51
|
Hanna RM, Lopez EA, Hasnain H, Selamet U, Wilson J, Youssef PN, Akladeous N, Bunnapradist S, Gorin MB. Three patients with injection of intravitreal vascular endothelial growth factor inhibitors and subsequent exacerbation of chronic proteinuria and hypertension. Clin Kidney J 2018; 12:92-100. [PMID: 30746134 PMCID: PMC6366143 DOI: 10.1093/ckj/sfy060] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 05/28/2018] [Indexed: 12/31/2022] Open
Abstract
Vascular endothelial growth factor (VEGF) receptor inhibition is a commonly used tool to prevent vascular proliferation in tumors and retinal diseases. The antiangiogenic effects of these drugs have made them potent adjunct therapies when given systemically for malignancies. They are also useful tools to ameliorate diminishing eyesight in retinopathy. Hypertension and proteinuria have been observed in systemic VEGF inhibitor therapy, with rarer presentations involving nephrotic-range proteinuria due to glomerulopathies. Pharmacokinetic studies have shown detectable blood levels of anti-VEGF inhibitors up to 30 days postintravitreal injection. Animal studies have also demonstrated binding of VEGF inhibitors in simian glomeruli 1 week after a single intravitreal injection. We report three patients who received intravitreal bevacizumab and/or aflibercept with worsening hypertension, proteinuria and renal injury. Data regarding emerging evidence of VEGF inhibitor nephrotoxicity after intravitreal injections are also presented. The clinical data and the existing literature are reviewed to support the hypothesis that intravitreal anti-VEGF agents may be unrecognized nephrotoxins. These agents are given to vulnerable patients with diabetes, hypertension and preexisting nephropathy and proteinuria. This case series is reported to spur further study of the systemic effects of intravitreal VEGF inhibitors.
Collapse
|
52
|
Phonphok K, Beaird O, Duong T, Datta N, Schaenman J, Bunnapradist S. Screening Coccidioides serology in kidney transplant recipients: A 10-year cross-sectional analysis. Transpl Infect Dis 2018; 20:e12932. [PMID: 29809303 DOI: 10.1111/tid.12932] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/28/2018] [Accepted: 05/17/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Kidney transplant recipients (KTRs) are at risk for reactivation and complicated infection due to Coccidioides. Pre-transplant serological screening should provide benefit for patients from endemic areas. We evaluated Coccidioides seroprevalence by area of residence in KTRs at a major transplant program in Los Angeles. METHODS We performed cross-sectional analyses of adult KTRs who underwent transplantation at UCLA between 2007-2016. Patients with Coccidioides serology by enzyme immunoassay (EIA) before or within 14 days from transplantation were included. Patients were classified as living in highly, established, suspected, or not endemic areas by their residential zip code. RESULTS Overall prevalence of Coccidioides IgG and IgM were 1.4% and 2.8%, respectively. Of patients with positive serology, 31.4% had isolated IgG and 66.3% isolated IgM. Patients from established and highly endemic areas had IgG seropositivity of 3.7% versus 1.3% for patients living in suspected endemic areas(P < .01). Rates of IgM seropositivity were 3.7% compared to 2.8% respectively (P = .28). No patients from non-endemic areas had positive screening serology. CONCLUSIONS Pre-transplant serological screening for Coccidioides is recommended in kidney transplant candidates from endemic areas. We observed high seroprevalence among patients from highly and established endemic areas, for whom universal prophylaxis is recommended. For residents from less well-established areas of endemicity, serological screening showed benefit in identifying patients at risk. In patients with isolated EIA IgM, performing repeat and confirmatory tests is recommended. Patients from non-endemic areas had low risk of infection, however, a thorough social history is necessary to evaluate risk.
Collapse
|
53
|
Hanna RM, Kamgar M, Hasnain H, Khorsan R, Nsair A, Kaldas F, Baas A, Bunnapradist S, Wilson JM. Case Report: First Reported Combined Heart-Liver Transplant in a Patient With a Congenital Solitary Kidney. Transplant Proc 2018; 50:943-946. [PMID: 29458999 DOI: 10.1016/j.transproceed.2017.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 11/11/2017] [Indexed: 10/18/2022]
Abstract
We report a case of successful combined heart liver transplant in a patient with a congenital solitary kidney. The patient had normal renal function before combined heart-liver transplantation and developed acute kidney injury requiring slow continuous dialysis and subsequent intermittent dialysis for almost 8 weeks post transplantation. Her renal function recovered and she remains off dialysis now 7 months post transplantation. She only currently has mild chronic renal insufficiency. We believe this is the first reported case of successful heart liver transplant in a patient with a congenital solitary kidney.
