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Wiseman A, Alhamad T, Alloway RR, Concepcion BP, Cooper M, Formica R, Klein CL, Kumar V, Leca N, Shihab F, Taber DJ, Mulnick S, Bushnell DM, Hadi M, Bunnapradist S. Use of LCP-Tacrolimus (LCPT) in Kidney Transplantation: A Delphi Consensus Survey of Expert Clinicians. Ann Transplant 2024; 29:e943498. [PMID: 38526543 PMCID: PMC10944009 DOI: 10.12659/aot.943498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/06/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND LCPT (Envarsus XR®) is a common once-daily, extended-release oral tacrolimus formulation used in kidney transplantation. However, there are minimal evidence-based recommendations regarding optimal dosing and treatment in the de novo and conversion settings. MATERIAL AND METHODS Using Delphi methodology, 12 kidney transplantation experts with LCPT experience reviewed available data to determine potential consensus topics. Key statements regarding LCPT use were generated and disseminated to the panel in an online Delphi survey. Statements were either accepted, revised, or rejected based on the level of consensus, perceived strength of evidence, and alignment with clinical practice. Consensus was defined a priori as ≥75% agreement. RESULTS Twenty-three statements were generated: 14 focused on de novo LCPT use and 9 on general administration or LCPT conversion use. After 2 rounds, consensus was achieved for 11/14 of the former and 7/9 of the latter statements. In a de novo setting, LCPT was recognized as a first-line option based on its safety and efficacy compared to immediate-release tacrolimus. In particular, African Americans and rapid metabolizer populations were identified as preferred for first-line LCPT therapy. In a conversion setting, full consensus was achieved for converting to LCPT to address neurological adverse effects related to immediate-release tacrolimus and for the time required (approximately 7 days) for steady-state LCPT trough levels to be reached. CONCLUSIONS When randomized clinical trials do not replicate current utilization patterns, the Delphi process can successfully generate consensus statements by expert clinicians to inform clinical decision-making for the use of LCPT in kidney transplant recipients.
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Affiliation(s)
- Alexander Wiseman
- AdventHealth Transplant Institute, Porter Adventist Hospital, Denver, CO, USA
| | - Tarek Alhamad
- Division of Nephrology, Washington University School of Medicine in St. Louis, Saint Louis, MO, USA
| | - Rita R. Alloway
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Matthew Cooper
- Transplant Center – Center for Advanced Care – Froedtert Hospital, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Richard Formica
- Yale New Haven Transplantation Center, Yale University School of Medicine, New Haven, CT, USA
| | - Christina L. Klein
- Department of Transplant Nephrology, Piedmont Transplant Institute, Atlanta, GA, USA
| | - Vineeta Kumar
- Renal Transplant Program, University of Alabama at Birmingham Hospital, Birmingham, AL, USA
| | - Nicolae Leca
- Kidney Care and Transplantation Services, University of Washington, Seattle, WA, USA
| | - Fuad Shihab
- Kidney and Liver Clinic, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - David J. Taber
- Transplant Immunobiology Laboratory, Medical University of South Carolina, Charleston, SC, USA
| | - Sarah Mulnick
- Patient-Centered Research, Evidera, Bethesda, MD, USA
| | | | - Monica Hadi
- Patient-Centered Research, Evidera, London, United Kingdom
| | - Suphamai Bunnapradist
- Division of Nephrology and Department of Medicine, David Geffen School of Medicine, Los Angeles, CA, USA
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Gonzalez Sepulveda JM, Mehrotra S, Yang JC, Schantz KJ, Becker Y, Formica R, Ladner DP, Kaufman D, Friedewald J. Physician Preferences when Selecting Candidates for Lower-Quality Kidney Offers. Clin J Am Soc Nephrol 2023; 18:1599-1609. [PMID: 37729938 PMCID: PMC10723918 DOI: 10.2215/cjn.0000000000000302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 09/14/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND In the United States, more than 50% of kidneys in the lowest 15% quality range (those with Kidney Donor Profile Index >85) are discarded. Studies suggest that using more of these kidneys could benefit patients waiting for a transplant. This study assesses the trade-offs physicians make when selecting recipients for lower-quality kidneys. METHODS A discrete choice experiment (DCE) was administered to surgeons and nephrologists in the United States who are involved in kidney acceptance decisions. The DCE presented kidneys that varied in terms of Kidney Donor Profile Index, expected cold ischemia time, donor age, pump parameters, serum creatinine levels, glomerulosclerosis, donor diabetes status, and whether donation was made after circulatory death. Candidate characteristics included recipients' age, diabetes history, time on dialysis, ejection fraction, HLA mismatch, calculated panel reactive antibody, and Karnofsky performance score. Regression analysis was used to estimate acceptability weights associated with kidney and recipient characteristics. RESULTS A total of 108 physicians completed the DCE. The likelihood of acceptance was significantly lower with deterioration of kidney quality, expected cold ischemia time at transplantation, and missing biopsy and pump information. Acceptance was prioritized for patients who were higher on the waiting list, younger recipients, those who have spent less time on dialysis, and those without a history of diabetes. Performance status (Karnofsky score) and calculated panel reactive antibody also had a statistically significant but smaller association. Finally, ejection fraction had a marginally significant association, and HLA match had no significant association with the acceptance of marginal kidneys. A group of respondents were found to be primarily concerned about cold ischemia time. CONCLUSIONS In this DCE, physicians considered the recipient characteristics that inform expected post-transplant survival score when they decided whether to accept a marginal kidney for a given recipient.
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Affiliation(s)
- Juan M. Gonzalez Sepulveda
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sanjay Mehrotra
- Industrial Engineering and Management Sciences, McCormick School of Engineering, Northwestern University, Evanston, Illinois
| | - Jui-Chen Yang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - Yolanda Becker
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Richard Formica
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Daniela P. Ladner
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Dixon Kaufman
- University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - John Friedewald
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Hricik DE, Armstrong B, Alhamad T, Brennan DC, Bromberg JS, Bunnapradist S, Chandran S, Fairchild RL, Foley DP, Formica R, Gibson IW, Kesler K, Kim SJ, Mannon RB, Menon MC, Newell KA, Nickerson P, Odim J, Poggio ED, Sung R, Shapiro R, Tinckam K, Vincenti F, Heeger PS. Infliximab Induction Lacks Efficacy and Increases BK Virus Infection in Deceased Donor Kidney Transplant Recipients: Results of the CTOT-19 Trial. J Am Soc Nephrol 2023; 34:145-159. [PMID: 36195441 PMCID: PMC10101585 DOI: 10.1681/asn.2022040454] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 04/18/2022] [Revised: 09/09/2022] [Accepted: 09/16/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Ischemia-reperfusion (IR) of a kidney transplant (KTx) upregulates TNF α production that amplifies allograft inflammation and may negatively affect transplant outcomes. METHODS We tested the effects of blocking TNF peri-KTx via a randomized, double-blind, placebo-controlled, 15-center, phase 2 clinical trial. A total of 225 primary transplant recipients of deceased-donor kidneys (KTx; 38.2% Black/African American, 44% White) were randomized to receive intravenous infliximab (IFX) 3 mg/kg or saline placebo (PLBO) initiated before kidney reperfusion. All patients received rabbit anti-thymocyte globulin induction and maintenance immunosuppression (IS) with tacrolimus, mycophenolate mofetil, and prednisone. The primary end point was the difference between groups in mean 24-month eGFR. RESULTS There was no difference in the primary end point of 24-month eGFR between IFX (52.45 ml/min per 1.73 m 2 ; 95% CI, 48.38 to 56.52) versus PLBO (57.35 ml/min per 1.73 m 2 ; 95% CI, 53.18 to 61.52; P =0.1). There were no significant differences between groups in rates of delayed graft function, biopsy-proven acute rejection (BPAR), development of de novo donor-specific antibodies, or graft loss/death. Immunosuppression did not differ, and day 7 post-KTx plasma analyses showed approximately ten-fold lower TNF ( P <0.001) in IFX versus PLBO. BK viremia requiring IS change occurred more frequently in IFX (28.9%) versus PLBO (13.4%; P =0.004), with a strong trend toward higher rates of BKV nephropathy in IFX (13.3%) versus PLBO (4.9%; P =0.06). CONCLUSIONS IFX induction therapy does not benefit recipients of kidney transplants from deceased donors on this IS regimen. Because the intervention unexpectedly increased rates of BK virus infections, our findings underscore the complexities of targeting peritransplant inflammation as a strategy to improve KTx outcomes.Clinical Trial registry name and registration number:clinicaltrials.gov (NCT02495077).
