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Eberhardt TE, Kim DH, Nethersole S, Pearson GJ. Assessment of immunosuppression induction with basiliximab compared to antithymocyte-globulin in adult heart transplant patients. Clin Transplant 2024; 38:e15332. [PMID: 38804609 DOI: 10.1111/ctr.15332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Patients undergoing heart transplants are at risk of rejection which can have significant morbidity and mortality. Induction immunosuppression at the time of transplant reduces the early risk and has additional benefits. The induction agent of choice within our program was changed from rabbit antithymocyte-globulin (rATG) to basiliximab, so it was necessary to evaluate whether this had any impact on patient outcomes. OBJECTIVES Our primary objective was to describe rejection, infection, and other outcomes in adult heart transplant patients at the University of Alberta Hospital in Edmonton, Canada. METHODS This study was a nonrandomized, retrospective cohort study. RESULTS Sixty-three patients were included with median ages 50 years versus 54 years. More female patients received rATG (20% vs. 42.4%). The most common indication for transplant in both cohorts was ICM (63.3% vs. 57.6%). Patients who received rATG had significantly higher PRA (0% vs. 43%, p < .001). Acute rejection episodes were similar between basiliximab and rATG at 3 months (16.7% vs. 15.1%; p = 1.0) and 6-months (30.0% vs. 18.1%; p = .376). Infections were not statistically different with basiliximab compared to rATG at 3-months, 43.3% vs. 63.6% and at 6-months 60.0% vs. 66.7%). There were no fatalities in either group. CONCLUSIONS Our study did not demonstrate differences in rejection with basiliximab compared to rATG. Mortality did not differ, but basiliximab-treated patients had fewer infections and infection-related hospitalizations than those treated with rATG. Larger studies with longer durations are needed to more completely describe the differences in rejection and infectious outcomes.
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Affiliation(s)
| | - Daniel H Kim
- Department of Medicine, University of Alberta, Division of Cardiology, Edmonton, Canada
| | - Shannon Nethersole
- Transplant Services, University of Alberta Hospital, Alberta Health Services, Edmonton, Canada
| | - Glen J Pearson
- Department of Medicine, University of Alberta, Division of Cardiology, Edmonton, Canada
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Kugathasan L, Rayner DG, Wang SM, Rodenas-Alesina E, Orchanian-Cheff A, Stehlik J, Gustafsson F, Greig D, McDonald M, Bertolotti AM, Demas-Clarke P, Kozuszko S, Guyatt G, Foroutan F, Alba AC. Induction therapy in heart transplantation: A systematic review and network meta-analysis for developing evidence-based recommendations. Clin Transplant 2024; 38:e15326. [PMID: 38716786 DOI: 10.1111/ctr.15326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 03/09/2024] [Accepted: 04/02/2024] [Indexed: 05/24/2024]
Abstract
INTRODUCTION Induction therapy (IT) utility in heart transplantation (HT) remains contested. Commissioned by a clinical-practice guidelines panel to evaluate the effectiveness and safety of IT in adult HT patients, we conducted this systematic review and network meta-analysis (NMA). METHODS We searched for studies from January 2000 to October 2022, reporting on the use of any IT agent in adult HT patients. Based on patient-important outcomes, we performed frequentist NMAs separately for RCTs and observational studies with adjusted analyses, and assessed the certainty of evidence using the GRADE framework. RESULTS From 5156 publications identified, we included 7 RCTs and 12 observational studies, and report on two contemporarily-used IT agents-basiliximab and rATG. The RCTs provide only very low certainty evidence and was uninformative of the effect of the two agents versus no IT or one another. With low certainty in the evidence from observational studies, basiliximab may increase 30-day (OR 1.13; 95% CI 1.06-1.20) and 1-year (OR 1.11; 95% CI 1.02-1.22) mortality compared to no IT. With low certainty from observational studies, rATG may decrease 5-year cardiac allograft vasculopathy (OR .82; 95% CI .74-.90) compared to no IT, as well as 30-day (OR .85; 95% CI .80-.92), 1-year (OR .87; 95% CI .79-.96), and overall (HR .84; 95% CI .76-.93) mortality compared to basiliximab. CONCLUSION With low and very low certainty in the synthetized evidence, these NMAs suggest possible superiority of rATG compared to basiliximab, but do not provide compelling evidence for the routine use of these agents in HT recipients.
