least partly mitigate the Transplant Nephrology work-force crisis.
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Affiliation(s)
| | - Prince M Anand
- Medical University of South Carolina, Lancaster Medical Center, Lancaster, SC
| | | | - Deirdre Sawinski
- Weill Cornell Medical College/New York-Presbyterian Hospital, New York, NY
| | - Oren Fix
- University of North Carolina, Chapel Hill, NC
| | - Deborah Adey
- University of California San Francisco, San Francisco, CA
| | | | | | - Darshana Dadhania
- Weill Cornell Medical College/New York-Presbyterian Hospital, New York, NY
| | | | | | | | | | | | | | | | | | - Song Ong
- University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | - Shikha Mehta
- University of Alabama at Birmingham, Birmingham, AL
| | - Karim Soliman
- Medical University of South Carolina, Charleston, SC
- Medical Services, Ralph H. Johnson VA Medical Center, Charleston, SC
| | - Saed Shawar
- Vanderbilt University Medical Center, Nashville, TN
| | | | | | | | | | | | | | | | - Bekir Tanriover
- University of Arizona, College of Medicine-Tucson, Tucson, AZ
| | - Roy Bloom
- University of Pennsylvania, Philadelphia, PA
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5
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Sibulesky L, Leca N, Bakthavatsalam R, Perkins JD. Kidney retransplantation outcomes in adults aged 70 and older: Analysis of risk factors and survival. Clin Transplant 2024; 38:e15170. [PMID: 37943592 DOI: 10.1111/ctr.15170] [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: 08/03/2023] [Revised: 10/10/2023] [Accepted: 10/12/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND An increasing number of older patients are undergoing kidney transplant. Because of a finite longevity, more patients will be faced with failing allografts. At present there is a limited understanding of the benefits and risks associated with kidney retransplantation in this challenging population. METHODS We performed a retrospective analysis of the Organ Procurement and Transplantation Network database of all adults ≥70 undergoing kidney retransplant from January 1, 2014 to December 31, 2022. We examined patient and graft survival of retransplanted patients compared to first time transplants. We also analyzed the risk factors that impacted the survival. RESULTS During the study period there has been a significant rise in the number of retransplants performed, with 631 patients undergoing the procedure. Although clinically insignificant, overall graft, and patient survival rates were slightly lower in the retransplant group compared to the primary transplant group. With retransplant, patient survival was 91.3%, 75.6%, and 56.9% compared to 93.4%, 81.4%, and 64.4% with primary transplant at 1, 3, and 5 years, respectively. With retransplant, graft survival was 89.5%, 73.5%, 57.4% compared to 91.5%, 79.0%, and 63.6% in a primary transplant group at 1, 3, and 5 years, respectively. Multivariable analysis showed that factors predicting poor survival included longer time on dialysis before retransplantation and decreased functional capacity. No survival difference was noted between recipients of deceased versus living donor kidneys. Patients who underwent retransplantation before initiating dialysis had better patient and graft survival. CONCLUSION Patients aged ≥70 achieve satisfactory outcomes following kidney retransplantation, highlighting that chronologic age should not preclude this medically complex population from this life-saving procedure. Improvement in functional status and timely retransplantation are the key factors to successful outcome.
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Affiliation(s)
- Lena Sibulesky
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA
- Clinical and Bio-Analytics Transplant Laboratory (CBATL), University of Washington, Seattle, Washington, USA
| | - Nicolae Leca
- Clinical and Bio-Analytics Transplant Laboratory (CBATL), University of Washington, Seattle, Washington, USA
- Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Ramasamy Bakthavatsalam
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA
| | - James D Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA
- Clinical and Bio-Analytics Transplant Laboratory (CBATL), University of Washington, Seattle, Washington, USA
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6
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Bakthavatsalam A, Sibulesky L, Leca N, Rayhill SC, Bakthavatsalam R, Perkins JD. Impact of Obesity on Kidney Transplant Outcomes in Older Adults. Transplant Proc 2024; 56:58-67. [PMID: 38195283 DOI: 10.1016/j.transproceed.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 11/30/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND The prevalence of obesity in older patients undergoing kidney transplantation is increasing. Older age and obesity are associated with higher risks of complications and mortality post-transplantation. The optimal management of this group of patients remains undefined. METHODS We retrospectively analyzed the United Network for Organ Sharing database of adults ≥70 years of age undergoing primary kidney transplant from January 1, 2014, to December 31, 2022. We examined patient and graft survival stratified by body mass index (BMI) in 3 categories, <30 kg/m2, 30 to 35 kg/m2, and >35 kg/m2. We also analyzed other risk factors that impacted survival. RESULTS A total of 14,786 patients ≥70 years underwent kidney transplantation. Of those, 9,731 patients had a BMI <30 kg/m2, 3,726 patients with a BMI of 30 to 35 kg/m2, and 1,036 patients with a BMI >35 kg/m2. During the study period, there was a significant increase in kidney transplants in patients ≥70 years old across all BMI groups. Overall, patient survival, death-censored graft survival, and all-cause graft survival were lower in obese patients compared with nonobese patients. Multivariable analysis showed worse patient survival and graft survival in patients with a BMI of 30 to 35 kg/m2, a BMI >35 kg/m2, a longer duration of dialysis, diabetes mellitus, and poor functional status. CONCLUSION Adults ≥70 years should be considered for kidney transplantation. Obesity with a BMI of 30 to 35 kg/m2 or >35 kg/m2, longer duration of dialysis, diabetes, and functional status are associated with worse outcomes. Optimization of these risk factors is essential when considering these patients for transplantation.
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Affiliation(s)
- Arvind Bakthavatsalam
- Department of Surgery, Vassar Brothers Medical Center, Nuvance Health, Poughkeepsie, New York
| | - Lena Sibulesky
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington; Clinical and Bio-Analytics Transplant Laboratory, University of Washington, Seattle, Washington.
| | - Nicolae Leca
- Clinical and Bio-Analytics Transplant Laboratory, University of Washington, Seattle, Washington; Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, Washington
| | - Stephen C Rayhill
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington
| | - Ramasamy Bakthavatsalam
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington
| | - James D Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington; Clinical and Bio-Analytics Transplant Laboratory, University of Washington, Seattle, Washington
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7
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Sibulesky L, Leca N, Bakthavatsalam R, Perkins JD. Intention-to-treat Analysis of Patients Aged 70 Years and Older Awaiting Kidney Transplantation in Post-Kidney Allocation System Era. Transplantation 2023; 107:2510-2525. [PMID: 37322588 DOI: 10.1097/tp.0000000000004677] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND The US population is aging, and so the number of patients treated for end-stage renal disease is on the rise. In the United States, 38% of people over 65 y old have chronic kidney disease. There continues to be a reluctance of clinicians to consider older candidates for transplant, including early referrals. METHODS We conducted a retrospective analysis of the Organ Procurement and Transplantation Network database of all adults ≥70 y old undergoing kidney transplants from December 1, 2014, to June 30, 2021. We compared patient and graft survival in candidates who were transplanted while on hemodialysis versus preemptive with a living versus deceased donor kidney transplant. RESULTS In 2021, only 43% of the candidates listed for transplant were preemptive. In an intention-to-treat analysis from the time of listing, candidate survival was significantly improved for those transplanted preemptively versus being on dialysis (hazard ratio 0.59; confidence interval, 0.56-0.63). All donor types, donor after circulatory death, donor after brain death, and living donor, had a significant decrease in death over remaining on the waiting list. Patients who were on dialysis or transplanted preemptively with a living donor kidney had significantly better survival than those receiving a deceased donor kidney. However, receiving a deceased donor kidney significantly decreased the chance of death over remaining on the waiting list. CONCLUSIONS Patients ≥70 y old who are transplanted preemptively, whether with a deceased donor or a living donor kidney, have a significantly better survival than those who are transplanted after initiating dialysis. Emphasis on timely referral for a kidney transplant should be placed in this population.
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Affiliation(s)
- Lena Sibulesky
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA
- Department of Surgery, Division of Transplant Surgery, Clinical and Bio-Analytics Transplant Laboratory, University of Washington, Seattle, WA
| | - Nicolae Leca
- Department of Surgery, Division of Transplant Surgery, Clinical and Bio-Analytics Transplant Laboratory, University of Washington, Seattle, WA
- Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Ramasamy Bakthavatsalam
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - James D Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA
- Department of Surgery, Division of Transplant Surgery, Clinical and Bio-Analytics Transplant Laboratory, University of Washington, Seattle, WA
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8
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Obrișcă B, Leca N, Chou-Wu E, Sibulesky L, Bakthavatsalam R, Kling CE, Alawieh R, Smith KD, Ismail G, Gimferrer I. Anti-GSTT1 antibodies and Null genotype correlate with histological changes of antibody mediated rejection in kidney transplantation. Transpl Immunol 2023; 81:101943. [PMID: 37866670 DOI: 10.1016/j.trim.2023.101943] [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: 08/10/2023] [Revised: 10/10/2023] [Accepted: 10/19/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND The presence of anti-Glutathione S-transferase T1 (GSTT1) antibodies (abs) has been hypothesized as a pathogenic contributor in antibody-mediated rejection (AMR). METHODS We aimed to evaluate the relationship between genetic variants of GSTT1, anti-GSTT1 abs and AMR in a cohort of 87 kidney transplant (KTx) patients using Immucor's non-HLA Luminex assay. Patients were classified according to biopsy-proven AMR and HLA-DSA status: AMR with positive anti-HLA-DSAs (AMR/DSA+, n = 29), AMR but no detectable anti-HLA-DSAs (AMR/DSA-, n = 28) and control patients with stable allograft function and no evidence of rejection (n = 30). RESULTS At an MFI cut-off of 3000, the overall prevalence of anti-GSTT1 abs was 18.3%. The proportion of patients with anti-GSTT1 abs was higher in the AMR/DSA- group (25%), compared to the control (13.3%) and AMR/DSA+ group (3.4%) (p = 0.06). Among patients with anti-GSTT1 abs, the MFI was higher in AMR/DSA- and GSTT1-Null patients. Of 81 patients who underwent GSTT1 genotyping, 19.8% were homozygotes for the null allele (GSTT1-Null). GSTT1-Null status in the transplant recipients was associated with the development of anti-GSTT1 abs (OR, 4.49; 95%CI, 1.2-16.7). In addition, GSTT1-Null genotype (OR 26.01; 95%CI, 1.63-404) and anti-GSTT1 ab positivity (OR 14.8; 95%CI, 1.1-190) were associated with AMR. Within AMR/DSA- patients, the presence of anti-GSTT1 abs didn't confer a higher risk of failure within the study observation period. CONCLUSION The presence of anti-GSTT1 abs and GSTT1-Null genotype is associated with AMR, but do not appear to lead to accelerated graft injury in this cohort of early allograft injury changes, with a limited period of follow-up.
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Affiliation(s)
- Bogdan Obrișcă
- Fundeni Clinical Institute, Division of Nephrology, Bucharest, Romania
| | - Nicolae Leca
- University of Washington, Division of Nephrology, Seattle, WA, USA
| | - Elaine Chou-Wu
- Bloodworks Northwest, Immunogenetics/HLA Laboratory, Seattle, WA, USA
| | - Lena Sibulesky
- University of Washington, Division of Transplant Surgery, Seattle, WA, USA
| | | | - Catherine E Kling
- University of Washington, Division of Transplant Surgery, Seattle, WA, USA
| | - Rasha Alawieh
- Yale Waterbury Internal Medicine Residency Program, Waterbury, CT, USA
| | - Kelly D Smith
- University of Washington, Department of Laboratory Medicine and Pathology, Seattle, WA, USA
| | - Gener Ismail
- Fundeni Clinical Institute, Division of Nephrology, Bucharest, Romania
| | - Idoia Gimferrer
- Bloodworks Northwest, Immunogenetics/HLA Laboratory, Seattle, WA, USA.