Collapse
|
54
|
Weinrauch LA, D'Elia JA, Weir MR, Bunnapradist S, Finn PV, Liu J, Claggett B, Monaco AP. Infection and Malignancy Outweigh Cardiovascular Mortality in Kidney Transplant Recipients: Post Hoc Analysis of the FAVORIT Trial. Am J Med 2018; 131:165-172. [PMID: 28943384 DOI: 10.1016/j.amjmed.2017.08.038] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/24/2017] [Accepted: 08/25/2017] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Now that long-term survival after successful renal transplantation is no longer limited by excessive cardiovascular risk, the primary care physician should consider that infection and malignancy are leading noncardiovascular causes of death even in the recipient with diabetes. METHODS We accessed the National Institutes of Health-sponsored Folic Acid for Vascular Outcome Reduction in Transplantation (FAVORIT) study population (4010 renal transplant recipients with elevated homocysteine levels) studied to determine whether folate and B12 supplementation would reduce cardiovascular end points. This trial had a null result. Patients were classified as being nondiabetic or having type 1 or type 2 diabetes. RESULTS We report an excess (cardiovascular and noncardiovascular) 6-year mortality risk associated with the presence of diabetes mellitus. Two thirds of fatal events in our renal transplant recipients were centrally adjudicated as noncardiovascular. The incidence of noncardiovascular death was 70% higher in the diabetic patient cohort than in the nondiabetic cohort. CONCLUSIONS These results demonstrate that infection (but not malignancy) risks are far higher in diabetic than nondiabetic immunosuppressed individuals (although noncardiovascular death rate in nondiabetic individuals also exceeded cardiovascular deaths) and may play a larger role in the excess mortality populations than previously thought. Given that follow-up in this study was 4 to 10 years after allograft surgery, there was a lesser degree of acute rejection requiring high-dose immunosuppression than in the initial postallograft years. This unique perspective allows transplant recipients to return to primary physicians when taking low doses of immunosuppressive agents and provides focus for follow-up care.
Collapse
|
55
|
Fabrizi F, Bunnapradist S, Lunghi G, Villa M, Martin P. Transplanting Solid Organs from HBsAg Negative Donors Positive for Antibody to Hepatitis B Core Antigen: The Implications. Int J Artif Organs 2018; 26:972-83. [PMID: 14708825 DOI: 10.1177/039139880302601102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
56
|
Fabrizi F, Martin P, Bunnapradist S, Villa M, Rusconi E, Messa PG. Lamivudine in the Treatment of HBV-related Liver Disease after Renal Transplantation: An Update. Int J Artif Organs 2018; 28:211-21. [PMID: 15818543 DOI: 10.1177/039139880502800305] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Diminished survival due to hepatitis B has been observed after renal transplantation (RT). Lamivudine, a second-generation nucleoside analogue, has been approved for the treatment of chronic hepatitis B virus (HBV) infection in patients with normal renal function. Numerous clinical experiences with lamivudine after RT have been recently published. Despite numerous shortcomings, all of these reports have shown encouraging results. The rate of clearance of HBV viremia ranged between 67% and 100%, and the frequency of ALT normalization was between 50% and 100% with lamivudine use. Even patients with fibrosing cholestatic hepatitis, a serious form of HBV-related liver disease with ominous course, have been successfully treated with lamivudine. Lamivudine therapy significantly improved the survival of HBsAg positive renal allograft recipients. However, numerous issues concerning the treatment of hepatitis B after RT remain unclear: the optimal time to initiate lamivudine, the appropriate duration of antiviral therapy after RT, and the role for pre-transplantation liver biopsy. Also, the management of lamivudine resistance remains a concern for physicians. Clinical trials are under way.