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Affiliation(s)
- Donald E Hricik
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - Tarek Alhamad
- Department of Medicine, Washington University, Saint Louis, Missouri
| | | | | | | | - Sindhu Chandran
- Departments of Medicine and Surgery, University of California, San Francisco, California
| | - Robert L Fairchild
- Glickman Urological and Kidney Institute and the Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - David P Foley
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Richard Formica
- Departments of Medicine and Surgery, Yale University, New Haven, Connecticut
| | - Ian W Gibson
- Departments of Medicine and Pathology, University of Manitoba, Winnipeg, Canada
| | | | - S Joseph Kim
- Department of Medicine, University Health Network, Toronto, Canada
| | - Roslyn B Mannon
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Madhav C Menon
- Departments of Medicine and Surgery, Yale University, New Haven, Connecticut
| | | | - Peter Nickerson
- Departments of Medicine and Pathology, University of Manitoba, Winnipeg, Canada
| | - Jonah Odim
- Transplant Branch, Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland
| | - Emilio D Poggio
- Glickman Urological and Kidney Institute and the Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Randall Sung
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Ron Shapiro
- Departments of Medicine, Icahn School of Medicine at Mount Sinai and Recanati Miller Transplant Institute, Mount Sinai Hospital, New York, New York
| | - Kathryn Tinckam
- Department of Medicine, University Health Network, Toronto, Canada
| | - Flavio Vincenti
- Departments of Medicine and Surgery, University of California, San Francisco, California
| | - Peter S Heeger
- Departments of Medicine, Icahn School of Medicine at Mount Sinai and Recanati Miller Transplant Institute, Mount Sinai Hospital, New York, New York
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4
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Chancay J, Liu C, Chauhan K, Andersen L, Harris C, Coca S, Delaney V, Tedla F, De Boccardo G, Sehgal V, Moledina D, Formica R, Reghuvaran A, Banu K, Florman S, Akalin E, Shapiro R, Salem F, Menon MC. Role of time from transplantation to biopsy in histologic ABMR: A single center report. Clin Transplant 2022; 36:e14802. [PMID: 36069577 PMCID: PMC10211409 DOI: 10.1111/ctr.14802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 06/24/2022] [Accepted: 08/19/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Allograft biopsies with lesions of Antibody-Mediated Rejection (ABMR) with Microvascular Inflammation (MVI) have shown heterogeneous etiologies and outcomes. METHODS To examine factors associated with outcomes in biopsies that meet histologic ABMR criteria, we retrospectively evaluated for-cause biopsies at our center between 2011 and 2017. We included biopsies that met the diagnosis of ABMR by histology, along with simultaneous evaluation for anti-Human Leukocyte Antigen (HLA) donor-specific antibodies (DSA). We evaluated death-censored graft loss (DCGL) and used a principal component analysis (PCA) approach to identify key predictors of outcomes. RESULTS Out of the histologic ABMR cohort (n = 118), 70 were DSA-positive ABMR, while 48 had no DSA. DSA(+)ABMR were younger and more often female recipients. DSA(+)ABMR occurred significantly later post-transplant than DSA(-)ABMR suggesting time-dependence. DSA(+)ABMR had higher inflammatory scores (i,t), chronicity scores (ci, ct) and tended to have higher MVI scores. Immunodominance of DQ-DSA in DSA(+)ABMR was associated with higher i+t scores. Clinical/histologic factors significantly associated with DCGL after biopsy were inputted into the PCA. Principal component-1 (PC-1), which contributed 34.8% of the variance, significantly correlated with time from transplantation to biopsy, ci/ct scores and DCGL. In the PCA analyses, i, t scores, DQ-DSA, and creatinine at biopsy retained significant correlations with GL-associated PCs. CONCLUSIONS Time from transplantation to biopsy plays a major role in the prognosis of biopsies with histologic ABMR and MVI, likely due to ongoing chronic allograft injury over time.
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Affiliation(s)
- Jorge Chancay
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Caroline Liu
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Kinsuk Chauhan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Lisa Andersen
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Cynthia Harris
- Transplant Center at Massachusetts General Hospital, Harvard Medical School, Cambridge, MA, United States
| | - Steven Coca
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Veronica Delaney
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Fasika Tedla
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Graciela De Boccardo
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Vinita Sehgal
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Dennis Moledina
- Yale New Haven Transplantation Center, Yale School of Medicine, New Haven, CT, United States
| | - Richard Formica
- Yale New Haven Transplantation Center, Yale School of Medicine, New Haven, CT, United States
| | - Anand Reghuvaran
- Yale New Haven Transplantation Center, Yale School of Medicine, New Haven, CT, United States
| | - Khadija Banu
- Yale New Haven Transplantation Center, Yale School of Medicine, New Haven, CT, United States
| | - Sander Florman
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Enver Akalin
- Montefiore Einstein Center for Transplantation, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Ron Shapiro
- Transplant Center at Massachusetts General Hospital, Harvard Medical School, Cambridge, MA, United States
| | - Fadi Salem
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Madhav C Menon
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Yale New Haven Transplantation Center, Yale School of Medicine, New Haven, CT, United States
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5
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Marvin JE, Azar MM, Belfield KD, Do V, Formica R, Cohen EA. Overall Infectious Complications Related to Belatacept Conversion in Comparison to Tacrolimus in Kidney Transplant Recipients. Prog Transplant 2022; 32:351-356. [PMID: 36039533 DOI: 10.1177/15269248221122894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction: Belatacept has demonstrated effectiveness for preventing rejection in kidney transplant and has a favorable side effect profile. Studies assessing long-term infectious complications with belatacept compared to tacrolimus are limited. Project Aims: The purpose of this program evaluation was to determine the proportion of patients who developed an infection when converted to belatacept compared to those on tacrolimus. Design: In this retrospective evaluation, kidney transplant recipients receiving belatacept were matched 1:1 to those receiving tacrolimus, based on transplant date, age, induction immunosuppression, and cytomegalovirus risk. Data collection was initiated in tacrolimus patients on the date of belatacept conversion in the belatacept-matched patients. Data were extracted until study conclusion, death, or discontinuation of belatacept. Patients were stratified into 3 groups based on time of conversion posttransplant, which included early, late, and very late conversion. The primary outcome was the proportion of patients with an infection in belatacept compared to tacrolimus. Outcome data were calculated using chi-square, Fisher's exact test, student's t-test or Mann-Whitney U test where appropriate. Results: A total of 328 matched patients were included in the analysis. More patients on belatacept developed an infection compared to tacrolimus (42.7% vs 29.9%, P = 0.02), which was primarily driven by pneumonia (6.1% vs 0.5%; P = 0.01). Higher incidences of infections were identified in those converted within 6 months from transplant. Conclusions: Belatacept was associated with a higher proportion of patients with infections compared to tacrolimus, particularly in those converted within 6 months from time of transplant.
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Affiliation(s)
- Jennifer E Marvin
- Department of Pharmacy, 25047Yale New Haven Hospital, New Haven, CT, USA
| | - Marwan M Azar
- Section of Infectious Diseases, 12228Yale School of Medicine, New Haven, CT, USA
| | - Kristen D Belfield
- Department of Pharmacy, 25047Yale New Haven Hospital, New Haven, CT, USA
| | - Vincent Do
- Department of Pharmacy, 25047Yale New Haven Hospital, New Haven, CT, USA
| | - Richard Formica
- Section of Nephrology, Yale School of Medicine, New Haven, CT, USA
| | - Elizabeth A Cohen
- Department of Pharmacy, 25047Yale New Haven Hospital, New Haven, CT, USA
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Sun Z, Zhang Z, Banu K, Azzi YA, Reghuvaran A, Fredericks S, Planoutene M, Hartzell S, Kim Y, Pell J, Tietjen G, Asch W, Kulkarni S, Formica R, Rana M, Maltzman JS, Zhang W, Akalin E, Heeger PS, Cravedi P, Menon MC. Blood Transcriptomes of SARS-CoV-2-Infected Kidney Transplant Recipients Associated with Immune Insufficiency Proportionate to Severity. J Am Soc Nephrol 2022; 33:2108-2122. [PMID: 36041788 PMCID: PMC9678030 DOI: 10.1681/asn.2022010125] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 01/31/2022] [Accepted: 07/10/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Among patients with COVID-19, kidney transplant recipients (KTRs) have poor outcomes compared with non-KTRs. To provide insight into management of immunosuppression during acute illness, we studied immune signatures from the peripheral blood during and after COVID-19 infection from a multicenter KTR cohort. METHODS We ascertained clinical data by chart review. A single sample of blood was collected for transcriptome analysis. Total RNA was poly-A selected and RNA was sequenced to evaluate transcriptome changes. We also measured cytokines and chemokines of serum samples collected during acute infection. RESULTS A total of 64 patients with COVID-19 in KTRs were enrolled, including 31 with acute COVID-19 (<4 weeks from diagnosis) and 33 with post-acute COVID-19 (>4 weeks postdiagnosis). In the blood transcriptome of acute cases, we identified genes in positive or negative association with COVID-19 severity scores. Functional enrichment analyses showed upregulation of neutrophil and innate immune pathways but downregulation of T cell and adaptive immune activation pathways. This finding was independent of lymphocyte count, despite reduced immunosuppressant use in most KTRs. Compared with acute cases, post-acute cases showed "normalization" of these enriched pathways after 4 weeks, suggesting recovery of adaptive immune system activation despite reinstitution of immunosuppression. Analysis of the non-KTR cohort with COVID-19 showed significant overlap with KTRs in these functions. Serum inflammatory cytokines followed an opposite trend (i.e., increased with disease severity), indicating that blood lymphocytes are not the primary source. CONCLUSIONS The blood transcriptome of KTRs affected by COVID-19 shows decreases in T cell and adaptive immune activation pathways during acute disease that, despite reduced immunosuppressant use, associate with severity. These pathways show recovery after acute illness.