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9
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Lin S, Minami E, O'Brien KD, Leca N, Bhattacharya R, Biggins SW, Lin Y, Chou-Wu E, Gimferrer I, Vanhoy S, Wang EP, Ramasamy Bakthavatsalam, Sturdevant M, Dimarakis I, Fishbein D, Pal JD. Heart after liver transplantation with domino for a highly sensitized patient. J Heart Lung Transplant 2023; 42:1632-1634. [PMID: 37394022 DOI: 10.1016/j.healun.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/12/2023] [Accepted: 06/23/2023] [Indexed: 07/04/2023] Open
Affiliation(s)
- Shin Lin
- University of Washington School of Medicine, Division of Cardiology, Seattle, Washington.
| | - Elina Minami
- University of Washington School of Medicine, Division of Cardiology, Seattle, Washington
| | - Kevin D O'Brien
- University of Washington School of Medicine, Division of Cardiology, Seattle, Washington
| | - Nicolae Leca
- University of Washington School of Medicine, Division of Nephrology, Seattle, Washington
| | - Renuka Bhattacharya
- University of Washington School of Medicine, Division of Gastroenterology, Seattle, Washington
| | - Scott W Biggins
- University of Washington School of Medicine, Division of Gastroenterology, Seattle, Washington
| | - Yiing Lin
- Washington University School of Medicine, Department of Surgery, St. Louis, Missouri
| | - Elaine Chou-Wu
- HLA/Immunogenetics Laboratory, Bloodworks Northwest, Seattle, Washington
| | - Idoia Gimferrer
- HLA/Immunogenetics Laboratory, Bloodworks Northwest, Seattle, Washington
| | - Steven Vanhoy
- University of Washington School of Medicine, Department of Anesthesia and Pain Medicine, Seattle, Washington
| | - Emily P Wang
- University of Washington School of Medicine, Department of Anesthesia and Pain Medicine, Seattle, Washington
| | | | - Mark Sturdevant
- University of Washington School of Medicine, Department of Surgery, Seattle, Washington
| | - Ioannis Dimarakis
- University of Washington School of Medicine, Department of Surgery, Seattle, Washington
| | - Daniel Fishbein
- University of Washington School of Medicine, Division of Cardiology, Seattle, Washington
| | - Jay D Pal
- University of Washington School of Medicine, Department of Surgery, Seattle, Washington
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10
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Sorohan BM, Ismail G, Leca N. Immunosuppression in HIV-positive kidney transplant recipients. Curr Opin Organ Transplant 2023:00075200-990000000-00061. [PMID: 37219235 DOI: 10.1097/mot.0000000000001076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
PURPOSE OF STUDY The purpose of this review is to provide the current state of immunosuppression therapy in kidney transplant recipients (KTR) with HIV and to discuss practical dilemmas to better understand and manage these patients. RECENT FINDINGS Certain studies find higher rates of rejection, which raises the need to critically assess the approach to immunosuppression management in HIV-positive KTR. Induction immunosuppression is guided by transplant center-level preference rather than by the individual patient characteristics. Earlier recommendations expressed concerns about the use of induction immunosuppression, especially utilizing lymphocyte-depleting agents; however, updated guidelines based on newer data recommend that induction can be used in HIV-positive KTR, and the choice of agent be made according to immunological risk. Likewise, most studies point out success with using first-line maintenance immunosuppression including tacrolimus, mycophenolate, and steroids. In selected patients, belatacept appears to be a promising alternative to calcineurin inhibitors with some well established advantages. Early discontinuation of steroids in this population carries a high risk of rejection and should be avoided. SUMMARY Immunosuppression management in HIV-positive KTR is complex and challenging, mainly because of the difficulty of maintaining a proper balance between rejection and infection. Interpretation and understanding of the current data towards a personalized approach of immunosuppression could improve management in HIV-positive KTR.
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Affiliation(s)
- Bogdan Marian Sorohan
- Carol Davila University of Medicine and Pharmacy
- Department of Kidney Transplantation
| | - Gener Ismail
- Carol Davila University of Medicine and Pharmacy
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Nicolae Leca
- Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
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11
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Boonpheng B, De Castro ICC, Ng YH, Blosser C, Bakthavatsalam R, Gimferrer I, Smith K, Leca N. Tocilizumab for treatment of chronic active antibody-mediated rejection in kidney transplant recipients. Clin Transplant 2023; 37:e14936. [PMID: 36787372 DOI: 10.1111/ctr.14936] [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: 08/22/2022] [Revised: 01/26/2023] [Accepted: 01/31/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND The optimal treatment for chronic active antibody-mediated rejection (ca-AMR) remains unclear. Tocilizumab (TCZ), a monoclonal antibody against IL-6, has been proposed as a therapeutic option. We reported our experience treating ca-AMR with TCZ either as the first line option or as a rescue therapy. METHODS We studied 11 adult kidney transplant recipients with biopsy-proven ca-AMR and preserved kidney function (eGFR 57 ± 18) who were treated with TCZ (8 mg/kg IV monthly). All biopsies were prompted by abnormal surveillance biomarker testing with DSA and/or dd-cfDNA. Clinical monitoring included dd-cfDNA and DSA testing every 3 months during the treatment with TCZ. RESULTS In this cohort, ca-AMR was diagnosed at a median of 90 months (range 14-224) post-transplant, and 4 of 11 patients had DSA negative ca-AMR. Patients received a minimum of 3 months of TCZ, with 6 patients receiving at least 12 months of TCZ. Dd-cfDNA was elevated in all patients, with a median 2.24% at the start of TCZ treatment. After 6 months of TCZ treatment, 8/11 patients had dd- cfDNA <1%, and 3/11 had values <0.5%. Among those who completed at least 12 months of TCZ, dd-cfDNA decreased by 29% at 6 months (p = .05) and 47% by 12 months (p = .04). DSA also stabilized and, by 12 months, was reduced by 29% (p = .047). Graft function remained stable with no graft loss during treatment. There was a nonsignificant trend towards proteinuria reduction. During the course of treatment with tocilizumab, two patients experienced moderate to severe infections. CONCLUSIONS In our early short-term experience, TCZ appears to reduce graft injury as measured by dd-cfDNA and modulate the immune response as evident by a modest reduction in immunodominant DSA MFI. Allograft function and proteinuria also stabilized.
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Affiliation(s)
- Boonphiphop Boonpheng
- Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | | | - Yue-Harn Ng
- Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Christopher Blosser
- Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Ramasamy Bakthavatsalam
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA.,Department of Urology, University of Washington, Seattle, Washington, USA
| | | | - Kelly Smith
- Department of Pathology, University of Washington, Seattle, Washington, USA
| | - Nicolae Leca
- Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
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12
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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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13
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Crannell WC, Perkins JD, Leca N, Kling CE. Deceased donor kidneys are discarded at higher rates when labeled as high kidney donor profile index. Am J Transplant 2022; 22:3087-3092. [PMID: 36088649 DOI: 10.1111/ajt.17197] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/10/2022] [Accepted: 09/07/2022] [Indexed: 01/25/2023]
Abstract
The kidney donor risk index (KDRI) and percentile conversion, kidney donor profile index (KDPI), provide a continuous measure of donor quality. Kidneys with a KDPI >85% (KDPI85 ) are referred to as "high KDPI." The KDPI85 cutoff changes every year, impacting which kidneys are labeled as KDPIHIGH . We examine kidney utilization around the KDPI85 cutoff and explore the "high KDPI" labeling effect. KDRI to KDPI Mapping Tables from 2012 to 2020 were used to determine the yearly KDRI85 value. Organ Procurement and Transplantation Network data was used to calculate discard rates and model organ use. KDRI85 varied between 1.768 and 1.888. In a multivariable analysis, kidney utilization was lower for KDPI 86% compared with KDPI 85% kidneys (p = .046). Kidneys with a KDRI between 1.785-1.849 were classified as KDPIHIGH in the years 2015-2017 and KDPILOW in the years 2018-2020. The discard rate was 44.9% when labeled as KDPIHIGH and 39.1% when labeled as KDPILOW (p < .01). For kidneys with the same KDRI, the high KDPI label is associated with increased discard. We should reconsider the appropriateness of the "high KDPI" label.
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Affiliation(s)
- William Christian Crannell
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA
| | - James D Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA.,Clinical and Bio-Analytics Transplant Laboratory (CBATL), University of Washington, Seattle, Washington, USA
| | - Nicolae Leca
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Catherine E Kling
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA.,Clinical and Bio-Analytics Transplant Laboratory (CBATL), University of Washington, Seattle, Washington, USA
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14
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Singh N, Doshi MD, Schold JD, Preczewski L, Klein C, Akalin E, Leca N, Nicoll K, Pesavento T, Dadhania DM, Friedewald J, Samaniego-Picota M, Bloom RD, Wiseman AC. Survey of Salary and Job Satisfaction of Transplant Nephrologists in the United States. Clin J Am Soc Nephrol 2022; 17:1372-1381. [PMID: 35914792 PMCID: PMC9625100 DOI: 10.2215/cjn.03490322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/09/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVES There are no standardized benchmarks to measure productivity and compensation of transplant nephrologists in the United States, and consequently, criteria set for general nephrologists are often used. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A web-based survey was sent to 809 nephrologists who were members of the American Society of Transplantation to gather data on measures of productivity, compensation, and job satisfaction. Factors associated with higher total compensation and job satisfaction were examined. RESULTS Of 365 respondents, 260 were actively practicing in the United States and provided data on compensation. Clinical productivity was assessed variably, and although 194 (76%) had their work relative value units (wRVUs) reported to them, only 107 (44%) had an established RVU target. Two hundred thirty-four respondents (90%) had fixed base compensation, and 172 (66%) received a bonus on the basis of clinical workload (68%), academic productivity (31%), service (32%), and/or teaching responsibility (31%). Only 127 respondents (49%) filled out time studies, and 92 (35%) received some compensation for nonbillable transplant activity. Mean total compensation (base salary and bonus) was $274,460±$91,509. The unadjusted mean total compensation was higher with older age and was higher for men; Hispanic and White respondents; adult care transplant nephrologists; residents of the western United States; US medical school graduates; nonuniversity hospital employees; and those with an administrative title, higher academic rank, and a higher number of years in practice. Two hundred and nine respondents (80%) thought their compensation was unfair, and 180 (70%) lacked a clear understanding of how they were compensated. One hundred forty-five respondents (55%) reported being satisfied or highly satisfied with their job. Job satisfaction was greater among those with higher amounts of compensation and US medical school graduates. CONCLUSIONS We report significant heterogeneity in the assessment of productivity and compensation for transplant nephrologists and the association of compensation with job satisfaction.
