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Diena D, Messina M, De Biase C, Fop F, Scardino E, Rossetti MM, Barreca A, Verri A, Biancone L. Relationship between early proteinuria and long term outcome of kidney transplanted patients from different decades of donor age. BMC Nephrol 2019; 20:443. [PMID: 31791270 PMCID: PMC6889703 DOI: 10.1186/s12882-019-1635-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/21/2019] [Indexed: 01/13/2023] Open
Abstract
Background Proteinuria after kidney transplantation portends a worse graft survival. However the magnitude of proteinuria related to patient and graft survival and its correlation with donor and recipient characteristics are poorly explored. Methods This study investigated the impact of post transplant proteinuria in the first year in 1127 kidney transplants analyzing the impact of different donor ages. Proteinuria cut off was set at 0.5 g/day. Results Transplants with proteinuria > 0.5 g/day correlated with poor graft and patient outcome in all donor age groups. In addition, 6-month-1-year proteinuria increase was significantly associated with graft outcome, especially with donors > 60 years old (p < 0.05; Odd Ratio 1.8). 1-year graft function (eGFR < or ≥ 44 ml/min) had similar impact to proteinuria (≥ 0.5 g/day) on graft failure (Hazard Ratio 2.77 vs Hazard Ratio 2.46). Low-grade proteinuria (0.2–0.5 g/day) demonstrated a trend for worse graft survival with increasing donor age. Also in kidney-paired analysis proteinuria ≥0.5 effect was more significant with donors > 50 years old (Odd Ratio 2.3). Conclusions Post-transplant proteinuria was increasingly harmful with older donor age. Proteinuria ≥0.5 g/day correlates with worse outcomes in all transplanted patients. Prognostic value of proteinuria and eGFR for graft and patient survival was comparable and these two variables remain significant risk factors even in a multivariate model that take into consideration the most important clinical variables (donor age, rejection, delayed graft function and cytomegalovirus viremia among others).
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Affiliation(s)
- Davide Diena
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, "Città della Salute e della Scienza Hospital", Department of Medical Sciences, University of Turin, Corso Dogliotti14, 10126, Torino, Italy
| | - Maria Messina
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, "Città della Salute e della Scienza Hospital", Department of Medical Sciences, University of Turin, Corso Dogliotti14, 10126, Torino, Italy
| | - Consuelo De Biase
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, "Città della Salute e della Scienza Hospital", Department of Medical Sciences, University of Turin, Corso Dogliotti14, 10126, Torino, Italy
| | - Fabrizio Fop
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, "Città della Salute e della Scienza Hospital", Department of Medical Sciences, University of Turin, Corso Dogliotti14, 10126, Torino, Italy
| | - Edoardo Scardino
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, "Città della Salute e della Scienza Hospital", Department of Medical Sciences, University of Turin, Corso Dogliotti14, 10126, Torino, Italy
| | - Maura M Rossetti
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, "Città della Salute e della Scienza Hospital", Department of Medical Sciences, University of Turin, Corso Dogliotti14, 10126, Torino, Italy
| | - Antonella Barreca
- Division of Pathology, "Città della Salute e della Scienza Hospital", Department of Medical Sciences, University of Turin, Turin, Italy
| | - Aldo Verri
- Department of Vascular Surgery, "Città della Salute e della Scienza Hospital", University of Turin, Turin, Italy
| | - Luigi Biancone
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, "Città della Salute e della Scienza Hospital", Department of Medical Sciences, University of Turin, Corso Dogliotti14, 10126, Torino, Italy.
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Everolimus in de novo kidney transplant recipients participating in the Eurotransplant senior program: Results of a prospective randomized multicenter study (SENATOR). PLoS One 2019; 14:e0222730. [PMID: 31536556 PMCID: PMC6752944 DOI: 10.1371/journal.pone.0222730] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 09/05/2019] [Indexed: 01/17/2023] Open
Abstract
Early conversion to everolimus was assessed in kidney transplant recipients participating in the Eurotransplant Senior Program (ESP), a population in whom data are lacking. The SENATOR multicenter study enrolled 207 kidney transplant recipients undergoing steroid withdrawal at week 2 post-transplant (ClinicalTrials.gov [NCT00956293]). At week 7, patients were randomized (1:2 ratio) to continue the previous calcineurin inhibitor (CNI)-based regimen with mycophenolic acid (MPA) and cyclosporine or switch to a CNI-free regimen with MPA, everolimus (5–10 ng/mL) and basiliximab at weeks 7 and 12, then followed for 18 weeks to month 6 post-transplant. The primary endpoint was estimated GFR (eGFR). At week 7, 77/207 (37.2%) patients were randomized (53 everolimus, 24 control). At month 6, eGFR was comparable: 36.5±10.8ml/min with everolimus versus 42.0±13.0ml/min in the control group (p = 0.784). Discontinuation due to adverse events occurred in 27.8% of everolimus-treated patients and 0.0% of control patients (p = 0005). Efficacy profiles showed no difference. In conclusion, eGFR, safety and efficacy outcomes at month 6 post-transplant showed no difference between groups. The everolimus group experienced a higher rate of discontinuation due to adverse events. However, the high rate of non-randomization is highly relevant, indicating this to be a somewhat unstable patient population regardless of treatment.
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Jawitz OK, Raman V, Klapper J, Hartwig M, Patel CB, Milano C. Donor and recipient age matching in heart transplantation: analysis of the UNOS Registry. Transpl Int 2019; 32:1194-1202. [PMID: 31328314 DOI: 10.1111/tri.13481] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 06/24/2019] [Accepted: 07/16/2019] [Indexed: 01/06/2023]
Abstract
The association of donor and recipient age with survival following adult heart transplantation has not been well characterized. The purpose of this study was to examine the impact of the relationship between donor and recipient age on post-transplant survival. We retrospectively reviewed the 2005-2018 UNOS heart transplant database for all adult recipients undergoing first-time isolated heart transplantation. The impact of donor and recipient age on survival was analyzed with Cox proportional hazards modeling using restricted cubic splines. A total of 25 480 heart transplant donor and recipient pairs met inclusion criteria. Unadjusted and adjusted Cox proportional hazards modeling demonstrated a near-linear association between increasing donor age and decreased survival; in addition, older and younger recipient age was associated with decreased survival. After adjustment, there was no significant interaction between donor and recipient age. Older donors decreased survival similarly in both older and younger recipients. Increasing donor age and both younger and older recipient age are independently associated with worsened post-heart transplant survival. The relationship between donor and recipient age does not significantly affect survival following heart transplant.
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Affiliation(s)
- Oliver K Jawitz
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Vignesh Raman
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jacob Klapper
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Matthew Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Chetan B Patel
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Carmelo Milano
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Kobashigawa J, Dadhania D, Bhorade S, Adey D, Berger J, Bhat G, Budev M, Duarte-Rojo A, Dunn M, Hall S, Harhay MN, Johansen KL, Joseph S, Kennedy CC, Kransdorf E, Lentine KL, Lynch RJ, McAdams-DeMarco M, Nagai S, Olymbios M, Patel J, Pinney S, Schaenman J, Segev DL, Shah P, Singer LG, Singer JP, Sonnenday C, Tandon P, Tapper E, Tullius SG, Wilson M, Zamora M, Lai JC. Report from the American Society of Transplantation on frailty in solid organ transplantation. Am J Transplant 2019; 19:984-994. [PMID: 30506632 PMCID: PMC6433498 DOI: 10.1111/ajt.15198] [Citation(s) in RCA: 160] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/06/2018] [Accepted: 11/24/2018] [Indexed: 02/06/2023]
Abstract
A consensus conference on frailty in kidney, liver, heart, and lung transplantation sponsored by the American Society of Transplantation (AST) and endorsed by the American Society of Nephrology (ASN), the American Society of Transplant Surgeons (ASTS), and the Canadian Society of Transplantation (CST) took place on February 11, 2018 in Phoenix, Arizona. Input from the transplant community through scheduled conference calls enabled wide discussion of current concepts in frailty, exploration of best practices for frailty risk assessment of transplant candidates and for management after transplant, and development of ideas for future research. A current understanding of frailty was compiled by each of the solid organ groups and is presented in this paper. Frailty is a common entity in patients with end-stage organ disease who are awaiting organ transplantation, and affects mortality on the waitlist and in the posttransplant period. The optimal methods by which frailty should be measured in each organ group are yet to be determined, but studies are underway. Interventions to reverse frailty vary among organ groups and appear promising. This conference achieved its intent to highlight the importance of frailty in organ transplantation and to plant the seeds for further discussion and research in this field.
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Affiliation(s)
| | | | | | - Deborah Adey
- University of California at San Francisco, San Francisco, CA, USA
| | - Joseph Berger
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Geetha Bhat
- Advocate Christ Medical Center, Oak Lawn, IL, USA
| | | | | | | | | | | | | | | | | | - Evan Kransdorf
- Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | | | | | | | | | | | - Jignesh Patel
- Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | | | | | | | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, VA, USA
| | | | | | | | | | | | - Stefan G. Tullius
- Division of Transplant Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Jennifer C. Lai
- University of California at San Francisco, San Francisco, CA, USA
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The Impact of Donor and Recipient Age: Older Lung Transplant Recipients Do Not Require Younger Lungs. Ann Thorac Surg 2019; 107:868-876. [DOI: 10.1016/j.athoracsur.2018.09.066] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 09/27/2018] [Accepted: 09/28/2018] [Indexed: 11/21/2022]
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Abstract
BACKGROUND Kidney transplantation holds much promise as a treatment of choice for patients with end-stage kidney disease. The impact of cold ischemia time (CIT) on acute renal transplant rejection (ARTR) remains to be fully studied in a large cohort of renal transplant patients. METHODS From the Organ Procurement and Transplantation Network database, we analyzed 63 798 deceased donor renal transplants performed between 2000 and 2010. We assessed the association between CIT and ARTR. We also evaluated the association between recipient age and ARTR. RESULTS Six thousand eight hundred two (11%) patients were clinically diagnosed with ARTR. Longer CIT was associated with an increased risk of ARTR. After multivariable adjustment, compared with recipients with CIT < 12 hours, the relative risk of ARTR was 1.13 (95% confidence interval, 1.04-1.23) in recipients with CIT ≥ 24 hours. The association of CIT and ARTR was more pronounced in patients undergoing retransplantation: compared with recipients with CIT less than 12 hours, the relative risk of ARTR was 1.66 (95% confidence interval, 1.01-2.73) in recipients with CIT of 24 hours or longer. Additionally, older age was associated with a decreased risk of ARTR. Compared with recipients aged 18 to 29 years, the relative risk of ARTR was 0.50 (95% confidence interval, 0.45-0.57) in recipients 60 years or older. Longer CIT was also associated with increased risk of death-censored graft loss. Compared with recipients with CIT less than 12 hours, the hazard ratio of death-censored graft loss was 1.22 (95% confidence interval, 1.14-1.30) in recipients with CIT of 24 hours or longer. CONCLUSIONS Prolonged CIT is associated with an increased risk of ARTR and death-censored graft loss. Older age was associated with a lower risk of ARTR.