Collapse
|
57
|
Kang W, Sampaio MS, Huang E, Bunnapradist S. Association of Pretransplant Skin Cancer With Posttransplant Malignancy, Graft Failure and Death in Kidney Transplant Recipients. Transplantation 2017; 101:1303-1309. [PMID: 27336396 DOI: 10.1097/tp.0000000000001286] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Posttransplant malignancy (PTM) is one of the leading causes of late death in kidney recipients. Those with a cancer history may be more prone to develop a recurrent or a new cancer. We studied the association between pretransplant skin cancer, PTM, death, and graft failure. METHODS Primary adult kidney recipients transplanted between 2005 and 2013 were included. Malignancy information was obtained from Organ Procurement Kidney Transplant Network/United Network for Organ Sharing registration and follow-up forms. Posttransplant malignancy was classified into skin cancer, solid tumor, and posttransplant lymphoproliferative disorder (PTLD). Competing risk and survival analysis with adjustment for confounders were used to calculate risk for PTM, death and graft failure in recipients with pretransplant skin cancer compared with those without cancer. Risk was reported in hazard ratios (HR) with 95% confidence interval (CI). RESULTS The cohort included 1671 recipients with and 102 961 without pretransplant skin malignancy. The 5-year cumulative incidence of PTM in patients with and without a pretransplant skin cancer history was 31.6% and 7.4%, respectively (P < 0.001). Recipients with pretransplant skin cancer had increased risk of PTM (sub-HR [SHR], 2.60; 95% CI, 2.27-2.98), and posttransplant skin cancer (SHR, 2.92; 95% CI, 2.52-3.39), PTLD (SHR, 1.93; 95% CI, 1.01-3.66), solid tumor (SHR, 1.44; 95% CI, 1.04-1.99), death (HR, 1.20; 95% CI, 1.07-1.34), and graft failure (HR, 1.17; 95% CI, 1.05-1.30) when compared with those without pretransplant malignancy. CONCLUSIONS Pretransplant skin cancer was associated with an increased risk of posttransplant skin cancer, PTLD, solid organ cancer, death and graft failure.
Collapse
|
58
|
Weinrauch LA, D'Elia JA, Weir MR, Bunnapradist S, Finn P, Liu J, Claggett B, Monaco AP. Does diabetes impact therapeutic immunomodulation therapy decisions for kidney transplant recipients? Data from the Folic Acid for Vascular Outcome Reduction in Transplant (FAVORIT) trial. Int J Nephrol Renovasc Dis 2017; 10:233-242. [PMID: 28860838 PMCID: PMC5571849 DOI: 10.2147/ijnrd.s139901] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Although survival has improved for kidney transplant recipients over the past several decades, long-term survival in diabetic cohorts still is significantly less than that of non-diabetic cohorts. We hypothesized that among stable kidney transplant recipients, there might be differences between subgroups with and without diabetes with respect to prevalence of prior cardiovascular events and post-transplant antihypertensive and immunosuppressive therapy. We performed a post hoc analysis of participants in the Folic Acid for Vascular Outcome Reduction in Transplant (FAVORIT) trial, a multicenter international trial of 4110 prevalent kidney transplant recipients enrolled from 2002 to 2007 evaluating the effect of homocysteine-lowering vitamin therapy on cardiovascular outcomes. There were 2447 participants without diabetes, 166 with type 1 diabetes, and 1447 with type 2 diabetes at study entry, which occurred on average 4 years post-transplant. Recipients with diabetes had a greater prevalence of prior cardiovascular events, were more likely to have required multiple medications to control hypertension, and were more likely to have received tacrolimus as opposed to cyclosporine than the non-diabetic transplant recipients (all p<0.001). The effect of differences in treatment of non-diabetic vs diabetic cohorts after stable renal transplantation upon outcomes has not yet been studied and could provide additional information that might lead to improved care.
Collapse
|
59
|
Schaenman J, Korin Y, Sidwell T, Kandarian F, Harre N, Gjertson D, Lum E, Reddy U, Huang E, Pham P, Bunnapradist S, Danovitch G, Veale J, Gritsch H, Reed E. Increased Frequency of BK Virus-Specific Polyfunctional CD8+ T Cells Predict Successful Control of BK Viremia After Kidney Transplantation. Transplantation 2017; 101:1479-1487. [PMID: 27391197 PMCID: PMC5219876 DOI: 10.1097/tp.0000000000001314] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND BK virus infection remains an important cause of loss of allograft function after kidney transplantation. We sought to determine whether polyfunctional T cells secreting multiple cytokines simultaneously, which have been shown to be associated with viral control, could be detected early after start of BK viremia, which would provide insight into the mechanism of successful antiviral control. METHODS Peripheral blood mononuclear cells collected during episodes of BK viral replication were evaluated by multiparameter flow cytometry after stimulation by overlapping peptide pools of BK virus antigen to determine frequency of CD8+ and CD4+ T cells expressing 1 or more cytokines simultaneously, as well as markers of T-cell activation, exhaustion, and maturation. RESULTS BK virus controllers, defined as those with episodes of BK viremia of 3 months or less, had an 11-fold increase in frequency of CD8+ polyfunctional T cells expressing multiple cytokines, as compared with patients with prolonged episodes of BK viremia. Patients with only low level BK viremia expressed low frequencies of polyfunctional T cells. Polyfunctional T cells were predominantly of the effector memory maturation subtype and expressed the cytotoxicity marker CD107a. CONCLUSIONS Noninvasive techniques for immune assessment of peripheral blood can provide insight into the mechanism of control of BK virus replication and may allow for future patient risk stratification and customization of immune suppression at the onset of BK viremia.