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Affiliation(s)
- Neeraj Singh
- John C. McDonald Regional Transplant Center, Willis Knighton Health System, Shreveport, Louisiana
| | - Mona D. Doshi
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Jesse D. Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Luke Preczewski
- Jackson Health System, Miami Transplant Institute, Miami, Florida
| | - Christina Klein
- Piedmont Healthcare, Piedmont Transplant Institute, Atlanta, Georgia
| | - Enver Akalin
- Renal Transplantation, Albert Einstein College of Medicine, Montefiore Medical Center, New York
| | - Nicolae Leca
- Division of Nephrology, University of Washington, Seattle, Washington
| | - Kimberly Nicoll
- US Transplant Reimbursement, TransMedics, Inc., Andover, Massachusetts
| | - Todd Pesavento
- Division of Nephrology, Ohio State University Medical Center, Columbus, Ohio
| | - Darshana M. Dadhania
- Division of Nephrology, Weill Cornell Medical College, Cornell University, New York, New York
| | - John Friedewald
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Roy D. Bloom
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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15
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Hendele J, Perkins J, Leca N, Biggins S, Sibulesky L. Optimizing Risk Assessment In Simultaneous Liver and Kidney Transplant: Donor and Recipient Factors Associated With Improved Outcome. Transplant Proc 2022; 54:715-718. [DOI: 10.1016/j.transproceed.2021.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/03/2021] [Accepted: 11/18/2021] [Indexed: 10/18/2022]
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16
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Robinson TJ, Hendele JB, Gimferrer I, Leca N, Biggins SW, Reyes JD, Sibulesky L. Acute liver failure secondary to acute antibody mediated rejection after compatible liver transplant: A case report. World J Hepatol 2022; 14:287-294. [PMID: 35126855 PMCID: PMC8790395 DOI: 10.4254/wjh.v14.i1.287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/23/2021] [Accepted: 12/31/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The liver has traditionally been regarded as resistant to antibody-mediated rejection (AMR). AMR in liver transplants is a field in its infancy compared to kidney and lung transplants. In our case we present a patient with alpha-1-antitrypsin disease who underwent ABO compatible liver transplant complicated by acute liver failure (ALF) with evidence of antibody mediated rejection on allograft biopsy and elevated serum donor-specific antibodies (DSA). This case highlights the need for further investigations and heightened awareness for timely diagnosis.
CASE SUMMARY A 56 year-old woman with alpha-1-antitrypsin disease underwent ABO compatible liver transplant from a deceased donor. The recipient MELD at the time of transplant was 28. The flow cytometric crossmatches were noted to be positive for T and B lymphocytes. The patient had an uneventful recovery postoperatively. Starting on postoperative day 5 the patient developed fevers, elevated liver function tests, distributive shock, renal failure, and hepatic encephalopathy. She went into ALF with evidence of antibody mediated rejection with portal inflammation, bile duct injury, endothelitis, and extensive centrizonal necrosis, and C4d staining on allograft biopsy and elevated DSA. Despite various interventions including plasmapheresis and immunomodulating therapy, she continued to deteriorate. She was relisted and successfully underwent liver retransplantation.
CONCLUSION This very rare case highlights AMR as the cause of ALF following liver transplant requiring retransplantation.
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Affiliation(s)
- Todd J Robinson
- Department of Surgery, Virginia Mason, Seattle, WA 98101, United States
| | - James B Hendele
- Department of Surgery, University of Washington Medical Center, Seattle, WA 98195, United States
| | | | - Nicolae Leca
- Department of Nephrology, University of Washington Medical Center, Seattle, WA 98195, United States
| | - Scott W Biggins
- Department of Gastroenterology and Hepatology, University of Washington Medical Center, Seattle, WA 98195, United States
| | - Jorge D Reyes
- Department of Surgery, University of Washington Medical Center, Seattle, WA 98195, United States
| | - Lena Sibulesky
- Department of Surgery, University of Washington Medical Center, Seattle, WA 98195, United States
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17
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Dasari M, Perkins JD, Hendele JB, Leca N, Biggins SW, Sibulesky L. Prescriptive Analytics Determining Which Patients Undergoing Simultaneous Liver-Kidney Transplant May Benefit From High-Risk Organs. EXP CLIN TRANSPLANT 2021; 19:1303-1312. [PMID: 34951349 DOI: 10.6002/ect.2021.0330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Simultaneous liver-kidney transplant is a treatment option for patients with end-stage liver disease and concomitant irreversible kidney injury. We developed a decision toolto aid transplant programs to advise their candidates for simultaneous liver-kidney transplant on accepting high-risk grafts versus waiting for lower-risk grafts. MATERIALS AND METHODS To find the critical decision factors, we used the prescriptive analytic technique of microsimulation.All probabilities used in the simulation model were calculated from Organ Procurement and Transplantation Network data collected from February 27, 2002 to June 30, 2018. RESULTS The simulated patient population results revealed, on average, that high-risk candidates for simultaneous liver-kidney transplant who accept highrisk organs have 254.8 ± 225.4 weeks of life compared with 285.6 ± 232.4 weeks if they waited for better organs. However, critical decision factors included the specific organ offer rates within individual transplant programs and the rank of the candidate in each program's waitlist. Thus, for programs with lower organ offer rates or for candidates with a rare blood type, a high-risk simultaneous liver-kidney transplant candidate might accept a high-risk organ for longer survival. CONCLUSIONS Our model can be utilized to determine when acceptance of high-risk organs for patients being considered for simultaneous liver-kidney transplant would lead to survival benefit, based on probabilities specific for their program.
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Affiliation(s)
- Mohini Dasari
- From the Department of Surgery, UW Medicine Kidney and Pancreas Transplantation Program, University of Washington, Seattle, Washington, USA
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18
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Budde K, Prashar R, Haller H, Rial MC, Kamar N, Agarwal A, de Fijter JW, Rostaing L, Berger SP, Djamali A, Leca N, Allamassey L, Gao S, Polinsky M, Vincenti F. Conversion from Calcineurin Inhibitor- to Belatacept-Based Maintenance Immunosuppression in Renal Transplant Recipients: A Randomized Phase 3b Trial. J Am Soc Nephrol 2021; 32:3252-3264. [PMID: 34706967 PMCID: PMC8638403 DOI: 10.1681/asn.2021050628] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [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: 05/10/2021] [Revised: 09/16/2021] [Accepted: 10/07/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Calcineurin inhibitors (CNIs) are standard of care after kidney transplantation, but they are associated with nephrotoxicity and reduced long-term graft survival. Belatacept, a selective T cell costimulation blocker, is approved for the prophylaxis of kidney transplant rejection. This phase 3 trial evaluated the efficacy and safety of conversion from CNI-based to belatacept-based maintenance immunosuppression in kidney transplant recipients. METHODS Stable adult kidney transplant recipients 6-60 months post-transplantation under CNI-based immunosuppression were randomized (1:1) to switch to belatacept or continue treatment with their established CNI. The primary end point was the percentage of patients surviving with a functioning graft at 24 months. RESULTS Overall, 446 renal transplant recipients were randomized to belatacept conversion ( n =223) or CNI continuation ( n =223). The 24-month rates of survival with graft function were 98% and 97% in the belatacept and CNI groups, respectively (adjusted difference, 0.8; 95.1% CI, -2.1 to 3.7). In the belatacept conversion versus CNI continuation groups, 8% versus 4% of patients experienced biopsy-proven acute rejection (BPAR), respectively, and 1% versus 7% developed de novo donor-specific antibodies (dnDSAs), respectively. The 24-month eGFR was higher with belatacept (55.5 versus 48.5 ml/min per 1.73 m 2 with CNI). Both groups had similar rates of serious adverse events, infections, and discontinuations, with no unexpected adverse events. One patient in the belatacept group had post-transplant lymphoproliferative disorder. CONCLUSIONS Switching stable renal transplant recipients from CNI-based to belatacept-based immunosuppression was associated with a similar rate of death or graft loss, improved renal function, and a numerically higher BPAR rate but a lower incidence of dnDSA.Clinical Trial registry name and registration number: A Study in Maintenance Kidney Transplant Recipients Following Conversion to Nulojix® (Belatacept)-Based, NCT01820572.
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Affiliation(s)
- Klemens Budde
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Rohini Prashar
- Division of Nephrology, Henry Ford Hospital, Detroit, Michigan
| | - Hermann Haller
- Department of Nephrology and Hypertension, The Hannover Medical School, Hannover, Germany
| | - Maria C. Rial
- Department of Nephrology, Dialysis and Organ Transplantation, Instituto de Nefrologia, Nephrology SA, Buenos Aires, Argentina
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Université de Toulouse, Toulouse, France
| | - Avinash Agarwal
- Department of Surgery, University of Virginia Health, Charlottesville, Virginia
| | - Johan W. de Fijter
- Department of Nephrology; Leiden University Medical Center, Leiden, The Netherlands
| | - Lionel Rostaing
- Department of Nephrology, Université Grenoble Alpes, Saint-Martin-d'Hères, France
| | - Stefan P. Berger
- Division of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Arjang Djamali
- Division of Nephrology, University of Wisconsin, Madison, Wisconsin
| | - Nicolae Leca
- Department of Medicine, University of Washington Medical Center, Seattle, Washington
| | | | - Sheng Gao
- Bristol-Myers Squibb, Princeton, New Jersey
| | | | - Flavio Vincenti
- Department of Surgery, Kidney Transplant Service, University of California, San Francisco, California
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19
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Minnelli C, Riazy M, Ohashi R, Kowalewska J, Leca N, Najafian B, Smith KD, Nicosia RF, Alpers CE, Akilesh S. Early Transplant Arteriopathy in Kidney Transplantation. Transplant Proc 2021; 53:1554-1561. [PMID: 33962774 DOI: 10.1016/j.transproceed.2021.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 12/15/2020] [Accepted: 02/25/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Early dysfunction of renal allografts may be associated with vascular injury, which raises the specter of active rejection processes that require medical intervention. In our practice, we have encountered patients who present with delayed graft function and demonstrate a unique pattern of endothelial cell injury that raises concern for rejection in their biopsy. Therefore, we sought to systematically determine the biopsy characteristics and outcome of these patients. METHODS During a 17-year period at the University of Washington in Seattle, United States, we identified 24 cases of a distinct arterial vasculopathy presenting in the first year posttransplantation. This early transplant arteriopathy (ETA) is characterized by endothelial cell swelling and intimal edema but without the intimal arteritis that defines vascular rejection. RESULTS Approximately 1% of transplant biopsies during the study period showed ETA, almost all of which were in deceased donor organs (96%), and most presented with delayed graft function (54%) or increased serum creatinine (38%) soon after transplantation (median 13 days; range, 5-139). In this study, 77% of patients were managed expectantly, with only 2 patients (7.6%) subsequently developing acute vascular rejection. Except for 1 patient who died, all patients had functioning allografts at 1 year follow-up. CONCLUSION Recognizing ETA and distinguishing it from vascular rejection is important to prevent over-treatment because most patients appear to recover allograft function rapidly with expectant management.
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Affiliation(s)
- Carrie Minnelli
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Maziar Riazy
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington; Department of Pathology and Laboratory Medicine, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Ryuji Ohashi
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington; Department of Pathology, Nippon Medical School, Tokyo, Japan
| | - Jolanta Kowalewska
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington; Department of Pathology and Anatomy, Eastern Virginia Medical School, Norfolk, Virginia
| | - Nicolae Leca
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Behzad Najafian
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Kelly D Smith
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Roberto F Nicosia
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Charles E Alpers
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Shreeram Akilesh
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington.