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Affiliation(s)
- Zeguo Sun
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Zhongyang Zhang
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
- Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Khadija Banu
- Division of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Yorg Al Azzi
- Montefiore Einstein Center for Transplantation, Albert Einstein College of Medicine, Bronx, New York
| | - Anand Reghuvaran
- Division of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Samuel Fredericks
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marina Planoutene
- Division of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Susan Hartzell
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Yesl Kim
- Geriatric Research Education and Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - John Pell
- Division of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Gregory Tietjen
- Department of Surgery, Yale University school of Medicine, New Haven, Connecticut
| | - William Asch
- Division of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Sanjay Kulkarni
- Department of Surgery, Yale University school of Medicine, New Haven, Connecticut
| | - Richard Formica
- Division of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Meenakshi Rana
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jonathan S. Maltzman
- Geriatric Research Education and Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Division of Nephrology, Department of Medicine, Stanford University, Palo Alto, California
| | - Weijia Zhang
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Enver Akalin
- Montefiore Einstein Center for Transplantation, Albert Einstein College of Medicine, Bronx, New York
| | - Peter S. Heeger
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Paolo Cravedi
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Madhav C. Menon
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Division of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
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7
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Sun Z, Zhang Z, Banu K, Azzi YA, Reghuvaran A, Fredericks S, Planoutene M, Hartzell S, Pell J, Tietjen G, Asch W, Kulkarni S, Formica R, Rana M, Zhang W, Akalin E, Cravedi P, Heeger PS, Menon MC. Blood transcriptomes of SARS-CoV-2 infected kidney transplant recipients demonstrate immune insufficiency. medRxiv 2022:2022.01.31.22270203. [PMID: 35132424 PMCID: PMC8820676 DOI: 10.1101/2022.01.31.22270203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Kidney transplant recipients (KTRs) with COVID-19 have poor outcomes compared to non-KTRs. To provide insight into management of immunosuppression during acute illness, we studied immune signatures from the peripheral blood during and after COVID-19 infection from a multicenter KTR cohort.□. METHODS Clinical data were collected by chart review. PAXgene blood RNA was poly-A selected and RNA sequencing was performed to evaluate transcriptome changes. RESULTS A total of 64 cases of COVID-19 in KTRs were enrolled, including 31 acute cases (< 4 weeks from diagnosis) and 33 post-acute cases (>4 weeks). In the blood transcriptome of acute cases, we identified differentially expressed genes (DEGs) in positive or negative association COVID-19 severity scores. Functional enrichment analyses showed upregulation of neutrophil and innate immune pathways, but downregulation of T-cell and adaptive immune-activation pathways proportional to severity score. This finding was independent of lymphocyte count and despite reduction in immunosuppression (IS) in most KTRs. Comparison with post-acute cases showed "normalization" of these enriched pathways after >4 weeks, suggesting recovery of adaptive immune system activation despite reinstitution of IS. The latter analysis was adjusted for COVID-19 severity score and lymphocyte count. DEGs associated with worsening disease severity in a non-KTR cohort with COVID-19 (GSE152418) showed significant overlap with KTRs in these identified enriched pathways. CONCLUSION Blood transcriptome of KTRs affected by COVID-19 shows decrease in T-cell and adaptive immune activation pathways during acute disease that associate with severity despite IS reduction and show recovery after acute illness. SIGNIFICANCE STATEMENT Kidney transplant recipients (KTRs) are reported to have worse outcomes with COVID-19, and empiric reduction of maintenance immunosuppression is pursued. Surprisingly, reported rates of acute rejection have been low despite reduced immunosuppression. We evaluated the peripheral blood transcriptome of 64 KTRs either during or after acute COVID-19. We identified transcriptomic signatures consistent with suppression of adaptive T-cell responses which significantly associated with disease severity and showed evidence of recovery after acute disease, even after adjustment for lymphocyte number. Our transcriptomic findings of immune-insufficiency during acute COVID-19 provide an explanation for the low rates of acute rejection in KTRs despite reduced immunosuppression. Our data support the approach of temporarily reducing T -cell-directed immunosuppression in KTRs with acute COVID-19.
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Miller PE, Mullan CW, Chouairi F, Sen S, Clark KA, Reinhardt S, Fuery M, Anwer M, Geirsson A, Formica R, Rogers JG, Desai NR, Ahmad T. Mechanical ventilation at the time of heart transplantation and associations with clinical outcomes. Eur Heart J Acute Cardiovasc Care 2021; 10:843-851. [PMID: 34389855 DOI: 10.1093/ehjacc/zuab063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/25/2021] [Accepted: 07/09/2021] [Indexed: 11/13/2022]
Abstract
AIMS The impact of mechanical ventilation (MV) at the time of heart transplantation is not well understood. In addition, MV was recently removed as a criterion from the new US heart transplantation allocation system. We sought to assess for the association between MV at transplantation and 1-year mortality. METHODS AND RESULTS We utilized the United Network for Organ Sharing database and included all adult, single organ heart transplantations from 1990 to 2019. We utilized multivariable logistic regression adjusting for demographics, comorbidities, and markers of clinical acuity. We identified 60 980 patients who underwent heart transplantation, 2.4% (n = 1431) of which required MV at transplantation. Ventilated patients were more likely to require temporary mechanical support, previous dialysis, and had a shorter median waitlist time (21 vs. 95 days, P < 0.001). At 1 year, the mortality was 33.7% (n = 484) for ventilated patients and 11.7% (n = 6967) for those not ventilated at the time of transplantation (log-rank P < 0.001). After multivariable adjustment, patients requiring MV continued to have a substantially higher 90-day [odds ratio (OR) 3.20, 95% confidence interval (CI): 2.79-3.66, P < 0.001] and 1-year mortality (OR 2.67, 95% CI: 2.36-3.03, P < 0.001). For those that survived to 90 days, the adjusted mortality at 1 year continued to be higher (OR 1.48, 95% CI: 1.16-1.89, P = 0.002). CONCLUSION We found a strong association between the presence of MV at heart transplantation and 90-day and 1-year mortality. Future studies are needed to identify which patients requiring MV have reasonable outcomes, and which are associated with substantially poorer outcomes.
