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Saddoughi SA, Martinu T, Patriquin C, Barth D, Huszti E, Ghany R, Tinckam K, McRae K, Singer LG, Keshavjee S, Cypel M, Aversa M. Impact of intraoperative therapeutic plasma exchange on bleeding in lung transplantation. J Heart Lung Transplant 2024; 43:414-419. [PMID: 37813131 DOI: 10.1016/j.healun.2023.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/21/2023] [Accepted: 10/02/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Our program uses a desensitization protocol that includes intraoperative therapeutic plasma exchange (iTPE) for crossmatch-positive lung transplants, which improves access to lung transplant for sensitized candidates while mitigating immunologic risk. Although we have reported excellent outcomes for sensitized patients with the use of this protocol, concern for perioperative bleeding appears to have hindered broader adoption of it at other programs. We conducted a retrospective cohort study to quantify the impact of iTPE on perioperative bleeding in lung transplantation. METHODS All first-time lung transplant recipients from 2014 to 2019 who received iTPE were compared to those who did not. Multivariable logistic regression was used to determine the association between iTPE and large-volume perioperative transfusion requirements (≥5 packed red blood cell units within 24 hours of transplant start), adjusted for disease type, transplant type, and extracorporeal membrane oxygenation or cardiopulmonary bypass use. The incidence of hemothorax (requiring reoperation within 7 days of lung transplant) and 30-day posttransplant mortality were compared between the 2 groups using chi-square test. RESULTS One hundred forty-two patients (16%) received iTPE, and 755 patients (84%) did not. The mean number of perioperative pRBC transfusions was 4.2 among patients who received iTPE and 2.9 among patients who did not. iTPE was associated with increased odds of requiring large-volume perioperative transfusion (odds ratio 1.9; 95% confidence interval: 1.2-2.9, p-value = 0.007) but was not associated with an increased incidence of hemothorax (5% in both groups, p = 0.99) or 30-day posttransplant mortality (3.5% among patients who received iTPE vs 2.1% among patients who did not, p = 0.31). CONCLUSIONS This study demonstrates that the use of iTPE in lung transplantation may increase perioperative bleeding but not to a degree that impacts important posttransplant outcomes.
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Affiliation(s)
- Sahar A Saddoughi
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Tereza Martinu
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Christopher Patriquin
- Division of Medical Oncology & Hematology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - David Barth
- Division of Medical Oncology & Hematology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Kathryn Tinckam
- Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Karen McRae
- Department of Anesthesia and Pain Management, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Lianne G Singer
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Meghan Aversa
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada.
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2
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Aversa M, Kiernan J, Martinu T, Patriquin C, Barth D, Li Q, Huszti E, Ghany R, Cypel M, Keshavjee S, Singer LG, Tinckam K. Outcomes after flow cytometry crossmatch-positive lung transplants managed with perioperative desensitization. Am J Transplant 2023; 23:1733-1739. [PMID: 37172694 DOI: 10.1016/j.ajt.2023.04.033] [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: 12/01/2022] [Revised: 03/06/2023] [Accepted: 04/03/2023] [Indexed: 05/15/2023]
Abstract
Our program previously reported successful outcomes following virtual crossmatch (VXM)-positive lung transplants managed with perioperative desensitization, but our ability to stratify their immunologic risk was limited without flow cytometry crossmatch (FCXM) data before 2014. The aim of this study was to determine allograft and chronic lung allograft dysfunction (CLAD)-free survival following VXM-positive/FCXM-positive lung transplants, which are performed at a minority of programs due to the high immunologic risk and lack of data on outcomes. All first-time lung transplant recipients between January 2014 and December 2019 were divided into 3 cohorts: VXM-negative (n = 764), VXM-positive/FCXM-negative (n = 64), and VXM-positive/FCXM-positive (n = 74). Allograft and CLAD-free survival were compared using Kaplan-Meier and multivariable Cox proportional hazards models. Five-year allograft survival was 53% in the VXM-negative cohort, 64% in the VXM-positive/FCXM-negative cohort, and 57% in the VXM-positive/FCXM-positive cohort (P = .7171). Five-year CLAD-free survival was 53% in the VXM-negative cohort, 60% in the VXM-positive/FCXM-negative cohort, and 63% in the VXM-positive/FCXM-positive cohort (P = .8509). This study confirms that allograft and CLAD-free survival of patients who undergo VXM-positive/FCXM-positive lung transplants with the use of our protocol does not differ from those of other lung transplant recipients. Our protocol for VXM-positive lung transplants improves access to transplant for sensitized candidates and mitigates even high immunologic risk.
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Affiliation(s)
- Meghan Aversa
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Jeffrey Kiernan
- HLA Laboratory, Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Tereza Martinu
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Christopher Patriquin
- Division of Medical Oncology & Hematology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - David Barth
- Division of Medical Oncology & Hematology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Qixuan Li
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Lianne G Singer
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Kathryn Tinckam
- HLA Laboratory, Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada.
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3
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Zuñiga AV, Kiernan J, Martinu T, Singer L, Ghany R, Yeung J, Cypel M, Keshavjee S, Tinckam K, Aversa M. Risk Stratifying by DQA and Risk Epitope Mismatches in Lung Transplantation. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1616] [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: 04/05/2023] Open
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4
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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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5
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Choe E, Ulahannah A, Ghany R, Kiernan J, Patriquin C, Barth D, Cypel M, Keshavjee S, Singer L, Tinckam K, Juvet S, Martinu T, Aversa M. The Role of Anti-Thymocyte Globulin in Peri-Operative Desensitization for Donor Specific Antibody Positive Lung Transplants. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1067] [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: 11/24/2022] Open
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6
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Wang A, Ribeiro RVP, Ali A, Brambate E, Abdelnour-Berchtold E, Michaelsen V, Zhang Y, Rahfeld P, Moon H, Gokhale H, Gazzalle A, Pal P, Liu M, Waddell TK, Cserti-Gazdewich C, Tinckam K, Kizhakkedathu JN, West L, Keshavjee S, Withers SG, Cypel M. Ex vivo enzymatic treatment converts blood type A donor lungs into universal blood type lungs. Sci Transl Med 2022; 14:eabm7190. [PMID: 35171649 DOI: 10.1126/scitranslmed.abm7190] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Donor organ allocation is dependent on ABO matching, restricting the opportunity for some patients to receive a life-saving transplant. The enzymes FpGalNAc deacetylase and FpGalactosaminidase, used in combination, have been described to effectively convert group A (ABO-A) red blood cells (RBCs) to group O (ABO-O). Here, we study the safety and preclinical efficacy of using these enzymes to remove A antigen (A-Ag) from human donor lungs using ex vivo lung perfusion (EVLP). First, the ability of these enzymes to remove A-Ag in organ perfusate solutions was examined on five human ABO-A1 RBC samples and three human aortae after static incubation. The enzymes removed greater than 99 and 90% A-Ag from RBCs and aortae, respectively, at concentrations as low as 1 μg/ml. Eight ABO-A1 human lungs were then treated by EVLP. Baseline analyses of A-Ag in lungs revealed expression predominantly in the endothelial and epithelial cells. EVLP of lungs with enzyme-containing perfusate removed over 97% of endothelial A-Ag within 4 hours. No treatment-related acute lung toxicity was observed. An ABO-incompatible transplant was then simulated with an ex vivo model of antibody-mediated rejection using ABO-O plasma as the surrogate for the recipient circulation using three donor lungs. The treatment of donor lungs minimized antibody binding, complement deposition, and antibody-mediated injury as compared with control lungs. These results show that depletion of donor lung A-Ag can be achieved with EVLP treatment. This strategy has the potential to expand ABO-incompatible lung transplantation and lead to improvements in fairness of organ allocation.