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20
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C Wiseman A, Akalin E, M Dadhania D, DeMattos A, Doshi M, Friedewald J, Klein C, Leca N, Nicoll K, Pesavento T, Preczewski L, Samaniego M, Singh N, Bloom R. Defining the roles and responsibilities of the kidney transplant medical director: A necessary step for future training, mentoring, and professional development. Am J Transplant 2021; 21:1556-1563. [PMID: 33021008 DOI: 10.1111/ajt.16332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 01/25/2023]
Abstract
The management of a kidney transplant program has evolved significantly in the last decades to become a highly specialized, multidisciplinary standard of care for end-stage kidney disease. Transplant center job descriptions have similarly morphed with increasing responsibilities to address a more complex patient mix, increasing medical and surgical therapeutic options, and increasing regulatory burden in the face of an ever-increasing organ shortage. Within this evolution, the role of the Kidney Transplant Medical Director (KTMD) has expanded beyond the basic requirements described in the United Network for Organ Sharing bylaws. Without a clear job description, transplant nephrology trainees may be inadequately trained and practicing transplant nephrologists may face opaque expectations for the roles and responsibilities of Medical Director. To address this gap and clarify the key areas in which the KTMD interfaces with the kidney transplant program, American Society of Transplantation (AST) formed a Task Force of 14 AST KTMDs to review and define the role of the KTMD in key aspects of administrative, regulatory, budgetary, and educational oversight of a kidney transplant program.
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Affiliation(s)
- Alexander C Wiseman
- Kidney Transplantation, Centura Transplant at Porter Hospital, Denver, Colorado
| | - Enver Akalin
- Montefiore Medical Center - Renal Transplantation, Albert Einstein College of Medicine,, Bronx, New York
| | | | - Angelo DeMattos
- Transplant Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon
| | - Mona Doshi
- Medicine, University of Michigan Hospital, Ann Arbor, Michigan
| | | | - Christina Klein
- Piedmont Healthcare - Piedmont Transplant Institute, Atlanta, Georgia
| | - Nicolae Leca
- Department of Medicine, Division of Nephrology, University of Washington Medical Center, Seattle, Washington
| | - Kim Nicoll
- US Transplant Reimbursement, TransMedics Inc, Andover, Massachusetts
| | - Todd Pesavento
- Ohio State Univ - Nephrology-Internal Medicine, Columbus, Ohio
| | - Luke Preczewski
- Transplant, Jackson Health System - Miami Transplant Institute, Miami, Florida
| | | | - Neeraj Singh
- Nephrology, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana
| | - Roy Bloom
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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21
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Puttarajappa CM, Schinstock CA, Wu CM, Leca N, Kumar V, Vasudev BS, Hariharan S. KDOQI US Commentary on the 2020 KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Am J Kidney Dis 2021; 77:833-856. [PMID: 33745779 DOI: 10.1053/j.ajkd.2020.11.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022]
Abstract
Evaluation of patients for kidney transplant candidacy is a comprehensive process that involves a detailed assessment of medical and surgical issues, psychosocial factors, and patients' physical and cognitive abilities with an aim of balancing the benefits of transplantation and potential risks of surgery and long-term immunosuppression. There is considerable variability among transplant centers in their approach to evaluation and decision-making regarding transplant candidacy. The 2020 KDIGO (Kidney Disease: Improving Guidelines Outcome) clinical practice guideline on the evaluation and management of candidates for kidney transplantation provides practice recommendations that can serve as a useful reference guide to transplant professionals. The guideline, covering a broad range of topics, was developed by an international group of experts from transplant and nephrology through a review of literature published until May 2019. A work group of US transplant nephrologists convened by NKF-KDOQI (National Kidney Foundation-Kidney Disease Quality Initiative) chose key topics for this commentary with a goal of presenting a broad discussion to the US transplant community. Each section of this article has a summary of the key KDIGO guideline recommendations, followed by a brief commentary on the recommendations, their clinical utility, and potential implementation challenges. The KDOQI work group agrees broadly with the KDIGO recommendations but also recognizes and highlights the decision-making challenges that arise from lack of high-quality evidence and the need to balance equity with utility of organ transplantation.
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Affiliation(s)
- Chethan M Puttarajappa
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Carrie A Schinstock
- Division of Nephrology & Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Christine M Wu
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Nicolae Leca
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Vineeta Kumar
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Brahm S Vasudev
- Division of Nephrology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Sundaram Hariharan
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA.
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Zelnick LR, Leca N, Young B, Bansal N. Association of the Estimated Glomerular Filtration Rate With vs Without a Coefficient for Race With Time to Eligibility for Kidney Transplant. JAMA Netw Open 2021; 4:e2034004. [PMID: 33443583 PMCID: PMC7809586 DOI: 10.1001/jamanetworkopen.2020.34004] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
IMPORTANCE Kidney transplant is associated with improved survival and quality of life among patients with kidney failure; however, significant racial disparities have been noted in transplant access. Common equations that estimate glomerular filtration rate (eGFR) include adjustment for Black race; however, how inclusion of the race coefficient in common eGFR equations corresponds with measured GFR and whether it is associated with delayed eligibility for kidney transplant listing are unknown. OBJECTIVE To compare eGFR with measured GFR and evaluate the association between eGFR calculated with vs without a coefficient for race and time to eligibility for kidney transplant. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study used data from the Chronic Renal Insufficiency Cohort, a multicenter cohort study of participants with chronic kidney disease (CKD). Self-identified Black participants from that study were enrolled between April 2003 and September 2008, with follow-up through December 2018. Statistical analyses were completed on November 11, 2020. EXPOSURE Estimated GFR, measured annually and estimated using the creatinine-based Chronic Kidney Disease-Epidemiology (CKD-EPI) equation with and without a race coefficient. MAIN OUTCOMES AND MEASURES Iothalamate GFR (iGFR) measured in a subset of participants (n = 311) and time to achievement of an eGFR less than 20 mL/min/1.73 m2, an established threshold for kidney transplant referral and listing. RESULTS Among 1658 self-identified Black participants, mean (SD) age was 58 (11) years, 848 (51%) were female, and mean (SD) eGFR was 44 (15) mL/min/1.73 m2. The CKD-EPI eGFR with the race coefficient overestimated iGFR by a mean of 3.1 mL/min/1.73 m2 (95% CI, 2.2-3.9 mL/min/1.73 m2; P < .001). The mean difference between CKD-EPI eGFR without the race coefficient and iGFR was of smaller magnitude (-1.7 mL/min/1.73 m2; 95% CI, -2.5 to -0.9 mL/min/1.73 m2). For participants with an iGFR of 20 to 25 mL/min/1.73 m2, the mean difference in eGFR with vs without the race coefficient and iGFR was 5.1 mL/min/1.73 m2 (95% CI, 3.3-6.9 mL/min/1.73 m2) vs 1.3 mL/min/1.73 m2 (95% CI, -0.3 to 2.9 mL/min/1.73 m2). Over a median follow-up time of 4 years (interquartile range, 1-10 years), use of eGFR calculated without vs with the race coefficient was associated with a 35% (95% CI, 29%-41%) higher risk of achieving an eGFR less than 20 mL/min/1.73 m2 and a shorter median time to this end point of 1.9 years. CONCLUSIONS AND RELEVANCE In this cohort study, inclusion of the race coefficient in the estimation of GFR was associated with greater bias in GFR estimation and with delayed achievement of a clinical threshold for kidney transplant referral and eligibility. These findings suggest that nephrologists and transplant programs should be cautious when using current estimating equations to determine kidney transplant eligibility.
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Affiliation(s)
- Leila R. Zelnick
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle
| | - Nicolae Leca
- Division of Nephrology, University of Washington, Seattle
| | - Bessie Young
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle
- Puget Sound Veterans Affairs Health Care System, Seattle, Washington
| | - Nisha Bansal
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle
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Sorohan BM, Ismail G, Leca N, Tacu D, Obrișcă B, Constantinescu I, Baston C, Sinescu I. Angiotensin II type 1 receptor antibodies in kidney transplantation: An evidence-based comprehensive review. Transplant Rev (Orlando) 2020; 34:100573. [DOI: 10.1016/j.trre.2020.100573] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 12/15/2022]
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Stites E, Kumar D, Olaitan O, John Swanson S, Leca N, Weir M, Bromberg J, Melancon J, Agha I, Fattah H, Alhamad T, Qazi Y, Wiseman A, Gupta G. High levels of dd-cfDNA identify patients with TCMR 1A and borderline allograft rejection at elevated risk of graft injury. Am J Transplant 2020; 20:2491-2498. [PMID: 32056331 PMCID: PMC7496411 DOI: 10.1111/ajt.15822] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [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] [Received: 09/14/2019] [Revised: 01/30/2020] [Accepted: 02/02/2020] [Indexed: 01/25/2023]
Abstract
The clinical importance of subclinical, early T cell-mediated rejection (Banff TCMR 1A and borderline lesions) remains unclear, due, in part to the fact that histologic lesions used to characterize early TCMR can be nonspecific. Donor-derived cell-free DNA (dd-cfDNA) is an important molecular marker of active graft injury. Over a study period from June 2017 to May 2019, we assessed clinical outcomes in 79 patients diagnosed with TCMR 1A/borderline rejection across 11 US centers with a simultaneous measurement of dd-cfDNA. Forty-two patients had elevated dd-cfDNA (≥0.5%) and 37 patients had low levels (<0.5%). Elevated levels of dd-cfDNA predicted adverse clinical outcomes: among patients with elevated cfDNA, estimated glomerular filtration rate declined by 8.5% (interquartile rate [IQR] -16.22% to -1.39%) (-3.50 mL/min/1.73 m2 IQR -8.00 to -1.00) vs 0% (-4.92%, 4.76%) in low dd-cfDNA patients (P = .004), de novo donor-specific antibody formation was seen in 40% (17/42) vs 2.7% (P < .0001), and future or persistent rejection occurred in 9 of 42 patients (21.4%) vs 0% (P = .003). The use of dd-cfDNA may complement the Banff classification and to risk stratify patients with borderline/TCMR 1A identified on biopsy.
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Affiliation(s)
| | - Dhiren Kumar
- Medicine/NephrologyVirginia Commonwealth University School of MedicineRichmondVirginiaUSA
| | | | | | - Nicolae Leca
- Division of NephrologyDepartment of MedicineUniversity of Washington Medical CenterSeattleWashingtonUSA
| | - Matthew Weir
- Division of NephrologyUniversity of MarylandBaltimoreMarylandUSA
| | | | - Joseph Melancon
- SurgeryGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Irfan Agha
- Medical City Dallas HospitalDallasTexasUSA
| | - Hasan Fattah
- University of Kentucky Medical CenterLexingtonKentuckyUSA
| | - Tarek Alhamad
- Washington University in Saint LouisSaint LouisMissouriUSA
| | - Yasir Qazi
- Keck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
- Internal MedicineDivision of NephrologyLos AngelesCaliforniaUSA
| | | | - Gaurav Gupta
- Medicine/NephrologyVirginia Commonwealth University School of MedicineRichmondVirginiaUSA
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Butler CR, Perkins JD, Johnson CK, Blosser CD, De Castro I, Leca N, Sibulesky L. Contemporary patterns in kidney graft survival from donors after circulatory death in the United States. PLoS One 2020; 15:e0233610. [PMID: 32469937 PMCID: PMC7259576 DOI: 10.1371/journal.pone.0233610] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 05/08/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Kidney transplants from donors after circulatory death (DCD) make up an increasing proportion of all deceased donor kidney transplants in the United States (US). However, DCD grafts are considered to be of lower quality than kidneys from donors after brain death (DBD). It is unclear whether graft survival is different for these two types of donor kidneys. MATERIALS AND METHODS We conducted a retrospective cohort study of US deceased donor kidney recipients using data from the United Network of Organ Sharing from 12/4/2014 to 6/30/2018. We employed a Cox proportional hazard model with mixed effects to compare all-cause graft loss and death-censored graft loss for DCD versus DBD deceased donor kidney transplant recipients. We used transplant center as the random effects term to account for cluster-specific random effects. In the multivariable analysis, we adjusted for recipient characteristics, donor factors, and transplant logistics. RESULTS Our cohort included 27,494 DBD and 7,770 DCD graft recipients transplanted from 2014 to 2018 who were followed over a median of 1.92 years (IQR 1.08-2.83). For DCD compared with DBD recipients, we did not find a significant difference in all-cause graft loss (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.87-1.05 in univariable and HR 1.03 [95% CI 0.95-1.13] in multivariable analysis) or for death-censored graft loss (HR 0.97 (95% CI 0.91-1.06) in univariable and 1.05 (95% CI 0.99-1.11) in multivariable analysis). CONCLUSIONS For a contemporary cohort of deceased donor kidney transplant recipients, we did not find a difference in the likelihood of graft loss for DCD compared with DBD grafts. These findings signal a need for additional investigation into whether DCD status independently contributes to other important outcomes for current kidney transplant recipients and indices of graft quality.