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Affiliation(s)
- Lakshmi Kugathasan
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Daniel G Rayner
- Department of Health Research Methods, Evidence, and Impact, McMaster, Hamilton, Ontario, Canada
| | | | | | | | - Josef Stehlik
- Department of Medicine, Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Finn Gustafsson
- Rigshospitalet - Copenhagen University Hospital, Copenhagen, Denmark
| | - Douglas Greig
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Michael McDonald
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | | | | | - Stella Kozuszko
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster, Hamilton, Ontario, Canada
| | - Farid Foroutan
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster, Hamilton, Ontario, Canada
| | - Ana Carolina Alba
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
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Foroutan F, Guyatt G, Stehlik J, Gustafsson F, Greig D, McDonald M, Bertolotti AM, Kugathasan L, Rayner DG, Cuello CA, Cook A, Zlatanoski D, Ram S, Demas-Clarke P, Kozuszko S, Alba AC. Use of induction therapy post-heart transplantation: Clinical practice recommendations based on systematic review and network meta-analysis of evidence. Clin Transplant 2024; 38:e15270. [PMID: 38445536 DOI: 10.1111/ctr.15270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/03/2024] [Accepted: 02/09/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND The use of induction therapy (IT) agents in the early post-heart transplant period remains controversial. The following recommendations aim to provide guidance on the use of IT agents, including Basiliximab and Thymoglobulin, as part of routine care in heart transplantation (HTx). METHODS We recruited an international, multidisciplinary panel of 15 stakeholders, including patient partners, transplant cardiologists and surgeons, nurse practitioners, pharmacists, and methodologists. We commissioned a systematic review on benefits and harms of IT on patient-important outcomes, and another on patients' values and preferences to inform our recommendations. We used the GRADE framework to summarize our findings, rate certainty in the evidence, and develop recommendations. The panel considered the balance between benefits and harms, certainty in the evidence, and patient's values and preferences, to make recommendations for or against the routine post-operative use of Thymoglobulin or Basiliximab. RESULTS The panel made recommendations on three major clinical problems in HTx: (1) We suggest against the routine post-operative use of Basiliximab compared to no IT, (2) we suggest against the routine use of Thymoglobulin compared to no IT, and (3) for those patients for whom IT is deemed desirable, we suggest for the use of Thymoglobulin as compared to Basiliximab. CONCLUSION This report highlights gaps in current knowledge and provides directions for clinical research in the future to better understand the clinical utility of IT agents in the early post heart transplant period, leading to improved management and care.
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Affiliation(s)
- Farid Foroutan
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster, Hamilton, Ontario, Canada
| | - Josef Stehlik
- Department of Medicine, Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Finn Gustafsson
- Rigshospitalet - Copenhagen University Hospital, Copenhagen, Denmark
| | - Douglas Greig
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Michael McDonald
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | | | - Lakshmi Kugathasan
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Daniel G Rayner
- Department of Health Research Methods, Evidence, and Impact, McMaster, Hamilton, Ontario, Canada
| | - Carlos A Cuello
- Department of Health Research Methods, Evidence, and Impact, McMaster, Hamilton, Ontario, Canada
| | - Amanda Cook
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Darko Zlatanoski
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Sujivan Ram
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | | | - Stella Kozuszko
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Ana Carolina Alba
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
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Gupta SK, Mostofsky E, Motiwala SR, Hage A, Mittleman MA. Induction immunosuppression and post-transplant diabetes mellitus: a propensity-matched cohort study. Front Endocrinol (Lausanne) 2023; 14:1248940. [PMID: 37929038 PMCID: PMC10623448 DOI: 10.3389/fendo.2023.1248940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/02/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction Post-transplant diabetes mellitus (PTDM) is a common complication among cardiac transplant recipients, causing diabetes-related complications and death. While certain maintenance immunosuppressive drugs increase PTDM risk, it is unclear whether induction immunosuppression can do the same. Therefore, we evaluated whether induction immunosuppression with IL-2 receptor antagonists, polyclonal anti-lymphocyte antibodies, or Alemtuzumab given in the peri-transplant period is associated with PTDM. Methods We used the Scientific Registry of Transplant Recipients database to conduct a cohort study of US adults who received cardiac transplants between January 2008-December 2018. We excluded patients with prior or multiple organ transplants and those with a history of diabetes, resulting in 17,142 recipients. We created propensity-matched cohorts (n=7,412) using predictors of induction immunosuppression and examined the association between post-transplant diabetes and induction immunosuppression by estimating hazard ratios using Cox proportional-hazards models. Results In the propensity-matched cohort, the average age was 52.5 (SD=13.2) years, 28.7% were female and 3,706 received induction immunosuppression. There were 867 incident cases of PTDM during 26,710 person-years of follow-up (32.5 cases/1,000 person-years). There was no association between induction immunosuppression and post-transplant diabetes (Hazard Ratio= 1.04, 95% confidence interval 0.91 - 1.19). Similarly, no associations were observed for each class of induction immunosuppression agents and post-transplant diabetes. Conclusion The use of contemporary induction immunosuppression in cardiac transplant patients was not associated with post-transplant diabetes.
