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Roedder S, Li L, Alonso MN, Hsieh SC, Vu MT, Dai H, Sigdel TK, Bostock I, Macedo C, Metes D, Zeevi A, Shapiro R, Salvatierra O, Scandling J, Alberu J, Engleman E, Sarwal MM. A Three-Gene Assay for Monitoring Immune Quiescence in Kidney Transplantation. J Am Soc Nephrol 2014; 26:2042-53. [PMID: 25429124 DOI: 10.1681/asn.2013111239] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [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: 11/27/2013] [Accepted: 09/23/2014] [Indexed: 12/13/2022] Open
Abstract
Organ transplant recipients face life-long immunosuppression and consequently are at high risk of comorbidities. Occasionally, kidney transplant recipients develop a state of targeted immune quiescence (operational tolerance) against an HLA-mismatched graft, allowing them to withdraw all immunosuppression and retain stable graft function while resuming immune responses to third-party antigens. Methods to better understand and monitor this state of alloimmune quiescence by transcriptional profiling may reveal a gene signature that identifies patients for whom immunosuppression could be titrated to reduce patient and graft morbidities. Therefore, we investigated 571 unique peripheral blood samples from 348 HLA-mismatched renal transplant recipients and 101 nontransplant controls in a four-stage study including microarray, quantitative PCR, and flow cytometry analyses. We report a refined and highly validated (area under the curve, 0.95; 95% confidence interval, 0.92 to 0.97) peripheral blood three-gene assay (KLF6, BNC2, CYP1B1) to detect the state of operational tolerance by quantitative PCR. The frequency of predicted alloimmune quiescence in stable renal transplant patients receiving long-term immunosuppression (n=150) was 7.3% by the three-gene assay. Targeted cell sorting of peripheral blood from operationally tolerant patients showed a significant shift in the ratio of circulating monocyte-derived dendritic cells with significantly different expression of the genes constituting the three-gene assay. Our results suggest that incorporation of patient screening by specific cellular and gene expression assays may support the safety of drug minimization trials and protocols.
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Affiliation(s)
- Silke Roedder
- Department of Surgery, Division of Transplant Surgery, University of California San Francisco, San Francisco, California
| | - Li Li
- Department of Biostatistics, Mount Sinai School of Medicine, New York, New York
| | - Michael N Alonso
- Department of Pathology, Stanford University, Palo Alto, California
| | - Szu-Chuan Hsieh
- Department of Surgery, Division of Transplant Surgery, University of California San Francisco, San Francisco, California
| | - Minh Thien Vu
- Department of Surgery, Division of Transplant Surgery, University of California San Francisco, San Francisco, California
| | - Hong Dai
- Department of Surgery, Division of Transplant Surgery, University of California San Francisco, San Francisco, California
| | - Tara K Sigdel
- Department of Surgery, Division of Transplant Surgery, University of California San Francisco, San Francisco, California
| | - Ian Bostock
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; and
| | - Camila Macedo
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Diana Metes
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Adrianna Zeevi
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ron Shapiro
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - John Scandling
- Department of Pathology, Stanford University, Palo Alto, California
| | - Josefina Alberu
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; and
| | - Edgar Engleman
- Department of Pathology, Stanford University, Palo Alto, California
| | - Minnie M Sarwal
- Department of Surgery, Division of Transplant Surgery, University of California San Francisco, San Francisco, California;
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2
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Roedder S, Sigdel T, Salomonis N, Hsieh S, Dai H, Bestard O, Metes D, Zeevi A, Gritsch A, Cheeseman J, Macedo C, Peddy R, Medeiros M, Vincenti F, Asher N, Salvatierra O, Shapiro R, Kirk A, Reed E, Sarwal MM. The kSORT assay to detect renal transplant patients at high risk for acute rejection: results of the multicenter AART study. PLoS Med 2014; 11:e1001759. [PMID: 25386950 PMCID: PMC4227654 DOI: 10.1371/journal.pmed.1001759] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [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] [Received: 01/28/2014] [Accepted: 10/10/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Development of noninvasive molecular assays to improve disease diagnosis and patient monitoring is a critical need. In renal transplantation, acute rejection (AR) increases the risk for chronic graft injury and failure. Noninvasive diagnostic assays to improve current late and nonspecific diagnosis of rejection are needed. We sought to develop a test using a simple blood gene expression assay to detect patients at high risk for AR. METHODS AND FINDINGS We developed a novel correlation-based algorithm by step-wise analysis of gene expression data in 558 blood samples from 436 renal transplant patients collected across eight transplant centers in the US, Mexico, and Spain between 5 February 2005 and 15 December 2012 in the Assessment of Acute Rejection in Renal Transplantation (AART) study. Gene expression was assessed by quantitative real-time PCR (QPCR) in one center. A 17-gene set--the Kidney Solid Organ Response Test (kSORT)--was selected in 143 samples for AR classification using discriminant analysis (area under the receiver operating characteristic curve [AUC] = 0.94; 95% CI 0.91-0.98), validated in 124 independent samples (AUC = 0.95; 95% CI 0.88-1.0) and evaluated for AR prediction in 191 serial samples, where it predicted AR up to 3 mo prior to detection by the current gold standard (biopsy). A novel reference-based algorithm (using 13 12-gene models) was developed in 100 independent samples to provide a numerical AR risk score, to classify patients as high risk versus low risk for AR. kSORT was able to detect AR in blood independent of age, time post-transplantation, and sample source without additional data normalization; AUC = 0.93 (95% CI 0.86-0.99). Further validation of kSORT is planned in prospective clinical observational and interventional trials. CONCLUSIONS The kSORT blood QPCR assay is a noninvasive tool to detect high risk of AR of renal transplants. Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Silke Roedder
- Department of Surgery, University of California San Francisco, San Francisco, California, United States of America
| | - Tara Sigdel
- Department of Surgery, University of California San Francisco, San Francisco, California, United States of America
| | - Nathan Salomonis
- Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Sue Hsieh
- Department of Surgery, University of California San Francisco, San Francisco, California, United States of America
| | - Hong Dai
- California Pacific Medical Center, San Francisco, California, United States of America
| | - Oriol Bestard
- Renal Transplant Unit, Bellvitge University Hospital, Barcelona, Spain
| | - Diana Metes
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Andrea Zeevi
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Albin Gritsch
- Immunogenetics Center, University of California Los Angeles, Los Angeles, California, United States of America
| | - Jennifer Cheeseman
- Department of Surgery, Emory University, Atlanta, Georgia, United States of America
| | - Camila Macedo
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Ram Peddy
- California Pacific Medical Center, San Francisco, California, United States of America
| | - Mara Medeiros
- Laboratorio de Investigacion en Nefrologia, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Flavio Vincenti
- Department of Surgery, University of California San Francisco, San Francisco, California, United States of America
| | - Nancy Asher
- Department of Surgery, University of California San Francisco, San Francisco, California, United States of America
| | | | - Ron Shapiro
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Allan Kirk
- Department of Surgery, Emory University, Atlanta, Georgia, United States of America
| | - Elaine Reed
- Immunogenetics Center, University of California Los Angeles, Los Angeles, California, United States of America
| | - Minnie M. Sarwal
- Department of Surgery, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
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3
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Abstract
BACKGROUND The copy number of donor-derived cell-free DNA (dd-cfDNA) in blood correlates with acute rejection (AR) in heart transplantation. We analyzed urinary dd-cfDNA as a surrogate marker of kidney transplant injury. METHODS Sixty-three biopsy-matched urine samples (41 stable and 22 allograft injury) were analyzed from female recipients of male donors for chromosome Y (donor)-specific dd-cfDNA. All biopsies were semiquantitatively scored by a single pathologist. Standard statistical measures of correlation and significance were used. RESULTS There was baseline scatter for urinary dd-cfDNA/μg urine creatinine across different patients, even at the time of stable graft (STA) function (undetected to 12.26 copies). The mean urinary dd-cfDNA in AR (20.5 ± 13.9) was significantly greater compared with STA (2.4 ± 3.3; P<0.0001) or those with chronic allograft injury (CAI; 2.4 ± 2.4; P=0.001) but no different from BK virus nephropathy (BKVN; 20.3±15.7; P=0.98). In AR and BKVN, the intrapatient drift was highly significant versus STA or CAI patients (10.3 ± 7.4 in AR; 12.3 ± 8.4 in BKVN vs. -0.5 ± 3.5 in STA and 2.3 ± 2.6 in CAI; P<0.05). Urinary dd-cfDNA correlated with protein/creatinine ratio (r=0.48; P<0.014) and calculated glomerular filtration rate (r=-0.52; P<0.007) but was most sensitive for acute allograft injury (area under the curve=0.80; P<0.0006; 95% confidence interval, 0.67-0.93). CONCLUSION Urinary dd-cfDNA after renal transplantation has patient specific thresholds, reflecting the apoptotic injury load of the donor organ. Serial monitoring of urinary dd-cfDNA can be a surrogate sensitive biomarker of acute injury in the donor organ but lacks the specificity to distinguish between AR and BKVN injury.
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Affiliation(s)
- Tara K. Sigdel
- California Pacific Medical Center Research Institute, San Francisco, CA
| | | | - Tim Q. Tran
- California Pacific Medical Center Research Institute, San Francisco, CA
| | - Hong Dai
- California Pacific Medical Center Research Institute, San Francisco, CA
| | - Szu-chuan Hsieh
- California Pacific Medical Center Research Institute, San Francisco, CA
| | | | - Minnie M. Sarwal
- California Pacific Medical Center Research Institute, San Francisco, CA
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Chaudhuri A, Ozawa M, Everly MJ, Ettenger R, Dharnidharka V, Benfield M, Mathias R, Portale A, McDonald R, Harmon W, Kershaw D, Vehaskari VM, Kamil E, Baluarte HJ, Warady B, Li L, Sigdel TK, Hsieh SC, Dai H, Naesens M, Waskerwitz J, Salvatierra O, Terasaki PI, Sarwal MM. The clinical impact of humoral immunity in pediatric renal transplantation. J Am Soc Nephrol 2013; 24:655-64. [PMID: 23449533 DOI: 10.1681/asn.2012070663] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The development of anti-donor humoral responses after transplantation associates with higher risks for acute rejection and 1-year graft survival in adults, but the influence of humoral immunity on transplant outcomes in children is not well understood. Here, we studied the evolution of humoral immunity in low-risk pediatric patients during the first 2 years after renal transplantation. Using data from 130 pediatric renal transplant patients randomized to steroid-free (SF) or steroid-based (SB) immunosuppression in the NIH-SNSO1 trial, we correlated the presence of serum anti-HLA antibodies to donor HLA antigens (donor-specific antibodies) and serum MHC class 1-related chain A (MICA) antibody with both clinical outcomes and histology identified on protocol biopsies at 0, 6, 12, and 24 months. We detected de novo antibodies after transplant in 24% (23% of SF group and 25% of SB group), most often after the first year. Overall, 22% developed anti-HLA antibodies, of which 6% were donor-specific antibodies, and 6% developed anti-MICA antibody. Presence of these antibodies de novo associated with significantly higher risks for acute rejection (P=0.02), chronic graft injury (P=0.02), and decline in graft function (P=0.02). In summary, antibodies to HLA and MICA antigens appear in approximately 25% of unsensitized pediatric patients, placing them at greater risk for acute and chronic rejection with accelerated loss of graft function. Avoiding steroids does not seem to modify this incidence. Whether serial assessments of these antibodies after transplant could guide individual tailoring of immunosuppression requires additional study.
