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Sá H, Leal R, Rosa MS. Renal transplant immunology in the last 20 years: A revolution towards graft and patient survival improvement. Int Rev Immunol 2016; 36:182-203. [PMID: 27682364 DOI: 10.1080/08830185.2016.1225300] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
To deride the hope of progress is the ultimate fatuity, the last word in poverty of spirit and meanness of mind. There is no need to be dismayed by the fact that we cannot yet envisage a definitive solution of our problems, a resting-place beyond which we need not try to go. -P.B. Medawar, 1969 * Thomas E. Starlz, also known as the Father of Clinical Transplantation, once said that organ transplantation was the supreme exception to the rule that most major advances in medicine spring from discoveries in basic science [Starzl T. The mystique of organ transplantation. J Am Coll Surg 2005 Aug;201(2):160-170]. In fact, the first successful identical-twin kidney transplantation performed by Murray's team in December 1954 (Murray J et al. Renal homotransplantations in identical twins. Surg Forum 1955;6:432-436) was the example of an upside down translation medicine: Human clinical transplantation began and researchers tried to understand the underlying immune response and how to control the powerful rejection pathways through experimental models. In the last 20 years, we have witnessed an amazing progress in the knowledge of immunological mechanisms regarding alloimmune response and an outstanding evolution on the identification and characterization of major and minor histocompatibility antigens. This review presents an historical and clinical perspective of those important advances in kidney transplantation immunology in the last 20 years, which contributed to the improvement in patients' quality of life and the survival of end-stage renal patients. In spite of these significant progresses, some areas still need substantial progress, such as the definition of non-invasive biomarkers for acute rejection; the continuous reduction of immunosuppression; the extension of graft survival, and finally the achievement of real graft tolerance extended to HLA mismatch donor: recipient pairs.
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Affiliation(s)
- Helena Sá
- a Department of Nephrology , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal.,b Faculty of Medicine , University of Coimbra , Coimbra , Portugal.,c Immunology Center, Faculty of Medicine , University of Coimbra , Coimbra , Portugal
| | - Rita Leal
- a Department of Nephrology , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal
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Rausch L, Koenecke C, Koch HF, Kaltenborn A, Emmanouilidis N, Pape L, Lehner F, Arelin V, Baumann U, Schrem H. Matched-pair analysis: identification of factors with independent influence on the development of PTLD after kidney or liver transplantation. Transplant Res 2016; 5:6. [PMID: 27486513 PMCID: PMC4970231 DOI: 10.1186/s13737-016-0036-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 07/24/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Post-transplant lymphoproliferative disorder (PTLD) adversely affects patients' long-term outcome. METHODS The paired t test and McNemar's test were applied in a retrospective 1:1 matched-pair analysis including 36 patients with PTLD and 36 patients without PTLD after kidney or liver transplantation. Matching criteria were age, gender, indication, type of transplantation, and duration of follow-up. All investigated PTLD specimen were histologically positive for EBV. Risk-adjusted multivariable regression analysis was used to identify independence of risk factors for PTLD detected in matched-pair analysis. The resultant prognostic model was assessed with ROC-curve analysis. RESULTS Patients suffering with PTLD had shorter mean survival (p = 0.004), more episodes of CMV infections or reactivations (p = 0.042), and fewer recipient HLA A2 haplotypes (p = 0.007), a tacrolimus-based immunosuppressive regimen (p = 0.052) and higher dosages of tacrolimus at hospital discharge (Tac dosage) (p = 0.052). Significant independent risk factors for PTLD were recipient HLA A2 (OR = 0.07, 95 % CI = 0.01-0.55, p = 0.011), higher Tac dosages (OR = 1.29, 95 % CI = 1.01-1.64, p = 0.040), and higher numbers of graft rejection episodes (OR = 0.38, 95 % CI = 0.17-0.87, p = 0.023). The following prognostic model for the prediction of PTLD demonstrated good model fit and a large area under the ROC curve (0.823): PTLD probability in % = Exp(y)/(1 + Exp(y)) with y = 0.671 - 1.096 × HLA A2-positive recipient + 0.151 × Tac dosage - 0.805 × number of graft rejection episodes. CONCLUSIONS This study suggests prognostic relevance for recipient HLA A2, CMV, and EBV infections or reactivations and strong initial tacrolimus-based immunosuppression. Patients with risk factors may benefit from intensified screening for PTLD.