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Affiliation(s)
- Aizhou Wang
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada
| | - Rafaela V P Ribeiro
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada
| | - Aadil Ali
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada
| | - Edson Brambate
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada
| | - Etienne Abdelnour-Berchtold
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada
| | - Vinicius Michaelsen
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada
| | - Yu Zhang
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada
| | - Peter Rahfeld
- Department of Chemistry, University of British Columbia, Vancouver, BC V6T 1Z1, Canada
| | - Haisle Moon
- Centre for Blood Research, Department of Pathology and Laboratory Medicine, Life Science Institute, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | - Hemant Gokhale
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada
| | - Anajara Gazzalle
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada
| | - Prodipto Pal
- Department of Laboratory Medicine and Pathobiology, University of Toronto, ON M5S 1A8, Canada
| | - Mingyao Liu
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada.,Departments of Surgery, Medicine and Physiology and Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON M5T 1P5, Canada
| | - Thomas K Waddell
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada.,Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
| | | | - Kathryn Tinckam
- Department of Laboratory Medicine and Pathobiology, University of Toronto, ON M5S 1A8, Canada.,Department of Medicine, University Health Network and University of Toronto, Toronto, ON M5G 2C4, Canada
| | - Jayachandran N Kizhakkedathu
- Centre for Blood Research, Department of Pathology and Laboratory Medicine, Life Science Institute, University of British Columbia, Vancouver, BC V6T 1Z3, Canada.,School of Biomedical Engineering, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | - Lori West
- Department of Pediatrics, University of Alberta, Edmonton, AB T6G 1C9, Canada.,Canadian Donation and Transplantation Research Program, Edmonton AB T6G 1C9, Canada
| | - Shaf Keshavjee
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada.,Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Stephen G Withers
- Department of Chemistry, University of British Columbia, Vancouver, BC V6T 1Z1, Canada
| | - Marcelo Cypel
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada.,Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
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7
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Aversa M, Martinu T, Patriquin C, Cypel M, Barth D, Ghany R, Ma J, Keshavjee S, Singer LG, Tinckam K. Long-term outcomes of sensitized lung transplant recipients after peri-operative desensitization. Am J Transplant 2021; 21:3444-3448. [PMID: 34058795 DOI: 10.1111/ajt.16707] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/07/2021] [Accepted: 05/22/2021] [Indexed: 01/25/2023]
Abstract
The Toronto Lung Transplant Program has been using a peri-operative desensitization regimen of plasma exchange, intravenous immune globulin, and antithymocyte globulin in order to accept donor-specific antibody (DSA)-positive lung transplants safely since 2008. There are no long-term data on the impact of this practice on allograft survival or the development of chronic lung allograft dysfunction (CLAD). We extended our prior study to include long-term follow-up of 340 patients who received lung transplants between January 1, 2008 and December 31, 2011. We compared allograft survival and CLAD-free survival among patients in three cohorts: DSA-positive, panel reactive antibody (PRA)-positive/DSA-negative, and unsensitized at the time of transplant. The median follow-up time in this extension study was 6.7 years. Among DSA-positive, PRA-positive/DSA-negative, and unsensitized patients, the median allograft survival was 8.4, 7.9, and 5.8 years, respectively (p = .5908), and the median CLAD-free survival was 6.8, 7.3, and 5.7 years, respectively (p = .5448). This follow-up study confirms that long-term allograft survival and CLAD-free survival of patients who undergo DSA-positive lung transplants with the use of our protocol do not differ from other lung transplant recipients. Use of protocols such as ours, therefore, may improve access to transplant for sensitized candidates.
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Affiliation(s)
- Meghan Aversa
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada.,Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Tereza Martinu
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada.,Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Christopher Patriquin
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Medical Oncology and Hematology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
| | - David Barth
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Medical Oncology and Hematology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Jin Ma
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Lianne G Singer
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada.,Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Kathryn Tinckam
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada
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8
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Qazi-Arisar FA, Uchila R, Limkemann A, Galvin Z, Monajemzadeh M, Cattral M, Tinckam K, Sayad B, Bhat M. Idiopathic Fulminant Graft Failure Rescued by Urgent ABO-Incompatible Liver Transplantation. Prog Transplant 2021; 31:190-192. [PMID: 34080485 PMCID: PMC8182294 DOI: 10.1177/15269248211002810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Fakhar Ali Qazi-Arisar
- Multi Organ Transplant Program, Toronto General Hospital, 7989University Health Network, Toronto, Ontario, Canada.,Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Raj Uchila
- Multi Organ Transplant Program, Toronto General Hospital, 7989University Health Network, Toronto, Ontario, Canada.,Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Ashley Limkemann
- Multi Organ Transplant Program, Toronto General Hospital, 7989University Health Network, Toronto, Ontario, Canada
| | - Zita Galvin
- Multi Organ Transplant Program, Toronto General Hospital, 7989University Health Network, Toronto, Ontario, Canada.,Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Maryam Monajemzadeh
- Department of Pathology, 7989University Health Network, Toronto, Ontario, Canada
| | - Mark Cattral
- Multi Organ Transplant Program, Toronto General Hospital, 7989University Health Network, Toronto, Ontario, Canada
| | - Kathryn Tinckam
- Multi Organ Transplant Program, Toronto General Hospital, 7989University Health Network, Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, 7989University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine & Pathobiology, 7989University Health Network, Toronto, Ontario, Canada
| | - Blayne Sayad
- Multi Organ Transplant Program, Toronto General Hospital, 7989University Health Network, Toronto, Ontario, Canada
| | - Mamatha Bhat
- Multi Organ Transplant Program, Toronto General Hospital, 7989University Health Network, Toronto, Ontario, Canada.,Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Ontario, Canada
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9
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Wang A, Ribeiro R, Ali A, Brambate E, Gokhale H, Michaelsen V, Zhang Y, Gazzalle A, Rahfeld P, Cserti C, Tinckam K, West L, Waddell T, Liu M, Keshavjee S, Withers S, Cypel M. Developing Universal ABO Blood Type Donor Lungs with Ex Vivo Enzymatic Treatment: A Proof of Concept Feasibility Study. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.1773] [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: 10/21/2022] Open
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10
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Feld JJ, Cypel M, Kumar D, Dahari H, Pinto Ribeiro RV, Marks N, Kamkar N, Bahinskaya I, Onofrio FQ, Zahoor MA, Cerrochi O, Tinckam K, Kim SJ, Schiff J, Reichman TW, McDonald M, Alba C, Waddell TK, Sapisochin G, Selzner M, Keshavjee S, Janssen HLA, Hansen BE, Singer LG, Humar A. Short-course, direct-acting antivirals and ezetimibe to prevent HCV infection in recipients of organs from HCV-infected donors: a phase 3, single-centre, open-label study. Lancet Gastroenterol Hepatol 2020; 5:649-657. [PMID: 32389183 PMCID: PMC7391837 DOI: 10.1016/s2468-1253(20)30081-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/28/2020] [Accepted: 03/12/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND An increasing percentage of potential organ donors are infected with hepatitis C virus (HCV). After transplantation from an infected donor, establishment of HCV infection in uninfected recipients is near-universal, with the requirement for post-transplant antiviral treatment. The aim of this study was to determine if antiviral drugs combined with an HCV entry blocker given before and for 7 days after transplant would be safe and reduce the likelihood of HCV infection in recipients of organs from HCV-infected donors. METHODS HCV-uninfected organ recipients without pre-existing liver disease were treated with ezetimibe (10 mg; an HCV entry inhibitor) and glecaprevir-pibrentasvir (300 mg/120 mg) before and after transplantation from HCV-infected donors aged younger than 70 years without co-infection with HIV, hepatitis B virus, or human T-cell leukaemia virus 1 or 2. Recipients received a single dose 6-12 h before transplant and once a day for 7 days after surgery (eight doses in total). HCV RNA was assessed once a day for 14 days and then once a week until 12 weeks post-transplant. The primary endpoint was prevention of chronic HCV infection, as evidenced by undetectable serum HCV RNA at 12 weeks after transplant, and assessed in the intention-to-treat population. Safety monitoring was according to routine post-transplant practice. 