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Affiliation(s)
- P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA.,Yale National Clinicians Scholar Program, New Haven, CT, USA
| | - Clancy W Mullan
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Fouad Chouairi
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Sounok Sen
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Katherine A Clark
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Samuel Reinhardt
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Michael Fuery
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Muhammad Anwer
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Richard Formica
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA.,Section of Nephrology, Yale School of Medicine, New Haven, CT, USA
| | - Joseph G Rogers
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
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9
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Mullan CW, Chouairi F, Sen S, Mori M, Clark KAA, Reinhardt SW, Miller PE, Fuery MA, Jacoby D, Maulion C, Anwer M, Geirsson A, Mulligan D, Formica R, Rogers JG, Desai NR, Ahmad T. Changes in Use of Left Ventricular Assist Devices as Bridge to Transplantation With New Heart Allocation Policy. JACC Heart Fail 2021; 9:420-429. [PMID: 33714748 DOI: 10.1016/j.jchf.2021.01.010] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The goal of this study was to describe outcomes of patients with bridge to heart transplantation (BTT) after changes were made to the donor heart allocation system. BACKGROUND Left ventricular assist devices (LVADs) have been used as a BTT. On October 18, 2018, the donor heart allocation system in the United States was updated. METHODS This study identified adults in the United Network for Organ Sharing database with durable, continuous-flow LVAD at listing or implanted while listed between April 2017 and April 2020. Baseline recipient and donor characteristics, waitlist survival, and post-transplantation outcomes were compared pre- and post-allocation system change. RESULTS A total of 1,794 patients met inclusion criteria: 983 in the pre-change period and 814 afterward. The number of patients listed with LVAD decreased nationally over time from 102 in April 2017 to 12 in April 2020 (p < 0.001). The proportion of patients with LVAD at time of transplant decreased from 47% to 14%. Before the change, the majority were Status 1A (75.8%) at transplantation; afterward, most were Status 2/3 (67.8%). Transplantation rates were not different (85.4% vs. 83.6%; p = 0.225), but waitlist time decreased in the post period (82 vs. 65 days; p = 0.004). Donors were more likely to be high risk (39.0% vs. 32.2%; p = 0.005), and both ischemic times and distance traveled increased (3.4 h vs. 3.1 h; p < 0.001; 199 miles vs. 82 miles; p < 0.001). Waitlist survival did not change, but post-transplantation survival was worse in patients with BTT post-change (p < 0.001). CONCLUSIONS The number of patients with BTT on the transplant list decreased steadily and dramatically after the allocation system change. Although time to transplant decreased, there was an increase in post-transplant mortality. These data suggest that the risks and benefits of LVAD implantation as a BTT have changed under the new allocation system and that the appropriate indication for this treatment strategy warrants a re-evaluation.
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Affiliation(s)
- Clancy W Mullan
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA.
| | - Fouad Chouairi
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sounok Sen
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Makoto Mori
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Katherine A A Clark
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Samuel W Reinhardt
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael A Fuery
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Daniel Jacoby
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Christopher Maulion
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Muhammad Anwer
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - David Mulligan
- Division of Transplantation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Richard Formica
- Division of Transplantation, Yale School of Medicine, New Haven, Connecticut, USA; Section of Nephrology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Joseph G Rogers
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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10
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Chouairi F, Mullan CW, Sen S, Mori M, Fuery M, Elder RW, Lesse J, Norton K, Clark KA, Miller PE, Mulligan D, Formica R, Rogers JG, Jacoby D, Maulion C, Anwer M, Geirsson A, Desai NR, Ahmad T. Impact of the new heart allocation policy on patients with restrictive, hypertrophic, or congenital cardiomyopathies. PLoS One 2021; 16:e0247789. [PMID: 33651802 PMCID: PMC7924739 DOI: 10.1371/journal.pone.0247789] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/15/2021] [Indexed: 02/06/2023] Open
Abstract
Background Patients with restrictive or hypertrophic cardiomyopathy (RCM/HCM) and congenital heart disease (CHD) do not derive clinical benefit from inotropes and mechanical circulatory support. Concerns were expressed that the new heart allocation system implemented in October 2018 would disadvantage these patients. This paper aimed to examine the impact of the new adult heart allocation system on transplantation and outcomes among patients with RCM/HCM/CHD. Methods We identified adult patients with RCM/HCM/CHD in the United Network for Organ Sharing (UNOS) database who were listed for or received a cardiac transplant from April 2017-June 2020. The cohort was separated into those listed before and after allocation system changes. Demographics and recipient characteristics, donor characteristics, waitlist survival, and post-transplantation outcomes were analyzed. Results The number of patients listed for RCM/HCM/CHD increased after the allocation system change from 429 to 517. Prior to the change, the majority RCM/HCM/CHD patients were Status 1A at time of transplantation; afterwards, most were Status 2. Wait times decreased significantly for all: RCM (41 days vs 27 days; P<0.05), HCM (55 days vs 38 days; P<0.05), CHD (81 days vs 49 days; P<0.05). Distance traveled increased for all: RCM (76 mi. vs 261 mi, P<0.001), HCM (88 mi. vs 231 mi. P<0.001), CHD (114 mi vs 199 mi, P<0.05). Rates of transplantation were higher for RCM and CHD (P<0.01), whereas post-transplant survival remained unchanged. Conclusions The new allocation system has had a positive impact on time to transplantation of patients with RCM, HCM, and CHD without negatively influencing survival.
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Affiliation(s)
- Fouad Chouairi
- Yale School of Medicine, New Haven, Connecticut, United States of America
- * E-mail: (TA); (FC)
| | - Clancy W. Mullan
- Yale School of Medicine, New Haven, Connecticut, United States of America
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Sounok Sen
- Yale School of Medicine, New Haven, Connecticut, United States of America
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Makoto Mori
- Yale School of Medicine, New Haven, Connecticut, United States of America
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Michael Fuery
- Yale School of Medicine, New Haven, Connecticut, United States of America
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Robert W. Elder
- Section of Pediatric Cardiology, Yale School of Medicine, New Haven, Connecticut, United States of America
- Division of Transplantation, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Joshua Lesse
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Kelsey Norton
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Katherine A. Clark
- Yale School of Medicine, New Haven, Connecticut, United States of America
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - P. Elliott Miller
- Yale School of Medicine, New Haven, Connecticut, United States of America
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - David Mulligan
- Yale School of Medicine, New Haven, Connecticut, United States of America
- Division of Transplantation, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Richard Formica
- Yale School of Medicine, New Haven, Connecticut, United States of America
- Section of Nephrology, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Joseph G. Rogers
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Daniel Jacoby
- Yale School of Medicine, New Haven, Connecticut, United States of America
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Christopher Maulion
- Yale School of Medicine, New Haven, Connecticut, United States of America
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Muhammad Anwer
- Yale School of Medicine, New Haven, Connecticut, United States of America
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Arnar Geirsson
- Yale School of Medicine, New Haven, Connecticut, United States of America
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Nihar R. Desai
- Yale School of Medicine, New Haven, Connecticut, United States of America
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Tariq Ahmad
- Yale School of Medicine, New Haven, Connecticut, United States of America
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
- * E-mail: (TA); (FC)
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11
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Girone G, Cohen E, Hartell S, Formica R, Klarman S. Levothyroxine-Induced Nonischemic Cardiomyopathy in a Kidney Transplant Candidate. Ann Pharmacother 2020; 54:1260-1262. [DOI: 10.1177/1060028020928957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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12
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Haakinson DJ, Tzvetanov IG, Turner A, Deshpande R, Formica R, Kulkarni S, Benedetti E, Mulligan DC. The Development of a Comprehensive Multi-Institutional, Multi-Disciplinary Infrastructure for the Successful Implementation of a Robotic-Assisted Kidney Transplant (RAKT) Program. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.08.597] [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: 10/23/2022]
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13
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Mehrotra S, Schantz K, Friedewald JJ, Ladner DP, Becker Y, Formica R, Barah M, Gu J, Gordon EJ. Physician and patient acceptance of policies to reduce kidney discard. Clin Transplant 2020; 34:e14054. [PMID: 32738167 PMCID: PMC7929781 DOI: 10.1111/ctr.14054] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 12/14/2022]
Abstract
Despite the shortage of kidneys for transplantation in the United States, approximately 18%‐20% of deceased donor kidneys are discarded each year. These discarded kidneys can offer a survival benefit to suitable patients. Revisions to the current kidney allocation policy may be needed to reduce deceased donor kidney discard. We surveyed transplant physicians and patients to assess their perceived acceptability of policy proposals to reduce the discard of deceased donor kidneys. Members of professional societies (AST, ASTS) and a patient organization (AAKP) were invited to complete the survey. Responses were obtained from 97 physicians and 107 patients. The majority of physicians (73.4%) and patients (73.8%) "somewhat" or "completely" accepted a policy for fast‐tracking kidneys at risk of discard. Physicians and patients also supported returning a proportion of waiting time to patients who accept KDPI >85 kidneys and experience graft failure within the first 12 months, with 36% of physicians and 50% of patients electing to return 100% of the waiting time. The majority of physicians (75%) "somewhat or completely" accepted a policy to skip less aggressive centers for KDPI 90 + offers. Physicians and patients provided insights into factors researchers, and policymakers should consider in the design and implementation of these policies.