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Affiliation(s)
- Catherine R. Butler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - James D. Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA, United States of America
| | - Christopher K. Johnson
- Division of Nephrology, Department of Medicine, University of Illinois College of Medicine, Peoria, IL, United States of America
| | - Christopher D. Blosser
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Iris De Castro
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Nicolae Leca
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Lena Sibulesky
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA, United States of America
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Crow LD, Jambusaria‐Pahlajani A, Chung CL, Baran DA, Lowenstein SE, Abdelmalek M, Ahmed RL, Anadkat MJ, Arcasoy SM, Berg D, Bibee KP, Billingsley E, Black WH, Blalock TW, Bleicher M, Brennan DC, Brodland DG, Brown MR, Carroll BT, Carucci JA, Chang TW, Chaux G, Cusack CA, Dilling DF, Doyle A, Emtiazjoo AM, Ferguson NH, Fosko SW, Fox MC, Goral S, Gray AL, Griffin JR, Hachem RR, Hall SA, Hanlon AM, Hayes D, Hickey GW, Holtz J, Hopkins RS, Hu J, Huang CC, Brian Jiang SI, Kapnadak SG, Kraus ES, Lease ED, Leca N, Lee JC, Leitenberger JJ, Lim MA, Longo MI, Malik SM, Mallea JM, Menter A, Myers SA, Neuburg M, Nijhawan RI, Norman DJ, Otley CC, Paek SY, Parulekar AD, Patel MJ, Patel VA, Patton TJ, Pugliano‐Mauro M, Ranganna K, Ravichandran AK, Redenius R, Roll GR, Samie FH, Shin T, Singer JP, Singh P, Soon SL, Soriano T, Squires R, Stasko T, Stein JA, Taler SJ, Terrault NA, Thomas CP, Tokman S, Tomic R, Twigg AR, Wigger MA, Zeitouni NC, Arron ST. Initial skin cancer screening for solid organ transplant recipients in the United States: Delphi method development of expert consensus guidelines. Transpl Int 2019; 32:1268-1276. [DOI: 10.1111/tri.13520] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 03/25/2019] [Accepted: 09/02/2019] [Indexed: 12/25/2022]
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27
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Butler CR, Perkins JD, Johnson CK, Blosser CD, Bakthavatsalam R, Leca N, Sibulesky L. Burden of excess mortality after implementation of the new kidney allocation system may be borne disproportionately by middle-aged recipients. PLoS One 2019; 14:e0210589. [PMID: 30677058 PMCID: PMC6345464 DOI: 10.1371/journal.pone.0210589] [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: 10/11/2018] [Accepted: 12/25/2018] [Indexed: 11/19/2022] Open
Abstract
Under the new kidney allocation system (KAS), implemented in 2014, the distribution of the best quality donor kidney grafts shifted between age groups, but it is unclear whether this change translates to meaningful differences in post-transplant outcomes. We conducted a retrospective cohort study of 20,345 deceased donor kidney transplant recipients before and 4,605 recipients after implementation of the KAS using data from the United Network of Organ Sharing. Overall, two-year mortality was greater among recipients in the post-KAS era compared with the pre-KAS era (6.31% vs 5.91% respectively, [p = 0.01]), and two-year graft loss was not significantly different between eras (9.95% and 9.65%, respectively [p = 0.13]). In analysis stratified by age group (18-45, 46-55, 56-65, and ≥66 years), relative risk of mortality was 1.48 (95% confidence interval [CI] 1.09-1.98) among recipients 46-55 years old and 1.47 (95% CI 1.18-1.81) among recipients 56-65 years old. Relative risk of all-cause graft loss was 1.43 (95% CI 1.20-1.70) among recipients 56-65 years old. There were no significant differences in relative risk of mortality or graft loss associated with the KAS era among other age groups. After adjustment for recipient characteristics and characteristics of the changing donor pool, relative risk of two-year mortality and graft loss associated with the post-KAS era was attenuated for recipients aged 46-55 and 56-65 years, but remained statistically significant. In this early analysis after implementation of the KAS, there is suggestion that increased risk of mortality and graft loss may be disproportionately borne by middle-aged recipients, which is only partially accounted for by changes in recipient and donor characteristics. These findings signal a need to continue to monitor the effects of the KAS to ensure that allocation practices both maximize utility of the kidney graft pool and respect fairness between age groups.
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Affiliation(s)
- Catherine R. Butler
- Department of Medicine, Division of Nephrology, University of Washington Medical Center, Seattle, WA, United States America
| | - James D. Perkins
- Department of Surgery, Division of Transplant Surgery, University of Washington Medical Center, Seattle, WA, United States America
| | - Christopher K. Johnson
- Department of Medicine, Division of Nephrology, University of Washington Medical Center, Seattle, WA, United States America
| | - Christopher D. Blosser
- Department of Medicine, Division of Nephrology, University of Washington Medical Center, Seattle, WA, United States America
| | - Ramasamy Bakthavatsalam
- Department of Surgery, Division of Transplant Surgery, University of Washington Medical Center, Seattle, WA, United States America
| | - Nicolae Leca
- Department of Medicine, Division of Nephrology, University of Washington Medical Center, Seattle, WA, United States America
| | - Lena Sibulesky
- Department of Surgery, Division of Transplant Surgery, University of Washington Medical Center, Seattle, WA, United States America
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Kim D, Gimferrer I, Warner P, Nelson K, Sibulesky L, Bakthavatsalam R, Leca N. Preformed Angiotensin II Type-1 Receptor Antibodies Are Associated With Rejection After Kidney Transplantation: A Single-Center, Cohort Study. Transplant Proc 2018; 50:3467-3472. [DOI: 10.1016/j.transproceed.2018.05.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/23/2018] [Indexed: 10/16/2022]
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29
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Kling CE, Perkins JD, Johnson CK, Blosser CD, Leca N, Sibulesky L. Utilization of Standard Criteria Donor and Expanded Criteria Donor Kidneys After Kidney Allocation System Implementation. Ann Transplant 2018; 23:691-703. [PMID: 30287804 PMCID: PMC6255331 DOI: 10.12659/aot.910504] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Implementation of the Kidney Allocation System (KAS) changed how kidneys are allocated and the information on which organ utilization decisions are based. We aimed to evaluate how KAS implementation changed kidney utilization and recipient outcomes. MATERIAL AND METHODS Using the United Network for Organ Sharing database, we identified recipients of kidney transplants from donors with kidney donor profile index (KDPI) of 61-90% in the 5-years pre- and 18-months post-KAS implementation and examined patient and graft survival and donor kidney discard rates based on standard criteria donor (SCD) or expanded criteria donor (ECD) status. RESULTS The proportion of ECD kidneys was unchanged pre- versus post-KAS. Post-KAS, SCD kidneys were less likely to be transplanted into young recipients while ECD kidneys were more likely to be transplanted. SCD kidneys in the post-KAS period conferred a 1.42 (95% CI: 1.18-1.73) times higher adjusted mortality and 2% lower 1-year survival (94.2% vs. 96.2%, P<0.001) but had unchanged graft failure compared to pre-KAS. For ECD kidneys, there was no difference in mortality or graft survival. The discard rate increased after KAS for both SCD and ECD kidneys (P<0.05) but was not different between SCD and ECD kidneys for any KDPI group. CONCLUSIONS After KAS implementation, patient survival for recipients of SCD kidneys was significantly worse.
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Affiliation(s)
- Catherine E Kling
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA, USA
| | - James D Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA, USA
| | - Christopher K Johnson
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Christopher D Blosser
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Nicolae Leca
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Lena Sibulesky
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA, USA
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Sibulesky L, Kling CE, Blosser C, Johnson CK, Limaye AP, Bakthavatsalam R, Leca N, Perkins JD. Are we underestimating the quality of aviremic hepatitis C-positive kidneys? Time to reconsider. Am J Transplant 2018; 18:2465-2472. [PMID: 29451354 DOI: 10.1111/ajt.14701] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [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: 12/05/2017] [Revised: 01/25/2018] [Accepted: 02/11/2018] [Indexed: 01/25/2023]
Abstract
Kidney Donor Risk Index (KDRI) introduced in 2009 included hepatitis C serologic but not viremic status of the donors. With nucleic acid amplification testing (NAT) now being mandatory, further evaluation of these donors is possible. We conducted a retrospective matched case-control analysis of adult deceased donor kidney transplants performed between December 5, 2014 to December 31, 2016 with the KDRI score and hepatitis C virus antibody (HCV Ab) and NAT testing status obtained from the United Network for Organ Sharing database. The 205 aviremic HCV Ab+ NAT - kidney transplants were compared to KDRI matched control kidneys that were HCV Ab-NAT-. The aviremic HCV kidneys were recovered from donors who were significantly younger, more likely to be white, and less likely to have hypertension and diabetes. The majority of the recipients of the aviremic HCV kidneys when compared to matched controls were HCV positive: 90.2% vs 4.3%. The recipients were significantly older, were on dialysis for a shorter time, and were transplanted sooner. The graft survival of aviremic HCV kidneys was similar (P < .08). If the HCV status of the aviremic kidneys was assumed to be negative, 122 more kidneys could have been allocated to patients with estimated posttransplant survival <20. Seven kidneys would no longer have Kidney Donor Profile Index >85%. Further policies might consider these findings to appropriately allocate these kidneys.
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Affiliation(s)
- L Sibulesky
- Division of Transplant Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - C E Kling
- Division of Transplant Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - C Blosser
- Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - C K Johnson
- Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - A P Limaye
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - R Bakthavatsalam
- Division of Transplant Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - N Leca
- Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - J D Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
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Rahnemai-Azar AA, Perkins JD, Leca N, Blosser CD, Johnson CK, Morrison SD, Bakthavatsalam R, Limaye AP, Sibulesky L. Unintended Consequences in Use of Increased Risk Donor Kidneys in the New Kidney Allocation Era. Transplant Proc 2018; 50:14-19. [PMID: 29407297 DOI: 10.1016/j.transproceed.2017.11.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 09/09/2017] [Accepted: 11/03/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND The new kidney allocation system (KAS) intends to allocate the top 20% of kidneys to younger recipients with longer life expectancy. We hypothesized that the new KAS would lead to greater allocation of Public Health Service (PHS) increased-risk donor organs to younger recipients. METHODS Analyses of the Organ Procurement and Transplantation Network data of patients who underwent primary deceased kidney transplantation were performed in pre- and post-KAS periods. RESULTS The allocation of PHS increased-risk kidney allografts in various age groups changed significantly after implementation of the new KAS, with an increased proportion of younger individuals receiving increased-risk kidneys (7% vs 10% in age group 20-29 y and 13% vs 18% in age group 30-39 y before and after KAS, respectively; P < .0001). This trend was reversed in recipients 50-59 years old, with 31% in the pre-KAS period compared with 26% after KAS (P < .0001). CONCLUSIONS The new KAS resulted in a substantial increase in allocation of PHS increased-risk kidneys to candidates in younger age groups. Because increased-risk kidneys are generally underutilized, future efforts to optimize the utilization of these organs should target younger recipients and their providers.