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Cheng XS, Lentine KL, Koraishy FM, Myers J, Tan JC. Implications of Frailty for Peritransplant Outcomes in Kidney Transplant Recipients. CURRENT TRANSPLANTATION REPORTS 2019; 6:16-25. [PMID: 31131186 DOI: 10.1007/s40472-019-0227-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose of Review Research over the past few decades points to the importance of frailty, or the lack of physiologic reserve, in the natural history of chronic diseases and in modifying the impact of potential interventions. End-stage kidney disease (ESKD) and the intervention of kidney transplantation are no exception. We review the recent epidemiologic and cohort-based evidence on the association between frailty and kidney transplant outcomes and provide a framework of questions with which to approach future research endeavors and clinical practice. Recent Findings Frailty in kidney transplant candidates can be measured in numerous ways, including descriptive phenotype, description scores, functional testing, and surrogate measures. Regardless of the metric, the presence of frailty is strongly associated with inferior pre- and posttransplant outcomes compared to the absence of frailty. However, some frail patients with ESKD can benefit from transplant over chronic dialysis. Evidence-based approaches for identifying frail ESKD patients who can benefit from transplant over dialysis, with acceptable posttransplant outcomes, are lacking. Interventional trials to improve frailty and physical function before transplant (prehabilitation) and after transplant (rehabilitation) are also lacking. Conclusion Frailty is increasingly recognized as highly relevant to peritransplant outcomes, but more work is needed to: 1) tailor management to the unique needs of frail patients, both pre- and posttransplant; 2) define phenotypes of frail patients who are expected to benefit from transplant over dialysis; and 3) develop interventions to reverse frailty, both pre- and post-transplant.
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Affiliation(s)
- Xingxing S Cheng
- Department of Medicine, Division of Nephrology, Stanford University, Stanford CA
| | - Krista L Lentine
- Department of Medicine, Division of Nephrology, Saint Louis University, St. Louis MO
| | - Farrukh M Koraishy
- Department of Medicine, Division of Nephrology, Saint Louis University, St. Louis MO
| | - Jonathan Myers
- Department of Medicine, Division of Cardiology, Palo Alto VA Hospital and Stanford University, Palo Alto CA
| | - Jane C Tan
- Department of Medicine, Division of Nephrology, Stanford University, Stanford CA
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Shroff S, Alex A, Paul VB, Navin S, Ramesh P, Michael J, Menon S. Did an increase in knowledge and awareness about organ donation improve organ donation rate in India over the past two decades? INDIAN JOURNAL OF TRANSPLANTATION 2019. [DOI: 10.4103/ijot.ijot_68_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Rapamycin Prolongs Graft Survival and Induces CD4+IFN-γ+IL-10+ Regulatory Type 1 Cells in Old Recipient Mice. Transplantation 2018; 102:59-69. [PMID: 28777210 DOI: 10.1097/tp.0000000000001902] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Although the elderly represents a rapidly growing population among transplant recipients, age-specific aspects have not been considered sufficiently in clinical trials. Moreover, age-specific effects of immunosuppressive therapies remain poorly understood. METHODS Here, we assessed the impact of rapamycin on alloimmune responses in old recipients using a fully major histocompatibility complex-mismatched murine transplantation model. RESULTS Old untreated recipients displayed a prolonged skin graft survival compared to their young counterparts, an observation that confirmed data of our previous experiments. Rapamycin led to a significant prolongation of graft survival in both young and old recipients. However, graft survival was age-dependent and extended in old versus young recipients (19 days vs 12 days, P = 0.004). This age-specific effect was not linked to changes in frequencies or subset composition of either cluster of differentiation (CD)8 or CD4 T cells. Moreover, antiproliferative effects of rapamycin on CD8 and CD4 T cells as assessed by in vivo bromdesoxyuridine incorporation were comparable and age-independent. In contrast, the systemic production of IL-10 was markedly elevated in old recipients treated with rapamycin. In parallel to this shift in cytokine balance, IFN-γ/IL-10 double-positive regulatory type 1 cells emerged during T helper type 1 differentiation of old T helper cells in presence of rapamycin. Similarly, CD4IFN-γIL-10 cells expanded among Foxp3-negative cells after in vivo treatment of old recipients with rapamycin. CONCLUSIONS Our results highlight novel aspects of age-dependent immunosuppressive effects of rapamycin, with relevance for age-specific immunosuppressive regimens.
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Schaenman JM, Rossetti M, Sidwell T, Groysberg V, Sunga G, Korin Y, Liang E, Zhou X, Abdalla B, Lum E, Bunnapradist S, Pham T, Danovitch G, Reed EF. Increased T cell immunosenescence and accelerated maturation phenotypes in older kidney transplant recipients. Hum Immunol 2018; 79:659-667. [PMID: 29913200 PMCID: PMC6429965 DOI: 10.1016/j.humimm.2018.06.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 06/14/2018] [Accepted: 06/14/2018] [Indexed: 12/19/2022]
Abstract
Older kidney transplant recipients experience increased rates of infection and death, and less rejection, compared with younger patients. However, little is known about immune dysfunction in older compared with younger kidney transplant recipients and whether it is associated with infection. We evaluated T cell phenotypes including maturation, immune senescence, and exhaustion in a novel investigation into differences in older compared with younger patients receiving identical immune suppression regimens. We evaluated PBMC from 60 kidney transplant recipients (23 older and 37 matched younger patients) by multiparameter immune phenotyping. Older kidney transplant recipients demonstrated decreased frequency of naïve CD4+ and CD8+ T cells, and increased frequency of terminally differentiated, immune senescent, and NK T cells expressing KLRG1. There was a trend towards increased frequency of T cell immune senescence in patients experiencing infection in the first year after transplantation, which reached statistical significance in a multivariate analysis. This pilot study reveals immune dysfunction in older compared with younger transplant recipients, and suggests a likely mechanism for increased vulnerability to infection. The ability to assess T cell maturation and immune senescence in transplant recipients offers the potential for risk stratification and customization of immune suppression to prevent infection and rejection after transplantation.
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Affiliation(s)
- J M Schaenman
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.
| | - M Rossetti
- Department of Pathology and Laboratory Medicine, UCLA Immunogenetics Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - T Sidwell
- Department of Pathology and Laboratory Medicine, UCLA Immunogenetics Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - V Groysberg
- Department of Pathology and Laboratory Medicine, UCLA Immunogenetics Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - G Sunga
- Department of Pathology and Laboratory Medicine, UCLA Immunogenetics Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Y Korin
- Department of Pathology and Laboratory Medicine, UCLA Immunogenetics Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - E Liang
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - X Zhou
- Department of Medicine Statistics Core, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - B Abdalla
- Department of Medicine, Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - E Lum
- Department of Medicine, Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - S Bunnapradist
- Department of Medicine, Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - T Pham
- Department of Medicine, Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - G Danovitch
- Department of Medicine, Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - E F Reed
- Department of Pathology and Laboratory Medicine, UCLA Immunogenetics Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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Coemans M, Süsal C, Döhler B, Anglicheau D, Giral M, Bestard O, Legendre C, Emonds MP, Kuypers D, Molenberghs G, Verbeke G, Naesens M. Analyses of the short- and long-term graft survival after kidney transplantation in Europe between 1986 and 2015. Kidney Int 2018; 94:964-973. [PMID: 30049474 DOI: 10.1016/j.kint.2018.05.018] [Citation(s) in RCA: 178] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/26/2018] [Accepted: 05/17/2018] [Indexed: 12/21/2022]
Abstract
The evolution of kidney allograft survival remains insufficiently studied in the context of the changing donor and recipient demographics. Since European data are lacking we performed a cohort study (1986-2015) that, based on the Collaborative Transplant Study, included 108 787 recipients of brain-death kidney donors in 135 hospitals across 21 European countries. We analyzed the hazard rate of kidney failure after transplantation. Between 1986 and 1999, improvement in graft survival was more pronounced in the short term than in the long term: one-, five- and ten-year hazard rates after transplantation declined 64% (95% confidence interval, 61%-66%), 53% (49%-57%) and 45% (39%-50%), respectively. Between 2000 and 2015, hazard rates at one, five and ten years post-transplant declined respectively 22% (12-30%), 47% (36-56%) and 64% (45-76%). Improvement in graft survival in the first five years post-transplant was significantly less since 2000, while improvement after five years was comparable to before. During the 2000-2015 period improvement of graft survival was greater in the long than in the short term. These changes were independent of changing donor and recipient characteristics, and reflect the evolution in global kidney transplant management over the past decades. Unfortunately, after accounting for the evolution of donor and recipient characteristics, we found that short-term improvement in graft survival decreased since 2000, while long-term improvement remained unchanged in Europe. Thus, deceleration of short-term graft survival improvement in more recent years illustrates an unmet need for innovation.