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Affiliation(s)
- Sanjay Mehrotra
- Department of Engineering and Management Sciences, Northwestern University, Evanston, IL, USA
| | - Karolina Schantz
- Department of Engineering and Management Sciences, Northwestern University, Evanston, IL, USA
| | - John J Friedewald
- Department of Engineering and Management Sciences, Northwestern University, Evanston, IL, USA
| | - Daniela P Ladner
- Comprehensive Transplant Center Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Masoud Barah
- Department of Engineering and Management Sciences, Northwestern University, Evanston, IL, USA
| | - Jiayi Gu
- Department of Engineering and Management Sciences, Northwestern University, Evanston, IL, USA
| | - Elisa J Gordon
- Comprehensive Transplant Center Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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14
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Tirri R, Barba M, Formica R, Irace R, Ciccia F. SAT0601 RELATIONSHIP BETWEEN BODY MASS INDEX AND NAILFOLD CAPILLAROSCOPY IN PRIMARY AND SECONDARY RAYNAUD’S PHENOMENON. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.4367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background:Raynaud’s phenomenon (RP) is a diffuse clinical manifestation (3-5% of general population) RP is often secondary to autoimmune systemic diseases, while the condition is classified primary if no underlying disorders can be found. A lower body mass index (BMI) was associated with a greater risk of developing RP, perhaps due to greatest sensivity to cold temperaturesObjectives:The objective of our study was to evaluate the association of BMI with clinical and capillaroscopic features in primary and secondary RP.Methods:Consecutive patients at the first access to a Rheumatology Outpatient Clinic over a 13 months period were screened to RP; nailfold videocapillaroscopy (NVC)was carried out and qualitative and quantitative assessment was performed. Diagnosis of RP was defined in patients who identified color pictures of witnessed attacks.Patients enrolled were screened for secondary causes of RP. RP was classified as primary when no abnormalities were found. Weight and height were collected in clinical records and patients were divided in 3 groups according to their BMI: underweight (BMI<18.5 kg/m2), normal weight (BMI 18.5–25 kg/m2), and overweight (BMI >25 kg/m2). Chi-square test to compare categorical variable and Parametric Student t-test to comparing mean values of normally distributed data were used. p<0.05 was considered to be statistically significant.Results:RP was diagnosticated in 100 of 1416 patients (7.06%). Of these, 73 (10 M, 63F) accepted to undergo NVC. An autoimmune disease was found in 35 patients (47.9%), of which 2 were underweight, 14 normal weight and 19 overweight. Of 38 patients with primary RP,3 were underweight, 23 normal weight and 12 overweight. BMI was significantly higher in secondary RP (p=0.03). Overweight patients with secondary RP were older (p=0.01), but with a disease duration not statistically significant longer (p=0.26). In secondary RP, avascular areas and neoangiogenesis were founded only in overweight patients. Moreover,in secondary RP overweight was correlated with decreased capillary density (p=0-04). There was not association between BMI and capillaroscopic abnormalities in primary RP.Conclusion:In our study BMI was correlated with microvascular changes only in patients with secondary RP. Our findings may suggests a role for obesity in the microcirculatory disfunction in the autoimmune diseases. Further studies are needed to generalize results and to find a causative role.References:[1]Lemmens HA. Vasa Suppl. 1987;18:10–4.[2]Le RoyEC,MedsgerTA.ClinExpRheumatol 1992;10;485-8[3]O Keeffe ST et al Journal Rheumat 1992:19:1415-7[4]Fraenkel L. Curr Rheumatol Rep. 2002;4(2): 123–8.[5]MaundrellA et al NY:Spinger New York 2015 p 21-35[6]Giurgea G. etalArthritis Rheumatol Vol. 67, No. 1, January 2015, pp 238–242[7]A.Eman et al. Ab / Atherosclerosis 287 (2019) e123-288Disclosure of Interests:Rosella Tirri: None declared, Marco Barba: None declared, Ranieri Formica: None declared, Rosaria Irace: None declared, francesco ciccia Grant/research support from: pfizer, novartis, roche, Consultant of: pfizer, novartis, lilly, abbvie, Speakers bureau: pfizer, novartis, lilly, abbvie
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15
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Abdallah CG, Averill LA, Gueorguieva R, Goktas S, Purohit P, Ranganathan M, Sherif M, Ahn KH, D'Souza DC, Formica R, Southwick SM, Duman RS, Sanacora G, Krystal JH. Modulation of the antidepressant effects of ketamine by the mTORC1 inhibitor rapamycin. Neuropsychopharmacology 2020; 45:990-997. [PMID: 32092760 PMCID: PMC7162891 DOI: 10.1038/s41386-020-0644-9] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [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: 09/25/2019] [Revised: 01/08/2020] [Accepted: 02/12/2020] [Indexed: 02/08/2023]
Abstract
Twenty-four hours after administration, ketamine exerts rapid and robust antidepressant effects that are thought to be mediated by activation of the mechanistic target of rapamycin complex 1 (mTORC1). To test this hypothesis, depressed patients were pretreated with rapamycin, an mTORC1 inhibitor, prior to receiving ketamine. Twenty patients suffering a major depressive episode were randomized to pretreatment with oral rapamycin (6 mg) or placebo 2 h prior to the intravenous administration of ketamine 0.5 mg/kg in a double-blind cross-over design with treatment days separated by at least 2 weeks. Depression severity was assessed using Montgomery-Åsberg Depression Rating Scale (MADRS). Rapamycin pretreatment did not alter the antidepressant effects of ketamine at the 24-h timepoint. Over the subsequent 2-weeks, we found a significant treatment by time interaction (F(8,245) = 2.02, p = 0.04), suggesting a prolongation of the antidepressant effects of ketamine by rapamycin. Two weeks following ketamine administration, we found higher response (41%) and remission rates (29%) following rapamycin + ketamine compared to placebo + ketamine (13%, p = 0.04, and 7%, p = 0.003, respectively). In summary, single dose rapamycin pretreatment failed to block the antidepressant effects of ketamine, but it prolonged ketamine's antidepressant effects. This observation raises questions about the role of systemic vs. local blockade of mTORC1 in the antidepressant effects of ketamine, provides preliminary evidence that rapamycin may extend the benefits of ketamine, and thereby potentially sheds light on mechanisms that contribute to depression relapse after ketamine administration.
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Affiliation(s)
- Chadi G Abdallah
- National Center for PTSD - Clinical Neurosciences Division, US Department of Veterans Affairs, West Haven, CT, USA.
- Departments of Psychiatry, Neuroscience, and Psychology Yale University, New Haven, CT, USA.