Collapse
|
60
|
Lum EL, Huang E, Bunnapradist S, Pham T, Danovitch G. Acute Kidney Allograft Rejection Precipitated by Lenalidomide Treatment for Multiple Myeloma. Am J Kidney Dis 2017; 69:701-704. [DOI: 10.1053/j.ajkd.2016.11.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 11/21/2016] [Indexed: 01/20/2023]
|
61
|
Bromberg JS, Brennan DC, Poggio E, Bunnapradist S, Langone A, Sood P, Matas AJ, Mannon RB, Mehta S, Sharfuddin A, Fischbach B, Narayanan M, Jordan SC, Cohen DJ, Zaky ZS, Hiller D, Woodward RN, Grskovic M, Sninsky JJ, Yee JP, Bloom RD. Biological Variation of Donor-Derived Cell-Free DNA in Renal Transplant Recipients: Clinical Implications. ACTA ACUST UNITED AC 2017; 2:309-321. [DOI: 10.1373/jalm.2016.022731] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 02/09/2017] [Indexed: 12/23/2022]
|
62
|
Bloom RD, Bromberg JS, Poggio ED, Bunnapradist S, Langone AJ, Sood P, Matas AJ, Mehta S, Mannon RB, Sharfuddin A, Fischbach B, Narayanan M, Jordan SC, Cohen D, Weir MR, Hiller D, Prasad P, Woodward RN, Grskovic M, Sninsky JJ, Yee JP, Brennan DC. Cell-Free DNA and Active Rejection in Kidney Allografts. J Am Soc Nephrol 2017; 28:2221-2232. [PMID: 28280140 DOI: 10.1681/asn.2016091034] [Citation(s) in RCA: 333] [Impact Index Per Article: 47.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 01/06/2017] [Indexed: 12/28/2022] Open
Abstract
Histologic analysis of the allograft biopsy specimen is the standard method used to differentiate rejection from other injury in kidney transplants. Donor-derived cell-free DNA (dd-cfDNA) is a noninvasive test of allograft injury that may enable more frequent, quantitative, and safer assessment of allograft rejection and injury status. To investigate this possibility, we prospectively collected blood specimens at scheduled intervals and at the time of clinically indicated biopsies. In 102 kidney recipients, we measured plasma levels of dd-cfDNA and correlated the levels with allograft rejection status ascertained by histology in 107 biopsy specimens. The dd-cfDNA level discriminated between biopsy specimens showing any rejection (T cell-mediated rejection or antibody-mediated rejection [ABMR]) and controls (no rejection histologically), P<0.001 (receiver operating characteristic area under the curve [AUC], 0.74; 95% confidence interval [95% CI], 0.61 to 0.86). Positive and negative predictive values for active rejection at a cutoff of 1.0% dd-cfDNA were 61% and 84%, respectively. The AUC for discriminating ABMR from samples without ABMR was 0.87 (95% CI, 0.75 to 0.97). Positive and negative predictive values for ABMR at a cutoff of 1.0% dd-cfDNA were 44% and 96%, respectively. Median dd-cfDNA was 2.9% (ABMR), 1.2% (T cell-mediated types ≥IB), 0.2% (T cell-mediated type IA), and 0.3% in controls (P=0.05 for T cell-mediated rejection types ≥IB versus controls). Thus, dd-cfDNA may be used to assess allograft rejection and injury; dd-cfDNA levels <1% reflect the absence of active rejection (T cell-mediated type ≥IB or ABMR) and levels >1% indicate a probability of active rejection.