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Affiliation(s)
- Lisa Rausch
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Christian Koenecke
- Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Hans-Friedrich Koch
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Alexander Kaltenborn
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
- Trauma and Orthopedic Surgery, Federal Armed Forces Hospital Westerstede, Westerstede, Germany
| | - Nikos Emmanouilidis
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
- General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Lars Pape
- Pediatric Nephrology, Hepatology and Metabolic Disorders, Hannover Medical School, Hannover, Germany
| | - Frank Lehner
- General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Viktor Arelin
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
- Nephrology, Hannover Medical School, Hannover, Germany
| | - Ulrich Baumann
- Pediatric Nephrology, Hepatology and Metabolic Disorders, Hannover Medical School, Hannover, Germany
| | - Harald Schrem
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
- General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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Esposito S, Bonanni P, Maggi S, Tan L, Ansaldi F, Lopalco PL, Dagan R, Michel JP, van Damme P, Gaillat J, Prymula R, Vesikari T, Mussini C, Frank U, Osterhaus A, Celentano LP, Rossi M, Guercio V, Gavazzi G. Recommended immunization schedules for adults: Clinical practice guidelines by the Escmid Vaccine Study Group (EVASG), European Geriatric Medicine Society (EUGMS) and the World Association for Infectious Diseases and Immunological Disorders (WAidid). Hum Vaccin Immunother 2016; 12:1777-94. [PMID: 27135390 PMCID: PMC4964839 DOI: 10.1080/21645515.2016.1150396] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 01/19/2016] [Accepted: 02/01/2016] [Indexed: 12/27/2022] Open
Abstract
Rapid population aging has become a major challenge in the industrialized world and progressive aging is a key reason for making improvement in vaccination a cornerstone of public health strategy. An increase in age-related disorders and conditions is likely to be seen in the near future, and these are risk factors for the occurrence of a number of vaccine-preventable diseases. An improvement in infectious diseases prevention specifically aimed at adults and the elderly can therefore also decrease the burden of these chronic conditions by reducing morbidity, disability, hospital admissions, health costs, mortality rates and, perhaps most importantly, by improving the quality of life. Among adults, it is necessary to identify groups at increased risk of vaccine-preventable diseases and highlight the epidemiological impact and benefits of vaccinations using an evidence-based approach. This document provides clinical practice guidance on immunization for adults in order to provide recommendations for decision makers and healthcare workers in Europe. Although immunization is considered one of the most impactful and cost-effective public health measures that can be undertaken, vaccination coverage rates among adults are largely lower than the stated goal of ≥ 95% among adults, and stronger efforts are needed to increase coverage in this population. Active surveillance of adult vaccine-preventable diseases, determining the effectiveness of the vaccines approved for marketing in the last 5 y, the efficacy and safety of vaccines in immunocompromised patients, as well as in pregnant women, represent the priorities for future research.
