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Antala S, DiNorcia J, Bucuvalas J. Balancing immunosuppression in pediatric liver transplantation: Playing the long game. Pediatr Transplant 2023; 27:e14575. [PMID: 37439035 DOI: 10.1111/petr.14575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/03/2023] [Indexed: 07/14/2023]
Abstract
The overarching goal in the care of pediatric liver transplant recipients is to optimize allograft and patient health. Balancing immunosuppression to maintain allograft health while avoiding medication side effects is essential for long-term survival and optimal quality of life in pediatric liver transplant recipients. Utilizing precision medicine to personalize immunosuppression, which includes minimization and withdrawal, is core to this effort. The unique anatomy and physiology of the liver make it more tolerant to immune-mediated injury and a more favorable organ for immunosuppression minimization and withdrawal. However, several challenges exist. Standard biochemical values and histologic features may not reliably predict allograft health after a reduction in immunosuppression. Additionally, biochemical values alone do not reliably identify which patients can successfully develop operational tolerance, as there may be occult allograft injury despite normal liver enzymes. Finally, the durability of tolerance after successful reduction in immunosuppression remains uncertain over time. Innovative tools show promise in circumventing these challenges, but more research is needed to determine actual clinical utility. While immunosuppression-free transplant may not be a current reality for most pediatric liver transplant recipients, strategies to safely minimize immunosuppression without compromising allograft health are within reach. Each liver allograft and recipient pair requires a different degree of immune modulation, and through a structured process of minimization and withdrawal, immunosuppression can indeed be tailored in a precise, personalized way to optimize outcomes. This review focuses on the progress that has been made to individualize immunosuppression in pediatric liver transplantation to ensure optimal allograft and recipient health.
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Affiliation(s)
- Swati Antala
- Department of Pediatrics, Icahn School of Medicine, Kravis Children's Hospital at Mount Sinai, New York City, New York, USA
| | - Joseph DiNorcia
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York City, New York, USA
| | - John Bucuvalas
- Department of Pediatrics, Icahn School of Medicine, Kravis Children's Hospital at Mount Sinai, New York City, New York, USA
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2
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Zeiser R, Ringden O, Sadeghi B, Gonen-Yaacovi G, Segurado OG. Novel therapies for graft versus host disease with a focus on cell therapies. Front Immunol 2023; 14:1241068. [PMID: 37868964 PMCID: PMC10585098 DOI: 10.3389/fimmu.2023.1241068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/11/2023] [Indexed: 10/24/2023] Open
Abstract
Graft versus host disease (GVHD) can occur at any period post allogeneic hematopoietic stem cell transplantation as a common clinical complication contributing to significant morbidity and mortality. Acute GVHD develops in approximately 30-50% of patients receiving transplants from matched related donors. High doses of steroids are used as first-line treatment, but are unsuccessful in around 40% of patients, resulting in the diagnosis of steroid-refractory acute GVHD. Consensus has yet to develop for the management of steroid-refractory acute GVHD, and prognosis at six months has been estimated at around 50%. Thus, it is critical to find effective treatments that increase survival of steroid-refractory acute GVHD. This article describes the currently known characteristics, pathophysiology, and treatments for GVHD, with a special focus on recent advances in cell therapies. In particular, a novel cell therapy using decidua stromal cells (DSCs) was recently shown to have promising results for acute GVHD, with improved effectiveness over previous treatments including mesenchymal stromal cells. At the Karolinska Institute, severe acute GVHD patients treated with placenta-derived DSCs supplemented with either 5% albumin or 10% AB plasma displayed a one-year survival rate of 76% and 47% respectively. Furthermore, patients with steroid-refractory acute GVHD, displayed survival rates of 73% with albumin and 31% with AB plasma-supplemented DSCs, compared to the 20% survival rate in the mesenchymal stromal cell control group. Adverse events and deaths were found to be attributed only to complications of hematopoietic stem cell transplant and GVHD, not to the study intervention. ASC Therapeutics, Inc, in collaboration with the Karolinska Institute, will soon initiate a phase 2 multicenter, open-label study to further assess the efficacy and safety of intravenous DSC treatment in sixty patients with Grade II-IV steroid-refractory acute GVHD. This novel cell therapy represents a promising treatment to combat the poor prognosis that steroid-refractory acute GVHD patients currently face.