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Affiliation(s)
- Maarten Coemans
- Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium; Leuven Biostatistics and Statistical Bioinformatics Centre, Leuven, Belgium
| | - Caner Süsal
- Institute of Immunology, University of Heidelberg, Heidelberg, Germany
| | - Bernd Döhler
- Institute of Immunology, University of Heidelberg, Heidelberg, Germany
| | - Dany Anglicheau
- Service de Néphrologie-Transplantation Adulte, Hôpital Necker, Paris, Université Paris Descartes & INSERM U 1151, Hôpital Necker, Paris, France
| | - Magali Giral
- Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM, Université de Nantes, Nantes, France
| | - Oriol Bestard
- Kidney Transplant Unit, Nephrology Department, Bellvitge University Hospital, Barcelona, Spain
| | - Christophe Legendre
- Service de Néphrologie-Transplantation Adulte, Hôpital Necker, Paris, Université Paris Descartes & INSERM U 1151, Hôpital Necker, Paris, France
| | - Marie-Paule Emonds
- Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium; Histocompatibility and Immunogenetic Laboratory, Red Cross Flanders, Mechelen, Belgium
| | - Dirk Kuypers
- Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Geert Molenberghs
- Leuven Biostatistics and Statistical Bioinformatics Centre, Leuven, Belgium
| | - Geert Verbeke
- Leuven Biostatistics and Statistical Bioinformatics Centre, Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.
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Cillo U, Bechstein WO, Berlakovich G, Dutkowski P, Lehner F, Nadalin S, Saliba F, Schlitt HJ, Pratschke J. Identifying risk profiles in liver transplant candidates and implications for induction immunosuppression. Transplant Rev (Orlando) 2018; 32:142-150. [DOI: 10.1016/j.trre.2018.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/03/2018] [Accepted: 04/05/2018] [Indexed: 12/16/2022]
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Arias-Cabrales C, Pérez-Sáez MJ, Redondo-Pachón D, Buxeda A, Burballa C, Bermejo S, Sierra A, Mir M, Burón A, Zapatero A, Crespo M, Pascual J. Usefulness of the KDPI in Spain: A comparison with donor age and definition of standard/expanded criteria donor. Nefrologia 2018; 38:503-513. [PMID: 29884503 DOI: 10.1016/j.nefro.2018.03.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 02/01/2018] [Accepted: 03/02/2018] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Kidney donor shortage requires expanding donor selection criteria, as well as use of objective tools to minimize the percentage of discarded organs. Some donor pre-transplant variables such as age, standard/expanded criteria donor (SCD/ECD) definition and calculation of the Kidney Donor Profile Index (KDPI), have demonstrated correlations with patient and graft outcomes. We aimed to establish the accuracy of the three models to determine the prognostic value of kidney transplantation (KT) major outcomes. MATERIAL AND METHODS We performed a retrospective study in deceased donor KTs at our institution. Unadjusted Cox and Kaplan-Meier survival, and multivariate Cox analyses were fitted to analyze the impact of donor age, SCD/ECD and KDPI on outcomes. RESULTS 389 KTs were included. Mean donor age was 53.6±15.2 years; 163 (41.9%) came from ECD; mean KDPI was 69.4±23.4%. Median follow-up was 51.9 months. The unadjusted Cox and Kaplan-Meier showed that the three prognostic variables of interest were related to increased risk of patient death, graft failure and death-censored graft failure. However, in the multivariate analysis only KDPI was related to a higher risk of graft failure (HR 1.03 [95% CI 1.01-1.05]; p=0.014). CONCLUSIONS SCD/ECD classification did not provide significant prognostic information about patient and graft outcomes. KDPI was linearly related to a higher risk of graft failure, providing a better assessment. More studies are needed before using KDPI as a tool to discard or accept kidneys for transplantation.
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Affiliation(s)
- Carlos Arias-Cabrales
- IMIM (Hospital del Mar Research Institute), Barcelona, Spain; Department of Intensive Care Medicine, Transplant Coordination Unit, Hospital del Mar, Barcelona, Spain
| | - María José Pérez-Sáez
- IMIM (Hospital del Mar Research Institute), Barcelona, Spain; Department of Intensive Care Medicine, Transplant Coordination Unit, Hospital del Mar, Barcelona, Spain
| | - Dolores Redondo-Pachón
- IMIM (Hospital del Mar Research Institute), Barcelona, Spain; Department of Intensive Care Medicine, Transplant Coordination Unit, Hospital del Mar, Barcelona, Spain
| | - Anna Buxeda
- IMIM (Hospital del Mar Research Institute), Barcelona, Spain; Department of Intensive Care Medicine, Transplant Coordination Unit, Hospital del Mar, Barcelona, Spain
| | - Carla Burballa
- IMIM (Hospital del Mar Research Institute), Barcelona, Spain; Department of Intensive Care Medicine, Transplant Coordination Unit, Hospital del Mar, Barcelona, Spain
| | - Sheila Bermejo
- IMIM (Hospital del Mar Research Institute), Barcelona, Spain; Department of Intensive Care Medicine, Transplant Coordination Unit, Hospital del Mar, Barcelona, Spain
| | - Adriana Sierra
- IMIM (Hospital del Mar Research Institute), Barcelona, Spain; Department of Intensive Care Medicine, Transplant Coordination Unit, Hospital del Mar, Barcelona, Spain
| | - Marisa Mir
- IMIM (Hospital del Mar Research Institute), Barcelona, Spain; Department of Intensive Care Medicine, Transplant Coordination Unit, Hospital del Mar, Barcelona, Spain
| | - Andrea Burón
- IMIM (Hospital del Mar Research Institute), Barcelona, Spain; Epidemiology and Evaluation Department, Hospital del Mar, Barcelona, Spain; REDISSEC (Health Services Research on Chronic Patients Network), Madrid, Spain
| | - Ana Zapatero
- IMIM (Hospital del Mar Research Institute), Barcelona, Spain; Department of Intensive Care Medicine, Transplant Coordination Unit, Hospital del Mar, Barcelona, Spain
| | - Marta Crespo
- IMIM (Hospital del Mar Research Institute), Barcelona, Spain; Department of Intensive Care Medicine, Transplant Coordination Unit, Hospital del Mar, Barcelona, Spain
| | - Julio Pascual
- IMIM (Hospital del Mar Research Institute), Barcelona, Spain; Department of Intensive Care Medicine, Transplant Coordination Unit, Hospital del Mar, Barcelona, Spain.
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Affiliation(s)
- Stefan G Tullius
- From Harvard Medical School and Brigham and Women's Hospital, Boston (S.G.T.); and Johns Hopkins University School of Medicine and the Johns Hopkins Hospital, Baltimore (H.R.)
| | - Hamid Rabb
- From Harvard Medical School and Brigham and Women's Hospital, Boston (S.G.T.); and Johns Hopkins University School of Medicine and the Johns Hopkins Hospital, Baltimore (H.R.)
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65
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Montero N, Redondo-Pachón D, Pérez-Sáez MJ, Crespo M, Cruzado JM, Pascual J. Dual kidney transplantation as a strategy to use expanded criteria donors: a systematic review. Transpl Int 2018; 31:838-860. [DOI: 10.1111/tri.13157] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 01/29/2018] [Accepted: 03/19/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Nuria Montero
- Department of Nephrology; Hospital Universitari de Bellvitge; L'Hospitalet del Llobregat; Barcelona Spain
| | | | | | - Marta Crespo
- Department of Nephrology; Hospital del Mar; Barcelona Spain
| | - Josep M. Cruzado
- Department of Nephrology; Hospital Universitari de Bellvitge; L'Hospitalet del Llobregat; Barcelona Spain
| | - Julio Pascual
- Department of Nephrology; Hospital del Mar; Barcelona Spain
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67
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Lau A, West L, Tullius SG. The Impact of Sex on Alloimmunity. Trends Immunol 2018; 39:407-418. [PMID: 29576409 DOI: 10.1016/j.it.2018.01.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 12/07/2017] [Accepted: 01/13/2018] [Indexed: 02/08/2023]
Abstract
Transplantation outcomes are known to be affected by multiple factors, including donor and recipient sex. Aside from the physiological characteristics of male and female donor allografts, accumulating evidence suggests that additional features underlie sex-specific immune responses that affect graft survival. We discuss here aspects of innate and adaptive alloimmunity that are specific to males and females in the context of underlying genetic and hormonal factors. These differences likely contribute to the observed disparities in graft survival. Understanding these features in more detail may lead to improved strategies for optimizing the results of organ transplantation.
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Affiliation(s)
- Ashley Lau
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lori West
- Alberta Transplant Institute, University of Alberta, 6-002 Li Ka Shing Health Research Centre East, Edmonton, Alberta T6G 2E1, Canada
| | - Stefan G Tullius
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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68
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Uehara M, Solhjou Z, Banouni N, Kasinath V, Xiaqun Y, Dai L, Yilmam O, Yilmaz M, Ichimura T, Fiorina P, Martins PN, Ohori S, Guleria I, Maarouf OH, Tullius SG, McGrath MM, Abdi R. Ischemia augments alloimmune injury through IL-6-driven CD4 + alloreactivity. Sci Rep 2018; 8:2461. [PMID: 29410442 PMCID: PMC5802749 DOI: 10.1038/s41598-018-20858-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 01/25/2018] [Indexed: 02/06/2023] Open
Abstract
Ischemia reperfusion injuries (IRI) are unavoidable in solid organ transplantation. IRI augments alloimmunity but the mechanisms involved are poorly understood. Herein, we examined the effect of IRI on antigen specific alloimmunity. We demonstrate that ischemia promotes alloimmune activation, leading to more severe histological features of rejection, and increased CD4+ and CD8+ T cell graft infiltration, with a predominantly CD8+ IFNγ+ infiltrate. This process is dependent on the presence of alloreactive CD4+ T cells, where depletion prevented infiltration of ischemic grafts by CD8+ IFNγ+ T cells. IL-6 is a known driver of ischemia-induced rejection. Herein, depletion of donor antigen-presenting cells reduced ischemia-induced CD8+ IFNγ+ allograft infiltration, and improved allograft outcomes. Following prolonged ischemia, accelerated rejection was observed despite treatment with CTLA4Ig, indicating that T cell costimulatory blockade failed to overcome the immune activating effect of IRI. However, despite severe ischemic injury, treatment with anti-IL-6 and CTLA4Ig blocked IRI-induced alloimmune injury and markedly improved allograft survival. We describe a novel pathway where IRI activates innate immunity, leading to upregulation of antigen specific alloimmunity, resulting in chronic allograft injury. Based on these findings, we describe a clinically relevant treatment strategy to overcome the deleterious effect of IRI, and provide superior long-term allograft outcomes.