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Affiliation(s)
- A A Rahnemai-Azar
- Division of Transplant Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Washington
| | - J D Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Washington
| | - N Leca
- Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, Washington
| | - C D Blosser
- Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, Washington
| | - C K Johnson
- Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, Washington
| | - S D Morrison
- Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Washington
| | - R Bakthavatsalam
- Division of Transplant Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Washington
| | - A P Limaye
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington Medical Center, Seattle, Washington
| | - L Sibulesky
- Division of Transplant Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Washington.
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Muczynski KA, Leca N, Anderson AE, Kieran N, Anderson SK. Multicolor Flow Cytometry and Cytokine Analysis Provides Enhanced Information on Kidney Transplant Biopsies. Kidney Int Rep 2018; 3:956-969. [PMID: 29989006 PMCID: PMC6035131 DOI: 10.1016/j.ekir.2018.02.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 01/28/2018] [Accepted: 02/26/2018] [Indexed: 12/31/2022] Open
Abstract
Introduction Current processing of renal biopsy samples provides limited information about immune mechanisms causing kidney injury and disease activity. We used flow cytometry with transplanted kidney biopsy samples to provide more information on the immune status of the kidney. Methods To enhance the information available from a biopsy, we developed a technique for reducing a fraction of a renal biopsy sample to single cells for multicolor flow cytometry and quantitation of secreted cytokines present within the biopsy sample. As proof of concept, we used our technique with transplant kidney biopsy samples to provide examples of clinically relevant immune information obtainable with cytometry. Results A ratio of CD8+ to CD4+ lymphocytes greater than or equal to 1.2 in transplanted allografts is associated with rejection, even before it is apparent by microscopy. Elevated numbers of CD45 leukocytes and higher levels of interleukin (IL)−6, IL-8, and IL-10 indicate more severe injury. Antibody binding to renal microvascular endothelial cells can be measured and corresponds to antibody-mediated forms of allograft rejection. Eculizumab binding to endothelial cells suggests complement activation, which may be independent of bound antibody. We compared intrarenal leukocyte subsets and activation states to those of peripheral blood from the same donor at the time of biopsy and found significant differences; thus the need for new techniques to evaluate immune responses within the kidney. Conclusion Assessment of leukocyte subsets, renal microvascular endothelial properties, and measurement of cytokines within a renal biopsy by flow cytometry enhance understanding of pathogenesis, indicate disease activity, and identify potential targets for therapy.
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Affiliation(s)
| | - Nicolae Leca
- Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Arthur E Anderson
- Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Niamh Kieran
- Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Susan K Anderson
- Division of Nephrology, University of Washington, Seattle, Washington, USA
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Philosophe B, Leca N, West-Thielke PM, Horwedel T, Culkin-Gemmell C, Kistler K, Stevens DR. Evaluation of Flexible Tacrolimus Drug Concentration Monitoring Approach in Patients Receiving Extended-Release Once-Daily Tacrolimus Tablets. J Clin Pharmacol 2018; 58:891-896. [PMID: 29462506 PMCID: PMC6032903 DOI: 10.1002/jcph.1082] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/21/2017] [Indexed: 11/10/2022]
Abstract
The majority of United States kidney transplant patients are treated with tacrolimus, a drug effective in preventing graft rejection, but with a narrow therapeutic range, necessitating close monitoring to avoid increased risks of transplant rejection or toxicity if the tacrolimus concentration is too low or too high, respectively. The trough drug concentration tests are time sensitive; patients treated on a twice-daily basis have blood draws exactly 12 hours after their previous dose. The schedule's rigidity causes problems for both patients and health care providers. Novel once-daily tacrolimus formulations such as LCPT (an extended-release tablet by Veloxis Pharmaceuticals, Inc., Cary, North Carolina) have allowed for blood draws on a once-daily basis; however, even that schedule can be restrictive. Results from tests taken either before or after that 24-hour target time may be discarded, or worse, may lead to inappropriate dose changes. Data from ASTCOFF, a phase 3B pharmacokinetic clinical trial (NCT02339246), demonstrated that the unique pharmacokinetic curve of LCPT may allow for a therapeutic monitoring window that extends for 3 hours before or after the 24-hour monitoring target. Furthermore, important tools to help clinicians interpret these levels, such as formulas to estimate the 24-hour trough level if an alternative monitoring time is used, were constructed from these data. These study results give treating clinicians access to data that allow them to safely use and monitor LCPT in their patients and expand the body of evidence surrounding differentiation and practical application of the novel LCPT tacrolimus formulation.
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Affiliation(s)
| | - Nicolae Leca
- University of Washington Medical Center, Seattle, WA, USA
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Sibulesky L, Hansen RN, Leca N, Blosser C, Rahnemai-Azar AA, Montenovo MI, Dick AA, Bakthavatsalam R, Rayhill S, Bhattacharya R, Reyes JD. Landscape of Kidney Transplantation in Patients With Compensated Liver Disease: Results of a Survey of Transplant Surgeons in the United States. Transplant Proc 2016; 48:3268-3273. [PMID: 27931567 DOI: 10.1016/j.transproceed.2016.09.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 09/28/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND The therapeutic options that provide the best long-term outcome for patients who have a combination of end-stage renal disease and compensated cirrhosis are unknown. METHODS Given the paucity of data and the lack of clinical guidance in this area, a national survey was conducted in the form of an e-mail-based questionnaire addressed to the transplantation surgeons registered with the American Society of Transplant Surgeons. RESULTS Of the 818 surgeons invited to participate in the survey, 167 (20%) responded. Twenty-one (12.6%) respondents indicated that their program performed <50 kidney transplantations per year, 49 (29.3%) reported performing 50 to 100 kidney transplantations per year, and the majority, 97 (58.1%) of respondents, performed >100 kidney transplantations per year. The majority, 116 (69.5%), believed that compensated cirrhotic patients with end-stage renal disease could be considered for renal transplantation alone, 45 (26.9%) respondents believed that compensated cirrhotic patients on dialysis could only be considered for simultaneous liver-kidney transplantation, and 6 (3.6%) believed that this population of patients was not suitable for kidney transplantation alone. CONCLUSIONS Our findings suggest that there is a substantial heterogeneity of opinion among transplantation surgeons towards transplantation options for compensated cirrhotic patients. Further data is needed to define best practices and clinical guidelines.
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Affiliation(s)
- L Sibulesky
- Department of Surgery, Division of Transplant Surgery, University of Washington, Seattle, Washington.
| | - R N Hansen
- Pharmaceutical Outcomes Research and Policy Program, School of Pharmacy, University of Washington, Seattle, Washington
| | - N Leca
- Department of Medicine, Division of Nephrology, University of Washington, Seattle, Washington
| | - C Blosser
- Department of Medicine, Division of Nephrology, University of Washington, Seattle, Washington
| | - A A Rahnemai-Azar
- Department of Surgery, Division of Transplant Surgery, University of Washington, Seattle, Washington
| | - M I Montenovo
- Department of Surgery, Division of Transplant Surgery, University of Washington, Seattle, Washington
| | - A A Dick
- Department of Surgery, Division of Transplant Surgery, University of Washington, Seattle, Washington
| | - R Bakthavatsalam
- Department of Surgery, Division of Transplant Surgery, University of Washington, Seattle, Washington
| | - S Rayhill
- Department of Surgery, Division of Transplant Surgery, University of Washington, Seattle, Washington
| | - R Bhattacharya
- Department of Medicine, Division of Gastroenterology, University of Washington, Seattle, Washington
| | - J D Reyes
- Department of Surgery, Division of Transplant Surgery, University of Washington, Seattle, Washington
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Sibulesky L, Leca N, Blosser C, Rahnemai-Azar AA, Bhattacharya R, Reyes J. Is MELD score failing patients with liver disease and hepatorenal syndrome? World J Hepatol 2016; 8:1155-1156. [PMID: 27721921 PMCID: PMC5037329 DOI: 10.4254/wjh.v8.i27.1155] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 07/15/2016] [Accepted: 08/08/2016] [Indexed: 02/06/2023] Open
Abstract
There is a need to reassess the application of MELD and the impact of renal insufficiency with consideration for developing an algorithm with exception points that would lead to timely allocation of livers to patients with hepatorenal syndrome prior to occurrence of permanent renal damage without jeopardizing post-transplant survival.
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Coghill AE, Johnson LG, Berg D, Resler AJ, Leca N, Madeleine MM. Immunosuppressive Medications and Squamous Cell Skin Carcinoma: Nested Case-Control Study Within the Skin Cancer after Organ Transplant (SCOT) Cohort. Am J Transplant 2016; 16:565-73. [PMID: 26824445 PMCID: PMC5500236 DOI: 10.1111/ajt.13596] [Citation(s) in RCA: 66] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 10/16/2015] [Accepted: 10/17/2015] [Indexed: 01/25/2023]
Abstract
Organ transplant recipients (OTRs) have a substantially elevated risk of squamous cell skin carcinoma (SCSC), largely attributed to immunosuppressive medications used to prevent graft rejection, although data to support the role of newer drugs in SCSC risk are sparse. We investigated the association between immunosuppressive medications and SCSC risk among cardiac and renal transplant recipients in the SCOT cohort study. Incident cases were ascertained through medical record review after self-report of skin biopsy (n = 170). Controls without SCSC (n = 324) were matched to cases on sex, age, race, transplant year, hospital, donor type, organ transplanted, and time between transplantation and interview. Conditional logistic regression was used to evaluate the association between specific medications and SCSC. Users of the antimetabolite azathioprine were more than twice as likely to develop SCSC (odds ratio [OR] = 2.67, 95% confidence interval [CI] 1.23-5.76). In contrast, the newer antimetabolite preparations (i.e., mycophenolic acid [MPA]) were associated with lower SCSC risk (OR = 0.45, 95% CI 0.29-0.69). This inverse association between MPA and SCSC persisted among OTRs with no history of azathioprine use, even after adjustment for simultaneous use of the calcineurin inhibitor tacrolimus (OR = 0.52, 95% CI 0.32-0.84). Our data suggest that the increased risk of SCSC historically associated with azathioprine is not seen in OTRs prescribed newer regimens, including MPA and tacrolimus.