Collapse
|
63
|
Talamantes E, Norris KC, Mangione CM, Moreno G, Waterman AD, Peipert JD, Bunnapradist S, Huang E. Linguistic Isolation and Access to the Active Kidney Transplant Waiting List in the United States. Clin J Am Soc Nephrol 2017; 12:483-492. [PMID: 28183854 PMCID: PMC5338711 DOI: 10.2215/cjn.07150716] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 11/15/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND OBJECTIVES Waitlist inactivity is a barrier to transplantation, because inactive candidates cannot receive deceased donor organ offers. We hypothesized that temporarily inactive kidney transplant candidates living in linguistically isolated communities would be less likely to achieve active waitlist status. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We merged Organ Procurement and Transplantation Network/United Network for Organ Sharing data with five-digit zip code socioeconomic data from the 2000 US Census. The cumulative incidence of conversion to active waitlist status, death, and delisting before conversion among 84,783 temporarily inactive adult kidney candidates from 2004 to 2012 was determined using competing risks methods. Competing risks regression was performed to characterize the association between linguistic isolation, incomplete transplantation evaluation, and conversion to active status. A household was determined to be linguistically isolated if all members ≥14 years old speak a non-English language and also, speak English less than very well. RESULTS A total of 59,147 candidates (70% of the study population) achieved active status over the study period of 9.8 years. Median follow-up was 110 days (interquartile range, 42-276 days) for activated patients and 815 days (interquartile range, 361-1244 days) for candidates not activated. The cumulative incidence of activation over the study period was 74%, the cumulative incidence of death before conversion was 10%, and the cumulative incidence of delisting was 13%. After adjusting for other relevant covariates, living in a zip code with higher percentages of linguistically isolated households was associated with progressively lower subhazards of activation both in the overall population (reference: <1% linguistically isolated households; 1%-4.9% linguistically isolated: subhazard ratio, 0.89; 95% confidence interval, 0.86 to 0.93; 5%-9.9% linguistically isolated: subhazard ratio, 0.83; 95% confidence interval, 0.80 to 0.87; 10%-19.9% linguistically isolated: subhazard ratio, 0.76; 95% confidence interval, 0.72 to 0.80; and ≥20% linguistically isolated: subhazard ratio, 0.71; 95% confidence interval, 0.67 to 0.76) and among candidates designated temporarily inactive due to an incomplete transplant evaluation. CONCLUSIONS Our findings indicate that candidates residing in linguistically isolated communities are less likely to complete candidate evaluations and achieve active waitlist status.
Collapse
|
64
|
Bunnapradist S, Danovitch GM. Marginal quality kidneys for simultaneous liver-kidney transplantation: To pass or double down? Liver Transpl 2017; 23:7-8. [PMID: 27805302 DOI: 10.1002/lt.24669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 10/26/2016] [Indexed: 01/01/2023]
|
65
|
Mehrnia A, Le TX, Tamer TR, Bunnapradist S. Effects of acute rejection vs new-onset diabetes after transplant on transplant outcomes in pediatric kidney recipients: analysis of the Organ Procurement and Transplant Network/United Network for Organ Sharing (OPTN/UNOS) database. Pediatr Transplant 2016; 20:952-957. [PMID: 27578397 DOI: 10.1111/petr.12790] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2016] [Indexed: 12/13/2022]
Abstract
Improving long-term transplant and patient survival is still an ongoing challenge in kidney transplant medicine. Our objective was to identify the subsequent risks of new-onset diabetes after transplant (NODAT) and acute rejection (AR) in the first year post-transplant in predicting mortality and transplant failure. A total of 4687 patients without preexisting diabetes (age 2-20 years, 2004-2010) surviving with a functioning transplant for longer than 1 year with at least one follow-up report were identified from the OPTN/UNOS database as of September 2014. Study population was stratified into four mutually exclusive groups: Group 1, patients with a history of AR; Group 2, NODAT+; Group 3, NODAT+ AR+; and Group 4, the reference group (neither). Multivariate regression was used to analyze the relative risks for the outcomes of transplant failure and mortality. The median follow-up time was 1827 days after 1 year post-transplant. AR was associated with an increased risk of adjusted graft and death-censored graft failure (HR 2.87, CI 2.48-3.33, P < .001 and HR 2.11, CI 1.81-2.47, P < .001), respectively. NODAT and AR were identified in 3.5% and 14.5% of all study patients, respectively. AR in the first year post-transplant was a major risk factor for overall and death-censored graft failure, but not mortality. However, NODAT was not a risk factor on graft survival or mortality.