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Affiliation(s)
- Mayuko Uehara
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Zhabiz Solhjou
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Naima Banouni
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Vivek Kasinath
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ye Xiaqun
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Li Dai
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Osman Yilmam
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mine Yilmaz
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Takaharu Ichimura
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Paolo Fiorina
- Division of Nephrology, Boston Children Hospital, Harvard Medical School, Boston, MA, USA
| | - Paulo N Martins
- Division of Surgery, University of Massachusetts Medical School, Boston, MA, USA
| | - Shunsuke Ohori
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Indira Guleria
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Omar H Maarouf
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stefan G Tullius
- Division of Transplant Surgery and Transplantation Surgery Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Martina M McGrath
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Reza Abdi
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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69
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Pippias M, Jager KJ, Caskey F, Casula A, Erlandsson H, Finne P, Heaf J, Heinze G, Hoitsma A, Kramar R, Lempinen M, Magaz A, Midtvedt K, Mumford LL, Pascual J, Prütz KG, Sørensen SS, Traynor JP, Massy ZA, Ravanan R, Stel VS. Kidney transplant outcomes from older deceased donors: a paired kidney analysis by the European Renal Association-European Dialysis and Transplant Association Registry. Transpl Int 2017; 31:708-719. [PMID: 29210108 DOI: 10.1111/tri.13103] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/28/2017] [Accepted: 11/24/2017] [Indexed: 12/28/2022]
Abstract
As the median age of deceased kidney donors rises, updated knowledge of transplant outcomes from older deceased donors in differing donor-recipient age groups is required. Using ERA-EDTA Registry data we determined survival outcomes of kidney allografts donated from the same older deceased donor (55-70 years), and transplanted into one recipient younger and one recipient of similar age to the donor. The recipient pairs were divided into two groups: group 1; younger (median age: 52 years) and older (60 years) and group 2; younger (41 years) and older (60 years). A total of 1410 adults were transplanted during 2000-2007. Compared to the older recipients, the mean number of functioning graft years at 10 years was 6 months longer in the group 1 and group 2 younger recipients (P < 0.001). Ten-year graft survival was 54% and 40% for the group 1 younger and older recipients, and 60% and 49% for the group 2 younger and older recipients. Paired Cox regression analyses showed a lower risk of graft failure (group 1 younger; adjusted relative risk [RRa]:0.57, 95% CI:0.41-0.79, and group 2 younger; RRa:0.63, 95% CI:0.47-0.85) in younger recipients. Outcomes from older deceased donor allografts transplanted into differing donor-recipient age groups are better than previously reported. These allografts remain a valuable transplant resource, particularly for similar-aged recipients.
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Affiliation(s)
- Maria Pippias
- Department of Medical Informatics, ERA-EDTA Registry, Academic Medical Center, Universiteit van Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Kitty J Jager
- Department of Medical Informatics, ERA-EDTA Registry, Academic Medical Center, Universiteit van Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Fergus Caskey
- UK Renal Registry, Southmead Hospital, Bristol, UK.,Population Health Sciences, University of Bristol, Bristol, UK
| | - Anna Casula
- UK Renal Registry, Southmead Hospital, Bristol, UK
| | - Helen Erlandsson
- Department of Transplantation Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Patrik Finne
- Department of Nephrology, Helsinki University Central Hospital, Helsinki, Finland.,Finnish Registry for Kidney Diseases, Helsinki, Finland
| | - James Heaf
- Department of Medicine, Roskilde Hospital, University of Copenhagen, Roskilde, Denmark
| | - Georg Heinze
- Section for Clinical Biometrics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Andries Hoitsma
- Dutch Transplant Foundation, Leiden, the Netherlands.,Department of Nephrology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | - Marko Lempinen
- Department of Transplantation and Liver Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Angela Magaz
- Unidad de Información sobre Pacientes Renales de la Comunidad Autónoma del País Vasco (UNIPAR), Basque Country, Spain
| | - Karsten Midtvedt
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Lisa L Mumford
- Statistics and Clinical Studies, NHS Blood and Transplant, Stoke Gifford, Bristol, UK
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Karl G Prütz
- Swedish Renal Registry, Medicinexp, Jönköping, Sweden
| | - Søren S Sørensen
- Department of Nephrology P, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | | | - Ziad A Massy
- Division of Nephrology, Ambroise Paré University Hospital, APHP, Boulogne-Billancourt, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) U1018, Team 5, CESP UVSQ, University Paris Saclay, Villejuif, France
| | - Rommel Ravanan
- Richard Bright Renal Unit, Southmead Hospital, Bristol, UK
| | - Vianda S Stel
- Department of Medical Informatics, ERA-EDTA Registry, Academic Medical Center, Universiteit van Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
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70
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Dedeoglu B, Litjens NHR, de Weerd AE, Dor FJ, Klepper M, Reijerkerk D, Baan CC, Betjes MGH. T-Cell Composition of the Lymph Node Is Associated with the Risk for Early Rejection after Renal Transplantation. Front Immunol 2017; 8:1416. [PMID: 29163492 PMCID: PMC5663687 DOI: 10.3389/fimmu.2017.01416] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 10/12/2017] [Indexed: 01/03/2023] Open
Abstract
Background The T-cell composition within the lymph node (LN) of end-stage renal disease (ESRD) patients differs from the composition within the circulation. Activation of the alloreactive T-cell response within secondary lymphoid organs is important after organ transplantation. However, to date no data are present on LN T-cell subsets and the risk for acute rejection after kidney transplantation. Methods T cells from LNs of ESRD patients were analyzed for frequency of recent thymic emigrants, relative telomere length, expression of differentiation markers, and were related to the development of early acute rejection (EAR), occurring within 3 months after renal transplantation (RT). Furthermore, the alloreactive potential of mononuclear cells isolated from the LN and peripheral blood of 10 patients was analyzed. Measures of alloreactive potential included proliferation, cytokine production, frequencies of interferon-gamma-producing cells, and the presence of cytotoxic molecules. Results Patients with EAR were younger (p = 0.019), cytomegalovirus-seropositive (p = 0.037) and usually received dialysis prior to RT (p = 0.030). Next to this, patients with EAR showed a lower CD4:CD8 ratio (p = 0.027) within the LN. T cells from the LN were similar with regard to alloreactive capacity compared with those within the circulation. Univariate regression analysis showed that the CD4:CD8 ratio (OR: 0.67, p = 0.039), patient age (OR: 0.93, p = 0.024), and preemptive RT (OR: 0.11, p = 0.046) were associated with EAR. After a multivariate analysis, only the CD4:CD8 ratio (OR: 0.58, p = 0.019) and preemptive RT (OR:0.05, p = 0.012) were associated with EAR. Conclusion A lower CD4:CD8 ratio in the LN is associated with a higher risk for the development of rejection within 3 months after RT.
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Affiliation(s)
- Burç Dedeoglu
- Department of Internal Medicine, Section Nephrology and Transplantation, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Nicolle H R Litjens
- Department of Internal Medicine, Section Nephrology and Transplantation, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Annelies E de Weerd
- Department of Internal Medicine, Section Nephrology and Transplantation, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Frank Jmf Dor
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Mariska Klepper
- Department of Internal Medicine, Section Nephrology and Transplantation, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Derek Reijerkerk
- Department of Internal Medicine, Section Nephrology and Transplantation, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Carla C Baan
- Department of Internal Medicine, Section Nephrology and Transplantation, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Michiel G H Betjes
- Department of Internal Medicine, Section Nephrology and Transplantation, Erasmus University Medical Center, Rotterdam, Netherlands
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71
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Age and Early Graft Function Relate With Risk-Benefit Ratio of Allogenic Islet Transplantation Under Antithymocyte Globulin-Mycophenolate Mofetil-Tacrolimus Immune Suppression. Transplantation 2017; 101:2218-2227. [DOI: 10.1097/tp.0000000000001543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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72
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Ashby VB, Leichtman AB, Rees MA, Song PXK, Bray M, Wang W, Kalbfleisch JD. A Kidney Graft Survival Calculator that Accounts for Mismatches in Age, Sex, HLA, and Body Size. Clin J Am Soc Nephrol 2017; 12:1148-1160. [PMID: 28596416 PMCID: PMC5498352 DOI: 10.2215/cjn.09330916] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 03/27/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Outcomes for transplants from living unrelated donors are of particular interest in kidney paired donation (KPD) programs where exchanges can be arranged between incompatible donor-recipient pairs or chains created from nondirected/altruistic donors. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using Scientific Registry of Transplant Recipients data, we analyzed 232,705 recipients of kidney-alone transplants from 1998 to 2012. Graft failure rates were estimated using Cox models for recipients of kidney transplants from living unrelated, living related, and deceased donors. Models were adjusted for year of transplant and donor and recipient characteristics, with particular attention to mismatches in age, sex, human leukocyte antigens (HLA), body size, and weight. RESULTS The dependence of graft failure on increasing donor age was less pronounced for living-donor than for deceased-donor transplants. Male donor-to-male recipient transplants had lower graft failure, particularly better than female to male (5%-13% lower risk). HLA mismatch was important in all donor types. Obesity of both the recipient (8%-18% higher risk) and donor (5%-11% higher risk) was associated with higher graft loss, as were donor-recipient weight ratios of <75%, compared with transplants where both parties were of similar weight (9%-12% higher risk). These models are used to create a calculator of estimated graft survival for living donors. CONCLUSIONS This calculator provides useful information to donors, candidates, and physicians of estimated outcomes and potentially in allowing candidates to choose among several living donors. It may also help inform candidates with compatible donors on the advisability of joining a KPD program.