12-week data are reported for the first 30 patients. The trial is registered on ClinicalTrials.gov, NCT04017338. The trial is closed to recruitment but follow-up is ongoing. FINDINGS 30 patients (23 men and seven women; median age 61 years (IQR 48-66) received transplants (13 lung, ten kidney, six heart, and one kidney-pancreas) from 18 HCV-infected donors. The median donor viral load was 5·11 log10IU/mL (IQR 4·55-5·63) and at least three HCV genotypes were represented (nine [50%] donors with genotype 1, two [11%] with genotype 2, five [28%] with genotype 3, and two [11%] with unknown genotype). All 30 (100%) transplant recipients met the primary endpoint of undetectable HCV RNA at 12 weeks post-transplant, and were HCV RNA-negative at last follow-up (median 36 weeks post-transplant [IQR 25-47]). Low-level viraemia was transiently detectable in 21 (67%) of 30 recipients in the early post-transplant period but not after day 14. Treatment was well tolerated with no dose reductions or treatment discontinuations; 32 serious adverse events occurred in 20 (67%) recipients, with one grade 3 elevation in alanine aminotransferase (ALT) possibly related to treatment. Non-serious transient elevations in ALT and creatine kinase during the study dosing period resolved with treatment completion. Among the serious adverse events were two recipient deaths due to causes unrelated to study drug treatment (sepsis at 49 days and subarachnoid haemorrhage at 109 days post-transplant), with neither patient ever being viraemic for HCV. INTERPRETATION Ezetimibe combined with glecaprevir-pibrentasvir given one dose before and for 7 days after transplant prevented the establishment of chronic HCV infection in recipients of different organs from HCV-infected donors. This study shows that an ultra-short course of direct-acting antivirals and ezetimibe can prevent the establishment of chronic HCV infection in the recipient, alleviating many of the concerns with transplanting organs from HCV-infected donors. FUNDING Canadian Institutes of Health Research; the Organ Transplant Program, University Health Network.
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Affiliation(s)
- Jordan J Feld
- Toronto Centre for Liver Disease, Toronto, ON, Canada; Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.
| | - Marcelo Cypel
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Deepali Kumar
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Harel Dahari
- Program for Experimental and Theoretical Modeling, Division of Hepatology, Department of Medicine, Loyola University Chicago, Chicago, IL, USA
| | | | - Nikki Marks
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Nellie Kamkar
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ilona Bahinskaya
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Fernanda Q Onofrio
- Toronto Centre for Liver Disease, Toronto, ON, Canada; Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Mohamed A Zahoor
- Toronto Centre for Liver Disease, Toronto, ON, Canada; Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Orlando Cerrochi
- Toronto Centre for Liver Disease, Toronto, ON, Canada; Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Kathryn Tinckam
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - S Joseph Kim
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jeffrey Schiff
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Trevor W Reichman
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Michael McDonald
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Carolina Alba
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Thomas K Waddell
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Gonzalo Sapisochin
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Markus Selzner
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto, ON, Canada; Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto, ON, Canada; Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Lianne G Singer
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Atul Humar
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Soham and Shaila Ajmera Family Transplant Centre, University Health Network, University of Toronto, Toronto, ON, Canada
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11
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Vaisman A, Bannerman G, Matelski J, Tinckam K, Hota SS. Out of sight, out of mind: a prospective observational study to estimate the duration of the Hawthorne effect on hand hygiene events. BMJ Qual Saf 2020; 29:932-938. [DOI: 10.1136/bmjqs-2019-010310] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 02/17/2020] [Accepted: 02/19/2020] [Indexed: 12/28/2022]
Abstract
BackgroundHuman auditing has been the gold standard for evaluating hand hygiene (HH) compliance but is subject to the Hawthorne effect (HE), the change in subjects’ behaviour due to their awareness of being observed. For the first time, we used electronic HH monitoring to characterise the duration of the HE on HH events after human auditors have left the ward.MethodsObservations were prospectively conducted on two transplant wards at a tertiary centre between May 2018 and January 2019. HH events were measured using the electronic GOJO Smartlink Activity Monitoring System located throughout the ward. Non-covert human auditing was conducted in 1-hour intervals at random locations on both wards on varying days of the week. Two adjusted negative binomial regression models were fit in order to estimate an overall auditor effect and a graded auditor effect.ResultsIn total, 365 674 HH dispensing events were observed out of a possible 911 791 opportunities. In the adjusted model, the presence of an auditor increased electronic HH events by approximately 2.5-fold in the room closest to where the auditor was standing (9.86 events per hour/3.98 events per hour; p<0.01), an effect sustained across only the partial hour before and after the auditor was present but not beyond the first hour after the auditor left. This effect persisted but was attenuated in areas distal from the auditor (total ward events of 6.91*6.32–7.55, p<0.01). Additionally, there was significant variability in the magnitude of the HE based on temporal and geographic distribution of audits.ConclusionThe HE on HH events appears to last for a limited time on inpatient wards and is highly dynamic across time and auditor location. These findings further challenge the validity and value of human auditing and support the need for alternative and complementary monitoring methods.
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12
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Tikkanen JM, Tinckam K. Intragraft donor-specific antibodies and lung transplantation. Eur Respir J 2019; 54:54/5/1901937. [PMID: 31699784 DOI: 10.1183/13993003.01937-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/11/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Jussi M Tikkanen
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Kathryn Tinckam
- HLA Laboratory, Laboratory Medicine Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Division of Nephrology, Dept of Medicine, Toronto General Hospital, University Health Network, Toronto, ON, Canada
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13
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Abstract
Human leukocyte antigen (HLA) compatibility is very important for successful transplantation of solid organs. In this paper, we focused on the humoral arm of immunity in the clinical setting of organ transplantation: how HLA antibodies develop, how they can be detected, and what they can do to injure organ transplants. Specifically, we explore the technical perspectives of detecting donor-specific antibodies (DSA) in HLA laboratories, and use real-life clinical cases to explain the principles. Currently there are many tools in our HLA antibody detection toolbox: conventional cytotoxicity cross match, flow cross match, and solid phase assays using beads conjugated with single or multiple HLA antigens. Single antigen bead (SAB) assay is the most sensitive tool available for detecting HLA antibodies and assessing the immunological risk for organ transplant. However, there are intrinsic limitations to solid-phase assays and they are prone to both false negativity and importantly, false positivity. Denatured antigens on single antigen beads might be the most prominent source of false positive reactivity, and may have been underestimated by many HLA experts. No single assay is perfect and therefore multiple methods, including the less sensitive assays, should be employed to determine the clinical relevance of detected HLA antibodies. Thoughtful process, including knowledge of HLA systems, cross reactivity, epitopes, and the patient's clinical history should be employed to correctly interpret data. The clinical team should work closely with HLA laboratories to ensure accurate interpretation of information and optimal management of patients before and after organ transplantation.