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Affiliation(s)
- Abanti Chaudhuri
- Department of Pediatrics, Stanford University, Stanford, California, USA
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5
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Li L, Khatri P, Sigdel TK, Tran T, Ying L, Vitalone M, Chen A, Hsieh SC, Dai H, Zhang M, Naesens M, Zarkhin V, Sansanwal P, Chen R, Mindrinos M, Xiao W, Benfield M, Ettenger R, Dharnidharka V, Mathias R, Portale A, McDonald R, Harmon W, Kershaw D, Vehaskari VM, Kamil E, Baluarte HJ, Warady B, Davis R, Butte AJ, Salvatierra O, Sarwal M. A peripheral blood diagnostic test for acute rejection in renal transplantation. Am J Transplant 2012; 12:2710-8. [PMID: 23009139 PMCID: PMC4148014 DOI: 10.1111/j.1600-6143.2012.04253.x] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Monitoring of renal graft status through peripheral blood (PB) rather than invasive biopsy is important as it will lessen the risk of infection and other stresses, while reducing the costs of rejection diagnosis. Blood gene biomarker panels were discovered by microarrays at a single center and subsequently validated and cross-validated by QPCR in the NIH SNSO1 randomized study from 12 US pediatric transplant programs. A total of 367 unique human PB samples, each paired with a graft biopsy for centralized, blinded phenotype classification, were analyzed (115 acute rejection (AR), 180 stable and 72 other causes of graft injury). Of the differentially expressed genes by microarray, Q-PCR analysis of a five gene-set (DUSP1, PBEF1, PSEN1, MAPK9 and NKTR) classified AR with high accuracy. A logistic regression model was built on independent training-set (n = 47) and validated on independent test-set (n = 198)samples, discriminating AR from STA with 91% sensitivity and 94% specificity and AR from all other non-AR phenotypes with 91% sensitivity and 90% specificity. The 5-gene set can diagnose AR potentially avoiding the need for invasive renal biopsy. These data support the conduct of a prospective study to validate the clinical predictive utility of this diagnostic tool.
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Affiliation(s)
- Li Li
- California Pacific Medical Center - Research Institute, San Francisco, CA, USA
- Department of Pediatrics, Stanford University, CA, USA
| | | | - Tara K. Sigdel
- California Pacific Medical Center - Research Institute, San Francisco, CA, USA
- Department of Pediatrics, Stanford University, CA, USA
| | - Tim Tran
- California Pacific Medical Center - Research Institute, San Francisco, CA, USA
- Department of Pediatrics, Stanford University, CA, USA
| | - Lihua Ying
- Department of Pediatrics, Stanford University, CA, USA
| | - Matthew Vitalone
- California Pacific Medical Center - Research Institute, San Francisco, CA, USA
- Department of Pediatrics, Stanford University, CA, USA
| | - Amery Chen
- Department of Pediatrics, Stanford University, CA, USA
| | - Szu-chuan Hsieh
- California Pacific Medical Center - Research Institute, San Francisco, CA, USA
- Department of Pediatrics, Stanford University, CA, USA
| | - Hong Dai
- California Pacific Medical Center - Research Institute, San Francisco, CA, USA
- Department of Pediatrics, Stanford University, CA, USA
| | - Meixia Zhang
- Department of Pediatrics, Stanford University, CA, USA
| | | | | | - Poonam Sansanwal
- California Pacific Medical Center - Research Institute, San Francisco, CA, USA
| | - Rong Chen
- Department of Pediatrics, Stanford University, CA, USA
| | | | - Wenzhong Xiao
- Massachusetts General Hospital, Harvard Medical School, MA, USA
| | - Mark Benfield
- Pediatric Nephrology, University of Alabama at Birmingham, AL, USA
| | - Robert Ettenger
- Division of Nephrology, Department of Pediatrics, David Geffen School of Medicine at UCLA, UCLA Children’s Health Center, University of California Los Angeles, CA, USA
| | - Vikas Dharnidharka
- Department of Pediatrics Nephrology, University of Florida College of Medicine & Shands Children’s Hospital, Gainesville FL USA
| | - Robert Mathias
- Pediatric Nephrology, Nemours Children’s Clinic Orlando, FL, USA
| | - Anthony Portale
- Department of Pediatrics, University of California San Francisco, CA, USA
| | - Ruth McDonald
- Children’s Hospital & Regional Medical Center Seattle, WA, USA
| | | | - David Kershaw
- Department of Pediatrics, University of Michigan, MI, USA
| | - V. Matti Vehaskari
- Department of Pediatrics, University of Louisiana Health Sciences Center, LA, USA
| | - Elaine Kamil
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Brad Warady
- Children’s Mercy Hospital, Kansas City, MO, USA
| | - Ron Davis
- Department of Biochemistry, Stanford University, CA, USA
| | - Atul J. Butte
- Department of Pediatrics, Stanford University, CA, USA
| | - Oscar Salvatierra
- Department of Pediatrics, Stanford University, CA, USA
- Department of Surgery, Stanford University, CA, USA
| | - Minnie Sarwal
- California Pacific Medical Center - Research Institute, San Francisco, CA, USA
- Department of Pediatrics, Stanford University, CA, USA
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6
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Naesens M, Salvatierra O, Benfield M, Ettenger R, Dharnidharka V, Harmon W, Mathias R, Sarwal MM. Subclinical inflammation and chronic renal allograft injury in a randomized trial on steroid avoidance in pediatric kidney transplantation. Am J Transplant 2012; 12:2730-43. [PMID: 22694733 PMCID: PMC3459071 DOI: 10.1111/j.1600-6143.2012.04144.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Steroid avoidance is safe and effective in children receiving kidney transplants in terms of graft function and survival, but the effects on allograft histology are unknown. In this multicenter trial, 130 pediatric renal transplant recipients were randomized to steroid-free (SF; n = 60) or steroid-based (SB; n = 70) immunosuppression, and underwent renal allograft biopsies at the time of graft dysfunction and per protocol at implantation and 6, 12 and 24 months after transplantation. Clinical follow-up was 3 years posttransplant. Subclinical acute rejection was present in 10.6% SF versus 11.3% SB biopsies at 6 months (p = 0.91), 0% SF versus 4.3% SB biopsies at 1 year (p = 0.21) and 0% versus 4.8% at 2 years (p = 0.20). Clinical acute rejection was present in 13.3% SF and 11.4% SB patients by 1 year (p = 0.74) and in 16.7% SF and 17.1% SB patients by 3 years (p = 0.94) after transplantation. The cumulative incidence of antibody-mediated rejection was 6.7% in SF and 2.9% in SB by 3 years after transplantation (p = 0.30). There was a significant increase in chronic histological damage over time (p < 0.001), without difference between SF and SB patients. Smaller recipient size and higher donor age were the main risk factors for chronic histological injury in posttransplant biopsies.
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Affiliation(s)
- Maarten Naesens
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium, EU
| | | | - Mark Benfield
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert Ettenger
- Division of Pediatric Nephrology, Mattel Children’s Hospital UCLA, Los Angeles, CA, USA
| | - Vikas Dharnidharka
- Division of Pediatric Nephrology, University of Florida College of Medicine, Gainesville, FL, USA
| | - William Harmon
- Department of Pediatrics, Harvard Medical School, Children’s Hospital Boston, Boston, MA, USA
| | - Robert Mathias
- Department of Pediatrics, University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Minnie M. Sarwal
- Department of Surgery, Stanford University, CA, USA,California Pacific Medical Center, Sutter Health Care, Fan Francisco, CA, USA,Corresponding author: Minnie M. Sarwal, M.D., FRCP, Ph.D., Director, The BIOMARC Program for Personalized Medicine, Sutter Health Care, Professor, California Pacific Medical Center (CPMC) and CPMC Research Institute, 475 Brannan Street, Ste 220, San Francisco, CA 94107, USA,
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7
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Sarwal MM, Ettenger R, Dharnidharka V, Benfield M, Mathias R, Portale A, McDonald R, Harmon W, Kershaw D, Vehaskari VM, Kamil E, Baluarte HJ, Warady B, Tang L, Liu J, Li L, Naesens M, Sigdel T, Waskerwitz J, Salvatierra O. Complete steroid avoidance is effective and safe in children with renal transplants: a multicenter randomized trial with three-year follow-up. Am J Transplant 2012; 12:2719-29. [PMID: 22694755 PMCID: PMC3681527 DOI: 10.1111/j.1600-6143.2012.04145.x] [Citation(s) in RCA: 128] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To determine whether steroid avoidance in pediatric kidney transplantation is safe and efficacious, a randomized, multicenter trial was performed in 12 pediatric kidney transplant centers. One hundred thirty children receiving primary kidney transplants were randomized to steroid-free (SF) or steroid-based (SB) immunosuppression, with concomitant tacrolimus, mycophenolate and standard dose daclizumab (SB group) or extended dose daclizumab (SF group). Follow-up was 3 years posttransplant. Standardized height Z-score change after 3 years follow-up was -0.99 ± 2.20 in SF versus -0.93 ± 1.11 in SB; p = 0.825. In subgroup analysis, recipients under 5 years of age showed improved linear growth with SF compared to SB treatment (change in standardized height Z-score at 3 years -0.43 ± 1.15 vs. -1.07 ± 1.14; p = 0.019). There were no differences in the rates of biopsy-proven acute rejection at 3 years after transplantation (16.7% in SF vs. 17.1% in SB; p = 0.94). Patient survival was 100% in both arms; graft survival was 95% in the SF and 90% in the SB arms (p = 0.30) at 3 years follow-up. Over the 3 year follow-up period, the SF group showed lower systolic BP (p = 0.017) and lower cholesterol levels (p = 0.034). In conclusion, complete steroid avoidance is safe and effective in unsensitized children receiving primary kidney transplants.
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Affiliation(s)
- Minnie M. Sarwal
- California Pacific Medical Center, Sutter Health Care, San Francisco
- Stanford University Medical School, Stanford
| | | | | | | | | | | | - Ruth McDonald
- Children’s Hospital & Regional Medical Center Seattle
| | | | - David Kershaw
- C.S. Mott Children’s Hospital, University of Michigan
| | | | - Elaine Kamil
- Maxine Dunitz Children’s Health Center, Cedars-Sinai Medical Center
| | | | | | - Lily Tang
- Pharmaceutical Product Development (PPD)
| | - Jun Liu
- Pharmaceutical Product Development (PPD)
| | - Li Li
- California Pacific Medical Center, Sutter Health Care, San Francisco
- Stanford University Medical School, Stanford
| | - Maarten Naesens
- California Pacific Medical Center, Sutter Health Care, San Francisco
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium, EU
| | - Tara Sigdel
- California Pacific Medical Center, Sutter Health Care, San Francisco
- Stanford University Medical School, Stanford
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8
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Naesens M, Khatri P, Li L, Sigdel TK, Vitalone MJ, Chen R, Butte AJ, Salvatierra O, Sarwal MM. Progressive histological damage in renal allografts is associated with expression of innate and adaptive immunity genes. Kidney Int 2011; 80:1364-76. [PMID: 21881554 DOI: 10.1038/ki.2011.245] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The degree of progressive chronic histological damage is associated with long-term renal allograft survival. In order to identify promising molecular targets for timely intervention, we examined renal allograft protocol and indication biopsies from 120 low-risk pediatric and adolescent recipients by whole-genome microarray expression profiling. In data-driven analysis, we found a highly regulated pattern of adaptive and innate immune gene expression that correlated with established or ongoing histological chronic injury, and also with development of future chronic histological damage, even in histologically pristine kidneys. Hence, histologically unrecognized immunological injury at a molecular level sets the stage for the development of chronic tissue injury, while the same molecular response is accentuated during established and worsening chronic allograft damage. Irrespective of the hypothesized immune or nonimmune trigger for chronic allograft injury, a highly orchestrated regulation of innate and adaptive immune responses was found in the graft at the molecular level. This occurred months before histologic lesions appear, and quantitatively below the diagnostic threshold of classic T-cell or antibody-mediated rejection. Thus, measurement of specific immune gene expression in protocol biopsies may be warranted to predict the development of subsequent chronic injury in histologically quiescent grafts and as a means to titrate immunosuppressive therapy.