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Affiliation(s)
- Suruchi K. Gupta
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Elizabeth Mostofsky
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Shweta R. Motiwala
- Harvard Medical School, Boston, MA, United States
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Ali Hage
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
- London Health Sciences Centre, Schulich School of Medicine, Western University, London, ON, Canada
| | - Murray A. Mittleman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
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5
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Salia S, Mostofsky E, Gupta S, Lehman L, Barrera FJ, Liou L, Motiwala SR, Mittleman MA. Post-transplant mortality and graft failure after induction immunosuppression among Black heart transplant recipients in the United States. Am J Transplant 2022; 22:2586-2597. [PMID: 35758522 PMCID: PMC9643611 DOI: 10.1111/ajt.17130] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 01/25/2023]
Abstract
Black heart transplant recipients are more likely to receive induction immunosuppression compared to other races because of higher rates of acute rejection, graft failure, and mortality. However, it is not known whether contemporary induction immunosuppression improves their post-transplant outcomes. To evaluate whether Black patients who were prescribed induction immunosuppression therapy have lower all-cause mortality or graft-failure rates compared to those who were not, we studied Black U.S. adult heart transplant recipients in the Scientific Registry of Transplant Recipients database (2008-2018). We used multivariable Cox proportional hazards regression analysis to compare the hazards of all-cause mortality or graft failure as a composite, for patients who were prescribed induction immunosuppression and those who were not. Among 5160 recipients, 2787 (54.0%) were prescribed induction immunosuppression and 2373 (46.0%) were not. There was no evidence of survival differences according to induction immunosuppression for the composite of all-cause mortality or graft failure (aHR = 1.13, 95% CI 0.96-1.32), mortality (aHR = 1.14, 95% CI 0.97-1.34), graft failure (aHR = 1.05, 95% CI 0.82-1.34) and acute rejection (aHR = 1.00, 95% CI 0.89-1.12). Given the side effects of treatment, future guidelines should reconsider the recommendation for induction immunosuppression among Black patients.
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Affiliation(s)
- Soziema Salia
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Internal Medicine, Cape Coast Teaching Hospital, Cape Coast, Ghana
| | - Elizabeth Mostofsky
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Suruchi Gupta
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Laura Lehman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Francisco J Barrera
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Lathan Liou
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Merck & Co., Merck Research Laboratories, Boston, Massachusetts
| | - Shweta R Motiwala
- Harvard Medical School, Boston, Massachusetts
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Murray A Mittleman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Predictive Factors for Humoral Response After 2-dose SARS-CoV-2 Vaccine in Solid Organ Transplant Patients. Transplant Direct 2021; 8:e1248. [PMID: 34966837 PMCID: PMC8710345 DOI: 10.1097/txd.0000000000001248] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 12/24/2022] Open
Abstract
Background A weak immunogenicity has been reported in solid organ transplant (SOT) recipients after 2 doses of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. The aim of this retrospective study was to identify the predictive factors for humoral response in SOT patients. Methods Three hundred and ninety-three SOT patients from our center with at least 4 wk of follow-up after 2 doses of mRNA-based vaccine were included in this study. Anti-SARS-Cov-2 spike protein antibodies were assessed before and after vaccination. Results Anti-SARS-CoV-2 antibodies were detected in 34% of the patients: 33.7% of kidney transplant patients, 47.7% of liver transplant patients, and 14.3% of thoracic transplant patients (P = 0.005). Independent predictive factors for humoral response after vaccination were male gender, a longer period between transplantation and vaccination, liver transplant recipients, a higher lymphocyte count at baseline, a higher estimated glomerular filtration rate and receiving the tacrolimus + everolimus ± steroids combination. Conversely, the nondevelopment of anti-SARS-CoV-2 antibodies after vaccination was associated with younger patients, thoracic organ recipients, induction therapy recipients, and tacrolimus + mycophenolic acid ± steroids recipients. Conclusions The immunosuppressive regimen is a modifiable predictive factor for humoral response to SARS-CoV-2 vaccine.