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Affiliation(s)
- Jennifer McCaughan
- Regional Histocompatibility Laboratory, University Health Network, Toronto, ON, Canada
| | - Qingyong Xu
- Transplant Immunology Lab, London Health Sciences Centre, London, ON, Canada
| | - Kathryn Tinckam
- Regional Histocompatibility Laboratory, University Health Network, Toronto, ON, Canada
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14
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Tambur AR, Campbell P, Claas FH, Feng S, Gebel HM, Jackson AM, Mannon RB, Reed EF, Tinckam K, Askar M, Chandraker A, Chang PP, Colvin M, Demetris AJ, Diamond JM, Dipchand AI, Fairchild RL, Ford ML, Friedewald J, Gill RG, Glotz D, Goldberg H, Hachem R, Knechtle S, Kobashigawa J, Levine DJ, Levitsky J, Mengel M, Milford E, Newell KA, O'Leary JG, Palmer S, Randhawa P, Smith J, Snyder L, Starling RC, Sweet S, Taner T, Taylor CJ, Woodle S, Zeevi A, Nickerson P. Sensitization in Transplantation: Assessment of Risk (STAR) 2017 Working Group Meeting Report. Am J Transplant 2018; 18:1604-1614. [PMID: 29603613 DOI: 10.1111/ajt.14752] [Citation(s) in RCA: 183] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 02/25/2018] [Accepted: 03/20/2018] [Indexed: 02/06/2023]
Abstract
The presence of preexisting (memory) or de novo donor-specific HLA antibodies (DSAs) is a known barrier to successful long-term organ transplantation. Yet, despite the fact that laboratory tools and our understanding of histocompatibility have advanced significantly in recent years, the criteria to define presence of a DSA and assign a level of risk for a given DSA vary markedly between centers. A collaborative effort between the American Society for Histocompatibility and Immunogenetics and the American Society of Transplantation provided the logistical support for generating a dedicated multidisciplinary working group, which included experts in histocompatibility as well as kidney, liver, heart, and lung transplantation. The goals were to perform a critical review of biologically driven, state-of-the-art, clinical diagnostics literature and to provide clinical practice recommendations based on expert assessment of quality and strength of evidence. The results of the Sensitization in Transplantation: Assessment of Risk (STAR) meeting are summarized here, providing recommendations on the definition and utilization of HLA diagnostic testing, and a framework for clinical assessment of risk for a memory or a primary alloimmune response. The definitions, recommendations, risk framework, and highlighted gaps in knowledge are intended to spur research that will inform the next STAR Working Group meeting in 2019.
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Affiliation(s)
| | | | - Frans H Claas
- Leiden University Medical Center, Leiden, Netherlands
| | - Sandy Feng
- UCSF Medical Center, San Francisco, California
| | | | | | | | - Elaine F Reed
- UCLA Pathology & Laboratory Medicine, Los Angeles, California
| | | | | | | | | | | | | | | | | | | | - Mandy L Ford
- Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | | | - Ramsey Hachem
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | | | | | | | - Edgar Milford
- Brigham and Women's' Hospital, Boston, Massachusetts
| | | | | | - Scott Palmer
- Duke University School of Medicine, Durham, North Carolina
| | | | - John Smith
- Royal Brompton & Harefield NHS Foundation Trust, Harefield, UK
| | - Laurie Snyder
- Duke University School of Medicine, Durham, North Carolina
| | | | - Stuart Sweet
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | | | - Adriana Zeevi
- University of Pittsburg Medical Center, Pittsburgh, Pennsylvania
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15
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Halloran K, Aversa M, Tinckam K, Martinu T, Binnie M, Chaparro C, Chow CW, Waddell T, McRae K, Pierre A, de Perrot M, Yasufuku K, Cypel M, Keshavjee S, Singer LG. Comprehensive outcomes after lung retransplantation: A single-center review. Clin Transplant 2018; 32:e13281. [DOI: 10.1111/ctr.13281] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Kieran Halloran
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Meghan Aversa
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Kathryn Tinckam
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Matthew Binnie
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Cecilia Chaparro
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Chung-Wai Chow
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Tom Waddell
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Karen McRae
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Andrew Pierre
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Marc de Perrot
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Kazuhiro Yasufuku
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Lianne G. Singer
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
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16
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Alhussein M, Moayedi Y, Posada JD, Tinckam K, Ross HJ. Peri-operative desensitization for highly sensitized heart transplant patients. J Heart Lung Transplant 2018; 37:667-670. [DOI: 10.1016/j.healun.2017.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 10/28/2017] [Accepted: 12/05/2017] [Indexed: 11/29/2022] Open
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17
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Zamel R, McCaughan J, Hirji A, Cypel M, Singer L, Keshavjee S, Tinckam K, Tikkanen J. Feasibility of Avoiding Higher Risk Epitope and Allele HLA Mismatch to Reduce de novo Donor Specific Antibody (dnDSA) in Lung Transplantation. J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2018.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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18
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Moayedi Y, McCaughan J, Posada JD, Alhussein M, Goldraich L, Runeckles K, Fan S, Foroutan F, Manhliot C, Kozuszko S, Alba A, Dipchand A, Tinckam K, Ross H. Donor Specific Antibodies in Heart Transplantation: Do Clinicians Need to do Something Always? J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2018.01.255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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19
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Gill JS, Tinckam K, Fortin MC, Rose C, Shick-Makaroff K, Young K, Lesage J, Cole EH, Toews M, Landsberg DN, Gill J. Reciprocity to Increase Participation of Compatible Living Donor and Recipient Pairs in Kidney Paired Donation. Am J Transplant 2017; 17:1723-1728. [PMID: 28321984 DOI: 10.1111/ajt.14275] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 03/02/2017] [Accepted: 03/09/2017] [Indexed: 01/25/2023]
Abstract
Inclusion of compatible living donor and recipient pairs (CPs) in kidney paired donation (KPD) programs could increase living donor transplantation. We introduce the concept of a reciprocity-based strategy in which the recipient of a CP who participates in KPD receives priority for a repeat deceased donor transplant in the event their primary living donor KPD transplant fails, and then we review the practical and ethical considerations of this strategy. The strategy limits prioritization to CPs already committed to living donation, minimizing the risk of unduly influencing donor behavior. The provision of a tangible benefit independent of the CP's actual KPD match avoids many of the practical and ethical challenges with strategies that rely on finding the CP recipient a better-matched kidney that might provide the CP recipient a future benefit to increase KPD participation. Specifically, the strategy avoids the potential to misrepresent the degree of future benefit of a better-matched kidney to the CP recipient and minimizes delays in transplantation related to finding a better-matched kidney. Preliminary estimates suggest the strategy has significant potential to increase the number of living donor transplants. Further evaluation of the acceptance of this strategy by CPs and by waitlisted patients is warranted.
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Affiliation(s)
- J S Gill
- Division of Nephrology, University of British Columbia, Vancouver, Canada.,Centre for Health Evaluation and Outcomes Sciences, Vancouver, Canada.,Division of Nephrology, Tuft-New England Medical Center, Boston, MA
| | - K Tinckam
- Department of Laboratory Medicine and Pathobiology, University Health Network, University of Toronto, Toronto, Canada
| | - M C Fortin
- Department of Nephrology and Transplantation, Centre Hospitalier de l'Université de Montréal, Montreal, Canada.,Centre de Recherché du Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - C Rose
- Division of Nephrology, University of British Columbia, Vancouver, Canada.,Centre for Health Evaluation and Outcomes Sciences, Vancouver, Canada
| | | | - K Young
- Canadian Blood Services, Ottawa, Canada
| | - J Lesage
- Division of Nephrology, University of British Columbia, Vancouver, Canada
| | - E H Cole
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Canada
| | - M Toews
- Health Law Institute, Faculty of Law, University of Alberta, Alberta, Canada
| | - D N Landsberg
- Division of Nephrology, University of British Columbia, Vancouver, Canada
| | - J Gill
- Division of Nephrology, University of British Columbia, Vancouver, Canada.,Centre for Health Evaluation and Outcomes Sciences, Vancouver, Canada
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20
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Miyamoto E, Martinu T, Klement W, Juvet S, Keshavjee S, Tinckam K, Tikkanen J. The Impact of De Novo Donor-Specific Antibodies on Bronchiolitis Obliterans Syndrome and Restrictive Allograft Syndrome. J Heart Lung Transplant 2017. [DOI: 10.1016/j.healun.2017.01.077] [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: 11/27/2022] Open
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21
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Tikkanen JM, Singer LG, Kim SJ, Li Y, Binnie M, Chaparro C, Chow CW, Martinu T, Azad S, Keshavjee S, Tinckam K. De NovoDQ Donor-Specific Antibodies Are Associated with Chronic Lung Allograft Dysfunction after Lung Transplantation. Am J Respir Crit Care Med 2016; 194:596-606. [DOI: 10.1164/rccm.201509-1857oc] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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22
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Abstract
This review paper discusses the impact of de novo donor-specific antibodies (DSA) to donor HLA antigens in kidney transplantation and summarizes the benefits and challenges that exist with DSA monitoring. Post-transplant DSA is associated with worse allograft outcomes and its detection may precede or coincide with clinical, biochemical, and histologic allograft dysfunction. There are no absolute features of DSA testing results that perfectly discriminate between states of disease and health. In a state of antibody-associated graft dysfunction, removal or reduction in DSA may only provide clinical benefit for some. Furthermore, various factors influence test results, and detection of HLA antibodies must be interpreted within the appropriate clinical and laboratory context. The utility of DSA monitoring is further affected by the limited effectiveness of treatment for antibody-mediated rejection. Although DSA monitoring is potentially beneficial in some circumstances, the optimal screening and treatment strategies are still to be defined.