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Affiliation(s)
- Maarten Naesens
- Division of Nephrology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
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9
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Gholami S, Sarwal MM, Naesens M, Ringertz HG, Barth RA, Balise RR, Salvatierra O. Standardizing resistive indices in healthy pediatric transplant recipients of adult-sized kidneys. Pediatr Transplant 2010; 14:126-31. [PMID: 19413712 DOI: 10.1111/j.1399-3046.2009.01180.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Small pediatric recipients of an adult-sized kidney have insufficient renal blood flow early after transplantation, with secondary chronic hypoperfusion and irreversible histological damage of the tubulo-interstitial compartment. It is unknown whether this is reflected by renal resistive indices. We measured renal graft resistive indices and volumes of 47 healthy pediatric kidney transplant recipients of an adult-sized kidney in a prospective study for six months post-transplant. A total of 205 measurements were performed. The smallest recipients (BSA <or=0.75 m(2)) had higher resistive indices compared to recipients with a BSA between 0.75 and 1.5 m(2) (p < 0.0001) and to recipients with a BSA >or= 1.5 m(2) (p < 0.0001). Resistive indices increased during the first six months in the smallest recipients (p = 0.02), but not in the two larger recipient groups (BSA 0.75-1.5 m(2) and >or=1.5 m(2)). All three BSA groups showed a reduction in renal volume after transplantation, with the greatest reduction occurring in the smallest recipients. In conclusion, renal transplant resistive indices reflect pediatric recipient BSA dependency. The higher resistance to intra-renal vascular flow and significant decrease in renal volume in the smallest group likely reflect accommodation of the size discrepant transplanted adult-sized kidney to the smaller pediatric recipient vasculature with associated lower renal artery flow.
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Affiliation(s)
- Sepideh Gholami
- Department of Surgery, Stanford University, Stanford, CA 94304, USA
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10
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Wojciechowski D, Hirose R, Stock P, Vincenti F, Baxter-Lowe LA, Salvatierra O. Kidney transplantation at UCSF: 8,300 transplants and onward. Clin Transpl 2010:161-167. [PMID: 21696039] [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] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Overall, the kidney transplant experience at UCSF has been highly successful. The program has made significant contributions to the field of kidney transplantation with advancements in organ allocation, crossmatching, clinical trials, pediatric transplantation, organ preservation and transplantation in HIV-positive recipients, to name a few. The program was built on the shoulders of giants in kidney transplantation but continues to be innovative and bold and does not rely on past success to pave the future. The program is truly a tribute to the many surgeons, nephrologists, fellows and ancillary personnel who have made this program a premiere center for kidney transplantation over the past 40 years.
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Chaudhuri A, Salvatierra O, Sarwal MM. Extended daclizumab monotherapy for rejection-free survival in non-adherent adolescent recipients of renal allografts. Pediatr Transplant 2009; 13:927-32. [PMID: 19017291 DOI: 10.1111/j.1399-3046.2008.01081.x] [Citation(s) in RCA: 5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Acute rejection episodes are almost inevitable in the face of immunosuppression non-adherence and a known risk factor for developing chronic allograft nephropathy and accelerated graft loss. Daclizumab, a humanized monoclonal antibody directed against the alpha chain of the IL-2 receptor, is an important advance for induction therapy in renal transplant immunosuppression, reducing early acute graft rejection without affecting the tolerability of standard immunosuppression, for both steroid-based and steroid-free immunosuppressive protocols, in children and adults. In the absence of depot immunosuppression for maintenance therapy, we explored extended daclizumab therapy as temporary maintenance immunosuppression for acute rejection prophylaxis in two patients with recalcitrant immunosuppression non-adherence. Both patients had prior episodes of aggressive acute rejection associated with their non-adherence but achieved stable and rejection-free renal allograft function with daclizumab monotherapy in the presence of documented non-adherence thus providing an effective bridge for up to 12 months until immunosuppression adherence was re-established with ongoing psychosocial support. This report suggests that daclizumab monotherapy over an extended period of time during the period of non-adherence in the post transplant period could be a rescue modality to avoid immune activation and thereby prevent acute rejection in the face of erratic maintenance immunosuppression.
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Affiliation(s)
- Abanti Chaudhuri
- Department of Pediatrics and Surgery, Stanford University School of Medicine, CA, USA
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12
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Li L, Chang A, Naesens M, Kambham N, Waskerwitz J, Martin J, Wong C, Alexander S, Grimm P, Concepcion W, Salvatierra O, Sarwal M. Steroid-free immunosuppression since 1999: 129 pediatric renal transplants with sustained graft and patient benefits. Am J Transplant 2009; 9:1362-72. [PMID: 19459814 PMCID: PMC2724986 DOI: 10.1111/j.1600-6143.2009.02640.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Despite early promising patient and graft outcomes with steroid-free (SF) immunosuppression in pediatric kidney transplant recipients, data on long-term safety and efficacy results are lacking. We present our single-center experience with 129 consecutive pediatric kidney transplant recipients on SF immunosuppression, with a mean follow-up of 5 years. Outcomes are compared against a matched cohort of 57 concurrent recipients treated with steroid-based (SB) immunosuppression. In the SF group, 87% of kidney recipients with functioning grafts remain corticosteroid-free. Actual intent-to-treat SF (ITT-SF) and still-on-protocol SF patient survivals are 96% and 96%, respectively, actual graft survivals for both groups are 93% and 96%, respectively and actual death-censored graft survivals for both groups are 97% and 99%, respectively. Unprecedented catch-up growth is observed in SF recipients below 12 years of age. Continued low rates of acute rejection, posttransplant diabetes mellitus (PTDM), hypertension and hyperlipidemia are seen in SF patients, with sustained benefits for graft function. In conclusion, extended enrollment and longer experience with SF immunosuppression for renal transplantation in low-risk children confirms protocol safety, continued benefits for growth and graft function, low acute rejection rates and reduced cardiovascular morbidity.
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Affiliation(s)
- L. Li
- Dept. of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - A. Chang
- Dept. of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - M. Naesens
- Dept. of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - N. Kambham
- Dept. of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - J. Waskerwitz
- Dept. of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA,Dept. of Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - J. Martin
- Dept. of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - C. Wong
- Dept. of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - S. Alexander
- Dept. of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - P. Grimm
- Dept. of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - W. Concepcion
- Dept. of Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - O. Salvatierra
- Dept. of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA,Dept. of Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA,Corresponding Authors: Minnie Sarwal, MD, MRCP, Ph.D., G306, 300 Pasteur Drive, Stanford University School of Medicine, Stanford, CA 94305 USA, , Phone: (650)723-4517, Fax: (650)498-6762, Salvatierra Oscar, MD., 703 Welch Rd., H2, Stanford University School of Medicine, Stanford, CA 94305 USA, , Phone: (650)498-5481
| | - M.M. Sarwal
- Dept. of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA,Corresponding Authors: Minnie Sarwal, MD, MRCP, Ph.D., G306, 300 Pasteur Drive, Stanford University School of Medicine, Stanford, CA 94305 USA, , Phone: (650)723-4517, Fax: (650)498-6762, Salvatierra Oscar, MD., 703 Welch Rd., H2, Stanford University School of Medicine, Stanford, CA 94305 USA, , Phone: (650)498-5481
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13
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Naesens M, Li L, Ying L, Sansanwal P, Sigdel TK, Hsieh SC, Kambham N, Lerut E, Salvatierra O, Butte AJ, Sarwal MM. Expression of complement components differs between kidney allografts from living and deceased donors. J Am Soc Nephrol 2009; 20:1839-51. [PMID: 19443638 DOI: 10.1681/asn.2008111145] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
A disparity remains between graft survival of renal allografts from deceased donors and from living donors. A better understanding of the molecular mechanisms that underlie this disparity may allow the development of targeted therapies to enhance graft survival. Here, we used microarrays to examine whole genome expression profiles using tissue from 53 human renal allograft protocol biopsies obtained both at implantation and after transplantation. The gene expression profiles of living-donor kidneys and pristine deceased-donor kidneys (normal histology, young age) were significantly different before reperfusion at implantation. Deceased-donor kidneys exhibited a significant increase in renal expression of complement genes; posttransplantation biopsies from well-functioning, nonrejecting kidneys, regardless of donor source, also demonstrated a significant increase in complement expression. Peritransplantation phenomena, such as donor death and possibly cold ischemia time, contributed to differences in complement pathway gene expression. In addition, complement gene expression at the time of implantation was associated with both early and late graft function. These data suggest that complement-modulating therapy may improve graft outcomes in renal transplantation.
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Affiliation(s)
- Maarten Naesens
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
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15
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Salvatierra O, Concepcion W, Sarwal MM. Renal transplantation in children with thrombosis of the inferior vena cava requires careful assessment and planning. Pediatr Nephrol 2008; 23:2107-9. [PMID: 18688652 DOI: 10.1007/s00467-008-0951-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2008] [Revised: 06/27/2008] [Accepted: 06/30/2008] [Indexed: 11/24/2022]
Abstract
Children with end-stage renal disease and inferior vena cava (IVC) thrombosis are rare, and their condition is complex and high risk for renal transplantation. Detailed imaging studies of the recipient's abdominal vasculature should be carried out prior to transplantation, followed by careful pre-operative joint planning by the pediatric transplant surgeon and nephrologist. Critical decisions need to be made as to whether a deceased child's kidney or an adult-sized kidney is to be used, and if the latter, whether it should be from a deceased or living donor. In addition, the contemplated site of the donor's renal vein anastomosis needs to be determined with a consideration of the possible consequences of the various choices. Sixteen cases of renal transplantation in children with pre-existing IVC thrombosis are reviewed, including the three reported by Shenoy et al. in this journal. With a full understanding of the difficulties noted, renal transplantation in a small child with IVC thrombosis can be successful. However, it requires thorough recipient assessment, coupled with a careful and thoughtful examination of options, to determine the best possible approach to the transplantation.
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Zarkhin V, Li L, Kambham N, Sigdel T, Salvatierra O, Sarwal MM. A randomized, prospective trial of rituximab for acute rejection in pediatric renal transplantation. Am J Transplant 2008; 8:2607-17. [PMID: 18808404 DOI: 10.1111/j.1600-6143.2008.02411.x] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We report 1-year outcomes of a randomized study of Rituximab versus standard-of-care immunosuppression (Thymoglobulin and/or pulse steroids) for treatment of biopsy confirmed, acute transplant rejection with B-cell infiltrates, in 20 consecutive recipients (2-23 years). Graft biopsies, with Banff and CADI scores, CD20 and C4d stains, were performed at rejection and 1 and 6 months later. Peripheral blood CMV, EBV and BK viral loads, graft function, DSA, immunoglobulins, serum humanized antichimeric antibody (HACA) and Rituximab, and lymphocyte counts were monitored until 1 year posttreatment. Rituximab infusions were given with a high index of safety without HACA development and increased infections complications. Rituximab therapy resulted in complete tissue B-cell depletion and rapid peripheral B-cell depletion. Peripheral CD19 cells recovered at a mean time of approximately 12 months. There were some benefits for the recovery of graft function (p = 0.026) and improvement of biopsy rejection scores at both the 1- (p = 0.0003) and 6-month (p < 0.0001) follow-up biopsies. Reappearance of C4d deposition was not seen on follow-up biopsies after Rituximab therapy, but was seen in 30% of control patients. There was no change in DSA in either group, independent of rejection resolution. This study reports safety and suggests further investigation of Rituximab as an adjunctive treatment for B-cell-mediated graft rejection.