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Affiliation(s)
- Anna E. Coghill
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD
| | | | - Dan Berg
- University of Washington Department of Medicine, Seattle, WA
| | - Alexa J. Resler
- Fred Hutchinson Cancer Research Center, Seattle WA,University of Washington School of Public Health, Seattle, WA
| | - Nicolae Leca
- University of Washington Department of Medicine, Seattle, WA
| | - Margaret M. Madeleine
- Fred Hutchinson Cancer Research Center, Seattle WA,University of Washington School of Public Health, Seattle, WA
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Venuto RC, Meaney CJ, Chang S, Leca N, Consiglio JD, Wilding GE, Brazeau D, Gundroo A, Nainani N, Morse SE, Cooper LM, Tornatore KM. Association of Extrarenal Adverse Effects of Posttransplant Immunosuppression With Sex and ABCB1 Haplotypes. Medicine (Baltimore) 2015; 94:e1315. [PMID: 26376376 PMCID: PMC4635790 DOI: 10.1097/md.0000000000001315] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Extrarenal adverse effects (AEs) associated with calcineurin inhibitor (CNI) and mycophenolic acid (MPA) occur frequently but are unpredictable posttransplant complications. AEs may result from intracellular CNI accumulation and low activity of P-glycoprotein, encoded by the ABCB1 gene. Since ABCB1 single nucleotide polymorphisms (SNPs) and sex influence P-glycoprotein, we investigated haplotypes and extrarenal AEs. A prospective, cross-sectional study evaluated 149 patients receiving tacrolimus and enteric coated mycophenolate sodium or cyclosporine and mycophenolate mofetil. Immunosuppressive AE assessment determined individual and composite gastrointestinal, neurologic, aesthetic, and cumulative AEs. Lipids were quantitated after 12-hour fast. ABCB1 SNPs: c.1236C>T (rs1128503), c.2677G>T/A (rs2032582), and c.3435C>T (rs1045642) were determined with haplotype associations computed using the THESIAS program, and evaluated by immunosuppression, sex and race using multivariate general linear models. Tacrolimus patients exhibited more frequent and higher gastrointestinal AE scores compared with cyclosporine with association to CTT (P = 0.018) and sex (P = 0.01). Aesthetic AE score was 3 times greater for cyclosporine with TTC haplotype (P = 0.005). Females had higher gastrointestinal (P = 0.022), aesthetic (P < 0.001), neurologic (P = 0.022), and cumulative AE ratios (P < 0.001). Total cholesterol (TCHOL), low-density lipoproteins (LDL), and triglycerides were higher with cyclosporine. The TTC haplotype had higher TCHOL (P < 0.001) and LDL (P = 0.005). Higher triglyceride (P = 0.034) and lower high-density lipoproteins (P = 0.057) were associated with TTT with sex-adjusted analysis. ABCB1 haplotypes and sex were associated with extrarenal AEs. Using haplotypes, certain female patients manifested more AEs regardless of CNI. Haplotype testing may identify patients with greater susceptibility to AEs and facilitate CNI individualization.
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Affiliation(s)
- Rocco C Venuto
- From the Nephrology Division; Medicine, School of Medicine and Biomedical Sciences (RCV, SC, NL, AG, NN, KMT); Erie County Medical Center, Buffalo, New York (RCV, AG, KMT); Immunosuppressive Pharmacology Research Program, Translational Pharmacology Research Core, NYS Center of Excellence in Bioinformatics and Life Sciences (CJM, SEM, LMC, KMT); Pharmacy, School of Pharmacy and Pharmaceutical Sciences (CJM, SEM, KMT); Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York (JDC, GEW); and Department of Pharmaceutical Sciences, College of Pharmacy, University of New England, Portland, Maine (DB)
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Leca N. Focal segmental glomerulosclerosis recurrence in the renal allograft. Adv Chronic Kidney Dis 2014; 21:448-52. [PMID: 25168835 DOI: 10.1053/j.ackd.2014.06.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 06/06/2014] [Accepted: 06/06/2014] [Indexed: 01/31/2023]
Abstract
Focal segmental glomerulosclerosis (FSGS) represents a common histologic pattern of glomerular injury associated with a multitude of disease mechanisms. The etiology of FSGS is often classified into primary (idiopathic) and secondary forms in response to genetic abnormalities, infections, toxins, and systemic disorders that lead to adaptive changes, glomerular hyperfiltration, and proteinuria. Our understanding of the pathogenic mechanisms responsible for FSGS was substantially enhanced in recent years because of major advances in the cell biology of the podocyte and parietal epithelial cell. Recurrence of FSGS occurs mainly in its primary form and is only rarely described in secondary forms. The re-enactment of pathologic mechanisms of FSGS as recurrent disease after kidney transplantation represents a biologic experiment that can provide unique insight. Nonetheless, recurrent FSGS remains a notable clinical problem that correlates with poorer renal allograft outcomes. This is the focus of this particular review, concentrating on the most recent developments.
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Tornatore KM, Brazeau D, Dole K, Danison R, Wilding G, Leca N, Gundroo A, Gillis K, Zack J, DiFrancesco R, Venuto RC. Sex differences in cyclosporine pharmacokinetics and ABCB1 gene expression in mononuclear blood cells in African American and Caucasian renal transplant recipients. J Clin Pharmacol 2013; 53:1039-47. [DOI: 10.1002/jcph.123] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 05/25/2013] [Indexed: 12/19/2022]
Affiliation(s)
| | - Daniel Brazeau
- Pharmaceutical Genomics Laboratory; Department of Pharmaceutical Sciences; School of Pharmacy and Pharmaceutical Sciences, University at Buffalo; Buffalo; NY; USA
| | - Kiran Dole
- Department of Pharmacy Practice; Translational Pharmacology Research Core, Center of Excellence in Bioinformatics and Life Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo; Buffalo; NY; USA
| | - Ryan Danison
- Department of Biostatistics; School of Public Health and Health Professions, University at Buffalo; Buffalo; NY; USA
| | - Gregory Wilding
- Department of Biostatistics; School of Public Health and Health Professions, University at Buffalo; Buffalo; NY; USA
| | - Nicolae Leca
- Division of Nephrology, Department of Medicine; School of Medicine and Biomedical Sciences, Erie County Medical Center, University at Buffalo; Buffalo; NY; USA
| | - Aijaz Gundroo
- Division of Nephrology, Department of Medicine; School of Medicine and Biomedical Sciences, Erie County Medical Center, University at Buffalo; Buffalo; NY; USA
| | - Kathryn Gillis
- Department of Pharmacy Practice; Translational Pharmacology Research Core, Center of Excellence in Bioinformatics and Life Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo; Buffalo; NY; USA
| | - Julia Zack
- Department of Pharmacy Practice; Translational Pharmacology Research Core, Center of Excellence in Bioinformatics and Life Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo; Buffalo; NY; USA
| | - Robin DiFrancesco
- Department of Pharmacy Practice; Translational Pharmacology Research Core, Center of Excellence in Bioinformatics and Life Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo; Buffalo; NY; USA
| | - Rocco C. Venuto
- Division of Nephrology, Department of Medicine; School of Medicine and Biomedical Sciences, Erie County Medical Center, University at Buffalo; Buffalo; NY; USA
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Purnell TS, Xu P, Leca N, Hall YN. Racial differences in determinants of live donor kidney transplantation in the United States. Am J Transplant 2013; 13:1557-65. [PMID: 23669021 PMCID: PMC4282921 DOI: 10.1111/ajt.12258] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [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: 09/11/2012] [Revised: 03/08/2013] [Accepted: 03/15/2013] [Indexed: 01/25/2023]
Abstract
Few studies have compared determinants of live donor kidney transplantation (LDKT) across all major US racial-ethnic groups. We compared determinants of racial-ethnic differences in LDKT among 208 736 patients who initiated treatment for end-stage kidney disease during 2005-2008. We performed proportional hazards and bootstrap analyses to estimate differences in LDKT attributable to sociodemographic and clinical factors. Mean LDKT rates were lowest among blacks (1.19 per 100 person-years [95% CI: 1.12-1.26]), American Indians/Alaska Natives-AI/ANs (1.40 [1.06-1.84]) and Pacific Islanders (1.10 [0.78-1.84]), intermediate among Hispanics (2.53 [2.39-2.67]) and Asians (3.89 [3.51-4.32]), and highest among whites (6.46 [6.31-6.61]). Compared with whites, the largest proportion of the disparity among blacks (20%) and AI/ANs (29%) was attributed to measures of predialysis care, while the largest proportion among Hispanics (14%) was attributed to health insurance coverage. Contextual poverty accounted for 16%, 4%, 18%, and 6% of the disparity among blacks, Hispanics, AI/ANs and Pacific Islanders but none of the disparity among Asians. In the United States, significant disparities in rates of LDKT persist, but determinants of these disparities vary by race-ethnicity. Efforts to expand preESKD insurance coverage, to improve access to high-quality predialysis care and to overcome socioeconomic barriers are important targets for addressing disparities in LDKT.
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Affiliation(s)
- T. S. Purnell
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD,Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD,Corresponding author: Tanjala S. Purnell,
| | - P. Xu
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle, Washington
| | - N. Leca
- Kidney–Pancreas Transplant Section, Division of Nephrology, University of Washington, Seattle, WA
| | - Y. N. Hall
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle, Washington
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Tornatore KM, Sudchada P, Dole K, DiFrancesco R, Leca N, Gundroo AC, Danison RT, Attwood K, Wilding GE, Zack J, Forrest A, Venuto RC. Mycophenolic Acid Pharmacokinetics During Maintenance Immunosuppression in African American and Caucasian Renal Transplant Recipients. J Clin Pharmacol 2013; 51:1213-22. [DOI: 10.1177/0091270010382909] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Pankewycz O, Leca N, Kohli R, Weber-Shrikant E, Said M, Alnimri M, Feng L, Patel S, Laftavi MR. Conversion to low-dose tacrolimus or rapamycin 3 months after kidney transplantation: a prospective, protocol biopsy-guided study. Transplant Proc 2011; 43:519-23. [PMID: 21440749 DOI: 10.1016/j.transproceed.2011.01.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [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: 12/30/2022]
Abstract
Long-term survival of kidney allografts is primarily limited by a progressive decline in function characterized by the presence of interstitial fibrosis (IF) and tubular atrophy (TA) on biopsy. Since chronic calcineurin-inhibitor (CNI) drug toxicity has been implicated as a significant cause of IF/TA, a major effort in transplantation has been to decrease or eliminate CNI therapy. We now report the clinical and histological consequences of converting renal transplant recipients at 3 months to either very low levels of tacrolimus (TAC; 4-6 ng/mL) or sirolimus (SRL; 6-10 ng/mL) therapy. Fifty-eight enrollees in this prospective randomized trial received low-dose (2.9±0.6 mg/kg) rabbit antithymocyte globulin induction followed by standard doses of TAC (10-15 ng/mL), mycophenolic acid, and low-dose steroids for 3 months. Protocol biopsies were performed at implantation and 3 and 12 months. Six patients had evidence of either borderline changes (n=5) or grade 1A rejection (n=1) on the 3-month protocol biopsy and were not randomized. Only one patient had clinically evident rejection that occurred after randomization to SRL. One patient in each group had borderline changes at 12 months. Renal function (estimated glomerular filtration rate) was equivalent in both groups at 12 months (TAC 74±15 vs SRL 66±18 mL/min, P=.22). Chronic allograft damage index scores at 1 year were similar in both groups (TAC 2.8±2.4 vs SRL 2.0±2.7, P=.71). The percentage of patients with IF/TA scores greater than 2 at 1 year was low in both groups (TAC 12% vs SRL 9%, P=.78). Therefore, in a low-risk population defined as having a normal 3-month protocol biopsy, TAC levels can be successfully decreased to very low concentrations. One-year graft function and histology were equally well maintained with either low-dose TAC or SRL immunosuppression.
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Affiliation(s)
- O Pankewycz
- Department of Surgery, State University of New York, University at Buffalo, Buffalo General Hospital, Kaleidahealth, Buffalo, New York 14203, USA.