Collapse
|
66
|
Kuo HT, Lum E, Martin P, Bunnapradist S. Effect of diabetes and acute rejection on liver transplant outcomes: An analysis of the organ procurement and transplantation network/united network for organ sharing database. Liver Transpl 2016; 22:796-804. [PMID: 26850091 DOI: 10.1002/lt.24414] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 01/19/2016] [Accepted: 01/29/2016] [Indexed: 12/18/2022]
Abstract
The effects of diabetic status and acute rejection (AR) on liver transplant outcomes are largely unknown. We studied 13,736 liver recipients from the United Network for Organ Sharing/Organ Procurement Transplant Network database who underwent transplantation between 2004 and 2007 with a functioning graft for greater than 1 year. The association of pretransplant diabetes mellitus (PDM), new-onset diabetes after transplant (NODAT), and AR rates on allograft failure, all-cause mortality, and cardiovascular mortality were determined. To determine the differential and joint effects of diabetic status and AR on transplant outcomes, recipients were further stratified into 6 groups: neither (reference, n = 6600); NODAT alone (n = 2054); PDM alone (n = 2414); AR alone (n = 1448); NODAT and AR (n = 707); and PDM and AR (n = 513). An analysis with hepatitis C virus (HCV) serostatus was also performed (HCV recipients, n = 6384; and non-HCV recipient, n = 5934). The median follow-up was 2537 days. The prevalence of PDM was 21.3%. At 1 year after transplant, the rates of NODAT and AR were 25.5% and 19.4%, respectively. Overall, PDM, NODAT, and AR were associated with increased risks for graft failure (PDM, hazard ratio [HR] = 1.31, P < 0.01; NODAT, HR = 1.11, P = 0.02; AR, HR = 1.28, P < 0.01). A multivariate Cox regression analysis of the 6 recipient groups demonstrated that NODAT alone was not significantly associated with any study outcomes. The presence of PDM, AR, NODAT and AR, and PDM and AR were associated with higher overall graft failure risk and mortality risk. The presence of PDM was associated with higher cardiovascular mortality risk. The analyses in both HCV-positive and HCV-negative cohorts showed a similar trend as in the overall cohort. In conclusion, PDM and AR, but not NODAT, is associated with increased mortality and liver allograft failure. Liver Transplantation 22 796-804 2016 AASLD.
Collapse
|
67
|
Bunnapradist S, Rostaing L, Alloway RR, West-Thielke P, Denny J, Mulgaonkar S, Budde K. LCPT once-daily extended-release tacrolimus tablets versus twice-daily capsules: a pooled analysis of two phase 3 trials in important de novo and stable kidney transplant recipient subgroups. Transpl Int 2016; 29:603-11. [PMID: 26953629 DOI: 10.1111/tri.12770] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 11/07/2015] [Accepted: 02/26/2016] [Indexed: 11/29/2022]
Abstract
African-American and elderly kidney transplant recipients (KTR) have increased risk for poor clinical outcomes post-transplant. Management of immunosuppression may be challenging in these patients and contribute to worse outcomes. A novel once-daily formulation of tacrolimus (LCPT) has demonstrated noninferiority, similar safety, improved bioavailability, a consistent concentration time profile, and less peak and peak-trough fluctuations vs. tacrolimus twice-daily (Tac BID). This pooled analysis of two phase 3 randomized, controlled trials, including 861 (LCPT N = 428; Tac BID N = 433; 38% of patients were stable KTR, and 62% were de novo KTR) patients, examined the efficacy of LCPT in KTR subgroups (blacks, females, and age ≥65). Overall, treatment failure [death, graft failure, centrally read biopsy-proven acute rejection (BPAR), or lost to follow-up] at 12 months was as follows: LCPT: 11.9%, BID Tac: 13.4% [-1.48% (-5.95%, 2.99%)]. BPAR rates were as follows: LCPT: 8.2%, Tac BID: 9.5% [-1.29% (-5.14%, 2.55%)]. Numerically, fewer treatment failure events with LCPT were found in the majority of subgroups, with significantly less treatment failure associated with LCPT among black KTR [-13.82% (-27.22%, -0.31%)] and KTR ≥65 [-13.46% (-25.27%, -0.78%)]. This pooled analysis suggests numerically lower efficacy failure rates associated with LCPT among high-risk subgroups, in particular black KTR and KTR ≥65 years old.