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Affiliation(s)
- Susanna Esposito
- Pediatric Highly Intensive Care Unit, University of Milan, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Bonanni
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Stefania Maggi
- CNR - Institute of Neuroscience, Aging Branch Center for Research, Padua, Italy
| | - Litjan Tan
- Immunization Action Coalition, St Paul, MN, USA
| | - Filippo Ansaldi
- Department of Health Sciences, University of Genoa, IRCCS San Martino-IST University Teaching Hospital, Genoa, Italy
| | | | - Ron Dagan
- Pediatric Infectious Disease Unit, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
| | | | - Pierre van Damme
- Vaccine & Infectious Disease Institute, Antwerp University, Wilrijk, Belgium
| | | | - Roman Prymula
- Department of Social Medicine, Faculty of Medicine, Charles University, Sokolska, Hradec Kralove, Czech Republic
| | - Timo Vesikari
- Vaccine Research Center, Tampere University Hospital, Tampere, Finland
| | - Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Uwe Frank
- Division of Infection Control and Hospital Epidemiology, Department of Infectious Diseases, Heidelberg University, Heidelberg, Germany
| | | | | | - Marta Rossi
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Valentina Guercio
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Gaetan Gavazzi
- University Clinic of Geriatric Medicine, University Hospital of Grenoble, and GREPI University of Grenoble-Alpes, Grenoble, France
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Tsipotis E, Gupta NR, Raman G, Zintzaras E, Jaber BL. Bioavailability, Efficacy and Safety of Generic Immunosuppressive Drugs for Kidney Transplantation: A Systematic Review and Meta-Analysis. Am J Nephrol 2016; 44:206-18. [PMID: 27576318 PMCID: PMC6584577 DOI: 10.1159/000449020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 07/05/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Concerns exist over the extrapolation of bioavailability studies of generic immunosuppressive drugs in healthy volunteers, regarding their efficacy and safety in kidney transplant recipients. We conducted a meta-analysis of trials examining the bioavailability of generic (test) immunosuppressive drugs relative to their brand (reference) counterparts in healthy volunteers, based on the US Food and Drug Administration requirements for approval of generics, and their efficacy and safety in kidney transplant recipients. METHODS Eligible studies were identified in PubMed, Cochrane Central Register of Controlled Trials, Scopus, ClinicalTrials.gov, and conference abstracts. RESULTS Twenty crossover trials of healthy volunteers (n = 641) and 6 parallel-arm randomized controlled trials of kidney transplant recipients (n = 594) were identified. The 90% CI of the pooled test-to-reference drug ratio for maximum or peak plasma concentration (Cmax) and area under the plasma concentration time-curve from time 0 to time of last determinable concentration (AUC(0-t)) fell within the required range (0.80-1.25) for cyclosporine (Cmax 0.91; 90% CI 0.86-0.95; and AUC(0-t) 0.97; 90% CI 0.94-1.00), tacrolimus (Cmax 1.17; 90% CI 1.09-1.24; and AUC(0-t) 1.00; 90% CI 0.97-1.03) and mycophenolate mofetil (Cmax 0.98; 90% CI 0.96-1.01; and AUC(0-t) 1.00; 90% CI 0.99-1.01). In subgroup analyses, some generic cyclosporine formulations did not meet criteria for bioequivalence. No significant differences were observed in the time to maximum plasma concentration and terminal plasma half-life between generic and brand drugs. In parallel-arm trials, generic cyclosporine was non-inferior to brand counterpart in terms of acute allograft rejection, infections, and death. CONCLUSIONS Not all generic immunosuppressive drugs have similar relative bioavailability to their brand name counterparts. Evidence on their efficacy and safety is inconclusive. Tighter regulatory requirement for approval of generic drugs with narrow therapeutic index is needed.
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Affiliation(s)
- Evangelos Tsipotis
- Department of Medicine, Tufts University School of
Medicine, Boston, Mass., USA,Department of Medicine, Division of Nephrology, St.
Elizabeth’s Medical Center, Tufts University School of Medicine, Boston,
Mass., USA
| | - Navin R. Gupta
- Department of Medicine, Tufts University School of
Medicine, Boston, Mass., USA
| | - Gowri Raman
- Center for Clinical Evidence Synthesis, The Institute for
Clinical Research and Health Policy Studies, Tufts Medical Center, Tufts University
School of Medicine, Boston, Mass., USA
| | - Elias Zintzaras
- Center for Clinical Evidence Synthesis, The Institute for
Clinical Research and Health Policy Studies, Tufts Medical Center, Tufts University
School of Medicine, Boston, Mass., USA,Department of Biomathematics, Evidence-Based Medicine Unit,
University of Thessaly School of Medicine, Larissa, Greece
| | - Bertrand L. Jaber
- Department of Medicine, Tufts University School of
Medicine, Boston, Mass., USA,Department of Medicine, Division of Nephrology, St.
Elizabeth’s Medical Center, Tufts University School of Medicine, Boston,
Mass., USA
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Affiliation(s)
- Gitanjali P Mansukhani
- Pediatric Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Jennifer Conway
- Pediatric Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada.
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