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23
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Tikkanen J, Hirji A, Zamel R, Zhao H, Singer L, Keshavjee S, Tinckam K. HLA-DQB-Matching Is Feasible and Does Not Prolong Wait Times for Lung Transplant Recipients. J Heart Lung Transplant 2016. [DOI: 10.1016/j.healun.2016.01.1068] [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: 11/27/2022] Open
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24
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Houston BL, Yan M, Tinckam K, Kamel-Reid S, Chang H, Kuo KHM, Tsien C, Seftel MD, Avitzur Y, Grant D, Cserti-Gazdewich CM. Extracorporeal photopheresis in solid organ transplant-associated acute graft-versus-host disease. Transfusion 2016; 56:962-9. [PMID: 26892365 DOI: 10.1111/trf.13467] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 10/18/2015] [Accepted: 10/19/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Extracorporeal photopheresis (ECP) culls pathogenic T lymphocytes, be these the clones of cutaneous T-cell lymphoma, or mediators of chronic graft-versus-host disease (GVHD) after allogeneic bone marrow transplantation (BMT-GVHD). Whether or not ECP may have an effect in the rarer instances of solid organ transplantation-associated GVHD (SOT-GVHD) is unclear. Mortality rates in SOT-GVHD rival those of transfusion-associated GVHD, with fatalities preceded by pancytopenia and peripheral blood chimerism (PBC) levels exceeding 20%. ECP has been described in two SOT-GVHD cases to date, with one surviving. STUDY DESIGN AND METHODS Clinicolaboratory features (including HLA relationships) in a case of multivisceral transplantation were reviewed from the time of surgery to the onset and progression of SOT-GVHD. ECP, which was introduced as a less immunosuppressive and more selective intervention, was assessed for its effect on serial PBC (as measured by short-tandem-repeat analysis) and clinical outcome. RESULTS Multivisceral SOT-GVHD manifested with erythroderma, neutropenic sepsis, and PBC increasing from 6% on Posttransplant Day (PTD) 38 to 78% by PTD 60 (at a doubling time of 6 days despite corticosteroids). ECP was administered on PTDs 62 and 67 and was associated with the first evidence of PBC decay to 67% on PTD 69. Death nevertheless ensued on the last day of salvage antithymocyte globulin (PTDs 69-73) despite further PBC reduction to 41%. CONCLUSION Further study is needed to determine if the sooner or more frequent application of ECP might attenuate the high case fatality rates of SOT-GVHD.
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Affiliation(s)
| | - Matthew Yan
- Department of Medical Oncology and Hematology, University of Toronto
| | - Kathryn Tinckam
- Department of Medicine.,Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Ontario
| | - Suzanne Kamel-Reid
- Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Ontario
| | - Hong Chang
- Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Ontario
| | - Kevin H M Kuo
- Department of Medicine.,Department of Medical Oncology and Hematology, University of Toronto
| | | | - Matthew D Seftel
- Department of Medical Oncology and Hematology, CancerCare Manitoba, and Section of Hematology/Oncology, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba
| | - Yaron Avitzur
- Department of Paediatrics, Hospital for Sick Children, Toronto
| | - David Grant
- Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Christine M Cserti-Gazdewich
- Department of Medicine.,Department of Medical Oncology and Hematology, University of Toronto.,Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Ontario
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25
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Duquesnoy RJ, Gebel HM, Woodle ES, Nickerson P, Baxter-Lowe LA, Bray RA, Claas FHJ, Eckels DD, Friedewald JJ, Fuggle SV, Gerlach JA, Fung JJ, Kamoun M, Middleton D, Shapiro R, Tambur AR, Taylor CJ, Tinckam K, Zeevi A. High-Resolution HLA Typing for Sensitized Patients: Advances in Medicine and Science Require Us to Challenge Existing Paradigms. Am J Transplant 2015; 15:2780-1. [PMID: 26177785 DOI: 10.1111/ajt.13376] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 04/26/2015] [Accepted: 04/26/2015] [Indexed: 01/25/2023]
Affiliation(s)
- R J Duquesnoy
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - H M Gebel
- HLA Laboratory, Emory University Hospital, Atlanta, GA
| | - E S Woodle
- University of Cincinnati, Cincinnati, OH
| | - P Nickerson
- Department of Internal Medicine and Immunology, University of Manitoba, Winnipeg, Canada
| | | | - R A Bray
- Emory University Hospital, Atlanta, GA
| | - F H J Claas
- Department of Immunohematology and Transfusion, Leiden University Medical Center, Leiden, the Netherlands
| | | | - J J Friedewald
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - S V Fuggle
- Transplant Immunology Laboratory, Oxford Transplant Centre, Oxford University Hospitals, Oxford University, Oxford, United Kingdom
| | - J A Gerlach
- Biomedical Laboratory Diagnostics Program, Michigan State University, East Lansing, MI
| | - J J Fung
- Digestive Disease Institute, Cleveland Clinic Main Campus, Cleveland, OH
| | - M Kamoun
- Immunology & Histocompatibility Testing Laboratories, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - D Middleton
- Department of Transplant Immunology, Royal Liverpool and Broadgreen University Hospital, Liverpool, United Kingdom
| | - R Shapiro
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mt. Sinai, New York, NY
| | - A R Tambur
- Transplant Immunology Laboratory, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - C J Taylor
- Addenbrooke's Hospital, Cambridge University, Cambridge, United Kingdom
| | - K Tinckam
- Division of Nephrology and HLA Laboratory, University Health Network, Toronto, Canada
| | - A Zeevi
- Division of Transplant Pathology, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
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26
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Chen CK, Manlhiot C, Conway J, Allain-Rooney T, McCrindle BW, Tinckam K, Dipchand AI. Development and Impact of De Novo Anti-HLA Antibodies in Pediatric Heart Transplant Recipients. Am J Transplant 2015; 15:2215-22. [PMID: 25784138 DOI: 10.1111/ajt.13259] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [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: 06/18/2014] [Revised: 01/08/2015] [Accepted: 02/04/2015] [Indexed: 01/25/2023]
Abstract
There is increasing evidence that de novo anti-HLA antibodies, more specifically de novo donor-specific antibodies (DSA) following solid organ transplantation may be associated with negative outcomes including rejection in the first year and graft loss. Limited data are available in pediatric heart transplant recipients. We sought to prospectively determine the incidence, class and early impact of de novo anti-HLA antibodies in a cohort of pediatric heart transplant recipients. Serial panel reactive antibody testing posttransplant was performed in 25 patients (14 males) transplanted between January 2008 and June 2010. Five patients were sensitized pretransplant; all patients had negative direct crossmatch. Seventy-two percent developed de novo anti-HLA antibodies at a median of 2.6 weeks (IQR 1.2 weeks to 6.2 months) posttransplant; 67% of these were DSA. The majority of recipients in our cohort developed de novo anti-HLA antibodies within the first year posttransplant, with two-thirds being donor-specific. Acute cellular rejection, though frequent, was not different in patients with antibody development regardless of class or specificity, and there was no antibody-mediated rejection, graft loss or early cardiac allograft vasculopathy.