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Adverse Effects of Immunosuppression: Nephrotoxicity, Hypertension, and Metabolic Disease. Handb Exp Pharmacol 2021; 272:337-348. [PMID: 34697665 DOI: 10.1007/164_2021_547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The use of Immunosuppression has led to the tremendous improvement in graft survival. However, immunosuppressants have been found to cause a variety of metabolic derangements including but not limited to: insulin resistance and diabetes, hyperlipidemia, hypertension, and weight gain after transplantation. This combination of metabolic risk factors may be associated with increased cardiovascular disease (Grundy et al., Circulation 112(17):2735, 2005). In addition many transplant recipients may have many of these risk factors pre-transplant that are exacerbated by immunosuppression. These facts emphasize the need for rigorous follow-up and management of these risk factors post-transplant.The most common immune suppressant regimens may include different combinations of these agents: Corticosteroids, Calcineurin inhibitors (CNIs), Mammalian Target of Rapamycin (mTOR) Inhibitors, Antimetabolite.
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Watanabe T, Yanase M, Seguchi O, Fujita T, Hamasaki T, Nakajima S, Kuroda K, Kumai Y, Toda K, Iwasaki K, Kimura Y, Mochizuki H, Anegawa E, Sujino Y, Yagi N, Yoshitake K, Wada K, Matsuda S, Takenaka H, Ikura M, Nakagita K, Yajima S, Matsumoto Y, Tadokoro N, Kakuta T, Fukushima S, Ishibashi-Ueda H, Kobayashi J, Fukushima N. Influence of Induction Therapy Using Basiliximab With Delayed Tacrolimus Administration in Heart Transplant Recipients - Comparison With Standard Tacrolimus-Based Triple Immunosuppression. Circ J 2020; 84:2212-2223. [PMID: 33148937 DOI: 10.1253/circj.cj-20-0164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Appropriate indications and protocols for induction therapy using basiliximab have not been fully established in heart transplant (HTx) recipients. This study elucidated the influence of induction therapy using basiliximab along with delayed tacrolimus (Tac) initiation on the outcomes of high-risk HTx recipients.Methods and Results:A total of 86 HTx recipients treated with Tac-based immunosuppression were retrospectively reviewed. Induction therapy was administered to 46 recipients (53.5%) with impaired renal function, pre-transplant sensitization, and recipient- and donor-related risk factors (Induction group). Tac administration was delayed in the Induction group. Induction group subjects showed a lower cumulative incidence of acute cellular rejection grade ≥1R after propensity score adjustment, but this was not significantly different (hazard ratio [HR]: 0.63, 95% confidence interval [CI]: 0.37-1.08, P=0.093). Renal dysfunction in the Induction group significantly improved 6 months post-transplantation (P=0.029). The cumulative incidence of bacterial or fungal infections was significantly higher in the Induction group (HR: 10.6, 95% CI: 1.28-88.2, P=0.029). CONCLUSIONS These results suggest that basiliximab-based induction therapy with delayed Tac initiation may suppress mild acute cellular rejection and improve renal function in recipients with renal dysfunction, resulting in its non-inferior outcome, even in high-risk patients, when applied to the appropriate recipients. However, it should be carefully considered in recipients at a high risk of bacterial and fungal infections.
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Affiliation(s)
- Takuya Watanabe
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Masanobu Yanase
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Osamu Seguchi
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | | | - Seiko Nakajima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Kensuke Kuroda
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Yuto Kumai
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Koichi Toda
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Keiichiro Iwasaki
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Yuki Kimura
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Hiroki Mochizuki
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Eiji Anegawa
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Yasumori Sujino
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Nobuichiro Yagi
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Koichi Yoshitake
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Kyoichi Wada
- Department of Pharmacy, National Cerebral and Cardiovascular Center
| | - Sachi Matsuda
- Department of Pharmacy, National Cerebral and Cardiovascular Center
| | - Hiromi Takenaka
- Department of Pharmacy, National Cerebral and Cardiovascular Center
| | - Megumi Ikura
- Department of Pharmacy, National Cerebral and Cardiovascular Center
| | - Kazuki Nakagita
- Department of Pharmacy, National Cerebral and Cardiovascular Center
| | - Shin Yajima
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Yorihiko Matsumoto
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Naoki Tadokoro
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Takashi Kakuta
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Satsuki Fukushima
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | | | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Norihide Fukushima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
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Giannis D, Moris D, Cendales LC. Costimulation Blockade in Vascularized Composite Allotransplantation. Front Immunol 2020; 11:544186. [PMID: 33042138 PMCID: PMC7527523 DOI: 10.3389/fimmu.2020.544186] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 08/19/2020] [Indexed: 12/14/2022] Open
Abstract
Vascular composite allotransplantation (VCA) is a field under research and has emerged as an alternative option for the repair of severe disfiguring defects that result from infections or traumatic amputation in a selected group of patients. VCA is performed in centers with appropriate expertise, experience and adequate resources to effectively manage the complexity and complications of this treatment. Lifelong immunosuppressive therapy, immunosuppression associated complications, and the effects of the host immune response in the graft are major concerns in VCA. VCA is considered a quality of life transplant and the risk-benefit ratio is dissimilar to life saving transplants. Belatacept seems a promising drug that prolongs patient and graft survival in kidney transplantation and it could also be an alternative approach to VCA immunosuppression. In this review, we are summarizing current literature about the role of costimulation blockade, with a focus on belatacept in VCA.