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Affiliation(s)
- V Zarkhin
- Department of Pediatrics, Stanford University Medical Center, Stanford, CA, USA
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Li L, Weintraub L, Concepcion W, Martin JP, Miller K, Salvatierra O, Sarwal MM. Potential influence of tacrolimus and steroid avoidance on early graft function in pediatric renal transplantation. Pediatr Transplant 2008; 12:701-7. [PMID: 18179640 DOI: 10.1111/j.1399-3046.2007.00884.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
With the increasing adoption of steroid-sparing immunosuppression protocols in renal transplantation, it is important to evaluate any adverse effects of steroid avoidance on graft function. Early graft function, measured by CrCl was retrospectively studied in 158 consecutive pediatric renal transplant recipients from 1996 to 2005, receiving either steroid-free or steroid-based immunosuppression. Patients receiving steroid-free immunosuppression vs. steroid-based immunosuppression had no difference change in CrCl (DeltaCrCl) in the first week post-transplantation (p = 0.12). When stratified by corticosteroid usage, patients with higher tacrolimus trough levels (> or =14 ng/mL) had slower graft function recovery in the first week post-transplantation than those with lower tacrolimus trough levels (p = 0.008) in the steroid-free group only. Despite initial slower graft function recovery in this subgroup, there was no negative impact on graft function in the steroid-free group; in fact steroid-free patients trended towards better CrCl at six months (p = 0.047) and 12 months (p < 0.001) post-transplant than the steroid-based group. With the improved immunological outcomes with steroid avoidance, close surveillance should be performed of tacrolimus levels to avoid levels >14 ng/mL. In patients with slow recovery of early graft function, short-term perioperative steroids may be considered.
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Affiliation(s)
- L Li
- Division of Pediatric Nephrology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305-5208, USA
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18
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Weintraub L, Li L, Kambham N, Alexander S, Concepcion W, Miller K, Wong C, Salvatierra O, Sarwal M. Patient selection critical for calcineurin inhibitor withdrawal in pediatric kidney transplantation. Pediatr Transplant 2008; 12:541-9. [PMID: 18564305 DOI: 10.1111/j.1399-3046.2007.00847.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
CNI withdrawal may be employed as a "rescue" strategy for patients with established renal allograft injury and/or declining allograft function, with the aim at eliminating CNI-associated nephrotoxic effects. This analysis reviews outcomes in a pediatric population and identifies risk factors for adverse events post-CNI withdrawal. We performed a retrospective analysis of 17 pediatric renal transplants who underwent CNI withdrawal, with conversion to sirolimus and MMF. Mean CrCl decreased from 64.3 +/- 22 to 59.38 +/- 28.6 mL/min/1.73 m(2) (p = 0.04) at six months and 57.46 +/- 31.1 mL/min/1.73 m(2) (p = 0.02) at 12 months post-withdrawal. Forty-one percent of patients experienced AR. Increased risk for AR was associated with prior AR history, lower sirolimus trough levels, and lower CNIT biopsy scores. Graft loss (24%) was associated with worse CrCl, proteinuria, and histologic chronicity. Proteinuria (spot protein/creatinine ratio) increased from 0.75 +/- 1.0 to 1.71 +/- 2.0 (p = 0.03), unrelated to de novo sirolimus use. Four patients returned to CNI-based immunosuppression due to AR (n = 3) and gastrointestinal side effects (n = 1). Careful selection of pediatric candidates for CNI withdrawal is recommended. Worsening graft function and graft loss may be minimized by selecting patients with high CNIT scores and low biopsy chronicity and excluding patients with prior AR history.
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Affiliation(s)
- Lauren Weintraub
- Department of Pediatrics, Stanford University, Stanford, CA, USA.
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Nagarajan S, Mansfield E, Hsieh S, Liu R, Hsieh F, Li L, Salvatierra O, Sarwal MM. Transplant reno-vascular stenoses associated with early erythropoietin use. Clin Transplant 2007; 21:597-608. [PMID: 17845633 DOI: 10.1111/j.1399-0012.2007.00694.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES This report describes an unusual presentation of severe hypertension (HTN) in a subset of pediatric kidney recipients treated with a steroid avoidance pediatric renal transplantation protocol. The HTN was secondary to atypical, reno-vascular abnormalities (RVA) of the transplanted vasculature, temporally associated with erythropoietin (EPO) use. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS To investigate the clinical significance underlying this event, a retrospective clinical study of 100 pediatric renal transplants was undertaken (50 steroid-free and 50 matched steroid-based controls), with peripheral blood transcriptional analysis of four RVA patients and controls. RESULTS Regardless of a higher observed incidence of anemia (p < 0.001) and greater overall EPO usage in the first post-transplant year in steroid-free patients, the incidence of new-onset HTN at one yr was significantly less in the steroid-free cohort (p = 0.03). Nevertheless, early EPO (first week post-transplant) was significantly associated with the combinatory findings of new-onset HTN (p = 0.03) and RVA (p = 0.007). Molecular mechanisms of RVA injury were investigated further by peripheral blood cDNA microarray gene expression profiling. A panel of 42 transcripts differentiated patients with RVA and HTN from three sets of matched controls, with and without HTN and EPO use, with 100% concordance (p < 0.001). The biological processes governed by these significant genes suggest a role for EPO regulation of growth factor receptor ubiquitination as a putative mechanism for renal vascular injury. CONCLUSION This study cautions against the use early post-transplant use of EPO in immunosuppression regimens with steroid minimization/avoidance, which may have an increased incidence of post-transplant anemia.
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Affiliation(s)
- Suja Nagarajan
- Department of Pediatrics (Nephrology) Stanford University, Palo Alto, CA 94305-5208, USA
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20
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Naesens M, Kambham N, Concepcion W, Salvatierra O, Sarwal M. The evolution of nonimmune histological injury and its clinical relevance in adult-sized kidney grafts in pediatric recipients. Am J Transplant 2007; 7:2504-14. [PMID: 17725681 DOI: 10.1111/j.1600-6143.2007.01949.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To describe the evolution, risk factors and impact of nonimmune histological injury after pediatric kidney transplantation, we analyzed 245 renal allograft protocol biopsies taken regularly from the time of transplantation to 2 years thereafter in 81 consecutive rejection-free pediatric recipients of an adult-sized kidney. Isometric tubular vacuolization was present early after transplantation was not progressive, and was associated with higher tacrolimus pre-dose trough levels. Chronic tubulo-interstitial damage and tubular microcalcifications were already noted at 3 months, were progressive and had a greater association with small recipient size, male donor gender, higher donor age and female recipient gender, but not with tacrolimus exposure. Renal function assessment showed that older recipients had a significant increase in absolute glomerular filtration rate with time after transplantation, which differed from small recipients who showed no increase. It is concluded that progressive, functionally relevant, nonimmune injury is detected early after adult-sized kidney transplantation in pediatric recipients. Renal graft ischemia associated with the donor-recipient size discrepancy appears to be a greater risk factor for this chronic histological injury, suggesting that the exploration of additional therapeutic approaches to increase allograft perfusion could further extend the graft survival benefit of adult-sized kidneys transplanted into small children.
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Affiliation(s)
- M Naesens
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
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21
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Brouard S, Mansfield E, Braud C, Li L, Giral M, Hsieh SC, Baeten D, Zhang M, Ashton-Chess J, Braudeau C, Hsieh F, Dupont A, Pallier A, Moreau A, Louis S, Ruiz C, Salvatierra O, Soulillou JP, Sarwal M. Identification of a peripheral blood transcriptional biomarker panel associated with operational renal allograft tolerance. Proc Natl Acad Sci U S A 2007; 104:15448-53. [PMID: 17873064 PMCID: PMC2000539 DOI: 10.1073/pnas.0705834104] [Citation(s) in RCA: 283] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2006] [Indexed: 12/13/2022] Open
Abstract
Long-term allograft survival generally requires lifelong immunosuppression (IS). Rarely, recipients display spontaneous "operational tolerance" with stable graft function in the absence of IS. The lack of biological markers of this phenomenon precludes identification of potentially tolerant patients in which IS could be tapered and hinders the development of new tolerance-inducing strategies. The objective of this study was to identify minimally invasive blood biomarkers for operational tolerance and use these biomarkers to determine the frequency of this state in immunosuppressed patients with stable graft function. Blood gene expression profiles from 75 renal-transplant patient cohorts (operational tolerance/acute and chronic rejection/stable graft function on IS) and 16 healthy individuals were analyzed. A subset of samples was used for microarray analysis where three-class comparison of the different groups of patients identified a "tolerant footprint" of 49 genes. These biomarkers were applied for prediction of operational tolerance by microarray and real-time PCR in independent test groups. Thirty-three of 49 genes correctly segregated tolerance and chronic rejection phenotypes with 99% and 86% specificity. The signature is shared with 1 of 12 and 5 of 10 stable patients on triple IS and low-dose steroid monotherapy, respectively. The gene signature suggests a pattern of reduced costimulatory signaling, immune quiescence, apoptosis, and memory T cell responses. This study identifies in the blood of kidney recipients a set of genes associated with operational tolerance that may have utility as a minimally invasive monitoring tool for guiding IS titration. Further validation of this tool for safe IS minimization in prospective clinical trials is warranted.