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Affiliation(s)
- C K Chen
- Department of Pediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - C Manlhiot
- Department of Pediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - J Conway
- Department of Pediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - T Allain-Rooney
- Department of Pediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - B W McCrindle
- Department of Pediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - K Tinckam
- Department of Medicine and Histocompatibility Laboratory, Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
| | - A I Dipchand
- Department of Pediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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27
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Hricik DE, Formica RN, Nickerson P, Rush D, Fairchild RL, Poggio ED, Gibson IW, Wiebe C, Tinckam K, Bunnapradist S, Samaniego-Picota M, Brennan DC, Schröppel B, Gaber O, Armstrong B, Ikle D, Diop H, Bridges ND, Heeger PS. Adverse Outcomes of Tacrolimus Withdrawal in Immune-Quiescent Kidney Transplant Recipients. J Am Soc Nephrol 2015; 26:3114-22. [PMID: 25925687 DOI: 10.1681/asn.2014121234] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 02/05/2015] [Indexed: 12/18/2022] Open
Abstract
Concerns about adverse effects of calcineurin inhibitors (CNIs) have prompted development of protocols that minimize their use. Whereas previous CNI withdrawal trials in heterogeneous cohorts showed unacceptable rates of acute rejection (AR), we hypothesized that we could identify individuals capable of tolerating CNI withdrawal by targeting immunologically quiescent kidney transplant recipients. The Clinical Trials in Organ Transplantation-09 Trial was a randomized, prospective study of nonsensitized primary recipients of living donor kidney transplants. Subjects received rabbit antithymocyte globulin, tacrolimus, mycophenolate mofetil, and prednisone. Six months post-transplantation, subjects without de novo donor-specific antibodies (DSAs), AR, or inflammation at protocol biopsy were randomized to wean off or remain on tacrolimus. The intended primary end point was the change in interstitial fibrosis/tubular atrophy score between implantation and 24-month protocol biopsies. Serially collected urine CXCL9 ELISA results were correlated with outcomes. The study was terminated prematurely because of unacceptable rates of AR (4 of 14) and/or de novo DSAs (5 of 14) in the tacrolimus withdrawal arm. Positive urinary CXCL9 predated clinical detection of AR by a median of 15 days. Analyses showed that >16 HLA-DQ epitope mismatches and pretransplant, peripheral blood, donor-reactive IFN-γ ELISPOT assay results correlated with development of DSAs and/or AR on tacrolimus withdrawal. Although data indicate that urinary CXCL9 monitoring, epitope mismatches, and ELISPOT assays are potentially informative, complete CNI withdrawal must be strongly discouraged in kidney transplant recipients who are receiving standard-of-care immunosuppression, including those who are deemed to be immunologically quiescent on the basis of current clinical and laboratory criteria.
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Affiliation(s)
- Donald E Hricik
- Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Richard N Formica
- Departments of Medicine and Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Peter Nickerson
- College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Rush
- College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Robert L Fairchild
- Department of Immunology and Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Emilio D Poggio
- Department of Immunology and Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ian W Gibson
- College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Chris Wiebe
- College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kathryn Tinckam
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Suphamai Bunnapradist
- Department of Medicine, University of California at Los Angeles Medical Center, Los Angeles, California
| | | | - Daniel C Brennan
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Bernd Schröppel
- Department of Medicine and Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Osama Gaber
- Department of Surgery, Houston Methodist Hospital, Houston, Texas; Weil Cornell Medical College, New York, New York
| | | | | | - Helena Diop
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Nancy D Bridges
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Peter S Heeger
- Department of Medicine and Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York;
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28
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Goldraich L, Alba A, Ross H, Tinckam K. Prevalence and Risk Factors for De Novo HLA Donor-Specific Antibodies in Adult Heart Transplant Recipients. J Heart Lung Transplant 2015. [DOI: 10.1016/j.healun.2015.01.817] [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] Open
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29
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Duquesnoy RJ, Kamoun M, Baxter-Lowe LA, Woodle ES, Bray RA, Claas FHJ, Eckels DD, Friedewald JJ, Fuggle SV, Gebel HM, Gerlach JA, Fung JJ, Middleton D, Nickerson P, Shapiro R, Tambur AR, Taylor CJ, Tinckam K, Zeevi A. Should HLA mismatch acceptability for sensitized transplant candidates be determined at the high-resolution rather than the antigen level? Am J Transplant 2015; 15:923-30. [PMID: 25778447 DOI: 10.1111/ajt.13167] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 10/19/2014] [Accepted: 11/11/2014] [Indexed: 01/25/2023]
Abstract
Defining HLA mismatch acceptability of organ transplant donors for sensitized recipients has traditionally been based on serologically defined HLA antigens. Now, however, it is well accepted that HLA antibodies specifically recognize a wide range of epitopes present on HLA antigens and that molecularly defined high resolution alleles corresponding to the same low resolution antigen can possess different epitope repertoires. Hence, determination of HLA compatibility at the allele level represents a more accurate approach to identify suitable donors for sensitized patients. This approach would offer opportunities for increased transplant rates and improved long term graft survivals.
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Affiliation(s)
- R J Duquesnoy
- Thomas E.Starzl Transplantation Institute, University of Pittsburgh, Medical Center, Pittsburgh, PA
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30
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Luk A, Alba AC, Butany J, Tinckam K, Delgado D, Ross HJ. C4d immunostaining is an independent predictor of cardiac allograft vasculopathy and death in heart transplant recipients. Transpl Int 2015; 28:857-63. [DOI: 10.1111/tri.12560] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 01/07/2015] [Accepted: 02/27/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Adriana Luk
- Division of Cardiology; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Ana Carolina Alba
- Division of Cardiology; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Jagdish Butany
- Department of Laboratory Medicine; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Kathryn Tinckam
- Department of Laboratory Medicine; University Health Network; University of Toronto; Toronto Ontario Canada
- Division of Nephrology; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Diego Delgado
- Division of Cardiology; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Heather J. Ross
- Division of Cardiology; University Health Network; University of Toronto; Toronto Ontario Canada
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31
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Abstract
HLA antigens are polymorphic proteins expressed on donor kidney allograft endothelium and are critical targets for recipient immune recognition. HLA antibodies are risk factors for acute and chronic rejection and allograft loss. Solid-phase immunoassays for HLA antibody detection represent a major advance in sensitivity and specificity over cell-based methods and are widely used in organ allocation and pretransplant risk assessment. Post-transplant, development of de novo donor-specific HLA antibodies and/or increase in donor-specific antibodies from pretransplant levels are associated with adverse outcomes. Although single antigen bead assays have allowed sensitive detection of recipient HLA antibodies and their specificities, a number of interpretive considerations must be appreciated to understand test results in clinical and research contexts. This review, which is especially relevant for clinicians caring for transplant patients, discusses the technical aspects of single antigen bead assays, emphasizes their quantitative limitations, and explores the utility of HLA antibody testing in identifying and managing important pre- and post-transplant clinical outcomes.