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Affiliation(s)
- Dimitrios Giannis
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Dimitrios Moris
- Duke Surgery, Duke University Medical Center, Durham, NC, United States
| | - Linda C. Cendales
- Duke Surgery, Duke University Medical Center, Durham, NC, United States
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Requirements for Proper Immunosuppressive Regimens to Limit Translational Failure of Cardiac Cell Therapy in Preclinical Large Animal Models. J Cardiovasc Transl Res 2020; 14:88-99. [PMID: 32476086 PMCID: PMC7892682 DOI: 10.1007/s12265-020-10035-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/19/2020] [Indexed: 12/16/2022]
Abstract
Various cell-based therapies are currently investigated in an attempt to tackle the high morbidity and mortality associated with heart failure. The need for these therapies to move towards the clinic is pressing. Therefore, preclinical large animal studies that use non-autologous cells are needed to evaluate their potential. However, non-autologous cells are highly immunogenic and trigger immune rejection responses resulting in potential loss of efficacy. To overcome this issue, adequate immunosuppressive regimens are of imminent importance but clear guidelines are currently lacking. In this review, we assess the immunological barriers regarding non-autologous cell transplantation and immune modulation with immunosuppressive drugs. In addition, we provide recommendations with respect to immunosuppressive regimens in preclinical cardiac cell-replacement studies.
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Cancer risks in recipients of renal transplants: a meta-analysis of cohort studies. Oncotarget 2017; 9:15375-15385. [PMID: 29632651 PMCID: PMC5880611 DOI: 10.18632/oncotarget.23841] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 10/05/2017] [Indexed: 01/20/2023] Open
Abstract
Renal transplantation is associated with an increased risk of cancers at multiple sites; however, the relationships between increased cancer risk and participant characteristics remain unclear. We searched PubMed, Embase, and the Cochrane Library to identify prospective observational studies performed up to July 2017. Totally 11 prospective studies reported data on 79,988 renal transplant recipients were included. Renal transplant recipients were found to display a higher risk of all cancers (standard incidence ratio [SIR]: 2.89; 95% CI: 2.13–3.91; P < 0.001), gastric cancer (SIR: 1.93; 95% CI: 1.60–2.34; P < 0.001), colon cancer (SIR: 1.85; 95% CI: 1.53–2.23; P < 0.001), pancreatic cancer (SIR: 1.53; 95% CI: 1.23–1.91; P < 0.001), hepatocellular carcinoma (SIR: 2.45; 95% CI: 1.63–3.66; P < 0.001), lung cancer (SIR: 1.68; 95% CI: 1.29–2.19; P < 0.001), thyroid cancer (SIR: 5.04; 95% CI: 3.79–6.71; P < 0.001), urinary bladder cancer (SIR: 3.52; 95% CI: 1.48–8.37; P = 0.004), renal cell cancer (SIR: 10.77; 95% CI: 6.40–18.12; P < 0.001), non-melanoma skin cancer (SIR: 12.14; 95% CI: 6.37–23.13; P < 0.001), melanoma (SIR: 2.48; 95% CI: 1.08–5.67; P = 0.032), Hodgkin's lymphoma (SIR: 4.90; 95% CI: 3.09–7.78; P < 0.001), non-Hodgkin lymphoma (SIR: 10.66; 95% CI: 8.54–13.31; P < 0.001), lip cancer (SIR: 29.45; 95% CI: 17.85–48.59; P < 0.001), breast cancer (SIR: 1.11; 95% CI: 1.00–1.24; P = 0.046), and ovarian cancer (SIR: 1.60; 95% CI: 1.23–2.07; P < 0.001). However, renal transplantation did not significantly influence the risks of uterine cancer (P = 0.171), and prostate cancers (P = 0.188). Our findings suggest that patients who receive renal transplantation have an increased risk of cancer at most sites, apart from uterine and prostate cancers patients.