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Affiliation(s)
- Sophie Brouard
- Institut National de la Santé et de la Recherche Médicale, U643, Centre Hospitalier Universitaire de Nantes, Institut de Transplantation et de Recherche en Transplantation, and Université de Nantes, Faculte de Medicine, F-44000 Nantes, France
| | - Elaine Mansfield
- Department of Pediatrics, Stanford University, 300 Pasteur Drive, Stanford, CA 94304
- Affymetrix, Inc., 3380 Central Expressway, Santa Clara, CA 95051
| | - Christophe Braud
- Institut National de la Santé et de la Recherche Médicale, U643, Centre Hospitalier Universitaire de Nantes, Institut de Transplantation et de Recherche en Transplantation, and Université de Nantes, Faculte de Medicine, F-44000 Nantes, France
| | - Li Li
- Department of Pediatrics, Stanford University, 300 Pasteur Drive, Stanford, CA 94304
| | - Magali Giral
- Institut National de la Santé et de la Recherche Médicale, U643, Centre Hospitalier Universitaire de Nantes, Institut de Transplantation et de Recherche en Transplantation, and Université de Nantes, Faculte de Medicine, F-44000 Nantes, France
| | - Szu-chuan Hsieh
- Department of Pediatrics, Stanford University, 300 Pasteur Drive, Stanford, CA 94304
| | - Dominique Baeten
- Institut National de la Santé et de la Recherche Médicale, U643, Centre Hospitalier Universitaire de Nantes, Institut de Transplantation et de Recherche en Transplantation, and Université de Nantes, Faculte de Medicine, F-44000 Nantes, France
- Clinical Immunology and Rheumatology, Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands; and
| | - Meixia Zhang
- Department of Pediatrics, Stanford University, 300 Pasteur Drive, Stanford, CA 94304
- Department of Clinical Pharmacology, China Medical University, Shenyang 110001, China
| | - Joanna Ashton-Chess
- Institut National de la Santé et de la Recherche Médicale, U643, Centre Hospitalier Universitaire de Nantes, Institut de Transplantation et de Recherche en Transplantation, and Université de Nantes, Faculte de Medicine, F-44000 Nantes, France
| | - Cécile Braudeau
- Institut National de la Santé et de la Recherche Médicale, U643, Centre Hospitalier Universitaire de Nantes, Institut de Transplantation et de Recherche en Transplantation, and Université de Nantes, Faculte de Medicine, F-44000 Nantes, France
| | - Frank Hsieh
- Department of Veterans Affairs Palo Alto Health Care System (151-K), Palo Alto, CA 94304
| | - Alexandre Dupont
- Institut National de la Santé et de la Recherche Médicale, U643, Centre Hospitalier Universitaire de Nantes, Institut de Transplantation et de Recherche en Transplantation, and Université de Nantes, Faculte de Medicine, F-44000 Nantes, France
| | - Annaik Pallier
- Institut National de la Santé et de la Recherche Médicale, U643, Centre Hospitalier Universitaire de Nantes, Institut de Transplantation et de Recherche en Transplantation, and Université de Nantes, Faculte de Medicine, F-44000 Nantes, France
| | - Anne Moreau
- Service d'Anatomie Pathologique, CHU Hôtel-Dieu, 30 Bd Jean Monnet, 44093 Nantes Cedex 01, France
| | - Stéphanie Louis
- Institut National de la Santé et de la Recherche Médicale, U643, Centre Hospitalier Universitaire de Nantes, Institut de Transplantation et de Recherche en Transplantation, and Université de Nantes, Faculte de Medicine, F-44000 Nantes, France
| | - Catherine Ruiz
- TcLand, Halle 13 Bio-Ouest Ile de Nantes, 21 Rue de la Noue Bras de Fer, 44200 Nantes, France
| | - Oscar Salvatierra
- Department of Pediatrics, Stanford University, 300 Pasteur Drive, Stanford, CA 94304
| | - Jean-Paul Soulillou
- Institut National de la Santé et de la Recherche Médicale, U643, Centre Hospitalier Universitaire de Nantes, Institut de Transplantation et de Recherche en Transplantation, and Université de Nantes, Faculte de Medicine, F-44000 Nantes, France
| | - Minnie Sarwal
- Department of Pediatrics, Stanford University, 300 Pasteur Drive, Stanford, CA 94304
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Abstract
A retrospective analysis was conducted on 10 consecutive cases of neonatal ARPKD, 9 of whom received kidney transplants (KT). All were diagnosed antenatally (n = 6) or at birth. In the first month of life 70% required ventilatory support. Pre-emptive bilateral nephrectomy and peritoneal dialysis (PD) catheter placement were performed in 9 at a mean age of 7.8 +/- 11.9 months. The indications for nephrectomy were massive kidneys, resulting in suboptimal nutrition and respiratory compromise. All patients received assisted enteral nutrition, with significant increase in mean tolerated feeds following nephrectomy (p < 0.05), with increase in mean normalized weight and height (0.92 and 1.2 delta SDS respectively), by one year post-transplantation. KT was performed at a mean age and weight of 2.5 +/- 1.4 years and 13.3 +/- 6.1 kg. The mean creatinine clearance at one year post-KT was 91.3 +/- 38.1 mls/min/1.73 m(2), with a projected graft life expectancy of 18.4 years. Patient survival was 89% and death censored graft survival was 100%, at a mean follow-up of 6.1 +/- 4.5 years post-transplant. Six patients demonstrated evidence of hepatic fibrosis, one of which required liver transplantation. In patients with massive kidneys from ARPKD, pre-emptive bilateral nephrectomy, supportive PD and early aggressive nutrition, can minimize early infant mortality, so that subsequent KT can be performed with excellent patient and graft survival.
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Affiliation(s)
- Mona Beaunoyer
- Department of Transplant Surgery, Stanford University, Stanford, CA 94304, USA
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Li L, Chaudhuri A, Weintraub LA, Hsieh F, Shah S, Alexander S, Salvatierra O, Sarwal MM. Subclinical cytomegalovirus and Epstein-Barr virus viremia are associated with adverse outcomes in pediatric renal transplantation. Pediatr Transplant 2007; 11:187-95. [PMID: 17300499 DOI: 10.1111/j.1399-3046.2006.00641.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Post-transplant clinical disease with cytomegalovirus (CMV) and Epstein-Barr virus (EBV) is a known risk factor for graft dysfunction and lymphoproliferation. We postulate that subclinical, asymptomatic viremia also adversely impacts outcomes, and may warrant re-assessment of current monitoring and antiviral prophylaxis protocols. A single-center study was conducted on 102 pediatric (51 steroid-free and 51 matched steroid-based historical controls). Quantitative viral loads were serially monitored and correlated with outcome measures. Overall, the incidence of CMV and EBV clinical disease was 5% (1% CMV and 4% EBV); however, the incidence of subclinical viremia was 44% (12.7% CMV, 38.2% EBV, 6.9% CMV + EBV). Risk factors for subclinical viremia were EBV naivety (p = 0.07), age less than five yr (p = 0.04), lack of prophylaxis (p = 0.01), and steroid usage (p = 0.0007). Subclinical viremia was associated with lower three-yr graft function (p = 0.03), increased risk of acute rejection (odds ratio 2.07; p = 0.025), hypertension (p = 0.04), and graft loss (p = 0.03). Subclinical asymptomatic CMV and EBV viremia is a risk factor for graft injury and loss. These findings support the need for aggressive, serial viral monitoring to better determine the appropriate length of post-transplant antiviral prophylaxis, and to determine the effect of immunosuppression protocols on the development of viremia.
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Affiliation(s)
- Li Li
- Department of Pediatrics, Stanford University, Palo Alto, CA, USA
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Abstract
Although normative values of post-transplant proteinuria have been reported in adults, data for pediatric renal transplant recipients have not been previously published. We hypothesized that pediatric renal transplant recipients achieve normal urinary protein to creatinine (UProt/UCr) ratios (<0.2) by 60 days post-transplant in the absence of early recurrent disease. Retrospective chart review of 108 consecutive pediatric renal transplant recipients at Stanford University was performed. Thirty-two (30%) patients who were eligible had > or = 1 UProt/UCr ratio obtained during the first 60 post-transplant days. Mean age at transplant was 13.9 +/- 4.2 yr. UProt/UCr ratios were grouped by week post-transplant for quantile analysis. Mean weekly UProt/UCr values were not lower than 0.2 until the ninth post-transplant week. No difference in post-transplant proteinuria existed between nephrectomized and non-nephrectomized transplant recipients. Experience with a single patient with proven focal segmental glomerulosclerosis (FSGS) recurrence suggests that normative UProt/UCr data may be useful in early identification of patients experiencing disease recurrence. Univariate correlations demonstrated that UProt/UCr negatively correlated with serum albumin levels (-0.415, p < 0.0001) and days post-transplant (-0.531, p < 0.0001). Independent of primary diagnosis, proteinuria persists throughout the first 60 days in most pediatric renal transplant patients, decreasing relative to time post-transplant.
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Affiliation(s)
- Annabelle N Chua
- Department of Pediatrics, Section of Pediatric Nephrology, Stanford University, Stanford, CA, USA.
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Eneriz-Wiemer M, Sarwal M, Donovan D, Costaglio C, Concepción W, Salvatierra O. Successful Renal Transplantation in High-Risk Small Children with a Completely Thrombosed Inferior Vena Cava. Transplantation 2006; 82:1148-52. [PMID: 17102765 DOI: 10.1097/01.tp.0000236644.76359.47] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [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: 11/26/2022]
Abstract
BACKGROUND Inferior vena cava (IVC) thrombosis is generally a contraindication to renal transplantation in small children because of the technical difficulty and limitations in allograft venous outflow drainage that risk graft thrombosis. METHODS The records of six consecutive children (9.9-27.4 kg) with end-stage renal disease and thrombosed IVCs were reviewed. Small deceased donor renal allografts were utilized in all cases where immediate posttransplant venous renal outflow would theoretically not exceed the drainage capacity of the iliac or adjacent pelvic collateral veins. RESULTS There is 100% patient survival with two patients returning to dialysis at seven and three years posttransplantation. There were no surgical complications or delayed graft function. Postoperatively, progressive renal vein and simultaneous iliac venous enlargement was observed in five of six recipients concomitant with renal allograft enlargement. In these patients, maximum renal volume achieved was between 152 and 275 ml and last recorded Schwartz glomerular filtration rates ranged from 67 to 118 ml/min. The sixth allograft had an early, severe rejection episode that limited renal growth and attainment of good renal function. All patients demonstrated resumption of growth rates commensurate with age but without significant catch-up growth. CONCLUSION A small deceased donor kidney can provide freedom from dialysis and better quality of life for small children with IVC thrombosis during an age when dialysis treatment is difficult and the complications of the thrombosed IVC may compromise life. Good renal function was attained in patients without rejection episodes. In those with rejection, our approach allowed for patient growth during allograft function, providing a bridge for a repeat transplant.
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Affiliation(s)
- Monica Eneriz-Wiemer
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA 94304, USA
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26
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Kambham N, Nagarajan S, Shah S, Li L, Salvatierra O, Sarwal MM. A Novel, Semiquantitative, Clinically Correlated Calcineurin Inhibitor Toxicity Score for Renal Allograft Biopsies. Clin J Am Soc Nephrol 2006; 2:135-42. [PMID: 17699397 DOI: 10.2215/cjn.01320406] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [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: 11/23/2022]
Abstract
Calcineurin inhibitor toxicity (CNIT) is an important cause of chronic allograft nephropathy (CAN), but clinically relevant, diagnostic pathologic criteria remain to be defined. A semiquantitative, clinically correlative CNIT scoring system was developed and validated by pathologic analyses of 254 renal transplant biopsies that were obtained from 50 consecutive pediatric renal transplant recipients. Differentially weighted pathologic criteria (glomerulosclerosis, tubular atrophy, arteriolar medial hyaline, and tubular isometric vacuolization) contributed to the composite CNIT model score. Unlike other established pathology chronicity scores, such as the chronic allograft damage index, Banff, and modified Banff, the CNIT score was highly correlated with future graft function. The 3-mo CNIT score correlated significantly with 12 mo (P = 0.021) and 24 mo (P = 0.03) calculated creatinine clearance. Arteriolar medial hyalinosis seems to be the most important factor contributing to the clinical impact of the CNIT score.
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27
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Abstract
Renal transplantation in the pediatric population, although conceptually similar to that in adults, differs in many aspects. This review will focus on the issues unique to the pediatric recipient. In particular, we will focus on the incidence and etiology of end stage renal disease in children, and the results as measured by patient and graft survival. Pretransplant surgical considerations of timing of the transplant, management of congenital urologic abnormalities and the abnormal bladder will be addressed. Etiologies of renal failure unique to the pediatric population will be discussed, including autosomal recessive polycystic kidney disease, congenital nephrotic syndrome, inferior vena cava thrombosis, and primary hyperoxaluria Type 1. Lastly, special transplant surgical considerations including transplantation of an adult-size kidney (ASK) into an infant or small child and ureteral implantation, management of the urinary bladder, and fluid management in infants and small children will be discussed.
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Affiliation(s)
- Oscar Salvatierra
- Department of Surgery, Stanford University Medical Center, Palo Alto, California 94304, USA.