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Affiliation(s)
- Valarie B. Ashby
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Alan B. Leichtman
- Arbor Research Collaborative for Health, Division of Nephrology, University of Michigan, Ann Arbor, Michigan; and
| | - Michael A. Rees
- Departments of Urology and Pathology, University of Toledo Medical Center, Toledo, Ohio
| | - Peter X.-K. Song
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Mathieu Bray
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Wen Wang
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
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73
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The Risk of Transplant Failure With HLA Mismatch in First Adult Kidney Allografts From Deceased Donors. Transplantation 2017; 100:1094-102. [PMID: 26901078 DOI: 10.1097/tp.0000000000001115] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Since the beginning of the technology, there has been active debate about the role of human leucocyte antigen (HLA) matching in kidney allograft survival. Recent studies have reported diminishing importance of HLA matching, which have, in turn, been challenged by reports that suggest the continuing importance of these loci. Given the controversies, we examined the effect of HLA compatibility on kidney allograft survival by studying all first adult kidney transplants in the United States from a deceased donor. METHODS Using the United Network for Organ Sharing data, we identified first deceased donor kidney transplants between October 1, 1987, and December 31, 2013. Recipients were classified by their number of HLA mismatches. Cox multivariate regression analyses adjusting for recipient and donor transplant characteristics were performed to determine the impact of HLA compatibility on kidney allograft survival. RESULTS Study cohort included 189 141 first adult kidney alone transplants, with a total of 994 558 years of kidney allograft follow-up time. Analyses adjusted for recipient and donor characteristics demonstrated a 13% higher risk (hazard ratio, 1.13; 95% confidence interval, 1.06-1.21) with 1 mismatch and a 64% higher risk (hazard ratio, 1.64, 95% confidence interval, 1.56-1.73) with 6 mismatches. Dividing the mismatch categories into 27 ordered permutations, and testing their 57 within mismatch category differences, demonstrated that all but 1 were equal, independent of locus. CONCLUSIONS A significant linear relationship of hazard ratios was associated with HLA mismatch and affects allograft survival even during the recent periods of increasing success in renal transplantation.
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74
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Sánchez-Escuredo A, Sagasta A, Revuelta I, Rodas LM, Paredes D, Musquera M, Diekmann F, Campistol JM, Solé M, Oppenheimer F. Histopathological evaluation of pretransplant donor biopsies in expanded criteria donors with high kidney donor profile index: a retrospective observational cohort study. Transpl Int 2017; 30:975-986. [PMID: 28403541 DOI: 10.1111/tri.12966] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/24/2017] [Accepted: 03/27/2017] [Indexed: 12/16/2022]
Abstract
There is no consensus on the allocation of renal transplants from expanded criteria donors (ECD). The Kidney Donor Profile Index (KDPI) is used without the need for pretransplant donor biopsies (PTDB). We explored whether PTDB based on Remuzzi Score (RS) allows identification of those marginal kidneys in the highest calculated KDPI risk group (>91%) that appropriate for single transplantation. A retrospective study was conducted of 485 consecutive kidneys procured from a single center and transplanted if the RS was ≤4. We compared 5-year kidney and patients survival between KDPI groups and between RS <4 or =4 in the highest KDPI group. The median KDPI (interquartile range) was 71 (66-76) for KDPI <80% (n = 77), 86 (81-90) for KDPI 81-90% (n = 82), and 97 (94-100) for KDPI >91% (n = 205). Patient survival at 5 years was 85.7%, 85.3%, and 76.09% (P = 0.058) and death-censored graft survival was 84.4%, 86.5%, 73.6% (P = 0.015), respectively for each KDPI group. In >91% calculated KDPI group, there were no differences in graft survival depending on the RS (<4 vs. =4) (P = 0.714). The implementation of PTDB based on RS used for allocation of organs with the highest KDPI range could support to the acceptance of suitable organs for single transplantation with good patient and graft survival rate.
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Affiliation(s)
- Ana Sánchez-Escuredo
- Nephrology and Renal Transplant Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Amaia Sagasta
- Pathology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Ignacio Revuelta
- Nephrology and Renal Transplant Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Lida M Rodas
- Nephrology and Renal Transplant Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - David Paredes
- Transplant Service Foundation, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Mireia Musquera
- Urology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Fritz Diekmann
- Nephrology and Renal Transplant Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Josep M Campistol
- Nephrology and Renal Transplant Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Manel Solé
- Pathology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Federico Oppenheimer
- Nephrology and Renal Transplant Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
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75
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Danger R, Chesneau M, Paul C, Guérif P, Durand M, Newell KA, Kanaparthi S, Turka LA, Soulillou JP, Houlgatte R, Giral M, Ramstein G, Brouard S. A composite score associated with spontaneous operational tolerance in kidney transplant recipients. Kidney Int 2017; 91:1473-1481. [PMID: 28242033 PMCID: PMC5432017 DOI: 10.1016/j.kint.2016.12.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 11/29/2016] [Accepted: 12/22/2016] [Indexed: 11/16/2022]
Abstract
New challenges in renal transplantation include using biological information to devise a useful clinical test for discerning high- and low-risk patients for individual therapy and ascertaining the best combination and appropriate dosages of drugs. Based on a 20-gene signature from a microarray meta-analysis performed on 46 operationally tolerant patients and 266 renal transplant recipients with stable function, we applied the sparse Bolasso methodology to identify a minimal and robust combination of six genes and two demographic parameters associated with operational tolerance. This composite score of operational tolerance discriminated operationally tolerant patients with an area under the curve of 0.97 (95% confidence interval 0.94-1.00). The score was not influenced by immunosuppressive treatment, center of origin, donor type, or post-transplant lymphoproliferative disorder history of the patients. This composite score of operational tolerance was significantly associated with both de novo anti-HLA antibodies and tolerance loss. It was validated by quantitative polymerase chain reaction using independent samples and demonstrated specificity toward a model of tolerance induction. Thus, our score would allow clinicians to improve follow-up of patients, paving the way for individual therapy.
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Affiliation(s)
- Richard Danger
- Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM, Université de Nantes, Nantes, France; Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Mélanie Chesneau
- Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM, Université de Nantes, Nantes, France; Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Chloé Paul
- Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM, Université de Nantes, Nantes, France; Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Pierrick Guérif
- Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM, Université de Nantes, Nantes, France; Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Maxim Durand
- Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM, Université de Nantes, Nantes, France; Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | | | | | - Laurence A Turka
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean-Paul Soulillou
- Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM, Université de Nantes, Nantes, France; Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Rémi Houlgatte
- INSERM UMR 954, Nancy, France; CHU de Nancy, DRCI, Nancy, France
| | - Magali Giral
- Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM, Université de Nantes, Nantes, France; Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France; Université de Nantes, Faculté de Médecine, Nantes, France; CIC Biotherapy, CHU Nantes, Nantes, France
| | - Gérard Ramstein
- LINA DUKe, UMR 6241, Université de Nantes, Ecole des Mines de Nantes and CNRS, Nantes, France
| | - Sophie Brouard
- Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM, Université de Nantes, Nantes, France; Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France; CIC Biotherapy, CHU Nantes, Nantes, France.
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Abstract
The old-for-old allocation policy used for kidney transplantation (KT) has confirmed the survival benefit compared to remaining listed on dialysis. Shortage of standard donors has stimulated the development of strategies aimed to expand acceptance criteria, particularly of kidneys from elderly donors. We have systematically reviewed the literature on those different strategies. In addition to the review of outcomes of expanded criteria donor or advanced age kidneys, we assessed the value of the Kidney Donor Profile Index policy, preimplantation biopsy, dual KT, machine perfusion and special immunosuppressive protocols. Survival and functional outcomes achieved with expanded criteria donor, high Kidney Donor Profile Index or advanced age kidneys are poorer than those with standard ones. Outcomes using advanced age brain-dead or cardiac-dead donor kidneys are similar. Preimplantation biopsies and related scores have been useful to predict function, but their applicability to transplant or refuse a kidney graft has probably been overestimated. Machine perfusion techniques have decreased delayed graft function and could improve graft survival. Investing 2 kidneys in 1 recipient does not make sense when a single KT would be enough, particularly in elderly recipients. Tailored immunosuppression when transplanting an old kidney may be useful, but no formal trials are available.Old donors constitute an enormous source of useful kidneys, but their retrieval in many countries is infrequent. The assumption of limited but precious functional expectancy for an old kidney and substantial reduction of discard rates should be generalized to mitigate these limitations.