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Furiasse N, Kobashigawa JA. Immunosuppression and adult heart transplantation: emerging therapies and opportunities. Expert Rev Cardiovasc Ther 2016; 15:59-69. [DOI: 10.1080/14779072.2017.1267565] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Nicholas Furiasse
- Cedars Sinai Medical Center, Department of Cardiology, Cedars Sinai Heart Institute, Los Angeles, CA, USA
| | - Jon A. Kobashigawa
- Cedars Sinai Medical Center, Department of Cardiology, Cedars Sinai Heart Institute, Los Angeles, CA, USA
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Abstract
OPINION STATEMENT Panel reactive antibody (PRA) testing has become standard in the evaluation of patients prior to cardiac transplant. Sensitizing events such as blood transfusions, which result in the accumulation of pre-transplant antibodies, should be avoided as clinically feasible. Desensitization therapy might be considered in sensitized patients with cPRA > 50 % although distinct cutoff PRA values for initiating therapy pre-transplant are patient and transplant program dependent. Post-cardiac transplant, quantitative antibodies should also be periodically analyzed, at intervals individualized to the patient. Donor-specific antibodies (DSA) after cardiac transplantation have been shown to be associated with worsened survival. It appears that complement fixing DSA confer the greatest risk for antibody-mediated rejection post-transplant. Desensitization strategies aim to reduce the number of clinically important antibodies prior to and after transplant, both by removal of antibodies and cessation of further production. Current desensitization regimens include pharmacologic, procedural, and surgical modalities, and must be individualized to the patient. Currently, most cardiac transplant programs tailor the post-transplant immunosuppressive regimen based on clinical factors and immunologic assays and may include the use of cytolytic induction and/or intravenous immune gammaglobulin in higher risk patients.
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Penninga L, Wettergren A, Wilson CH, Chan A, Steinbrüchel DA, Gluud C. Antibody induction versus placebo, no induction, or another type of antibody induction for liver transplant recipients. Cochrane Database Syst Rev 2014; 2014:CD010253. [PMID: 24901467 PMCID: PMC8925015 DOI: 10.1002/14651858.cd010253.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Liver transplantation is an established treatment option for end-stage liver failure. To date, no consensus has been reached on the use of immunosuppressive T-cell antibody induction for preventing rejection after liver transplantation. OBJECTIVES To assess the benefits and harms of immunosuppressive T-cell specific antibody induction compared with placebo, no induction, or another type of T-cell specific antibody induction for prevention of acute rejection in liver transplant recipients. SEARCH METHODS We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index Expanded, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) until September 2013. SELECTION CRITERIA Randomised clinical trials assessing immunosuppression with T-cell specific antibody induction compared with placebo, no induction, or another type of antibody induction in liver transplant recipients. Our inclusion criteria stated that participants within each included trial should have received the same maintenance immunosuppressive therapy. We planned to include trials with all of the different types of T-cell specific antibodies that are or have been used for induction (ie., polyclonal antibodies (rabbit of horse antithymocyte globulin (ATG), or antilymphocyte globulin (ALG)), monoclonal antibodies (muromonab-CD3, anti-CD2, or alemtuzumab), and interleukin-2 receptor antagonists (daclizumab, basiliximab, BT563, or Lo-Tact-1)). DATA COLLECTION AND ANALYSIS We used RevMan analysis for statistical analysis of dichotomous data with risk ratio (RR) and of continuous data with mean difference (MD), both with 95% confidence intervals (CIs). We assessed the risk of systematic errors (bias) using bias risk domains with definitions. We used trial sequential analysis to control for random errors (play of chance). We presented outcome results in a summary of findings table. MAIN RESULTS We included 19 randomised clinical trials with a total of 2067 liver transplant recipients. All 19 trials were with high risk of bias. Of the 19 trials, 16 trials were two-arm trials, and three trials were three-arm trials. Hence, we found 25 trial comparisons with antibody induction agents: interleukin-2 receptor antagonist (IL-2 RA) versus no induction (10 trials with 1454 participants); monoclonal antibody versus no induction (five trials with 398 participants); polyclonal antibody versus no induction (three trials with 145 participants); IL-2 RA versus monoclonal antibody (one trial with 87 participants); and IL-2 RA versus polyclonal antibody (two trials with 112 participants). Thus, we were able to compare T-cell specific antibody induction versus no induction (17 trials with a total of 1955 participants). Overall, no difference in mortality (RR 0.91; 95% CI 0.64 to 1.28; low-quality of evidence), graft loss including death (RR 0.92; 95% CI 0.71 to 1.19; low-quality of evidence), and adverse events ((RR 0.97; 95% CI 0.93 to 1.02; low-quality