[Modern immunosuppression after solid organ transplantation]

SARS-CoV-2 infection in liver transplant recipients: A complex relationship

The recent manuscript reviewed investigations involving liver damage in coronavirus disease 2019 (COVID-19) patients, and COVID-19 in patients with previous chronic hepatological diseases, such as patients with liver graft. The literature presents several conflicting results concerning the anti-SARS-CoV-2 response in patients with solid organ transplants, in liver transplant recipients. Therefore, we would like to humbly state a few points for consideration involving liver transplant recipients and COVID-19, such as the time since transplantation, comorbidities, and immunosuppressive regimens.

COVID-19 Severity and Mortality in Solid Organ Transplantation: Differences between Liver, Heart, and Kidney Recipients

The infection by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) can generate a wide spectrum of clinical manifestations ranging from asymptomatic to severe respiratory and systemic disease with coagulation disorder named coronavirus disease 2019 (COVID-19). Patients with comorbidities have been identified as risk groups for severe COVID-19, also having a higher death risk. Previous reports have conflicting results regarding if solid organ transplant recipients present an increased risk for COVID-19. Nevertheless, previous investigations failed to distinguish between different organs received or made a longitudinal investigation on those patients. We recruited 39 solid organ transplant recipients: 25 kidney transplant recipients, 7 heart transplant recipients, and 7 liver transplant recipients and 25 age-matched non-transplant COVID-19 patients without comorbidities (control group) and compared daily laboratory data in addition to performing survival analysis. Heart and kidney transplant recipients presented an increase in several COVID-19 severity-associated biomarkers, such as neutrophil-to-lymphocyte ratio and thrombocytopenia, in comparison to the control group and liver transplant recipients. Heart and kidney transplant recipients also presented an increase in the need for intensive care and invasive mechanical ventilation during the disease’s course. Importantly, heart and kidney transplant recipients presented a higher mortality rate in comparison to liver transplant recipients and non-transplant recipients. In our cohort, heart and kidney transplant recipients presented a difference in clinical characteristics and survival rate in comparison to liver transplant recipients. Further investigation involving immune response to SARS-CoV-2 in solid organ recipients should consider and separate patients according to the organ grafted.

Utilization of Mycophenolic Acid, Azathioprine, Tacrolimus, Cyclosporin, Sirolimus, and Everolimus: Multinational Study

Background: Organ transplantations are difficult, complicated and very expensive interventions. In order to preserve the transplanted organs, it is necessary to provide medical care to the patients in terms of immunosuppression. According to the guidelines, the first-line therapy choices for achieving immunosuppression after transplantation are tacrolimus, cyclosporine, mycophenolic acid, azathioprine, sirolimus, everolimus„ and corticosteroids. The aim of our study was to examine the utilization of this drugs in Montenegro and to compare the results with the ones from Finland, Croatia, and Serbia.

Methods: In our investigation we used Anatomical Therapeutic Chemical/Defined Daily Dose (ATC/DDD) methodology. Prices per DDD of drugs are presented in euros (€).

Results: In all observed countries, there is a positive trend in the consumption of all 6 drugs during the analyzed period. The prices per DDD of these drugs generally show a negative trend. Tacrolimus and mycophenolic acid in Montenegro recorded the largest reduction in the price per DDD. Price per one DDD of tacrolimus decreased from €13.28 in 2009 to €5.11 in 2019, thus by about 260%, and as regards mycophenolic acid, the price per one DDD decreased from €9.59 in 2009 to € 3.36 in 2019, thus by almost 300%.

Conclusion: Despite the reduction in the price per DDD, drugs that are used as immunosuppressants are showing increasing costs from year to year. Since these drugs are expensive, they participate in a significant percentage in the budget for medicines in each country.

Posteriores reversibles enzephalopathisches Syndrom und Hyperammonämie: zwei Entitäten für Hirnödem und Status epilepticus bei einer Patientin nach Lungentransplantation

Fünf Wochen nach primär erfolgreicher Lungentransplantation entwickelt eine 58-jährige Patientin rasch progrediente neurologische Symptome mit Vigilanzverlust. Als Ursachen können einerseits ein posteriores reversibles enzephalopathisches Syndrom (PRES) unter Therapie mit Tacrolimus, andererseits eine schwere Hyperammonämie durch Sepsis mit Ureaplasma urealyticum identifiziert werden. Infektionen mit Ureaplasmen, die Ammoniak als Stoffwechselprodukt produzieren, werden durch spezifische „polymerase chain reaction“(PCR, Polymerase Kettenreaktion)-Verfahren zunehmend bei Immunsupprimierten identifiziert und sollten grundsätzlich als Ursache für unklare neurologische Symptome in Betracht gezogen werden.

[Skin cancer screening and treatment costs : Utilisation of the skin cancer screening and skin cancer treatment costs in organ transplant recipients]

BACKGROUND

Organ transplant recipients have an up to 250-times higher risk to develop skin cancer. This article evaluated the utilisation of skin cancer screening and the treatment costs for skin cancer in organ transplant recipients. Patients of the health insurance AOK Bremen/Bremerhaven had been identified and the need for skin cancer prevention trainings was derived.

METHODS

The number of organ transplant recipients (ICD code Z94.0-4) with and without any history of skin cancer (ICD code C43/C44), the utilisation of dermatologic health care services, and the costs for treatments with the diagnosis Z94.0-4 with and without C43/C44 were evaluated. The analyses were carried out for the period from 2009-2014 by using the accounting systems of the AOK.

RESULTS

Between 2009 and 2014, 231 organ transplant recipients had been recorded. By mid-2014, 20% of these insured persons developed skin cancer and the mean incidence was 2.76% per year. On average, 43% of these patients were seen by a dermatologist at least once a year, whereby only 15% of the organ transplant recipients participated in the annual skin cancer screening. In 29% of the patients without any history of skin cancer, a skin examination was never performed by a dermatologist or a general practitioner. In all, 17 inpatient cases of organ transplant recipients with the primary diagnosis C43/C44 were analyzed. This resulted in total costs of 54,707 € (on average about 3200 € per case).

CONCLUSIONS

The increased incidence of skin cancer and the associated treatment costs indicate the need for skin cancer prevention training.

Drug repurposing: Ibrutinib exhibits immunosuppressive potential in organ transplantation

Long-term administration of classic immunosuppressants can induce severe adverse effects. The development of novel immunosuppressants confronts great challenges and opportunities. Ibrutinib, an approved drug for B-cell lineages and chronic graft versus host disease (cGVHD), exhibits immunosuppressive efficacy in autoimmune diseases. Ibrutinib's potential as an immunosuppressant in organ transplantation has not been investigated to date. In a xeno-artery patch model ex vivo, ibrutinib inhibited the proliferation of PBMCs (POD 14-42), mainly CD3⁺CD4⁺ and CD3⁺CD8⁺ T cells ex vivo. The secretion of cytokines (IL-6, IL-2 and IFN-γ) was suppressed in response to ibrutinib. In allo-skin transplantation models, ibrutinib delayed the rejection of grafted skins. Ibrutinib decreased the amount of T/B cells and lymphocyte infiltration. Altogether, ibrutinib exhibited immunosuppressive potential through cytokine regulation and T cell inhibition ex vivo and in vitro. Repositioning of ibrutinib as an immunosuppressant will greatly facilitate novel immunosuppressant development.