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Messina M, Diena D, Dellepiane S, Guzzo G, Lo Sardo L, Fop F, Segoloni GP, Amoroso A, Magistroni P, Biancone L. Long-Term Outcomes and Discard Rate of Kidneys by Decade of Extended Criteria Donor Age. Clin J Am Soc Nephrol 2017; 12:323-331. [PMID: 27979977 PMCID: PMC5293338 DOI: 10.2215/cjn.06550616] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 10/19/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Extended criteria donors represent nowadays a main resource for kidney transplantation, and recovery criteria are becoming increasingly inclusive. However, the limits of this approach are not clear as well as the effects of extreme donor ages on long-term kidney transplantation outcomes. To address these issues, we performed a retrospective study on extended criteria donor kidney transplantation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In total, 647 consecutive extended criteria donor kidney transplantations performed over 11 years (2003-2013) were included. Donor, recipient, and procedural variables were classified according to donor age decades (group A, 50-59 years old [n=91]; group B, 60-69 years old [n=264]; group C, 70-79 years old [n=265]; and group D, ≥80 years old [n=27]). Organs were allocated in single- or dual-kidney transplantation after a multistep evaluation including clinical and histologic criteria. Long-term outcomes and main adverse events were analyzed among age groups and in either single- or dual-kidney transplantation. Kidney discard rate incidence and causes were evaluated. RESULTS Median follow-up was 4.9 years (25th; 75th percentiles: 2.7; 7.6 years); patient and graft survival were comparable among age groups (5-year patient survival: group A, 87.8%; group B, 88.1%; group C, 88.0%; and group D, 90.1%; P=0.77; graft survival: group A, 74.0%; group B, 74.2%; group C, 75.2%; and group D, 65.9%; P=0.62) and between dual-kidney transplantation and single-kidney transplantation except for group D, with a better survival for dual-kidney transplantation (P=0.04). No difference was found analyzing complications incidence or graft function over time. Kidney discard rate was similar in groups A, B, and C (15.4%, 17.7%, and 20.1%, respectively) and increased in group D (48.2%; odds ratio, 5.1 with A as the reference group; 95% confidence interval, 2.96 to 8.79). CONCLUSIONS Discard rate and long-term outcomes are similar among extended criteria donor kidney transplantation from donors ages 50-79 years old. Conversely, discard rate was strikingly higher among kidneys from octogenarian donors, but appropriate selection provides comparable long-term outcomes, with better graft survival for dual-kidney transplantation.
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Affiliation(s)
- Maria Messina
- Renal Transplant Center “A. Vercellone,” Nephrology, Dialysis and Renal Transplant Division, “Città della Salute e della Scienza di Torino” University Hospital, Department of Medical Sciences, Università degli Studi di Torino, Turin, Italy; and
| | - Davide Diena
- Renal Transplant Center “A. Vercellone,” Nephrology, Dialysis and Renal Transplant Division, “Città della Salute e della Scienza di Torino” University Hospital, Department of Medical Sciences, Università degli Studi di Torino, Turin, Italy; and
| | - Sergio Dellepiane
- Renal Transplant Center “A. Vercellone,” Nephrology, Dialysis and Renal Transplant Division, “Città della Salute e della Scienza di Torino” University Hospital, Department of Medical Sciences, Università degli Studi di Torino, Turin, Italy; and
| | - Gabriella Guzzo
- Renal Transplant Center “A. Vercellone,” Nephrology, Dialysis and Renal Transplant Division, “Città della Salute e della Scienza di Torino” University Hospital, Department of Medical Sciences, Università degli Studi di Torino, Turin, Italy; and
| | - Luca Lo Sardo
- Renal Transplant Center “A. Vercellone,” Nephrology, Dialysis and Renal Transplant Division, “Città della Salute e della Scienza di Torino” University Hospital, Department of Medical Sciences, Università degli Studi di Torino, Turin, Italy; and
| | - Fabrizio Fop
- Renal Transplant Center “A. Vercellone,” Nephrology, Dialysis and Renal Transplant Division, “Città della Salute e della Scienza di Torino” University Hospital, Department of Medical Sciences, Università degli Studi di Torino, Turin, Italy; and
| | - Giuseppe P. Segoloni
- Renal Transplant Center “A. Vercellone,” Nephrology, Dialysis and Renal Transplant Division, “Città della Salute e della Scienza di Torino” University Hospital, Department of Medical Sciences, Università degli Studi di Torino, Turin, Italy; and
| | - Antonio Amoroso
- Immunogenetics and Transplant Biology Service, “Città della Salute e della Scienza di Torino,” Department of Medical Sciences, University of Turin, Turin, Italy
| | - Paola Magistroni
- Immunogenetics and Transplant Biology Service, “Città della Salute e della Scienza di Torino,” Department of Medical Sciences, University of Turin, Turin, Italy
| | - Luigi Biancone
- Renal Transplant Center “A. Vercellone,” Nephrology, Dialysis and Renal Transplant Division, “Città della Salute e della Scienza di Torino” University Hospital, Department of Medical Sciences, Università degli Studi di Torino, Turin, Italy; and
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78
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Sturmlechner I, Durik M, Sieben CJ, Baker DJ, van Deursen JM. Cellular senescence in renal ageing and disease. Nat Rev Nephrol 2016; 13:77-89. [DOI: 10.1038/nrneph.2016.183] [Citation(s) in RCA: 184] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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79
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Concepcion BP, Forbes RC, Schaefer HM. Older candidates for kidney transplantation: Who to refer and what to expect? World J Transplant 2016; 6:650-657. [PMID: 28058214 PMCID: PMC5175222 DOI: 10.5500/wjt.v6.i4.650] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 07/22/2016] [Accepted: 09/22/2016] [Indexed: 02/05/2023] Open
Abstract
The number of older end-stage renal disease patients being referred for kidney transplantation continues to increase. This rise is occurring alongside the continually increasing prevalence of older end-stage renal disease patients. Although older kidney transplant recipients have decreased patient and graft survival compared to younger patients, transplantation in this patient population is pursued due to the survival advantage that it confers over remaining on the deceased donor waiting list. The upper limit of age and the extent of comorbidity and frailty at which transplantation ceases to be advantageous is not known. Transplant physicians are therefore faced with the challenge of determining who among older patients are appropriate candidates for kidney transplantation. This is usually achieved by means of an organ systems-based medical evaluation with particular focus given to cardiovascular health. More recently, global measures of health such as functional status and frailty are increasingly being recognized as potential tools in risk stratifying kidney transplant candidates. For those candidates who are deemed eligible, living donor transplantation should be pursued. This may mean accepting a kidney from an older living donor. In the absence of any living donor, the choice to accept lesser quality kidneys should be made while taking into account the organ shortage and expected waiting times on the deceased donor list. Appropriate counseling of patients should be a cornerstone in the evaluation process and includes a discussion regarding expected outcomes, expected waiting times in the setting of the new Kidney Allocation System, benefits of living donor transplantation and the acceptance of lesser quality kidneys.
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80
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Raza A, Firasat S, Khaliq S, Khan AR, Mahmood S, Aziz T, Mubarak M, Naqvi SAA, Rizvi SAH, Abid A. Monocyte Chemoattractant Protein-1 (MCP-1/CCL2) Levels and Its Association with Renal Allograft Rejection. Immunol Invest 2016; 46:251-262. [PMID: 27960564 DOI: 10.1080/08820139.2016.1248559] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Ali Raza
- Centre for Human Genetics and Molecular Medicine, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Sadaf Firasat
- Centre for Human Genetics and Molecular Medicine, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Shagufta Khaliq
- Centre for Human Genetics and Molecular Medicine, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
- Department of Human Genetics, University of Health Sciences, Lahore, Pakistan
| | - Abdul Rafay Khan
- Centre for Human Genetics and Molecular Medicine, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Shafaq Mahmood
- Centre for Human Genetics and Molecular Medicine, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Tahir Aziz
- Department of Urology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Muhammad Mubarak
- Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Syed Ali Anwar Naqvi
- Department of Urology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | | | - Aiysha Abid
- Centre for Human Genetics and Molecular Medicine, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
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81
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Criteria for and Appropriateness of Renal Transplantation in Elderly Patients With End-Stage Renal Disease. Transplantation 2016; 100:e55-65. [DOI: 10.1097/tp.0000000000001367] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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82
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Schmuck RB, Reutzel-Selke A, Raschzok N, Morgul HM, Struecker B, Lippert S, de Carvalho Fischer C, Schmelzle M, Boas-Knoop S, Bahra M, Pascher A, Pratschke J, Sauer IM. Bile: miRNA pattern and protein-based biomarkers may predict acute cellular rejection after liver transplantation. Biomarkers 2016; 22:19-27. [DOI: 10.1080/1354750x.2016.1201538] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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83
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Halleck F, Khadzhynov D, Liefeldt L, Schrezenmeier E, Lehner L, Duerr M, Schmidt D, Bamoulid J, Lachmann N, Waiser J, Budde K, Staeck O. Immunologic outcome in elderly kidney transplant recipients: is it time for HLA-DR matching? Nephrol Dial Transplant 2016; 31:2143-2149. [DOI: 10.1093/ndt/gfw248] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 05/20/2016] [Indexed: 01/15/2023] Open
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84
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Shuker N, Shuker L, van Rosmalen J, Roodnat JI, Borra LCP, Weimar W, Hesselink DA, van Gelder T. A high intrapatient variability in tacrolimus exposure is associated with poor long-term outcome of kidney transplantation. Transpl Int 2016; 29:1158-1167. [PMID: 27188932 DOI: 10.1111/tri.12798] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/15/2016] [Accepted: 05/13/2016] [Indexed: 12/30/2022]
Abstract
Tacrolimus is a critical dose drug with a considerable intrapatient variability (IPV) in its pharmacokinetics. We investigated whether a high IPV in tacrolimus exposure is associated with adverse long-term renal transplantation outcomes. Tacrolimus IPV was calculated from predose concentrations measured between 6 and 12 months post-transplantation of 808 renal transplant recipients (RTRs) transplanted between 2000 and 2010. One hundred and eighty-eight (23.3%) patients reached the composite end point consisting of graft loss, late biopsy-proven rejection, transplant glomerulopathy, or doubling of serum creatinine concentration between month 12 and the last follow-up. The cumulative incidence of the composite end point was significantly higher in patients with high IPV than in patients with low IPV (hazard ratio: 1.41, 95% CI: 1.06-1.89; P = 0.019). After the adjustment for several factors, the higher incidence of the composite end point for RTRs with a high IPV remained statistically significant (hazard ratio: 1.42, 95% CI: 1.06-1.90; P = 0.019). Younger recipient age at transplantation, previous transplantation, worse graft function (at month 6 post-transplantation), and low mean tacrolimus concentration at 1 year post-transplantation were additional predictors for worse long-term transplant outcome. A high tacrolimus IPV is an independent risk factor for adverse kidney transplant outcomes that can be used as an easy monitoring tool to help identify high-risk RTRs.