| | - Lynnette A Averill
- National Center for PTSD - Clinical Neurosciences Division, US Department of Veterans Affairs, West Haven, CT, USA
- Departments of Psychiatry, Neuroscience, and Psychology Yale University, New Haven, CT, USA
| | - Ralitza Gueorguieva
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
| | - Selin Goktas
- National Center for PTSD - Clinical Neurosciences Division, US Department of Veterans Affairs, West Haven, CT, USA
- Departments of Psychiatry, Neuroscience, and Psychology Yale University, New Haven, CT, USA
| | - Prerana Purohit
- National Center for PTSD - Clinical Neurosciences Division, US Department of Veterans Affairs, West Haven, CT, USA
- Departments of Psychiatry, Neuroscience, and Psychology Yale University, New Haven, CT, USA
| | - Mohini Ranganathan
- Departments of Psychiatry, Neuroscience, and Psychology Yale University, New Haven, CT, USA
| | - Mohamed Sherif
- Departments of Psychiatry, Neuroscience, and Psychology Yale University, New Haven, CT, USA
| | - Kyung-Heup Ahn
- Departments of Psychiatry, Neuroscience, and Psychology Yale University, New Haven, CT, USA
| | - Deepak Cyril D'Souza
- Departments of Psychiatry, Neuroscience, and Psychology Yale University, New Haven, CT, USA
| | - Richard Formica
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Steven M Southwick
- National Center for PTSD - Clinical Neurosciences Division, US Department of Veterans Affairs, West Haven, CT, USA
- Departments of Psychiatry, Neuroscience, and Psychology Yale University, New Haven, CT, USA
| | - Ronald S Duman
- National Center for PTSD - Clinical Neurosciences Division, US Department of Veterans Affairs, West Haven, CT, USA
- Departments of Psychiatry, Neuroscience, and Psychology Yale University, New Haven, CT, USA
| | - Gerard Sanacora
- National Center for PTSD - Clinical Neurosciences Division, US Department of Veterans Affairs, West Haven, CT, USA
- Departments of Psychiatry, Neuroscience, and Psychology Yale University, New Haven, CT, USA
| | - John H Krystal
- National Center for PTSD - Clinical Neurosciences Division, US Department of Veterans Affairs, West Haven, CT, USA
- Departments of Psychiatry, Neuroscience, and Psychology Yale University, New Haven, CT, USA
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16
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Redfield RR, Jordan SC, Busque S, Vincenti F, Woodle ES, Desai N, Reed EF, Tremblay S, Zachary AA, Vo AA, Formica R, Schindler T, Tran H, Looney C, Jamois C, Green C, Morimoto A, Rajwanshi R, Schroeder A, Cascino MD, Brunetta P, Borie D. Safety, pharmacokinetics, and pharmacodynamic activity of obinutuzumab, a type 2 anti-CD20 monoclonal antibody for the desensitization of candidates for renal transplant. Am J Transplant 2019; 19:3035-3045. [PMID: 31257724 PMCID: PMC6899639 DOI: 10.1111/ajt.15514] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 05/28/2019] [Accepted: 06/18/2019] [Indexed: 01/25/2023]
Abstract
The limited effectiveness of rituximab plus intravenous immunoglobulin (IVIG) in desensitization may be due to incomplete B cell depletion. Obinutuzumab is a type 2 anti-CD20 antibody that induces increased B cell depletion relative to rituximab and may therefore be more effective for desensitization. This open-label phase 1b study assessed the safety, pharmacokinetics, and pharmacodynamics of obinutuzumab in highly sensitized patients with end-stage renal disease. Patients received 1 (day 1, n = 5) or 2 (days 1 and 15; n = 20) infusions of 1000-mg obinutuzumab followed by 2 doses of IVIG on days 22 and 43. Eleven patients received additional obinutuzumab doses at the time of transplant and/or at week 24. The median follow-up duration was 9.4 months. Obinutuzumab was well tolerated, and most adverse events were grade 1-2 in severity. There were 11 serious adverse events (SAEs) in 9 patients (36%); 10 of these SAEs were infections and 4 occurred after kidney transplant. Obinutuzumab plus IVIG resulted in profound peripheral B cell depletion and appeared to reduce B cells in retroperitoneal lymph nodes. Reductions in anti-HLA antibodies, number of unacceptable antigens, and the calculated panel reactive antibody score as centrally assessed using single-antigen bead assay were limited and not clinically meaningful for most patients (NCT02586051).
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Affiliation(s)
| | | | | | | | | | - Niraj Desai
- Johns Hopkins University School of MedicineBaltimoreMaryland
| | - Elaine F. Reed
- David Geffen School of MedicineUniversity of CaliforniaLos AngelesCalifornia
| | - Simon Tremblay
- University of Cincinnati College of MedicineCincinnatiOhio
| | | | - Ashley A. Vo
- Cedars‐Sinai Medical CenterLos AngelesCalifornia
| | | | | | - Ha Tran
- Genentech, Inc.South San FranciscoCalifornia
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17
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Faddoul G, Nadkarni GN, Bridges ND, Goebel J, Hricik DE, Formica R, Menon MC, Morrison Y, Murphy B, Newell K, Nickerson P, Poggio ED, Rush D, Heeger PS. Analysis of Biomarkers Within the Initial 2 Years Posttransplant and 5-Year Kidney Transplant Outcomes: Results From Clinical Trials in Organ Transplantation-17. Transplantation 2018; 102:673-680. [PMID: 29189482 DOI: 10.1097/tp.0000000000002026] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND An early posttransplant biomarker/surrogate marker for kidney allograft loss has the potential to guide targeted interventions. Previously published findings, including results from the Clinical Trials in Organ Transplantation (CTOT)-01 study, showed that elevated urinary chemokine CXCL9 levels and elevated frequencies of donor-reactive interferon gamma (IFNγ)-producing T cells by enzyme-linked immunosorbent spot (ELISPOT) assay associated with acute cellular rejection within the first year and with lower 1-year posttransplant estimated glomerular filtration rate (eGFR). How well these biomarkers correlate with late outcomes, including graft loss, is unclear. METHODS In CTOT-17, we obtained 5-year outcomes in the CTOT-01 cohort and correlated them with (a) biomarker results and (b) changes in eGFR (Chronic Kidney Disease Epidemiology Collaboration formula) over the initial 2 years posttransplant using univariable analysis and multivariable logistic regression. RESULTS Graft loss occurred in 14 (7.6%) of 184 subjects 2 to 5 years posttransplant. Neither IFNγ ELISPOTs nor urinary CXCL9 were informative. In contrast, a 40% or greater decline in eGFR from 6 months to 2 years posttransplant independently correlated with 13-fold odds of 5-year graft loss (adjusted odds ratio, 13.1; 95% confidence interval, 3.0-56.6), a result that was validated in the independent Genomics of Chronic Allograft Rejection cohort (n = 165; adjusted odds ratio, 11.2). CONCLUSIONS We conclude that although pretransplant and early posttransplant ELISPOT and chemokine measurements associate with outcomes within 2 years posttransplant, changes in eGFR between 3 or 6 months and 24 months are better surrogates for 5-year outcomes, including graft loss.
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Affiliation(s)
- Geovani Faddoul
- Department of Medicine, Translational Transplant Research Center, Recanati Miller Transplant Institute, Immunology Institute Icahn School of Medicine at Mount Sinai, New York, NY
| | - Girish N Nadkarni
- Department of Medicine, Translational Transplant Research Center, Recanati Miller Transplant Institute, Immunology Institute Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nancy D Bridges
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Jens Goebel
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Donald E Hricik
- Department of Medicine, University Hospitals Case Medical Center, Cleveland, OH
| | - Richard Formica
- Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Madhav C Menon
- Department of Medicine, Translational Transplant Research Center, Recanati Miller Transplant Institute, Immunology Institute Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yvonne Morrison
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Barbara Murphy
- Department of Medicine, Translational Transplant Research Center, Recanati Miller Transplant Institute, Immunology Institute Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kenneth Newell
- Department of Surgery, Emory University Medical Center, Atlanta, GA
| | - Peter Nickerson
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Emilio D Poggio
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, OH
| | - David Rush
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Peter S Heeger
- Department of Medicine, Translational Transplant Research Center, Recanati Miller Transplant Institute, Immunology Institute Icahn School of Medicine at Mount Sinai, New York, NY
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Cooper M, Formica R, Friedewald J, Hirose R, O’Connor K, Mohan S, Schold J, Axelrod D, Pastan S. Report of National Kidney Foundation Consensus Conference to Decrease Kidney Discards. Clin Transplant 2018; 33:e13419. [DOI: 10.1111/ctr.13419] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 09/29/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Matthew Cooper
- Medstar Georgetown Transplant Institute; Georgetown University; Washington District of Columbia
| | - Richard Formica
- Department of Medicine, Section of Nephrology; Yale School of Medicine; New Haven Connecticut
| | - John Friedewald
- Northwestern University Comprehensive Transplant Center; Chicago Illinois
| | - Ryutaro Hirose
- Department of Surgery; University of California San Francisco; San Francisco California
| | | | - Sumit Mohan
- Division of Nephrology, Department of Medicine; Vagelos College of Physicians & Surgeons, Columbia University; New York New York
- Department of Epidemiology, Mailman School of Public Health; Columbia University; New York New York
| | - Jesse Schold
- Department of Quantitative Health Sciences; Cleveland Clinic; Cleveland Ohio
| | - David Axelrod
- Department of Surgery; Lahey Hospital and Medical Center; Burlington Massachusetts
| | - Stephen Pastan
- Renal Division, Department of Medicine; Emory University School of Medicine; Atlanta Georgia
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Kulkarni S, Hall I, Formica R, Thiessen C, Stewart D, Gan G, Greene E, Deng Y. Transition probabilities between changing sensitization levels, waitlist activity status and competing-risk kidney transplant outcomes using multi-state modeling. PLoS One 2017; 12:e0190277. [PMID: 29287087 PMCID: PMC5747475 DOI: 10.1371/journal.pone.0190277] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 12/11/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Sensitization and activity status are associated with kidney transplant waitlist mortality. Unknown is how changes in these covariates after listing impact transplant outcomes. METHODS Two cohorts were created from the OPTN (Organ Procurement and Transplantation Network) database, one pre-KAS (new kidney allocation system) (10/01/2009-12/04/2013, n = 97,793) and one post-KAS (12/04/2014-06/17/2015, n = 13,113). Multi-state modeling provides transition probabilities between intermediate states (CPRA category/activity status combinations) and competing-risk outcomes: transplant (living), transplant (deceased), death, or other/well. RESULTS Transition probabilities show chances of converting between intermediate states prior to a competing-risk outcome. One year transplant probabilities for post-KAS candidates with a CPRA of 0%(P, 0.123[95% CI, 0.117,0.129]), 1-79%(P, 0.125 [95% CI, 0.112,0.139]), 95-98%(P, 0.242[95% CI, 0.188, 0.295]) and 99-100%(P, 0.252 [95% CI, 0.195, 0.308]) were significantly higher than the pre-KAS cohort; they were lower for CPRA 80-89%(P, 0.152 [95% CI, 0.116,0.189]) and not statistically different for CPRA 90-94%(P, 0.180 [95% CI, 0.137,0.223]) candidates. Post-KAS, Whites had a statistically higher transplant probability only at a CPRA of 99-100%. CONCLUSION Multi-state modeling provides transition probabilities between CPRA/activity status combinations, giving estimates on how changing patient characteristic's after listing impact outcomes. Preliminarily, across most CPRA categories, there was no statistical difference in transplant probabilities between Whites, Blacks and Hispanics following KAS implementation, however, this finding requires longer follow-up for validation.