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Affiliation(s)
| | - Kathryn Tinckam
- Department of Medicine, Division of Nephrology and Laboratory Medicine Program, HLA Laboratory, University Health Network, University of Toronto, Toronto, Ontario, Canada
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32
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Sapir-Pichhadze R, Tinckam K, Quach K, Logan AG, Laupacis A, John R, Beyene J, Kim SJ. HLA-DR and -DQ eplet mismatches and transplant glomerulopathy: a nested case-control study. Am J Transplant 2015; 15:137-48. [PMID: 25521856 DOI: 10.1111/ajt.12968] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 08/04/2014] [Accepted: 08/05/2014] [Indexed: 01/25/2023]
Abstract
We conducted a nested case-control study from a cohort of adult kidney transplant recipients to assess the risk of transplant glomerulopathy (TG) as a function of donor and recipient HLA-DR and -DQ incompatibility at the eplet level. Cases (n = 52) were defined as patients diagnosed with transplant glomerulopathy based on biopsies showing glomerular basement membrane duplication without immune complex deposition. Controls (n = 104) with a similar follow-up from transplantation were randomly selected from the remaining cohort. HLAMatchmaker was used to ascertain the number of DRB1/3/4/5, DQA1 and DQB1 related eplet mismatches (eplet load). Multivariable conditional logistic regression models demonstrated an increase in the odds of TG (odds ratios [OR] of 2.84 [95% confidence interval (CI): 1.03, 7.84] and 4.62 [95% CI: 1.51, 14.14]) in the presence of 27-43 and >43 HLA-DR + DQ related eplet mismatches versus <27 eplet mismatches, respectively. When the eplet load was modeled as a continuous variable, the OR for TG was 1.25 (95% CI: 1.04, 1.50) for every 10 additional HLA-DR + DQ eplet mismatches. Our study suggests that minimization of HLA-DR + DQ eplet mismatches may decrease the incidence of transplant glomerulopathy diagnosed by indication biopsies. The role of eplet immunogenicity/antigenicity as determinants of allograft outcomes requires further study.
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Affiliation(s)
- R Sapir-Pichhadze
- Division of Nephrology and The Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
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33
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Remport A, Ivanyi B, Mathe Z, Tinckam K, Mucsi I, Molnar MZ. Better understanding of transplant glomerulopathy secondary to chronic antibody-mediated rejection. Nephrol Dial Transplant 2014; 30:1825-33. [PMID: 25473123 DOI: 10.1093/ndt/gfu371] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Accepted: 11/03/2014] [Indexed: 01/08/2023] Open
Abstract
Transplant glomerulopathy (TG) is generally accepted to result from repeated episodes of endothelial activation, injury and repair, leading to pathological abnormalities of double contouring or multi-layering of the glomerular basement membrane. TG is a major sequel of chronic active antibody-mediated rejection (cABMR), from pre-existing or de novo anti-HLA antibodies. Hepatitis C infection, thrombotic microangiopathy or other factors may also contribute to TG development. TG prevalence is 5-20% in most series, reaching 55%, in some high-risk cohorts, and is associated with worse allograft outcomes. Despite its prevalence and clinical significance, few well-studied treatment options have been proposed. Similar to desensitization protocols, plasmapheresis with or without immunoabsorption, high-dose intravenous immunoglobulin, rituximab, bortezomib and eculizumab have been proposed in the treatment of TG due to cABMR individually or in various combinations. Robust clinical trials are urgently needed to address this major cause of allograft loss. This review summarizes the current knowledge of the epidemiology, etiology, pathology, and the preventive and treatment options for TG secondary to cABMR.
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Affiliation(s)
- Adam Remport
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Bela Ivanyi
- Department of Pathology, University of Szeged, Szeged, Hungary
| | - Zoltan Mathe
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Kathryn Tinckam
- Division of Nephrology, Department of Medicine,University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Istvan Mucsi
- Division of Nephrology, Department of Medicine,University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
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34
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Sapir-Pichhadze R, Curran SP, John R, Tricco AC, Uleryk E, Laupacis A, Tinckam K, Sis B, Beyene J, Logan AG, Kim SJ. A systematic review of the role of C4d in the diagnosis of acute antibody-mediated rejection. Kidney Int 2014; 87:182-94. [PMID: 24827778 DOI: 10.1038/ki.2014.166] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 03/21/2014] [Accepted: 03/27/2014] [Indexed: 01/03/2023]
Abstract
In this study, we conducted a systematic review of the literature to re-evaluate the role of C4d in the diagnosis of acute antibody-mediated rejection of kidney allografts. Electronic databases were searched until September 2013. Eligible studies allowed derivation of diagnostic tables for the performance of C4d by immunofluorescence or immunohistochemistry with comparison to histopathological features of acute antibody-mediated rejection and/or donor-specific antibody (DSA) assays. Of 3492 unique abstracts, 29 studies encompassing 3485 indication and 868 surveillance biopsies were identified. Assessment of C4d by immunofluorescence and immunohistochemistry exhibited slight to moderate agreement with glomerulitis, peritubular capillaritis, solid-phase DSA assays, DSA with glomerulitis, and DSA with peritubular capillaritis. The sensitivity and specificity of C4d varied as a function of C4d and comparator test thresholds. Prognostically, the presence of C4d was associated with inferior allograft survival compared with DSA or histopathology alone. Thus, our findings support the presence of complement-dependent and -independent phenotypes of acute antibody-mediated rejection. Whether the presence of C4d in combination with histopathology or DSA should be considered for the diagnosis of acute antibody-mediated rejection warrants further study.
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Affiliation(s)
- Ruth Sapir-Pichhadze
- 1] Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada [2] Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada [3] Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Simon P Curran
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Rohan John
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Andrea C Tricco
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Andreas Laupacis
- 1] Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada [2] Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Kathryn Tinckam
- 1] Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada [2] Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Banu Sis
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Joseph Beyene
- 1] Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada [2] Population Health Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada [3] Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Alexander G Logan
- 1] Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada [2] Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada [3] Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - S Joseph Kim
- 1] Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada [2] Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada [3] Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada [4] Division of Nephrology and the Renal Transplant Program, St Michael's Hospital, Toronto, Ontario, Canada
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35
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Tikkanen J, Singer L, Azad S, Binnie M, Chaparro C, Chow C, Cypel M, dePerrot M, Pierre A, Yasufuku K, Waddell T, Keshavjee S, Tinckam K. De Novo DQ Donor-Specific Antibodies Are Associated With Chronic Lung Allograft Dysfunction. J Heart Lung Transplant 2014. [DOI: 10.1016/j.healun.2014.01.297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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36
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Tinckam K, Campbell P. Angiotensin II Type 1 receptor antibodies: great expectations? Am J Transplant 2013; 13:2515-6. [PMID: 23924147 DOI: 10.1111/ajt.12396] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 06/18/2013] [Indexed: 01/25/2023]
Affiliation(s)
- K Tinckam
- Laboratory Medicine Program, University Hospital Network, Toronto, Ontario, Canada
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37
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Luk A, Alba C, Butany J, Tinckam K, Delgado D, Ross H. C4d Immunostaining Is an Independent Predictor of Graft Dysfunction, Cardiac Allograft Vasculopathy and Death in Heart Transplant Recipients. J Heart Lung Transplant 2013. [DOI: 10.1016/j.healun.2013.01.627] [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: 11/29/2022] Open
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38
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Chen C, Manlhiot C, Conway J, Allain-Rooney T, McCrindle B, Tinckam K, Dipchand A. Development of De Novo Anti-HLA Antibodies in Pediatric Heart Transplant Recipients. J Heart Lung Transplant 2013. [DOI: 10.1016/j.healun.2013.01.471] [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: 10/27/2022] Open
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39
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Tinckam K, Azad S, Barth D, Binnie M, Chaparro C, Chow CW, Cypel M, dePerrot M, Pierre A, Waddell T, Yasufuku K, Keshavjee S, Singer L. Improved Survival with Perioperative Desensitization in Lung Transplant Patients with Donor Specific Antibodies (DSA). J Heart Lung Transplant 2013. [DOI: 10.1016/j.healun.2013.01.188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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40
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Mengel M, Campbell P, Gebel H, Randhawa P, Rodriguez ER, Colvin R, Conway J, Hachem R, Halloran PF, Keshavjee S, Nickerson P, Murphey C, O'Leary J, Reeve J, Tinckam K, Reed EF. Precision diagnostics in transplantation: from bench to bedside. Am J Transplant 2013; 13:562-8. [PMID: 23279692 DOI: 10.1111/j.1600-6143.2012.04344.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 10/01/2012] [Accepted: 10/14/2012] [Indexed: 01/25/2023]
Abstract
The Canadian and American Societies of Transplantation held a symposium on February 22, 2012 in Quebec City focused on discovery, validation and translation of new diagnostic tools into clinical transplantation. The symposium focused on antibody testing, transplantation pathology, molecular diagnostics and laboratory support for the incompatible patient. There is an unmet need for more precise diagnostic approaches in transplantation. Significant potential for increasing the diagnostic precision in transplantation was recognized through the integration of conventional histopathology, molecular technologies and sensitive antibody testing into one enhanced diagnostic system.