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Affiliation(s)
- Nauras Shuker
- Department of Internal Medicine, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands. .,Department of Hospital Pharmacy, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands.
| | - Lamis Shuker
- Department of Internal Medicine, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Joke I Roodnat
- Department of Internal Medicine, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Lennaert C P Borra
- Department of Hospital Pharmacy, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Willem Weimar
- Department of Internal Medicine, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Teun van Gelder
- Department of Internal Medicine, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
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85
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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.
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Affiliation(s)
| | | | - Rita R Alloway
- University of Cincinnati Medical Center & The Christ Hospital, Cincinnati, OH, USA
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86
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Pratschke J, Dragun D, Hauser IA, Horn S, Mueller TF, Schemmer P, Thaiss F. Immunological risk assessment: The key to individualized immunosuppression after kidney transplantation. Transplant Rev (Orlando) 2016; 30:77-84. [DOI: 10.1016/j.trre.2016.02.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 02/10/2016] [Indexed: 12/18/2022]
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87
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Filiopoulos V, Boletis JN. Renal transplantation with expanded criteria donors: Which is the optimal immunosuppression? World J Transplant 2016; 6:103-114. [PMID: 27011908 PMCID: PMC4801786 DOI: 10.5500/wjt.v6.i1.103] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 11/03/2015] [Accepted: 01/04/2016] [Indexed: 02/05/2023] Open
Abstract
The growing gap between demand and supply for kidney transplants has led to renewed interest in the use of expanded criteria donor (ECD) kidneys in an effort to increase the donor pool. Although most studies of ECD kidney transplantation confirm lower allograft survival rates and, generally, worse outcomes than standard criteria donor kidneys, recipients of ECD kidneys generally have improved survival compared with wait-listed dialysis patients, thus encouraging the pursuit of this type of kidney transplantation. The relative benefits of transplantation using kidneys from ECDs are dependent on patient characteristics and the waiting time on dialysis. Because of the increased risk of poor graft function, calcineurin inhibitor (CNI)-induced nephrotoxicity, increased incidence of infections, cardiovascular risk, and malignancies, elderly recipients of an ECD kidney transplant are a special population that requires a tailored immunosuppressive regimen. Recipients of ECD kidneys often are excluded from transplant trials and, therefore, the optimal induction and maintenance immunosuppressive regimen for them is not known. Approaches are largely center specific and based upon expert opinion. Some data suggest that antithymocyte globulin might be the preferred induction agent for elderly recipients of ECD kidneys. Maintenance regimens that spare CNIs have been advocated, especially for older recipients of ECD kidneys. CNI-free regimens are not universally accepted due to occasionally high rejection rates. However, reduced CNI exposure and CNI-free regimens based on mammalian target of rapamycin inhibitors have shown acceptable outcomes in appropriately selected ECD transplant recipients.
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88
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Stratta RJ, Farney AC, Orlando G, Farooq U, Al-Shraideh Y, Palanisamy A, Reeves-Daniel A, Doares W, Kaczmorski S, Gautreaux MD, Iskandar SS, Hairston G, Brim E, Mangus M, El-Hennawy H, Khan M, Rogers J. Dual kidney transplants from adult marginal donors successfully expand the limited deceased donor organ pool. Clin Transplant 2016; 30:380-92. [PMID: 26782941 DOI: 10.1111/ctr.12697] [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] [Accepted: 01/12/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND The need to expand the organ donor pool remains a formidable challenge in kidney transplantation (KT). The use of expanded criteria donors (ECDs) represents one approach, but kidney discard rates are high because of concerns regarding overall quality. Dual KT (DKT) may reduce organ discard and optimize the use of kidneys from marginal donors. STUDY DESIGN We conducted a single-center retrospective review of outcomes in adult recipients of DKTs from adult marginal deceased donors (DD) defined by limited renal functional capacity. If the calculated creatinine clearance in an adult DD was <65 mL/min, then the kidneys were transplanted as a DKT. RESULTS Over 11.5 yr, 72 DKTS were performed including 45 from ECDs, 17 from donation after cardiac death (DCD) donors, and 10 from standard criteria donors (SCD). Mean adult DD and recipient ages were both 60 yr, including 29 DDs and 26 recipients ≥65 yr of age. Mean pre-DKT waiting and dialysis vintage times were 12 months and 25 months, respectively. Actual patient and graft survival rates were 84.7% and 70.8%, respectively, with a mean follow-up of 58 months. One yr and death-censored graft survival rates were 90% and 80%, respectively. Outcomes did not differ by DD category, recipient age, or presence of delayed graft function (DGF). Eleven patients died at a mean of 32 months post-DKT (eight with functioning grafts) and 13 other patients experienced graft losses at a mean of 33 months. The incidence of DGF was 25%; there were two cases (2.8%) of primary non-function. Mean length of initial hospital stay was 7.2 d. Mean serum creatinine and glomerular filtration rate levels at 12 and 24 months were 1.5 and 53 and 1.5 mg/dL and 51 mL/min/1.73 m(2) , respectively. DKT graft survival and function were superior to concurrent single ECD and similar to concurrent SCD KTs. Two patients underwent successful kidney retransplantation, so the dialysis-free rate in surviving patients was 87%. The proportion of total renal function transplanted from adult DD to DKT recipients was 77% compared to 56% for patients receiving single KTs. CONCLUSIONS Dual kidney transplantation using kidneys from adult marginal DDs that otherwise might be discarded offer a viable option to counteract the growing shortage of acceptable single kidneys. Excellent medium-term outcomes can be achieved and waiting times can be reduced in a predominantly older recipient population.
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Affiliation(s)
- Robert J Stratta
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Alan C Farney
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Giuseppe Orlando
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Umar Farooq
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Yousef Al-Shraideh
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Amudha Palanisamy
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Amber Reeves-Daniel
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - William Doares
- Department of Pharmacy, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Scott Kaczmorski
- Department of Pharmacy, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael D Gautreaux
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Samy S Iskandar
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Gloria Hairston
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Elizabeth Brim
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Margaret Mangus
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Hany El-Hennawy
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Muhammad Khan
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jeffrey Rogers
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Abstract
Demographic changes are associated with a steady increase of older patients with end-stage organ failure in need for transplantation. As a result, the majority of transplant recipients are currently older than 50 years, and organs from elderly donors are more frequently used. Nevertheless, the benefit of transplantation in older patients is well recognized, whereas the most frequent causes of death among older recipients are potentially linked to side effects of their immunosuppressants.Immunosenescence is a physiological part of aging linked to higher rates of diabetes, bacterial infections, and malignancies representing the major causes of death in older patients. These age-related changes impact older transplant candidates and may have significant implications for an age-adapted immunosuppression. For instance, immunosenescence is linked to lower rates of acute rejections in older recipients, whereas the engraftment of older organs has been associated with higher rejection rates. Moreover, new-onset diabetes mellitus after transplantation is more frequent in the elderly, potentially related to corticosteroids, calcineurin inhibitors, and mechanistic target of rapamycin inhibitors.This review presents current knowledge for an age-adapted immunosuppression based on both, experimental and clinical studies in and beyond transplantation. Recommendations of maintenance and induction therapy may help to improve graft function and to design future clinical trials in the elderly.
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90
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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.
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Affiliation(s)
| | | | | | | | | | | | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin, Berlin, Germany
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91
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Sutherland AI, IJzermans JNM, Forsythe JLR, Dor FJMF. Kidney and liver transplantation in the elderly. Br J Surg 2015; 103:e62-72. [PMID: 26662845 DOI: 10.1002/bjs.10064] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 10/27/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Transplant surgery is facing a shortage of deceased donor organs. In response, the criteria for organ donation have been extended, and an increasing number of organs from older donors are being used. For recipients, the benefits of transplantation are great, and the growing ageing population has led to increasing numbers of elderly patients being accepted for transplantation. METHODS The literature was reviewed to investigate the impact of age of donors and recipients in abdominal organ transplantation, and to highlight aspects of the fine balance in donor and recipient selection and screening, as well as allocation policies fair to young and old alike. RESULTS Overall, kidney and liver transplantation from older deceased donors have good outcomes, but are not as good as those from younger donors. Careful donor selection based on risk indices, and potentially biomarkers, special allocation schemes to match elderly donors with elderly recipients, and vigorous recipient selection, allows good outcomes with increasing age of both donors and recipients. The results of live kidney donation have been excellent for donor and recipient, and there is a trend towards inclusion of older donors. Future strategies, including personalized immunosuppression for older recipients as well as machine preservation and reconditioning of donor organs, are promising ways to improve the outcome of transplantation between older donors and older recipients. CONCLUSION Kidney and liver transplantation in the elderly is a clinical reality. Outcomes are good, but can be optimized by using strategies that modify donor risk factors and recipient co-morbidities, and personalized approaches to organ allocation and immunosuppression.