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28
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Abstract
Bartter's syndrome (BS) is an incurable genetic disease, with variable response to supportive therapy relating to fluid and electrolyte management. Poor control or therapy non-compliance may result in frequent life threatening episodes of dehydration, acidosis and hypokalemia, with resultant adverse effects on patient quality of life (QOL). We report, for the first time, pre-emptive bilateral native nephrectomies and successful renal transplantation, prior to the onset of ESRD, for severe, clinically brittle, neonatal BS, resulting in correction of metabolic abnormalities and excellent graft function. We propose that fragile BS should be considered as a possible indication for early native nephrectomies and pre-emptive renal transplantation, procedures that results in a 'cure' for the underlying disease and significant improvements in patient QOL.
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Affiliation(s)
- Abanti Chaudhuri
- Department of Pediatrics and Surgery, Stanford University, CA, USA
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29
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Abstract
Hyperhomocysteinemia (HHcy) has been recently identified as an important and reversible cardiovascular risk factor in adult and pediatric renal transplant recipients. A retrospective cross-sectional analysis of 70 pediatric and young adult renal transplant recipients was performed to determine the prevalence, and important clinical and laboratory correlates of HHcy. Total homocysteine concentration, free and protein bound, was determined by fluorescence polarization immunoassay using an IMX analyzer. Hyperhomocysteinemia was defined as a serum homocysteine (Hcy) level above the 95th percentile for age. Fifty-four of 70 patients (77%) had HHcy. Comparison of patients with HHcy with patients without HHcy demonstrated no statistical difference in age (p = 0.35), gender (p = 0.76) or donor type (p = 0.20). Patients with HHcy had significantly lower calculated creatinine clearance values (Ccr) (p = 0.02), 67.3 +/- 21.2 mL/min/1.73 m(2) vs. 90.7 +/- 32.3 mL/min/1.73 m(2) for patients without HHcy. Immunosuppression did not correlate with the diagnosis of HHcy. Stepwise logistic regression identified patient age (0.18, p = 0.013) and Ccr (-0.04, p = 0.011) as significant variables. In conclusion, HHcy is more common than expected in pediatric renal transplant recipients. Patients with Ccr <80 mL/min/1.73 m(2) were statistically more likely to have a diagnosis of HHcy. We recommend that Hcy levels should be evaluated in this high risk population.
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Affiliation(s)
- Amir Belson
- Section of Pediatric Nephrology, Department of Pediatrics, Lucile Salter Packard Children's Hospital, Stanford University, CA 94304, USA.
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31
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Millan MT, Berquist WE, So SK, Sarwal MM, Wayman KI, Cox KL, Filler G, Salvatierra O, Esquivel CO. One hundred percent patient and kidney allograft survival with simultaneous liver and kidney transplantation in infants with primary hyperoxaluria: a single-center experience. Transplantation 2004; 76:1458-63. [PMID: 14657686 DOI: 10.1097/01.tp.0000084203.76110.ac] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Combined liver-kidney transplantation is the definitive treatment for end-stage renal disease caused by primary hyperoxaluria type I (PH1). The infantile form is characterized by renal failure early in life, advanced systemic oxalosis, and a formidable mortality rate. Although others have reported on overall results of transplantation for PH1 covering a wide age spectrum, none has specifically addressed the high-risk infantile form of the disease. METHODS Six infants with PH1 underwent simultaneous liver-kidney transplantation at our center between May 1994 and August 1998. Diagnosis was made at 5.2+/-3.3 months of age, they were on dialysis for 11.8+/-2.3 months, and they underwent transplantation at 14.8+/-3.0 months of age when they weighed 10.6+/-1.7 kg. RESULTS At a mean follow-up of 6.4+/-1.7 years (range, 3.9-8.1 years), we report 100% patient and kidney allograft survival. There were no cases of acute tubular necrosis. Long-term kidney allograft function remained stable in all patients, with serum creatinine values of less than 1.1 mg/dL and a mean creatinine clearance of 99 mL/min/1.73 m2 at follow-up. Those who received combined hemodialysis and peritoneal dialysis pretransplant had lower posttransplant urinary oxalate values than those receiving peritoneal dialysis alone. There was improvement in growth and psychomotor and mental developmental scores after transplantation. CONCLUSIONS Combined liver-kidney transplantation for the infantile presentation of PH1 is associated with excellent outcome when the approach includes early diagnosis and early combined transplantation, aggressive pretransplant dialysis, and avoidance of posttransplant renal dysfunction.
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Affiliation(s)
- Maria T Millan
- Stanford University School of Medicine, Palo Alto, CA 94304, USA.
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Sarwal MM, Vidhun JR, Alexander SR, Satterwhite T, Millan M, Salvatierra O. Continued superior outcomes with modification and lengthened follow-up of a steroid-avoidance pilot with extended daclizumab induction in pediatric renal transplantation1. Transplantation 2003; 76:1331-9. [PMID: 14627912 DOI: 10.1097/01.tp.0000092950.54184.67] [Citation(s) in RCA: 203] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Corticosteroids have been invariant transplant immunosuppressives with numerous adverse effects. We previously reported 6-month results in 10 patients using extended daclizumab induction to safely eliminate steroid use in pediatric renal transplantation. This expanded pilot series discusses immunosuppression dosing modification to further minimize drug toxicity without sacrificing regimen efficacy. METHODS Fifty-seven pediatric renal transplant recipients were enrolled in the pilot steroid-free protocol. Extended daclizumab induction, tacrolimus, and mycophenolate mofetil (MMF) were intended maintenance drugs. Fourteen patients were equal to or younger than 5 years, and 43 patients were older than 5 years of age at transplantation. There were seven protocol breaks. Study patients underwent serial protocol transplant biopsies (n=246), and serum daclizumab and mycophenolic acid (MPA) trough levels were evaluated. In this efficacy study, controls were 50 historical-matched steroid-based children receiving tacrolimus with 100% 2-year graft survival and without delayed graft function. RESULTS Mean follow-up was 20 (range, 4.5-41) months with 98% overall graft and patient survival. At 1 year of analysis, steroid-free recipients showed significant improvements for clinical acute rejection (8%), graft function, hypertension, and growth, without increased infectious complications. Leukopenia, anemia, and allograft nephrotoxicity were addressed by solely decreasing MMF and tacrolimus dosing and/or by replacing MMF with sirolimus, without increasing acute rejection. Early daclizumab levels of more than 5 microg/mL were observed for the first time in children of all ages. CONCLUSIONS Pediatric renal transplantation is safe without steroids. Daclizumab first-dose doubling and extended use for 6 months replaces steroids effectively without evidence of overimmunosuppression and may be the pivotal cause for the reduced acute rejection seen in this trial. This pilot study provides preliminary data to test this protocol in a prospective, multicenter randomized study.
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Affiliation(s)
- Minnie M Sarwal
- Department of Pediatrics, Stanford University, Palo Alto, CA 94305, USA
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Vidhun J, Masciandro J, Varich L, Salvatierra O, Sarwal M. Safety and risk stratification of percutaneous biopsies of adult-sized renal allografts in infant and older pediatric recipients. Transplantation 2003; 76:552-7. [PMID: 12923443 DOI: 10.1097/01.tp.0000076097.90123.21] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Allograft biopsies are the gold standard for evaluating renal graft dysfunction. Adult-sized kidney (ASK) allografts are placed extraperitoneally in older children and adults and transperitoneally in infant recipients. Transperitoneal graft biopsies may be accompanied by a greater risk of bleeding and bowel injury, although no standardized pediatric study of procedure risk relating to transplant placement exists. METHODS A retrospective single-center study of 328 consecutive ASK biopsies (277 extraperitoneal and 51 transperitoneal) performed since 1995 was conducted to stringently categorize all identified biopsy procedure complications (bleeding, transfusion requirement, bowel perforation, surgical intervention, and graft loss) relating to allograft placement, surveillance versus protocol biopsies, recipient age, and biopsy needle use, with risk stratification and recommendations for improving procedure safety. Two distinct methods of real-time ultrasound guidance were used. RESULTS The overall incidence of all adverse effects was 16.1%, with perinephric hematomas accounting for 13.4% and gross hematuria accounting for 2.7%. Hematomas less than 1 cm accounted for 81.4% of all hematomas. Complications of transperitoneal biopsies (using a modified patient placement approach) paralleled those seen in extraperitoneally placed allografts (15.7% vs. 15.5%, P=0.976). Hematomas occurred more frequently (17.8% vs. 8.3%, P=0.010) in clinically indicated versus surveillance biopsies and with 16- versus 18-gauge biopsy needle use (43% vs. 13.3%, P=0.19). CONCLUSION Pediatric allograft ASK biopsies can be performed with minimal adverse outcomes. Transperitoneal ASK placement is not a contraindication for percutaneous biopsy. Strategies to improve biopsy safety include recommendations for patient positioning for transperitoneal ASKs, improved techniques for real-time ultrasound guidance, and use of finer gauge needles.
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Affiliation(s)
- Jayakumar Vidhun
- Department of Pediatrics, Stanford University, Palo Alto, California 94304, USA
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Sarwal M, Chua MS, Kambham N, Hsieh SC, Satterwhite T, Masek M, Salvatierra O. Molecular heterogeneity in acute renal allograft rejection identified by DNA microarray profiling. N Engl J Med 2003; 349:125-38. [PMID: 12853585 DOI: 10.1056/nejmoa035588] [Citation(s) in RCA: 538] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The causes and clinical course of acute rejection vary, and it is not possible to predict graft outcome reliably on the basis of available clinical, pathological, and genetic markers. We hypothesized that previously unrecognized molecular heterogeneity might underlie some of the variability in the clinical course of acute renal allograft rejection and in its response to treatment. METHODS We used DNA microarrays in a systematic study of gene-expression patterns in biopsy samples from normal and dysfunctional renal allografts. A combination of exploratory and supervised bioinformatic methods was used to analyze these profiles. RESULTS We found consistent differences among the gene-expression patterns associated with acute rejection, nephrotoxic effects of drugs, chronic allograft nephropathy, and normal kidneys. The gene-expression patterns associated with acute rejection suggested at least three possible distinct subtypes of acute rejection that, although indistinguishable by light microscopy, were marked by differences in immune activation and cellular proliferation. Since the gene-expression patterns pointed to substantial variation in the composition of immune infiltrates, we used immunohistochemical staining to define these subtypes further. This analysis revealed a striking association between dense CD20+ B-cell infiltrates and both clinical glucocorticoid resistance (P=0.01) and graft loss (P<0.001). CONCLUSIONS Systematic analysis of gene-expression patterns provides a window on the biology and pathogenesis of renal allograft rejection. Biopsy samples from patients with acute rejection that are indistinguishable on conventional histologic analysis reveal extensive differences in gene expression, which are associated with differences in immunologic and cellular features and clinical course. The presence of dense clusters of B cells in a biopsy sample was strongly associated with severe graft rejection, suggesting a pivotal role of infiltrating B cells in acute rejection.
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Affiliation(s)
- Minnie Sarwal
- Department of Pediatrics, Stanford University, Stanford, Calif, USA.