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Affiliation(s)
- M Mengel
- Transplant Diagnostics Community of Practice of the American Society of Transplantation, USA.
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41
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43
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44
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Fairhead T, Hendren E, Tinckam K, Rose C, Sherlock CH, Shi L, Crowcroft NS, Gubbay JB, Landsberg D, Knoll G, Gill J, Kumar D. Poor seroprotection but allosensitization after adjuvanted pandemic influenza H1N1 vaccine in kidney transplant recipients. Transpl Infect Dis 2012; 14:575-83. [PMID: 22999005 DOI: 10.1111/tid.12006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 04/20/2012] [Accepted: 07/04/2012] [Indexed: 01/05/2023]
Abstract
BACKGROUND Seasonal and pandemic influenza virus infections in renal transplant patients are associated with poor outcomes. During the pandemic of 2009-2010, the AS03-adjuvanted monovalent H1N1 influenza vaccine was recommended for transplant recipients, although its immunogenicity in this population was unknown. We sought to determine the safety and immunogenicity of an adjuvant-containing vaccine against pandemic influenza A H1N1 2009 (pH1N1) administered to kidney transplant recipients. METHODS We prospectively enrolled 124 adult kidney transplant recipients in the fall of 2009 at two transplant centers. Cohort 1 (n = 42) was assessed before and after pH1N1 immunization, while Cohort 2 (n = 82) was only assessed post immunization. Humoral response was measured by the hemagglutination inhibition assay. Vaccine safety was assessed by adverse event reporting, graft function, and human leukocyte antigen (HLA) alloantibody measurements. RESULTS Cohort 1 had a low rate of baseline seroprotection to pH1N1 (7%) and a low rate of seroprotection after immunization (31%). No patient <6 months post transplant (n = 5) achieved seroprotection. Seroprotection rate was greater in patients receiving double as compared with triple immunosuppression (80% vs. 24%, P = 0.01). In Cohort 2, post-immunization seroprotection was 35%. In both cohorts, no confirmed cases of pH1N1 infection occurred. No difference was seen in estimated glomerular filtration rate before (54.3 mL/min/1.73 m(2) ) and after (53.8 mL/min/1.73 m(2) ) immunization, and no acute rejections had occurred after immunization at last follow-up. In Cohort 1, 11.9% of patients developed new anti-HLA antibodies. CONCLUSION An adjuvant-containing vaccine to pH1N1 provided poor seroprotection in renal transplant recipients. Receiving triple immunosuppression was associated with a poor seroresponse. Vaccination appeared safe, but some patients developed new anti-HLA antibodies post vaccination. Alternative strategies to improve vaccine responses are necessary.
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Affiliation(s)
- T Fairhead
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
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45
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Noone D, Al-Matrafi J, Tinckam K, Zipfel PF, Herzenberg AM, Thorner PS, Pluthero FG, Kahr WHA, Filler G, Hebert D, Harvey E, Licht C. Antibody mediated rejection associated with complement factor h-related protein 3/1 deficiency successfully treated with eculizumab. Am J Transplant 2012; 12:2546-53. [PMID: 22681773 DOI: 10.1111/j.1600-6143.2012.04124.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Antibody mediated rejection (AMR) activates the classical complement pathway and can be detrimental to graft survival. AMR can be accompanied by thrombotic microangiopathy (TMA). Eculizumab, a monoclonal C5 antibody prevents induction of the terminal complement cascade (TCC) and has recently emerged as a therapeutic option for AMR. We present a highly sensitized 13-year-old female with end-stage kidney disease secondary to spina bifida-associated reflux nephropathy, who developed severe steroid-, ATG- and plasmapheresis-resistant AMR with TMA 1 week post second kidney transplant despite previous desensitization therapy with immunoglobulin infusions. Eculizumab rescue therapy resulted in a dramatic improvement in biochemical (C3; creatinine) and hematological (platelets) parameters within 6 days. The patient was proven to be deficient in complement Factor H-related protein 3/1 (CFHR3/1), a plasma protein that regulates the complement cascade at the level of C5 conversion and has been involved in the pathogenesis of atypical hemolytic uremic syndrome caused by CFH autoantibodies (DEAP-HUS). CFHR1 deficiency may have worsened the severe clinical progression of AMR and possibly contributed to the development of donor-specific antibodies. Thus, screening for CFHR3/1 deficiency should be considered in patients with severe AMR associated with TMA.
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Affiliation(s)
- D Noone
- Division of Nephrology, The Hospital for Sick Children, University of Toronto, ON, Canada
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Chruscinski A, Huang F, Tinckam K, Rao V, Levy G, Ross H. 97 Non-HLA Antibodies in Heart Transplant Recipients with AMR: Profiling with Antigen Microarrays. J Heart Lung Transplant 2012. [DOI: 10.1016/j.healun.2012.01.101] [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: 11/30/2022] Open
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Chih S, Tinckam K, Ross H. 205 A Survey of Current Practice for Antibody Mediated Rejection in Heart Transplantation To Guide Treatment Standardization. J Heart Lung Transplant 2012. [DOI: 10.1016/j.healun.2012.01.204] [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: 10/28/2022] Open
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Alba A, Tinckam K, Nelson L, Gustafsson F, Sander K, Bruunsgaard H, Rao V, Delgado D, Ross H. 121 Factors Associated with Anti-HLA Antibodies in Patients Supported with Continuous Flow Devices and Impact on Probability of Transplant. J Heart Lung Transplant 2012. [DOI: 10.1016/j.healun.2012.01.125] [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: 11/26/2022] Open
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Chruscinski A, Huang F, Tinckam K, Rao V, Levy G, Ross H. 288 Non-HLA Antibodies and Risk of Rejection after Heart Transplantation: Profiling with Antigen Microarrays. J Heart Lung Transplant 2012. [DOI: 10.1016/j.healun.2012.01.296] [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: 10/28/2022] Open
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Goodwin J, Tinckam K, denHollander N, Haroon A, Keshavjee S, Cserti-Gazdewich CM. Transfusion-related acute lung injury (TRALI) in graft by blood donor antibodies against host leukocytes. J Heart Lung Transplant 2010; 29:1067-70. [DOI: 10.1016/j.healun.2010.04.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 04/13/2010] [Accepted: 04/16/2010] [Indexed: 11/15/2022] Open
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