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Affiliation(s)
- A I Sutherland
- Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - J N M IJzermans
- Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - J L R Forsythe
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - F J M F Dor
- Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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92
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Cippà PE, Schiesser M, Ekberg H, van Gelder T, Mueller NJ, Cao CA, Fehr T, Bernasconi C. Risk Stratification for Rejection and Infection after Kidney Transplantation. Clin J Am Soc Nephrol 2015; 10:2213-20. [PMID: 26430088 PMCID: PMC4670759 DOI: 10.2215/cjn.01790215] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 08/12/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Definition of individual risk profile is the first step to implement strategies to keep the delicate balance between under- and overimmunosuppression after kidney transplantation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We used data from the Efficacy Limiting Toxicity Elimination Symphony Study (1190 patients between 2002 and 2004) to model risk of rejection and infection in the first year after kidney transplantation. External validation was performed in a study population from the Fixed-Dose Concentration-Controlled Trial (630 patients between 2003 and 2006). RESULTS Despite different temporal dynamics, rejections and severe infections had similar overall incidences in the first year after transplantation (23.4% and 25.5%, respectively), and infections were the principal cause of death (43.2% of all deaths). Recipient older age, deceased donor, higher number of HLA mismatches, and high risk for cytomegalovirus disease were associated with infection; deceased donor, higher number of HLA mismatches, and immunosuppressive therapy including cyclosporin A (compared with tacrolimus), with rejection. These factors were integrated into a two-dimensional risk stratification model, which defined four risk groups: low risk for infection and rejection (30.8%), isolated risk for rejection (36.1%), isolated risk for infection (7.0%), and high risk for infection and rejection (26.1%). In internal validation, this model significantly discriminated the subgroups in terms of composite end point (low risk for infection/rejection, 24.4%; isolated risk for rejection and isolated risk for infection, 31.3%; high risk for infection/rejection, 54.4%; P<0.001), rejection episodes (isolated risk for infection and low risk for infection/rejection, 13.0%; isolated risk for rejection and high risk for infection/rejection, 24.2%; P=0.001), and infection episodes (low risk for infection/rejection and isolated risk for rejection, 12.0%; isolated risk for infection and high risk for infection/rejection, 37.6%; P<0.001). External validation confirmed the applicability of the model to an independent cohort. CONCLUSIONS We propose a two-dimensional risk stratification model able to disentangle the individual risk for rejection and infection in the first year after kidney transplantation. This concept can be applied to implement a personalized immunosuppressive and antimicrobial treatment approach.
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Affiliation(s)
| | | | - Henrik Ekberg
- Department of Nephrology and Transplantation, Skåne University Hospital, Malmö, Sweden
| | - Teun van Gelder
- Departments of Hospital Pharmacy and Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Nicolas J Mueller
- Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
| | | | - Thomas Fehr
- Divisions of Nephrology, Department of Internal Medicine, Cantonal Hospital Graubünden, Graubünden, Switzerland; and
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93
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Scalea JR, Redfield RR, Muth BL, Mohamed M, Wilson NA, Ellis TM, Kaufman DB, Djamali A. Older kidney transplant patients experience less antibody-mediated rejection: a retrospective study of patients with mild to moderate sensitization. Clin Transplant 2015; 29:1090-7. [DOI: 10.1111/ctr.12632] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2015] [Indexed: 01/30/2023]
Affiliation(s)
- Joseph R. Scalea
- Division of Transplantation; Department of Surgery; University of Wisconsin; Madison WI USA
| | - Robert R. Redfield
- Division of Transplantation; Department of Surgery; University of Wisconsin; Madison WI USA
| | - Brenda L. Muth
- Division of Nephrology; Department of Medicine; University of Wisconsin; Madison WI USA
| | - Maha Mohamed
- Division of Nephrology; Department of Medicine; University of Wisconsin; Madison WI USA
| | - Nancy A. Wilson
- Division of Nephrology; Department of Medicine; University of Wisconsin; Madison WI USA
| | - Thomas M. Ellis
- Department of Surgery; HLA Laboratory; University of Wisconsin; Madison WI USA
| | - Dixon B. Kaufman
- Division of Transplantation; Department of Surgery; University of Wisconsin; Madison WI USA
| | - Arjang Djamali
- Division of Nephrology; Department of Medicine; University of Wisconsin; Madison WI USA
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94
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Understanding alterations in drug handling with aging: a focus on the pharmacokinetics of maintenance immunosuppressants in the elderly. Curr Opin Organ Transplant 2015; 20:424-30. [PMID: 26126198 DOI: 10.1097/mot.0000000000000220] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW This review presents current knowledge of the impact of age on the pharmacokinetics of maintenance immunosuppressants. RECENT FINDINGS Over the past decade, there has been a steady increase in older patients on organ transplant waiting lists. As a result, the average age of transplant recipients has significantly increased. The survival and quality-of-life benefits of transplantation in the elderly population have been demonstrated. Advancing age is associated with changes in immune responses, as well as changes in drug handling. Immunosenescence is a physiological part of aging and is linked to reduced rejection rates, but also higher rates of diabetes, infections and malignancies. Physiologic changes associated with age can have a significant impact on the pharmacokinetics of the maintenance immunosuppressive agents. Taken together, these age-related changes impact older transplant candidates and may have significant implications for managing immunosuppression in the elderly. SUMMARY Despite the lack of formal efficacy, safety and pharmacokinetic studies of individual immunosuppressants in the elderly transplant population, there are enough data available for practitioners to be able to adequately manage their older patients. A proficient understanding of the factors that impact the pharmacokinetics of the immunosuppressants in the elderly is essential to managing these patients successfully.
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95
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Immunosenescence in renal transplantation: a changing balance of innate and adaptive immunity. Curr Opin Organ Transplant 2015; 20:417-23. [PMID: 26154914 DOI: 10.1097/mot.0000000000000210] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW With global demographic changes and an overall improved healthcare, more older end-stage renal disease (ESRD) patients receive kidney transplants. At the same time, organs from older donors are utilized more frequently. Those developments have and will continue to impact allocation, immunosuppression and efforts improving organ quality. RECENT FINDINGS Findings mainly outside the field of transplantation have provided insights into mechanisms that drive immunosenescence and immunogenicity, thus providing a rationale for an age-adapted immunosuppression and relevant clinical trials in the elderly. With fewer rejections in the elderly, alloimmune responses appear to be characterized by a decline in effectiveness and an augmented unspecific immune response. SUMMARY Immunosenescence displays broad and ambivalent effects in elderly transplant recipients. Those changes appear to compensate a decline in allospecific effectiveness by a shift towards an augmented unspecific immune response. Immunosuppression needs to target those age-specific changes to optimize outcomes in elderly transplant recipients.
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96
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Oberhuber R, Liu G, Heinbokel T, Tullius SG. Emerging issues in transplantation. Transpl Immunol 2015. [DOI: 10.1002/9781119072997.ch14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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97
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Le Meur Y. What immunosuppression should be used for old-to-old recipients? Transplant Rev (Orlando) 2015; 29:231-6. [PMID: 26409505 DOI: 10.1016/j.trre.2015.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 08/25/2015] [Accepted: 08/31/2015] [Indexed: 12/18/2022]
Abstract
Elderly patients receiving a kidney from old donors (old-to-old) are a growing population of transplant recipients. This population cumulates risks of complications due to the co-morbidities and the immunodeficiency state and the frailty of the recipients together with the kidney senescence of the donors. In this context, the choice of immunosuppression is complicated and must take into account some contradictory principles explaining why no consensus exists today.
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Affiliation(s)
- Yannick Le Meur
- Department of Nephrology, University Hospital La Cavale Blanche, European University of Brittany, Brest, France.
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98
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Dreyer GJ, Hemke AC, Reinders MEJ, de Fijter JW. Transplanting the elderly: Balancing aging with histocompatibility. Transplant Rev (Orlando) 2015; 29:205-11. [PMID: 26411382 DOI: 10.1016/j.trre.2015.08.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 08/30/2015] [Accepted: 08/30/2015] [Indexed: 01/10/2023]
Abstract
Across the world, the proportions of senior citizens (i.e. those ≥65years) increase rapidly and are predicted to constitute over 25% of the general population by 2050. In 2012 already 48% of the population with end stage renal disease (ESRD) was aged 65years or older. Transplantation is considered the preferred treatment option for ESRD offering survival advantage over long-term dialysis in the majority of patients. Indeed, acceptable outcomes have been documented for selected patients over the age of 70years or even cases over 80years. The reality of organ scarcity and prolonged waiting times for a deceased donor kidney transplantation, however, indicate that at best 50% of the selected elderly may have realistic expectations to receive a timely transplant offer. By choice or medical selection, access to transplantation also decreases with increasing age. In order to expedite the chance for elderly to receive a kidney transplant dedicated allocation systems have been developed. These allocation systems, like the Eurotransplant Senior Program (ESP), support preferential local allocation of kidneys from older donors to older patients in order to match recipient and graft life while disregarding histocompatibility for HLA antigens. The consequence has been more acute rejection episodes and an increase in immunosuppressive load. In the elderly, the most common cause of graft loss is death with functioning graft and death from infectious diseases is one of the dominant causes. The Eurotransplant Senior DR-compatible Program (ESDP) was designed to further improve the perspective of successful transplantation in the elderly in terms of life and quality of life by re-introducing matching criteria for HLA-DR in the old-for-old algorithm.
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Affiliation(s)
- G J Dreyer
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - A C Hemke
- Nefrovision/Renine, Dutch Transplant Foundation, Leiden, The Netherlands
| | - M E J Reinders
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - J W de Fijter
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands.
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99
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Srinivas TR, Oppenheimer F. Identifying endpoints to predict the influence of immunosuppression on long-term kidney graft survival. Clin Transplant 2015; 29:644-53. [DOI: 10.1111/ctr.12554] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2015] [Indexed: 01/12/2023]
Affiliation(s)
- Titte R. Srinivas
- Kidney and Pancreas Transplant Programs; Division of Nephrology; Medical University of South Carolina; Mount Pleasant SC USA
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100
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Abstract
Purpose of review Important trends are being observed in pancreas transplantation in the USA. We will describe recent trends in simultaneous pancreas kidney (SPK) transplantation related to immunosuppression, treatment of rejection, and transplantation for patients of advanced age and C-peptide positive diabetes. Recent findings Rates of pancreas transplantation have declined, despite improved pancreatic graft outcomes. Regarding immunosuppression, trends in SPK transplantation include T-cell depletion induction therapy, waning mammalian target of rapamycin inhibitor use and steroid use in greater than 50% of pancreas transplant recipients with few patients undergoing late steroid weaning. Rejection of the pancreas may be discordant with the kidney after SPK and there is a greater appreciation of antibody-mediated rejection of the pancreas allograft. De-novo donor-specific antibody without graft dysfunction remains an active area of study, and the treatment for this condition is unclear. SPKs are being performed with greater frequency in type 2 diabetes mellitus patients and in patients of advanced age, with exemplary results. Summary The current state of the art in SPK transplantation is yielding superb and improving results.
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