Collapse
|
68
|
Rostaing L, Bunnapradist S, Grinyó JM, Ciechanowski K, Denny JE, Silva HT, Budde K. Novel Once-Daily Extended-Release Tacrolimus Versus Twice-Daily Tacrolimus in De Novo Kidney Transplant Recipients: Two-Year Results of Phase 3, Double-Blind, Randomized Trial. Am J Kidney Dis 2015; 67:648-59. [PMID: 26717860 DOI: 10.1053/j.ajkd.2015.10.024] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 10/16/2015] [Indexed: 01/02/2023]
Abstract
BACKGROUND 1-year data from this trial showed the noninferiority of a novel once-daily extended-release tacrolimus (LCPT; Envarsus XR) to immediate-release tacrolimus (IR-Tac) twice daily after kidney transplantation. STUDY DESIGN Final 24-month analysis of a 2-armed, parallel-group, randomized, double-blind, double-dummy, multicenter, phase 3 trial. SETTING & PARTICIPANTS 543 de novo kidney recipients randomly assigned to LCPT (n=268) or IR-Tac (n=275); 507 (93.4%) completed the 24-month study. INTERVENTION LCPT tablets once daily at 0.17 mg/kg/d or IR-Tac twice daily at 0.1 mg/kg/d; subsequent doses were adjusted to maintain target trough ranges (first 30 days, 6-11 ng/mL; thereafter, 4-11 ng/mL). The intervention was 24 months; the study was double blinded for the entirety. OUTCOMES & MEASUREMENTS Treatment failure (death, transplant failure, biopsy-proven acute rejection, or loss to follow up) within 24 months. Safety end points included adverse events, serious adverse events, new-onset diabetes, kidney function, opportunistic infections, and malignancies. Pharmacokinetic measures included total daily dose (TDD) of study drugs and tacrolimus trough levels. RESULTS 24-month treatment failure was LCPT, 23.1%; IR-Tac, 27.3% (treatment difference, -4.14% [95% CI, -11.38% to +3.17%], well below the +10% noninferiority criterion defined for the primary 12-month end point). Subgroup analyses showed fewer treatment failures for LCPT versus IR-Tac among black, older, and female recipients. Safety was similar between groups. From month 1, TDD was lower for LCPT; the difference increased over time. At month 24, mean TDD for LCPT was 24% lower than for the IR-Tac group (P<0.001), but troughs were similar (means at 24 months: LCPT, 5.47 ± 0.17 ng/mL; IR-Tac, 5.8 ± 0.30 ng/mL; P=0.4). LIMITATIONS Trial participant eligibility criteria may limit the generalizability of results to the global population of de novo kidney transplant recipients. CONCLUSIONS Results suggest that once-daily LCPT in de novo kidney transplantation has comparable efficacy and safety profile to that of IR-Tac. Lower TDD reflects LCPT's improved bioavailability and absorption.
Collapse
|
69
|
Huang E, Bunnapradist S. Pre-Transplant Weight Loss and Survival after Kidney Transplantation. Am J Nephrol 2015; 41:448-55. [PMID: 26228385 DOI: 10.1159/000437341] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 06/29/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS We examined post-transplant survival among obese kidney candidates who were temporarily designated waitlist inactive (status 7) due to their weight. METHODS Using OPTN/United Network for Organ Sharing data, patient and graft survival of adult status 7 recipients with a registration body mass index (BMI) ≥30 kg/m(2) (n = 328) were compared to all others (controls; n = 74,066). Status 7 recipients were then matched to controls to assess whether pre-transplant weight loss was associated with a survival benefit. RESULTS Median BMI at registration (38 vs. 27 kg/m(2), p < 0.001) and transplant (36 vs. 27 kg/m(2), p < 0.001) and reduction in BMI while waitlisted (-5.0 vs. 0.0%, p < 0.001) were higher among status 7 than controls. Patient (status 7: 87.3%; control: 89.3%; p = 0.90) and graft survival (status 7: 82.9%; control: 81.6%; p = 0.75) were similar over 4 years. There was no association between status 7 and mortality (HR 0.96, 95% CI 0.59-1.57) or graft loss (HR 0.95, 95% CI 0.66-1.38) in the overall population nor between matched status 7 recipients and controls (patient survival: 86.0 vs. 87.5%, p = 0.20; graft survival: 82.6 vs. 77.2%, p = 0.61). CONCLUSION Among obese status 7 kidney candidates previously considered too obese for transplant, patient and graft survival were comparable to the general transplant population. No difference in survival was observed with pre-transplant weight loss.
Collapse
|
70
|
Parke CY, Martin P, Bunnapradist S. Renal dysfunction in cirrhosis. Clin Liver Dis (Hoboken) 2015; 5:150-153. [PMID: 31040973 PMCID: PMC6490530 DOI: 10.1002/cld.485] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 01/21/2015] [Accepted: 04/19/2015] [Indexed: 02/04/2023] Open
|
71
|
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] [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.