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Affiliation(s)
- Sanjay Kulkarni
- Department of Surgery, Section of Organ Transplantation & Immunology, Yale School of Medicine, New Haven, CT, United States of America
- Department of Medicine, Section of Nephrology, Yale School of Medicine, New Haven, CT, United States of America
| | - Isaac Hall
- Department of Medicine, Section of Nephrology, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Richard Formica
- Department of Surgery, Section of Organ Transplantation & Immunology, Yale School of Medicine, New Haven, CT, United States of America
- Department of Medicine, Section of Nephrology, Yale School of Medicine, New Haven, CT, United States of America
| | - Carrie Thiessen
- Department of Surgery, Section of Organ Transplantation & Immunology, Yale School of Medicine, New Haven, CT, United States of America
| | - Darren Stewart
- United Network for Organ Sharing, Richmond, VA, United States of America
| | - Geliang Gan
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, United States of America
| | - Erich Greene
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, United States of America
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, United States of America
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20
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Merola J, Yoo PS, Schaub J, Smith JD, Rodriguez-Davalos MI, Tichy E, Mulligan DC, Asch W, Formica R, Kashgarian M, Kulkarni S. Belatacept and Eculizumab for Treatment of Calcineurin Inhibitor-induced Thrombotic Microangiopathy After Kidney Transplantation: Case Report. Transplant Proc 2017; 48:3106-3108. [PMID: 27932157 DOI: 10.1016/j.transproceed.2016.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 04/27/2016] [Indexed: 11/25/2022]
Abstract
Thrombotic microangiopathy (TMA) after kidney transplantation is an uncommon and challenging cause of graft dysfunction and is associated with early graft loss. An idiosyncratic endothelial reaction to calcineurin inhibitors (CNIs) has been implicated as a frequent cause of TMA. This reaction is marked by uncontrolled activation of complement and subsequent cellular destruction. Usual therapy consists of withdrawal of the inciting drug and plasmapheresis to minimize levels of circulating complement. Recently, eculizumab, a monoclonal antibody to complement component C5, has been used for the treatment of atypical hemolytic uremic syndrome. Belatacept, an inhibitor of T cell costimulatory protein CTLA-4 has been used in immunosuppression strategies aimed at minimization of CNI. Here we report the first case of treatment of CNI-associated TMA/hemolytic uremic syndrome with withdrawal of tacrolimus and initiation of both belatacept and eculizumab. The case describes a favorable clinical course for both graft and patient, and is accompanied by a review of the literature.
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Affiliation(s)
- J Merola
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - P S Yoo
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
| | - J Schaub
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - J D Smith
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - E Tichy
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, Connecticut
| | - D C Mulligan
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - W Asch
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - R Formica
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - M Kashgarian
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - S Kulkarni
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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21
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Thiessen C, Kim YA, Formica R, Bia M, Kulkarni S. Opting out: confidentiality and availability of an 'alibi' for potential living kidney donors in the USA. J Med Ethics 2015; 41:506-510. [PMID: 25368413 DOI: 10.1136/medethics-2014-102184] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 10/02/2014] [Indexed: 06/04/2023]
Abstract
Ethicists and guidelines have suggested that potential living kidney donors who withdraw from evaluation be offered an 'alibi.' We sought to determine what potential living kidney donors are told about their ability to opt out, alibi availability and postwithdrawal confidentiality. We reviewed 148 consent forms for living kidney donor evaluation from US transplant centres that performed >5 living kidney transplants in 2010-2011 (response rate 87%). We found that while 98% of centres used evaluation consent forms that indicated that the donor could withdraw, only 21% of these documents offered an alibi. Another 23% of centres' consent forms indicated that the transplant team would be willing to inform the intended recipient that an individual was not a potential donor. Relatively few consent documents explicitly addressed the confidentiality of the donor's health information (31%), candidacy status (18%), decision (24%) or reasons (23%) following withdrawal. To preserve potential donors' autonomy and relationships, we advocate that all transplant centres offer general alibis in their evaluation consent forms. We conclude by offering recommendations for evaluation consent discussions of opting out, alibis and postwithdrawal confidentiality.
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Affiliation(s)
- Carrie Thiessen
- Section of Organ Transplantation & Immunology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Yunsoo A Kim
- Section of Organ Transplantation & Immunology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Richard Formica
- Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Margaret Bia
- Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sanjay Kulkarni
- Section of Organ Transplantation & Immunology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
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22
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Stewart D, Leishman R, Kucheryavaya A, Formica R, Aeder M, Bingaman A, Gentry S, Sandholm T, Ashlagi I. Exploring the Candidate/Donor Compatibility Matrix to Identify Opportunities to Improve the OPTN KPD Pilot Programʼs Priority Point Schedule. Transplantation 2014. [DOI: 10.1097/00007890-201407151-01604] [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: 11/25/2022]
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23
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Thiessen C, Kim YA, Formica R, Bia M, Kulkarni S. Written informed consent for living kidney donors: practices and compliance with CMS and OPTN requirements. Am J Transplant 2013; 13:2713-21. [PMID: 24020884 DOI: 10.1111/ajt.12406] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 06/19/2013] [Accepted: 06/25/2013] [Indexed: 01/25/2023]
Abstract
We sought to assess how written informed consent practices for candidate living kidney donors have changed over the last 5 years and to assess compliance with Centers for Medicare and Medicaid (CMS) and Organ Procurement and Transplantation Network (OPTN) regulations that took effect in 2007. We requested evaluation consent forms from US centers that performed >5 living kidney transplants during the prior year (n = 184). We received 148 consent forms; each was reviewed for information provided and inclusion of CMS- and OPTN-required elements. We found that nearly all transplant centers now obtain written consent for living kidney donor evaluation. However, most centers' evaluation consent forms do not include all CMS and OPTN requirements. Multiple items balancing donor and recipient interests and confidentiality were omitted. In addition, information about payment for routine follow-up care, complications related to surgery and other health problems following surgery were highly variable and frequently ambiguous. As centers revise their consent forms to address the 2013 OPTN policies, our findings may help them identify areas of potential deficiency. We propose that UNOS develop a uniform donor evaluation consent form to improve the clarity, consistency and efficiency of living donor consent.