evidence) outcomes was observed between any kind of T-cell specific antibody induction compared with no induction when the T-cell specific antibody induction agents were analysed together or separately. Acute rejection seemed to be reduced when any kind of T-cell specific antibody induction was compared with no induction (RR 0.85, 95% CI 0.75 to 0.96; moderate-quality evidence), and when trial sequential analysis was applied, the trial sequential monitoring boundary for benefit was crossed before the required information size was obtained. Furthermore, serum creatinine was statistically significantly higher when T-cell specific antibody induction was compared with no induction (MD 3.77 μmol/L, 95% CI 0.33 to 7.21; low-quality evidence), as well as when polyclonal T-cell specific antibody induction was compared with no induction, but this small difference was not clinically significant. We found no statistically significant differences for any of the remaining predefined outcomes - infection, cytomegalovirus infection, hepatitis C recurrence, malignancy, post-transplant lymphoproliferative disease, renal failure requiring dialysis, hyperlipidaemia, diabetes mellitus, and hypertension - when the T-cell specific antibody induction agents were analysed together or separately. Limited data were available for meta-analysis on drug-specific adverse events such as haematological adverse events for antithymocyte globulin. No data were found on quality of life.When T-cell specific antibody induction agents were compared with another type of antibody induction, no statistically significant differences were found for mortality, graft loss, and acute rejection for the separate analyses. When interleukin-2 receptor antagonists were compared with polyclonal T-cell specific antibody induction, drug-related adverse events were less common among participants treated with interleukin-2 receptor antagonists (RR 0.23, 95% CI 0.09 to 0.63; low-quality evidence), but this was caused by the results from one trial, and trial sequential analysis could not exclude random errors. We found no statistically significant differences for any of the remaining predefined outcomes: infection, cytomegalovirus infection, hepatitis C recurrence, malignancy, post-transplant lymphoproliferative disease, renal failure requiring dialysis, hyperlipidaemia, diabetes mellitus, and hypertension. No data were found on quality of life. AUTHORS' CONCLUSIONS The effects of T-cell antibody induction remain uncertain because of the high risk of bias of the randomised clinical trials, the small number of randomised clinical trials reported, and the limited numbers of participants and outcomes in the trials. T-cell specific antibody induction seems to reduce acute rejection when compared with no induction. No other clear benefits or harms were associated with the use of any kind of T-cell specific antibody induction compared with no induction, or when compared with another type of T-cell specific antibody. Hence, more randomised clinical trials are needed to assess the benefits and harms of T-cell specific antibody induction compared with placebo, and compared with another type of antibody, for prevention of rejection in liver transplant recipients. Such trials ought to be conducted with low risks of systematic error (bias) and low risk of random error (play of chance).
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Affiliation(s)
- Luit Penninga
- Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812Blegdamsvej 9CopenhagenDenmarkDK‐2100
- Rigshospitalet, Copenhagen University HospitalDepartment of Surgery and Transplantation C2122Blegdamsvej 9CopenhagenDenmarkDK‐2100 Ø
| | - André Wettergren
- Surgical Clinic HvidovreHvidovrevej 342, 1. floorHvidovreDenmark2650
| | - Colin H Wilson
- The Freeman HospitalInstitute of TransplantationFreeman RoadHigh HeatonNewcastle upon TyneTyne and WearUKNE7 7DN
| | - An‐Wen Chan
- University of TorontoWomen's College Research Institute790 Bay St, Rm 735TorontoONCanada
| | - Daniel A Steinbrüchel
- Rigshospitalet, Copenhagen University HospitalDepartment of Cardiothoracic SurgeryBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
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Penninga L, Wettergren A, Wilson CH, Chan A, Steinbrüchel DA, Gluud C. Antibody induction versus corticosteroid induction for liver transplant recipients. Cochrane Database Syst Rev 2014; 2014:CD010252. [PMID: 24880007 PMCID: PMC10577808 DOI: 10.1002/14651858.cd010252.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Liver transplantation is an established treatment option for end-stage liver failure. To date, no consensus has been reached on the use of immunosuppressive T-cell specific antibody induction compared with corticosteroid induction of immunosuppression after liver transplantation. OBJECTIVES To assess the benefits and harms of T-cell specific antibody induction versus corticosteroid induction for prevention of acute rejection in liver transplant recipients. SEARCH METHODS We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index Expanded, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 30 September 2013 together with reference checking, citation searching, contact with trial authors and pharmaceutical companies to identify additional trials. SELECTION CRITERIA We included all randomised clinical trials assessing immunosuppression