Collapse
|
72
|
Huang J, Danovitch G, Pham PT, Bunnapradist S, Huang E. Kidney retransplantation for BK virus nephropathy with active viremia without allograft nephrectomy. J Nephrol 2015; 28:773-7. [PMID: 25910469 DOI: 10.1007/s40620-015-0200-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 04/16/2015] [Indexed: 12/16/2022]
Abstract
BK virus nephropathy is an important cause of kidney allograft failure. Retransplantation has been successfully performed for patients with previous allograft loss due to BK virus nephropathy; however, whether allograft nephrectomy and viral clearance are required prior to retransplantation is controversial. Some recent studies have suggested that retransplantion can be successfully achieved without allograft nephrectomy if viremia is cleared prior to retransplant. The only published experience of successful retransplantation in the presence of active viremia occurred in the presence of concomitant allograft nephrectomy of the failing kidney. In this report, we describe a case of successful repeat kidney transplant in a patient with high-grade BK viremia and fulminant hepatic failure without concomitant allograft nephrectomy performed under the setting of a simultaneous liver-kidney transplant.
Collapse
|
73
|
Sampaio M, Shekhtman G, Ahearn P, Huang E, Bunnapradist S. Recent Trends in Kidney Transplant in the United States . Clin Transplant 2015; 2015:1-13. [PMID: 29134794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The number of new wait list registrants has increased in the last decade but not to the same magnitude as the increase in the number of end stage renal disease patients in the United States. The number of wait list patients has increased at a much higher pace due to the lack of kidney supply. The overall number of kidney transplants only increased slightly. Paired exchange kidney transplant is a viable source of increasing the availability of kidney transplant and also offers access to transplant to patients with immunologic barriers to their intended donors. Paired donor exchange results in similar outcomes despite recipients' having a higher immunologic risk profile. The kidney allocation system (KAS) was recently implemented and so far has resulted in more access for patients with very high immunologic risk and allocation of lower kidney donor profile index organs to younger recipients. Longer follow up is needed to determine the net benefit of the KAS.
Collapse
|
74
|
Sampaio M, Shekhtman G, Ahearn P, Huang E, Bunnapradist S. Recent Trends in Kidney Transplant in the United States. CLINICAL TRANSPLANTS 2015; 31:1-13. [PMID: 28514563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The number of new wait list registrants has increased in the last decade but not to the same magnitude as the increase in the number of end stage renal disease patients in the United States. The number of wait list patients has increased at a much higher pace due to the lack of kidney supply. The overall number of kidney transplants only increased slightly. Paired exchange kidney transplant is a viable source of increasing the availability of kidney transplant and also offers access to transplant to patients with immunologic barriers to their intended donors. Paired donor exchange results in similar outcomes despite recipients' having a higher immunologic risk profile. The kidney allocation system (KAS) was recently implemented and so far has resulted in more access for patients with very high immunologic risk and allocation of lower kidney donor profile index organs to younger recipients. Longer follow up is needed to determine the net benefit of the KAS.
Collapse
|
75
|
Klomjit N, Mehrnia A, Sampaio M, Bunnapradist S. Impact of Diabetes Mellitus on Survival Outcome of Lung Transplant Recipients: An Analysis of OPTN/UNOS Data. CLINICAL TRANSPLANTS 2015; 31:43-55. [PMID: 28514567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND There are limited data on the outcome of diabetic lung recipients, especially in those with new-onset diabetes after transplantation (NODAT). METHODS We studied prevalence of pre-transplant diabetes mellitus (PDM) and cumulative incidence of NODAT in lung recipients using the Organ Procurement and Transplantation Network /United Network for Organ Sharing database. Between 2004 and 2011, adult (≥18 years old) recipients transplanted with either first single- or double-lung were included. Those who lacked a diabetes record or received multi-organ transplants were excluded. Patient survival were studied in recipients who had functioning grafts for at least one year. RESULTS There were 10,226 recipients who had at least one diabetes record, the prevalence of PDM was 18.25% and the cumulative incidence of NODAT during the five years post-transplant was 39.43%. Of 9,117 recipients who had functioning grafts for at least one year, adjusted hazard ratios (HR) of PDM and NODAT, compared to the diabetes-free group, were 1.12 (p=0.048) and 1.12 (p=0.025), respectively. Independent risk factors for mortality included the presence of rejection in the one year, cytomegalovirus serology donor positive/recipient negative, and recipient age >60 years. Among recipients with cystic fibrosis, there was no statistical difference in mortality between diabetic recipients and the diabetes-free group. Compared to the diabetes-free group, the adjusted HRs for mortality of PDM and NODAT in recipients without cystic fibrosis were 1.15 (p=0.031) and 1.14 (p=0.011), respectively. CONCLUSIONS Diabetes was associated with mortality in lung transplant recipients overall and in lung recipients without cystic fibrosis. However, there was no association between diabetes and mortality in lung recipients with cystic fibrosis.
Collapse
|