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Affiliation(s)
- C Thiessen
- Section of Organ Transplantation and Immunology, Department of Surgery, Yale University School of Medicine, New Haven, CT
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24
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Cimsit B, Schilsky M, Moini M, Cartiera K, Arvelakis A, Kulkarni S, Formica R, Caldwell C, Taddei T, Asch W, Emre S. Combined liver kidney transplantation: critical analysis of a single-center experience. Transplant Proc 2011; 43:901-4. [PMID: 21486624 DOI: 10.1016/j.transproceed.2011.02.033] [Citation(s) in RCA: 8] [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] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Combined liver kidney transplantation (LKT) can be successfully performed on patients with liver and renal failure; however, outcomes are inferior to liver transplantation alone (OLT). Our aim was to determine the indications for and outcome of LKT and whether patients with longer wait times required more frequent LKT versus OLT alone. We included 18/93 adults who underwent LKT from August 2007 to August 2010 for hepatitis C virus (HCV, n = 7), alcohol (n = 5), nonalcoholic steatohepatitis (n = 2), primary biliary sclerosis, polycystic kidney disease with liver involvement, hepatic adenomatosis, and ischemic hepatitis. Eleven were originally listed for LKT and 7 required listing for-kidney transplantation while awaiting OLT. Eight were on dialysis when first listed and 10 had a low glomerular filtration rate or known kidney disease. The mean calculated Model for End-Stage Liver Disease (MELD) score for LKT was 31.2 ± 3.54. Seven had hepatocellular carcinoma in explants. Two patients had acute cellular kidney rejection that responded to treatment. Recurrence of HCV was documented in 5 patients within 6 months of LKT; 2/5 received HCV therapy (interferon and ribavirin) without renal allograft rejection. One-year liver graft/patient survival was 94% after LKT. One patient died at 6 months post LKT due to severe HCV recurrence. Last mean serum creatinine level was 1.35 ± 0.28 mg/dL for LKT patients. LKT is a safe procedure with favorable outcomes even in patients with a high MELD score. Transplantation of patients with a high MELD score due to regional variations in organ allocation results in additional use of kidneys by OLT patients. Improved organ allocation algorithms in OLT would help to reduce combined transplants, sparing more kidneys.
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Affiliation(s)
- B Cimsit
- Yale School of Medicine, Department of Surgery, New Haven, CT, USA
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25
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Kulkarni S, Emre S, Arvelakis A, Asch W, Bia M, Formica R, Israel G. Multidetector CT angiography in living donor renal transplantation: accuracy and discrepancies in right venous anatomy. Clin Transplant 2011; 25:77-82. [PMID: 20070320 DOI: 10.1111/j.1399-0012.2009.01193.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- S Kulkarni
- Department of Surgery, Section of Organ Transplantation & Immunology, Yale University School of Medicine, New Haven, CT 06410, USA.
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26
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Cuffy MC, Singh M, Formica R, Simmons E, Abu Alfa AK, Carlson K, Girardi M, Cowper SE, Kulkarni S. Renal transplantation for nephrogenic systemic fibrosis: a case report and review of the literature. Nephrol Dial Transplant 2010; 26:1099-101. [PMID: 21079195 DOI: 10.1093/ndt/gfq693] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Nephrogenic systemic fibrosis (NSF) is a rare fibrosing disorder described among patients with renal disease. Currently, no standard therapy exists, although therapeutic modalities have included plasmapheresis, extracorporeal photopheresis, sodium thiosulphate, imatinib and renal transplantation. We describe a patient with NSF who was physically debilitated and underwent renal transplantation. After transplantation, the patient's lesions improved clinically, and the patient was ambulatory. Despite developing worsening renal function, her lesions remained unchanged. We conclude that renal transplantation improves symptoms of NSF, and believe that in patients with NSF, careful consideration should be made for early renal transplantation.
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Affiliation(s)
- Madison C Cuffy
- Department of Renal Unit of Internal Medicine, Hachioji Medical Center of Tokyo Medical University, 1163 Tate-machi, Hachioji-shi, Tokyo 193-0998, Japan
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Solomon DA, Rabidou N, Kulkarni S, Formica R, Fraenkel L. Accepting a donor kidney: an evaluation of patients' and transplant surgeons' priorities. Clin Transplant 2010; 25:786-93. [PMID: 20964716 DOI: 10.1111/j.1399-0012.2010.01342.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Despite a trend toward patient autonomy in clinical practice, the decision whether or not to accept a kidney for transplantation is made predominantly by the transplant surgeon. The purpose of this study is to examine how patients and surgeons prioritize relevant factors when deciding to accept or decline an available kidney. METHODS We elicited patient and surgeon rankings for a list of factors involved in the decision using a validated computer survey. We computed the relative importance of each factor and examined associations between patient characteristics and priorities using Spearman's correlation coefficient and the Mann-Whitney U-test for continuous and categorical variables, respectively. RESULTS Patients placed the greatest value on kidney quality and predictors of transplant outcome. Patients who were on the waiting list longer gave less importance to kidney quality and function. Surgeons placed the greatest value on kidney quality, difficulty for the patient to be matched to a kidney, and the age of the donor. CONCLUSION The results of this study suggest that decision support tools can be used to improve the understanding of patient priorities in the decision to accept a donor kidney.
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Affiliation(s)
- Daniel A Solomon
- Department of Medicine, Yale University School of Medicine, New Haven, CT 06520-8031, USA
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Barrantes F, Kalyesubula R, Arvelakis A A, Lettieri D, Asch W, Bia M, Formica R, Kulkarni S. 45: Single-Day Work-Up Protocol Is Associated With a Shorter Time to Kidney Transplant: The Yale-New Haven Transplantation Center Experience. Am J Kidney Dis 2010. [DOI: 10.1053/j.ajkd.2010.02.052] [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: 11/11/2022]
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29
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Karamehić J, Lorber M, Formica R, Gavrankapetanović F, Heljić B, Subasić D, Zecević L. Immunosuppressive therapy protocols in kidney transplantation in adults. Bosn J Basic Med Sci 2006; 6:43-7. [PMID: 16995847 PMCID: PMC7193658 DOI: 10.17305/bjbms.2006.3143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In practical terms, regardless of HLA compatibility level, whenever tissues are transplanted from one person to another it is essential to suppress the immune response of the recipient. A variety of methods are available however, the most frequently used ones have the disadvantage of being immunologicaly non specific. The consequence is a difficult balance between immunosuppression sufficient to prevent the tissue rejection and maintenance of immune system at the level of ability to adequately deal with an infection. The goal, not yet achieved, is to find a way of generating donor specific immunosuppression that leaves the immune machinery otherwise completely intact. The major approaches to immunosuppression are described below.
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Affiliation(s)
- Jasenko Karamehić
- Institute of Clinical Immunology, Sarajevo University Clinics Centre, Sarajevo, Bosnia and Herzegovina
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Lorber MI, Basadonna GP, Friedman AL, Lorber KM, Bia MJ, Formica R, Smith JD. The evolving role of tor inhibitors for individualizing posttransplant immunosuppression. Transplant Proc 2001; 33:3075-7. [PMID: 11750322 DOI: 10.1016/s0041-1345(01)02311-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- M I Lorber
- Department of Surgery, Organ Transplantation & Immunology Section, Yale University School of Medicine, New Haven, CT 06520, USA
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Marshall NA, Howe JG, Formica R, Krause D, Wagner JE, Berliner N, Crouch J, Pilip I, Cooper D, Blazar BR, Seropian S, Pamer EG. Rapid reconstitution of Epstein-Barr virus-specific T lymphocytes following allogeneic stem cell transplantation. Blood 2000; 96:2814-21. [PMID: 11023516] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
Epstein-Barr virus (EBV)-specific CD8 T lymphocytes are present at remarkably high frequencies in healthy EBV(+) individuals and provide protection from EBV-associated lymphoproliferative diseases. Allogeneic peripheral blood stem cell transplantation (allo-PBSCT) is a commonly used therapy in which T-cell surveillance for EBV is temporarily disrupted. Herein, human leukocyte antigen (HLA) class I tetramers were used to investigate the reestablishment of the EBV-specific CD8 T-cell repertoire in patients following allo-PBSCT. CD8(+) T cells specific for lytic and latent cycle-derived EBV peptides rapidly repopulate the periphery of matched sibling allo-PBSCT patients. The relative frequencies of T cells specific for different EBV peptides in transplantation recipients closely reflect those of their respective donors. Investigation of patients at monthly intervals following unmanipulated allo-PBSCT demonstrated that the frequency of EBV-specific T cells correlates with the number of EBV genome copies in the peripheral blood and that expansion of EBV-specific T-cell populations occurs even in the setting of immunosuppressive therapy. In contrast, patients undergoing T-cell-depleted or unrelated cord blood transplantation have undetectable EBV-specific T cells, even in the presence of Epstein-Barr viremia. The protective shield provided by EBV-specific CD8 T cells is rapidly established following unmanipulated matched sibling allo-PBSCT and demonstrates that HLA class I tetramers complexed with viral peptides can provide direct and rapid assessment of pathogen-specific immunity in this and other vulnerable patient populations. (Blood. 2000;96:2814-2821)
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Affiliation(s)
- N A Marshall
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
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Affiliation(s)
- R Formica
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn., USA
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33
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Formica R. Immigration of non-Community countries: problems, measures and prospectives. J Reg Policy 1988; 8:491-500. [PMID: 12282857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
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