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35
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Satterwhite T, Chua MS, Hsieh SC, Chang S, Scandling J, Salvatierra O, Sarwal MM. Increased expression of cytotoxic effector molecules: different interpretations for steroid-based and steroid-free immunosuppression. Pediatr Transplant 2003; 7:53-8. [PMID: 12581329 DOI: 10.1034/j.1399-3046.2003.02053.x] [Citation(s) in RCA: 31] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Cytotoxic T lymphocyte (CTL) effector molecules have been studied as markers of acute rejection in renal allograft recipients on steroid-based immunosuppression. We hypothesized that basal CTL gene expression may vary with time post-transplantation as well as with different immunosuppression protocols (steroid-based or steroid-free). Variations in CTL gene expression may thus impact on the ability to predict acute allograft rejection. We used the non-invasive method of quantitative competitive-reverse transcription-polymerase chain reaction (QC-RT-PCR) to quantify the amounts of CTL effector molecules (granulysin, GL; perforin, P; granzyme B, GB) in serial peripheral blood lymphocyte (PBL) samples from steroid-free and steroid-based adult and pediatric renal allograft recipients. Patients on both protocols were clinically monitored by protocol biopsies at 1, 3, 6, and 12 months post-transplantation and for graft function at 1 yr post-transplantation in a separate clinical study. Steroid-free patients with stable graft function showed an increase in GL, P, and GB gene expression over time post-transplantation with the increase being seen largely by the first post-transplant month. A further increase in GL expression was noted at the end of the first post-transplant year in the absence of acute rejection, whereas GB and P levels were unchanged. At comparative time-points post-transplantation, CTL genes were found to be higher in steroid-free patients with stable graft function, compared to steroid-based recipients with either clinically stable graft function or acute rejection. This study suggests that levels of CTL gene expression, although important in a steroid-based regimen to monitor the risk of acute rejection, may not be similarly applied in patients on steroid-free immunosuppression. The early increase in levels seen in steroid-free patients appears to correlate with the total absence of steroids. As steroid-free patients seem to have a lower incidence of acute rejection and better long-term graft function at 1 yr, the early increase in CTL genes in the absence of acute rejection may suggest an early adaptive immune activation response, promoting early graft acceptance in this protocol.
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MESH Headings
- Adult
- Antibodies, Monoclonal/pharmacology
- Antibodies, Monoclonal, Humanized
- Antigens, Differentiation, T-Lymphocyte/genetics
- Antigens, Differentiation, T-Lymphocyte/metabolism
- Child
- Cytotoxicity, Immunologic
- Daclizumab
- Gene Expression/drug effects
- Graft Rejection/metabolism
- Granzymes
- Humans
- Immunoglobulin G/pharmacology
- Immunosuppressive Agents/pharmacology
- Kidney Transplantation
- Membrane Glycoproteins/genetics
- Membrane Glycoproteins/metabolism
- Mycophenolic Acid/analogs & derivatives
- Mycophenolic Acid/pharmacology
- Perforin
- Pore Forming Cytotoxic Proteins
- Reverse Transcriptase Polymerase Chain Reaction
- Serine Endopeptidases/genetics
- Serine Endopeptidases/metabolism
- T-Lymphocytes, Cytotoxic/drug effects
- T-Lymphocytes, Cytotoxic/immunology
- T-Lymphocytes, Cytotoxic/metabolism
- Tacrolimus/pharmacology
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Affiliation(s)
- Thomas Satterwhite
- Department of Pediatrics, Stanford University School of Medicine, 269 Campus Drive, CCSR, Stanford, California 94305, USA
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36
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Abstract
Compromised renal function after renal allograft transplantation often results in anemia in the recipient. Molecular mechanisms leading to anemia during acute rejection are not fully understood; inadequate erythropoietin production and iron deficiency have been reported to be the main contributors. To increase our understanding of the molecular events underlying anemia in acute rejection, we analyzed the gene expression profiles of peripheral blood lymphocytes (PBL) from four pediatric renal allograft recipients with acute rejection and concurrent anemia, using DNA microarrays containing 9000 human cDNA clones (representing 7469 unique genes). In these anemic rejecting patients, an 'erythropoiesis cluster' of 11 down-regulated genes was identified, involved in hemoglobin transcription and synthesis, iron and folate binding and transport. Additionally, some alloimmune response genes were simultaneously down-regulated. An independent data set of 36 PBL samples, some with acute rejection and some with concurrence of acute rejection and anemia, were analyzed to support a possible association between acute rejection and anemia. In conclusion, analysis using DNA microarrays has identified a cluster of genes related to hemoglobin synthesis and/or erythropoeisis that was altered in kidneys with renal allograft rejection compared with normal kidneys. The possible relationship between alterations in the expression of this cluster, reduced renal function, the alloimmune process itself, and other influences on the renal transplant awaits further analysis.
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Affiliation(s)
- Mei-Sze Chua
- Department of Pediatrics, Stanford University School of Medicine, CCSR, Stanford CA, USA
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Yorgin PD, Belson A, Sanchez J, Al Uzri AY, Sarwal M, Bloch DA, Oehlert J, Salvatierra O, Alexander SR. Unexpectedly high prevalence of posttransplant anemia in pediatric and young adult renal transplant recipients. Am J Kidney Dis 2002; 40:1306-18. [PMID: 12460052 DOI: 10.1053/ajkd.2002.36910] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Although posttransplant anemia (PTA) is recognized as a common problem in adult renal transplant recipients, few pediatric studies have been published. METHODS In this retrospective cohort study of 162 pediatric renal transplant recipients treated at Stanford University, the authors sought to determine the prevalence, severity, and the predictive factors of PTA. Anemia was defined as a hematocrit (HCT) level greater than 2 SD below published means for age or as erythropoietin dependency to maintain a normal HCT. RESULTS Sixty-seven percent of pediatric renal transplant recipients were anemic at the time of transplantation. The prevalence of anemia increased to 84.3% in the first month posttransplant. From 6 months to 60 months posttransplant, the prevalence of anemia remained high at 64.2% to 82.2%. Only 4 patients (2.5%) were never anemic. Iron depletion was detected in 19 of 26 and 23 of 23 anemic patients 12 and 60 months posttransplant, respectively. Serum erythropoietin levels were low relative to hematocrit levels in 38 of 56 anemic patients. Logistic regression at 3 months posttransplant showed that discharge hematocrit level (P < 0.0001), calcium (P = 0.0004), and cyclosporine dose (P = 0.0002) correlated with anemia. Creatinine clearance (P = 0.002) and white blood cell count (P = 0.004) correlated with anemia at 12 months posttransplant, but only creatinine clearance (P = 0.011) correlated with anemia 60 months posttransplant. CONCLUSION Nearly all pediatric renal transplant recipients experience PTA. However, few children less than 2 years of age were anemic during the first year posttransplant. Antirejection therapy, bone disease, iron depletion, and creatinine clearance appear to play pivotal roles in the development of PTA in children.
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Affiliation(s)
- Peter D Yorgin
- Section of Pediatric Nephrology, Department of Pediatrics, Lucile Salter Packard Children's Hospital, Stanford University, Stanford, CA 94304, USA.
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38
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Salvatierra O. Felix Rapaport memorial lecture: moving toward a perfect transplant for pediatric kidney recipients. Transplant Proc 2002; 34:2763-5. [PMID: 12431599 DOI: 10.1016/s0041-1345(02)03400-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Oscar Salvatierra
- Pediatric Kidney Transplant and Dialysis, Stanford University Medical Center Stanford, Palo Alto, California 94301, USA
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Bartsch L, Sarwal M, Orlandi P, Yorgin PD, Salvatierra O. Limited surgical interventions in children with posterior urethral valves can lead to better outcomes following renal transplantation. Pediatr Transplant 2002; 6:400-5. [PMID: 12390427 DOI: 10.1034/j.1399-3046.2002.02025.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
There is currently no consensus as to the most appropriate means by which children with posterior urethral valves (PUV) are to be managed prior to transplantation. We compared (i) renal allograft survival and function in patients with PUV vs. those with non-obstructive causes of ESRD and (ii) graft outcomes in children who had limited interventions (Group 1) vs. those with more extensive urologic surgeries to decompress the urinary tract (Group 2). Twenty-six pediatric renal transplant recipients had ESRD due to PUV (Group 1, n = 16; Group 2, n = 10). The study group was compared to 23 matched controls with ESRD due to non-obstructive causes. Five yr patient and graft survival was similar in all patients with PUV (Groups 1 and 2) when compared to all other kidney recipients in the transplant program, 96.2% vs. 98.0% and 87.5% vs. 87.0%, respectively. Although calculated creatinine clearance (Ccr), was similar between the PUV group and controls for the first 4 yr, the 5 yr graft function was significantly lower in the PUV group. (53.7 +/- 15.7 vs. 70.2 +/- 21.0 mL/min/1.73 m2; p = 0.03). When the two PUV groups were compared, graft survival was equivalent, but graft function was significantly better at 5 yr in Group 1(60.4 +/- 10.8 vs. 33.8 +/- 9.3 mL/min/1.73 m2; p = 0.02). Thus, patients with PUV managed by a limited intervention approach of vesicostomy with delayed valve ablation or primary valve ablation, had better outcomes. When ESRD is virtually certain, additional pre-transplant surgeries affecting the urinary tract should be avoided.
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Affiliation(s)
- Leah Bartsch
- Department of Pediatrics, Section of Pediatric Nephrology, Lucile Salter Packard Children's Hospital, Stanford University, Stanford, CA 94305, USA.
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40
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Falco DA, Nepomuceno RR, Krams SM, Lee PP, Davis MM, Salvatierra O, Alexander SR, Esquivel CO, Cox KL, Frankel LR, Martinez OM. Identification of Epstein-Barr virus-specific CD8+ T lymphocytes in the circulation of pediatric transplant recipients. Transplantation 2002; 74:501-10. [PMID: 12352909 DOI: 10.1097/00007890-200208270-00012] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pediatric transplant recipients are at increased risk for Epstein Barr virus (EBV)-related B cell lymphomas. In healthy individuals, the expansion of EBV-infected B cells is controlled by CD8+ cytotoxic T cells. However, immunosuppressive therapy may compromise antiviral immunity. We identified and determined the frequency of EBV-specific T cells in the peripheral blood of pediatric transplant recipients. METHODS HLA-B*0801 and HLA-A*0201 tetramers folded with immunodominant EBV peptides were used to detect EBV-specific CD8+ T cells by flow cytometry in peripheral blood mononuclear cells from 24 pediatric liver and kidney transplant recipients. The expression of CD38 and CD45RO on EBV-specific, tetramer-binding cells was also examined in a subset of patients by immunofluorescent staining and flow cytometry. RESULTS Tetramer-binding CD8+ T cells were identified in 21 of 24 transplant recipients. EBV-specific CD8+ T cells were detected as early as 4 weeks after transplant in EBV seronegative patients receiving an organ from an EBV seropositive donor. The frequencies (expressed as a percentage of the CD8+ T cells) of the tetramer-binding cells were HLA-B8-RAKFKQLL (BZLF1 lytic antigen peptide) tetramer, range=0.96 to 3.94%; HLA-B8-FLRGRAYGL (EBNA3A latent antigen peptide) tetramer, range=0.03 to 0.59%; and HLA-A2-GLCTLVAML (BMLF1 lytic antigen peptide) tetramer, range=0.06 to 0.76%. The majority of tetramer reactive cells displayed an activated/memory phenotype. CONCLUSIONS Pediatric transplant recipients receiving immunosuppression can generate EBV-specific CD8+ T cells. Phenotypic and functional analysis of tetramer cells may prove useful in defining and monitoring EBV infection in the posttransplant patient.