with T-cell specific antibody induction versus corticosteroid induction in liver transplant recipients. Our inclusion criteria stated that participants within each included trial should have received the same maintenance immunosuppressive therapy. DATA COLLECTION AND ANALYSIS We used RevMan for statistical analysis of dichotomous data with risk ratio (RR) and of continuous data with mean difference (MD), both with 95% confidence intervals (CIs). We assessed risk of systematic errors (bias) using bias risk domains with definitions. We used trial sequential analysis to control for random errors (play of chance). MAIN RESULTS We included 10 randomised trials with a total of 1589 liver transplant recipients, which studied the use of T-cell specific antibody induction versus corticosteroid induction. All trials were with high risk of bias. We compared any kind of T-cell specific antibody induction versus corticosteroid induction in 10 trials with 1589 participants, including interleukin-2 receptor antagonist induction versus corticosteroid induction in nine trials with 1470 participants, and polyclonal T-cell specific antibody induction versus corticosteroid induction in one trial with 119 participants.Our analyses showed no significant differences regarding mortality (RR 1.01, 95% CI 0.72 to 1.43), graft loss (RR 1.12, 95% CI 0.82 to 1.53) and acute rejection (RR 0.84, 95% CI 0.70 to 1.00), infection (RR 0.96, 95% CI 0.85 to 1.09), hepatitis C virus recurrence (RR 0.89, 95% CI 0.79 to 1.00), malignancy (RR 0.59, 95% CI 0.13 to 2.73), and post-transplantation lymphoproliferative disorder (RR 1.00, 95% CI 0.07 to 15.38) when any kind of T-cell specific antibody induction was compared with corticosteroid induction (all low-quality evidence). Cytomegalovirus infection was less frequent in patients receiving any kind of T-cell specific antibody induction compared with corticosteroid induction (RR 0.50, 95% CI 0.33 to 0.75; low-quality evidence). This was also observed when interleukin-2 receptor antagonist induction was compared with corticosteroid induction (RR 0.55, 95% CI 0.37 to 0.83; low-quality evidence), and when polyclonal T-cell specific antibody induction was compared with corticosteroid induction (RR 0.21, 95% CI 0.06 to 0.70; low-quality evidence). However, when trial sequential analysis regarding cytomegalovirus infection was applied, the required information size was not reached. Furthermore, diabetes mellitus occurred less frequently when T-cell specific antibody induction was compared with corticosteroid induction (RR 0.45, 95% CI 0.34 to 0.60; low-quality evidence), when interleukin-2 receptor antagonist induction was compared with corticosteroid induction (RR 0.45, 95% CI 0.35 to 0.61; low-quality evidence), and when polyclonal T-cell specific antibody induction was compared with corticosteroid induction (RR 0.12, 95% CI 0.02 to 0.95; low-quality evidence). When trial sequential analysis was applied, the trial sequential monitoring boundary for benefit was crossed. We found no subgroup differences for type of interleukin-2 receptor antagonist (basiliximab versus daclizumab). Four trials reported on adverse events. However, no differences between trial groups were noted. Limited data were available for meta-analysis on drug-specific adverse events such as haematological adverse events for antithymocyte globulin. No data were available on quality of life. AUTHORS' CONCLUSIONS Because of the low quality of the evidence, the effects of T-cell antibody induction remain uncertain. T-cell specific antibody induction seems to reduce diabetes mellitus and may reduce cytomegalovirus infection when compared with corticosteroid induction. No other clear benefits or harms were associated with the use of T-cell specific antibody induction compared with corticosteroid induction. For some analyses, the number of trials investigating the use of T-cell specific antibody induction after liver transplantation is small, and the numbers of participants and outcomes in these randomised trials are limited. Furthermore, the included trials are heterogeneous in nature and have applied different types of T-cell specific antibody induction therapy. All trials were at high risk of bias. Hence, additional randomised clinical trials are needed to assess the benefits and harms of T-cell specific antibody induction compared with corticosteroid induction for liver transplant recipients. Such trials ought to be conducted with low risks of systematic error and of random error.
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Affiliation(s)
- Luit Penninga
- Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812Blegdamsvej 9CopenhagenDenmarkDK‐2100
- Rigshospitalet, Copenhagen University HospitalDepartment of Surgery and Transplantation C2122Blegdamsvej 9CopenhagenDenmarkDK‐2100 Ø
| | - André Wettergren
- Surgical Clinic HvidovreHvidovrevej 342, 1. floorHvidovreDenmark2650
| | - Colin H Wilson
- The Freeman HospitalInstitute of TransplantationFreeman RoadHigh HeatonNewcastle upon TyneTyne and WearUKNE7 7DN
| | - An‐Wen Chan
- University of TorontoWomen's College Research Institute790 Bay St, Rm 735TorontoONCanada
| | - Daniel A Steinbrüchel
- Rigshospitalet, Copenhagen University HospitalDepartment of Cardiothoracic SurgeryBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
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