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Zhang L, Kolokythas O, Dighe M, Kim JH, Leca N, Kim Y. Two-dimensional flow index mapping for hemodynamic imaging: a feasibility study. Ultrasound Med Biol 2010; 36:2011-2017. [PMID: 21030136 DOI: 10.1016/j.ultrasmedbio.2010.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 08/05/2010] [Accepted: 09/03/2010] [Indexed: 05/30/2023]
Abstract
The resistive index (RI) is a functional hemodynamic index used to measure flow resistance within an organ, such as the kidney, to assess if there is any vascular disease associated with that organ. Currently, the measurement of RI values using spectral Doppler ultrasound (US) is performed in one location at a time. As a result, RI values are typically obtained only from a few locations. To visualize the entire two-dimensional distribution of RI values, we developed a method called two-dimensional flow index mapping (2D-FIM). To evaluate this method, we performed a feasibility study using 16 kidney data sets, with eight from healthy volunteers with normal native kidneys and eight from kidney transplant recipients. Quadrature-demodulated baseband Doppler data were used to calculate the spatial distribution of RI values using 2D-FIM. For comparison, the intrarenal RI values at different levels of renal arterial branches were measured with conventional spectral Doppler US. The RI values determined from 2D-FIM were compared with those from spectral Doppler US, which led to a Pearson correlation coefficient of 0.84. There was no significant difference between 2D-FIM- and spectral Doppler US-produced RI values. With the ability to visualize RI in more than one dimension, 2D-FIM could help guide placement of the spectral Doppler range gate to regions of abnormal RI, thus potentially reducing exam times.
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Affiliation(s)
- Liang Zhang
- Image Computing Systems Laboratory, Department of Bioengineering, University of Washington, Seattle, WA 98195-5061, USA
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Muczynski KA, Leca N, Anderson SK. Proliferative potential of human kidney endothelial cells: bone marrow-derived cells may not be required for high proliferation. Nephrol Dial Transplant 2010; 25:2953-60. [DOI: 10.1093/ndt/gfq130] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Warner PR, Youngs D, Leca N, Davis C, Nelson K. 128-P: IVIG interference of antithymocyte globulin activity. Hum Immunol 2009. [DOI: 10.1016/j.humimm.2009.09.161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Kieran N, Wang X, Perkins J, Davis C, Kendrick E, Bakthavatsalam R, Dunbar N, Warner P, Nelson K, Smith KD, Nicosia RF, Alpers CE, Leca N, Kowalewska J. Combination of peritubular c4d and transplant glomerulopathy predicts late renal allograft failure. J Am Soc Nephrol 2009; 20:2260-8. [PMID: 19729438 DOI: 10.1681/asn.2009020199] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The histologic associations and clinical implications of peritubular capillary C4d staining from long-term renal allografts are unknown. We identified 99 renal transplant patients who underwent an allograft biopsy for renal dysfunction at least 10 yr after transplantation, 25 of whom were C4d-positive and 74 of whom were C4d-negative. The average time of the index biopsy from transplantation was 14 yr in both groups. Compared with C4d-negative patients, C4d-positive patients were younger at transplantation (29 +/- 13 versus 38 +/- 12 yr; P < 0.05) and were more likely to have received an allograft from a living donor (65 versus 35%; P < 0.001). C4d-positive patients had more inflammation, were more likely to have transplant glomerulopathy, and had worse graft outcome. The combined presence of C4d positivity, transplant glomerulopathy, and serum creatinine of >2.3 mg/dl at biopsy were very strong predictors of rapid graft loss. C4d alone did not independently predict graft loss. Retrospective staining of historical samples from C4d-positive patients demonstrated C4d deposition in the majority of cases. In summary, these data show that in long-term renal allografts, peritubular capillary staining for C4d occurs in approximately 25% of biopsies, can persist for many years after transplantation, and strongly predicts graft loss when combined with transplant glomerulopathy.
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Affiliation(s)
- Niamh Kieran
- Department of Medicine, Division of Nephrology,University of Washington, Seattle, Washington 98195-6521, USA.
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Leca N, Muczynski KA, Jefferson JA, de Boer IH, Kowalewska J, Kendrick EA, Pichler R, Davis CL. Higher levels of leflunomide are associated with hemolysis and are not superior to lower levels for BK virus clearance in renal transplant patients. Clin J Am Soc Nephrol 2008; 3:829-35. [PMID: 18372319 DOI: 10.2215/cjn.03930907] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Leflunomide use in renal transplantation has been increasing. Outcome correlation and safety data are still to be refined. The goals of this study were to report one center's experience with leflunomide, specifically the correlation of leflunomide levels with the outcomes of BK nephropathy and the observed toxic effects during the treatment with leflunomide. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Leflunomide was used in 21 patients with BK nephropathy. These patients were divided into two groups on the basis of the leflunomide levels achieved: Low-level group (<40 microg/ml) and high-level group (>40 microg/ml). RESULTS During 13 mo of follow-up, there was no difference in the rate of serum BK viral clearance between the groups. There were three graft losses in the low-level group and one in the high-level group; however, creatinine levels were higher at the time of starting leflunomide in the low-level group. Leflunomide was also used in six patients with chronic allograft injury. No graft loss was observed during the follow-up period of 16 mo. Treatment with leflunomide seemed to be associated with a new toxicity, hemolysis, seen in four of the 27 patients so treated. Patients with hemolysis had high leflunomide levels (81.4 +/- 14 microg/ml) and worsening allograft function. Two patients had histologic evidence of thrombotic microangiopathy, which led to graft loss in one patient. CONCLUSIONS The clinical correlation between leflunomide levels and outcomes needs to be further refined. This study described a possible association of leflunomide with thrombotic microangiopathy, especially at higher levels.
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Affiliation(s)
- Nicolae Leca
- Department of Medicine, Division of Nephrology, University of Washington, Seattle, Washington 98195, USA.
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Bracamonte E, Leca N, Smith KD, Nicosia RF, Nickeleit V, Kendrick E, Furmanczyk PS, Davis CL, Alpers CE, Kowalewska J. Tubular basement membrane immune deposits in association with BK polyomavirus nephropathy. Am J Transplant 2007; 7:1552-60. [PMID: 17425622 DOI: 10.1111/j.1600-6143.2007.01794.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [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: 01/25/2023]
Abstract
Tubular basement membrane immune deposits (TBMID) are rare in renal allografts and usually have been found in association with immune complex mediated glomerular injury. We report an association between TBMID and BK polyomavirus nephropathy (BKN). We reviewed clinical data and results of allograft biopsies of 30 patients with BKN (16 with and 14 without TBMID). TBMID were detected by immunofluorescence or electron microscopy. Initial and follow-up biopsies were assessed for degree of interstitial inflammation and fibrosis and severity of viral infection, and were correlated with patients' clinical data. Biopsies initially diagnostic for BKN with TBMID, compared to BKN biopsies without deposits, demonstrated more severe interstitial inflammation and fibrosis, and greater numbers of virally infected cells. Similar findings were present in follow-up biopsies. Utilizing three different antibodies directed against viral epitopes, viral antigens could not be detected within TBMID. Thirty percent of patients with TBMID and 70% without deposits had follow-up biopsies, in which virus could not be detected immunohistochemically. Treatment for all included decreasing immunosuppression, cidofovir and/or leflunomide. Clinical data correlated well with histological findings. We conclude that a significant proportion of patients with BKN show TBMID on kidney biopsy. The prognostic significance of this finding remains to be elucidated.
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Affiliation(s)
- E Bracamonte
- Department of Pathology and Department of Medicine, University of Washington, Seattle, WA, USA
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Leca N, Laftavi M, Gundroo A, Kohli R, Min I, Karam J, Sridhar N, Blessios G, Venuto R, Pankewycz O. Early and severe hyperparathyroidism associated with hypercalcemia after renal transplant treated with cinacalcet. Am J Transplant 2006; 6:2391-5. [PMID: 16869807 DOI: 10.1111/j.1600-6143.2006.01475.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [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: 01/25/2023]
Abstract
Bone disease is a common clinical problem following renal transplantation. In renal transplant recipients, multiple underlying factors determine the extent of bone loss and the subsequent risk of fractures. In addition to the well-recognized risk to bone disease posed by steroids, calcineurin inhibitors and pre-existing bone disease, persistent hyperparathyroidism (HPT) contributes to post-transplant bone loss. HPT is usually treated with vitamin D supplements combined with calcium. Patients whose HPT is associated with hypercalcemia pose a difficult therapeutic dilemma which often requires parathyroidectomy. Cinacalcet, a calcium mimetic agent, offers a unique pharmacologic approach to the treatment of patients with post-transplant hypercalcemia and HPT. In this paper, we describe the clinical course and biochemical changes in 10 renal transplant recipients with hypercalcemia and severe HPT early after renal transplantation treated with cinacalcet. Cinacalcet therapy corrected hypercalcemia and decreased parathyroid hormone (PTH) levels in all cases. A transient rise in the level of alkaline phosphatase was noted following initiation of cinacalcet therapy. In this patient population, correction of HPT was not permanent as discontinuing cinacalcet therapy led to a rapid rise in PTH level.
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Affiliation(s)
- N Leca
- Department of Medicine, SUNY University at Buffalo, NY, USA
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50
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Laftavi MR, Stephan R, Stefanick B, Kohli R, Dagher F, Applegate M, O'Keefe J, Pierce D, Rubino A, Guzowski H, Leca N, Dayton M, Pankewycz O. Randomized prospective trial of early steroid withdrawal compared with low-dose steroids in renal transplant recipients using serial protocol biopsies to assess efficacy and safety. Surgery 2005; 137:364-71. [PMID: 15746793 DOI: 10.1016/j.surg.2004.10.013] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.3] [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: 12/20/2022]
Abstract
BACKGROUND Corticosteroid therapy after renal transplantation is associated with many adverse effects. Newer immunosuppressive agents may allow for safe and effective reductions in dose or early steroid withdrawal. METHODS In this prospective, single-center clinical trial, 60 patients were randomized into 2 groups: control patients (n = 28), who received low doses of prednisone throughout, and study patients (n = 32), who were withdrawn from steroids 7 days posttransplant. Patients received a limited course of rabbit antilymphocyte globulin (rALG) induction therapy, tacrolimus (TAC), and mycophenolate mofetil (MMF). Patients were followed for clinical outcomes and renal function. Protocol biopsies were performed at 1, 6, and 12 months. RESULTS Clinical rejections occurred in 11% of controls and 13% of study patients. Renal function was well maintained and equivalent in both groups. In all, 111 protocol biopsies were performed without complications. Subclinical rejection was noted in only 2 protocol biopsies, and borderline changes were seen in 12 biopsies, all of which were distributed equally between both groups. Unsuspected acute TAC toxicity was seen in 8 biopsies. Protocol biopsies led to changes in therapy in 10% of patients. In both groups, serial protocol biopsies demonstrated increased allograft fibrosis over time, which was significant at 1 year in the steroid withdrawal group. CONCLUSION The immunosuppressive combination of rALG, TAC, and MMF prevents subclinical rejection and the need for high doses of steroids after transplantation. However, continual low-dose steroid therapy may aid in preventing chronic allograft fibrosis. Protocol biopsies help define the short-term and long-term risks of steroid withdrawal therapy.
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Affiliation(s)
- Mark R Laftavi
- Departments of Surgery, SUNY-University at Buffalo, Buffalo General Hospital, Buffalo, NY, USA
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