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Affiliation(s)
- Daniel A Falco
- Department of Pediatrics, Stanford University School of Medicine, CA 94305, USA
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Millan MT, Shizuru JA, Hoffmann P, Dejbakhsh-Jones S, Scandling JD, Grumet FC, Tan JC, Salvatierra O, Hoppe RT, Strober S. Mixed chimerism and immunosuppressive drug withdrawal after HLA-mismatched kidney and hematopoietic progenitor transplantation. Transplantation 2002; 73:1386-91. [PMID: 12023614 DOI: 10.1097/00007890-200205150-00005] [Citation(s) in RCA: 172] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Rodents and dogs conditioned with total-lymphoid irradiation (TLI), with or without antithymocyte globulin (ATG), have been shown to develop mixed chimerism and immune tolerance without graft-versus-host disease (GVHD) after the infusion of major histocompatability complex (MHC)-mismatched donor bone marrow cells given alone or in combination with an organ allograft. METHODS Four human leukocyte antigen (HLA)-mismatched recipients of living donor kidney transplants were conditioned with TLI and ATG posttransplantation and infused with cyropreserved donor granulocyte colony-stimulating factor (G-CSF) "mobilized" hematopoietic progenitor (CD34+) cells (3-5x10(6) cells/kg) thereafter. Maintenance prednisone and cyclosporine dosages were tapered, and recipients were monitored for chimerism, GVHD, graft function, T-cell subsets in the blood, and antidonor reactivity in the mixed leukocyte reaction (MLR). RESULTS Three of the four patients achieved multilineage macrochimerism, with up to 16% of donor-type cells among blood mononuclear cells without evidence of GVHD. Prolonged depletion of CD4+ T cells was observed in all four patients. Rejection episodes were not observed in the three macrochimeric recipients, and immunosuppressive drugs were withdrawn in the first patient by 12 months. Prednisone was withdrawn from a second patient at 9 months, and cyclosporine was tapered thereafter. CONCLUSIONS Multilineage macrochimerism can be achieved without GVHD in HLA-mismatched recipients of combined kidney and hematopoietic progenitor transplants. Conditioning of the host with posttransplant TLI and ATG was nonmyeloablative and was not associated with severe infections. Recipients continue to be studied for the development of immune tolerance.
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Affiliation(s)
- Maria T Millan
- Department of Surgery, Division of Transplantation, Stanford University School of Medicine, Stanford, CA 94305, USA
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Belson A, Yorgin PD, Al-Uzri AY, Salvatierra O, Higgins J, Alexander SR. Long-term plasmapheresis and protein A column treatment of recurrent FSGS. Pediatr Nephrol 2001; 16:985-9. [PMID: 11793085 DOI: 10.1007/s004670100008] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2001] [Accepted: 06/15/2001] [Indexed: 12/01/2022]
Abstract
Transient or intermittent plasmapheresis with concurrent immunosuppressive therapy is thought to be beneficial in the treatment of recurrent focal segmental glomerulosclerosis (FSGS) in the early post-transplant period. The results of long-term (6-year) plasmapheresis therapy, in a 9-year-old female with an immediate recurrence of FSGS [urinary protein/urinary creatinine (UP/UC)=17.7] after cadaveric renal transplant, are presented. A 4-week plasmapheresis course induced a decline in the proteinuria, but a relapse occurred after cessation of plasmapheresis. Addition of protein A column therapy led to a further decrease in the proteinuria, to a non-nephrotic range. Long-term control of the nephrotic syndrome was established using a chronic treatment regimen consisting of a single-volume plasmapheresis, followed by a protein A column treatment, performed on sequential days every 3-4 weeks. Mean UP/UC values decreased to 1.15+/-0.9. A course of cyclophosphamide was successfully used to control a worsening of proteinuria 4 years post transplant. Although sequential renal biopsies demonstrated progressive glomerular sclerosis, the patient's mean calculated creatinine clearance only modestly declined from 78.3 ml/min per 1.73 m2, at the time of transplantation, to 62.7 ml/min per 1.73 m2, 6 years later. This patient demonstrated dependence on plasmapheresis/protein A column therapy to maintain a clinical remission of her FSGS recurrence. While long-term plasmapheresis and protein A column therapy in combination with immunosuppressive therapy reversed the effects of uncontrolled nephrosis and possibly facilitated long-term renal allograft survival, the glomerular sclerosis continued to progress.
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Affiliation(s)
- A Belson
- Department of Pediatrics, Section of Pediatric Nephrology, Lucile Salter Packard Children's Hospital, Stanford University, Stanford, CA 94305, USA.
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Sarwal MM, Yorgin PD, Alexander S, Millan MT, Belson A, Belanger N, Granucci L, Major C, Costaglio C, Sanchez J, Orlandi P, Salvatierra O. Promising early outcomes with a novel, complete steroid avoidance immunosuppression protocol in pediatric renal transplantation. Transplantation 2001; 72:13-21. [PMID: 11468528 DOI: 10.1097/00007890-200107150-00006] [Citation(s) in RCA: 183] [Impact Index Per Article: 8.0] [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: 01/18/2023]
Abstract
BACKGROUND Corticosteroids have been a cornerstone of immunosuppression for four decades despite their adverse side effects. Past attempts at steroid withdrawal in pediatric renal transplantation have had little success. This study tests the hypothesis that a complete steroid-free immunosuppressive protocol avoids steroid dependency for suppression of the immune response with its accompanying risk of acute rejection on steroid withdrawal. METHODS An open labeled prospective study of complete steroid avoidance immunosuppressive protocol was undertaken in 10 unsensitized pediatric recipients (ages 5-21 years; mean 14.4 years) of first renal allografts. Steroids were substituted with extended daclizumab use, in combination with tacrolimus and mycophenolate mofetil. Protocol biopsies were performed in the steroid-free group at 0, 1, 3, 6, and 12 months posttransplantation. Clinical outcomes were compared to a steroid-based group of 37 matched historical controls. RESULTS Graft and patient survival was 100% in both groups. Clinical acute rejection was absent in the steroid-free group at a mean follow-up time of 9 months (range 3-13.7 months). Protocol biopsies in the steroid-free group (includes 10 patients at 3 months, 7 at 6 months, and 4 at 12 months) revealed only two instances of mild (Banff 1A) subclinical rejection (reversed by only a nominal increase in immunosuppression) and no chronic rejection. At 6 months the steroid-free group had no hypertension requiring treatment (P=0.003), no hypercholesterolemia (P=0.007), and essentially no body disfigurement (P=0.0001). Serum creatinines, Schwartz GFR, and mean delta height Z scores trended better in the steroid-free group. In the steroid-free group, one patient had cytomegalovirus disease at 1 month and three had easily treated herpes simplex stomatitis, but with no significant increase in bacterial infections or rehospitalizations over the steroid-based group. The steroid-free group was more anemic early posttransplantation (P=0.004), suggesting an early role of steroids in erythrogenesis; erythropoietin use normalized hematocrits by 6 months. CONCLUSIONS Complete steroid-free immunosuppression is efficacious and safe in this selected group of children with no early clinical acute rejection episodes. This protocol avoids the morbid side effects of steroids without increasing infection, and may play a future critical role in avoiding noncompliance, although optimizing renal function and growth.
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Affiliation(s)
- M M Sarwal
- Department of Surgery, Stanford University Medical Center, 703 Welch Road, Suite H-5, Palo Alto, CA 94304, USA
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Desai DM, Scandling JD, Alfrey EJ, Pavlakis M, Salvatierra O, Conley SB, Tanney DC, Dafoe DC. Kidney and kidney/pancreas transplantation at Stanford University Medical Center. Clin Transpl 2001:135-47. [PMID: 9919398] [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] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
The disparity between the supply of cadaveric donors and the demand for renal allografts continues to grow. We have taken a multifaceted approach to increase the allograft pool: 1. Spiral computed tomography to evaluate potential living kidney donors is safer, less invasive, less expensive and more time efficient and thus should encourage living organ donation. 2. Use of selected expanded criteria cadaveric donor kidneys (aged 60 or over, hypertensive) in size- and age-matched recipients have short-term function at 3 and 6 months comparable to standard cadaveric renal allografts. 3. Kidneys from expanded criteria donors over age 59 and with an adjusted creatinine clearance less than 90 ml/min should be used as a dual kidney transplant into an appropriate sized- and aged-matched recipient. 4. Kidneys from pediatric donors < 5 years of age should be utilized as en-bloc grafts, when transplanted into adult recipients. Pediatric renal transplantation poses numerous challenges given the different and problematic etiologies of ESRD, the surgical considerations in small children and infants and the enhanced immune response witnessed in children. Nevertheless, renal transplantation is clearly the therapy of choice for children with ESRD and excellent results can be obtained through strict adherence to surgical detail, tight immunosuppressive management, and aggressive fluid management in infants and small children. We feel it is also critically important that transplantation and follow-up care be carried out by an integrated and experienced surgical and medical team. Managed healthcare has had profound effects on the practice and management of transplantation centers. The one area of greatest impact has been the pressure upon programs to reduce their cost of transplantation. We have initiated a number of new outpatient treatment protocols as part of an effort to contain costs. Most patients with acute rejection are evaluated (including transplant kidney biopsy) and treated in an ambulatory setting. Completion of OKT3 therapy in selected patients is also performed at home through visiting nurses or at our ambulatory care center. Additionally, treatment of CMV disease is now performed almost exclusively on an outpatient basis.
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Affiliation(s)
- D M Desai
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
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Salvatierra O. Special welcome message from the president. Transplant Proc 2001. [DOI: 10.1016/s0041-1345(01)01919-4] [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: 10/18/2022]
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Affiliation(s)
- O Salvatierra
- Stanford University Medical Center, Palo Alto, California, USA
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Affiliation(s)
- M Sarwal
- Department of Pediatrics (M.S., S.C.), Stanford University, Stanford, California, USA
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Sarwal MM, Jani A, Chang S, Huie P, Wang Z, Salvatierra O, Clayberger C, Sibley R, Krensky AM, Pavlakis M. Granulysin expression is a marker for acute rejection and steroid resistance in human renal transplantation. Hum Immunol 2001; 62:21-31. [PMID: 11165712 DOI: 10.1016/s0198-8859(00)00228-7] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Differentiating etiologies of transplant dysfunction without biopsy and optimizing therapy for acute rejection by predicting steroid resistance will reduce patient morbidity. Granulysin is a cytolytic molecule released by CTL and NK cells and coexpressed with effectors of acute allograft rejection, like perforin and granzymes. Granulysin mRNA and protein expression were studied in peripheral blood lymphocytes (PBL; n = 61 total, n = 10 with intercurrent infections) and biopsy tissue from adult and children renal transplant recipients (n = 97) by competitive quantitative-reverse transcriptase-PCR (QC-RT-PCR) and immunohistochemistry. Differences in cell phenotypes were studied in steroid sensitive and resistant acute rejection biopsies. Granulysin was studied in phytohemagglutinin (PHA) stimulated cell lines (donor PBL and CD45RO(+) T cells) by FACS, Western blotting, and RT-PCR after pretreating with cyclosporine A (CSA), azathioprine, mycophenolic acid, and steroids. Granulysin mRNA was significantly increased in patient PBL and transplant biopsies during acute rejection (p < 0.0001) and infection (p < 0.001). Rejecting biopsies alone (n = 53) had mononuclear cell granulysin staining. Steroid resistant biopsies (n = 25) had denser granulysin staining (>2 cells/high power field) and CD45RO(+) lymphocytes, when compared with steroid sensitive (n = 28) rejecting tissue. Granulysin levels were unchanged after azathioprine and mycophenolic acid treatment, decreased after treating activated PBL with steroids and cyclosporine A (CSA), and paradoxically, increased (p < 0.05) after treating CD45RO(+) CTL with CSA. Elevated PBL granulysin is a peripheral marker for acute rejection and infection and dense granulysin staining a tissue marker for steroid resistance. Memory CTL abound in steroid resistant grafts and may have a markedly different response to CSA immunotherapy, suggesting a possible mechanism for steroid resistance.
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Affiliation(s)
- M M Sarwal
- Department of Pediatrics, Stanford University, Stanford, CA 94305, USA.
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