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Affiliation(s)
- Robert Zeiser
- Department of Medicine at the University of Freiburg, Freiburg, Germany
| | - Olle Ringden
- Department of Clinical Sciences, Karolinska Institute, Stockholm, Sweden
| | - Behnam Sadeghi
- Department of Clinical Sciences, Karolinska Institute, Stockholm, Sweden
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Woolley AE, Gandhi AR, Jones ML, Kim JJ, Mallidi HR, Givertz MM, Baden LR, Mehra MR, Neilan AAM. The Cost-effectiveness of Transplanting Hearts From Hepatitis C-infected Donors Into Uninfected Recipients. Transplantation 2023; 107:961-969. [PMID: 36525554 PMCID: PMC10065819 DOI: 10.1097/tp.0000000000004378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/29/2022] [Accepted: 08/13/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The DONATE HCV trial demonstrated the safety and efficacy of transplanting hearts from hepatitis C viremic (HCV+) donors. In this report, we examine the cost-effectiveness and impact of universal HCV+ heart donor eligibility in the United States on transplant waitlist time and life expectancy. METHODS We developed a microsimulation model to compare 2 waitlist strategies for heart transplant candidates in 2018: (1) status quo (SQ) and (2) SQ plus HCV+ donors (SQ + HCV). From the DONATE HCV trial and published national datasets, we modeled mean age (53 years), male sex (75%), probabilities of waitlist mortality (0.01-0.10/month) and transplant (0.03-0.21/month) stratified by medical urgency, and posttransplant mortality (0.003-0.052/month). We assumed a 23% increase in transplant volume with SQ + HCV compared with SQ. Costs (2018 United States dollar) included waitlist care ($2200-190 000/month), transplant ($213 400), 4-wk HCV treatment ($26 000), and posttransplant care ($2500-11 300/month). We projected waitlist time, quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs [$/QALY, discounted 3%/year]; threshold ≤$100 000/QALY). RESULTS Compared with SQ, SQ + HCV decreased waitlist time from 8.7 to 6.7 months, increased undiscounted life expectancy from 8.9 to 9.2 QALYs, and increased discounted lifetime costs from $671 400/person to $690 000/person. Four-week HCV treatment comprised 0.5% of lifetime costs. The ICER of SQ + HCV compared with SQ was $74 100/QALY and remained ≤$100 000/QALY with up to 30% increases in transplant and posttransplant costs. CONCLUSIONS Transplanting hearts from HCV-infected donors could decrease waitlist times, increase life expectancy, and be cost-effective. These findings were robust within the context of current high HCV treatment costs.
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Affiliation(s)
- Ann E Woolley
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Aditya R Gandhi
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Michelle L Jones
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Jane J Kim
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Hari R Mallidi
- Harvard Medical School, Boston, MA
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Michael M Givertz
- Harvard Medical School, Boston, MA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Lindsey R Baden
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Mandeep R Mehra
- Harvard Medical School, Boston, MA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - And Anne M Neilan
- Harvard Medical School, Boston, MA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital, Boston, MA
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Long-term Prolonged-release Tacrolimus-based Immunosuppression in De Novo Kidney Transplant Recipients: 5-Y Prospective Follow-up of Patients in the ADVANCE Study. Transplant Direct 2023; 9:e1432. [PMID: 36875940 PMCID: PMC9977488 DOI: 10.1097/txd.0000000000001432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 11/15/2022] [Indexed: 02/11/2023] Open
Abstract
Although prolonged-release tacrolimus (PR-T) is widely approved for posttransplantation immunosuppression in kidney recipients, large-scale studies are required to assess long-term outcomes. We present follow-up data from the Advagraf-based Immunosuppression Regimen Examining New Onset Diabetes Mellitus in Kidney Transplant Recipients (ADVANCE) trial, in which kidney transplant patients (KTPs) received corticosteroid minimization with PR-T. Methods ADVANCE was a 24-wk, randomized, open-label, phase-4 study. De novo KTPs received PR-T with basiliximab and mycophenolate mofetil and were randomized to receive an intraoperative corticosteroid bolus plus tapered corticosteroids until day 10 (arm 1) or an intraoperative corticosteroid bolus (arm 2). In this 5-y, noninterventional follow-up, patients received maintenance immunosuppression according to standard practice. The primary endpoint was graft survival (Kaplan-Meier). Secondary endpoints included patient survival, biopsy-confirmed acute rejection-free survival, and estimated glomerular filtration rate (4-variable modification of diet in renal disease). Results Follow-up study included 1125 patients. Overall graft survival at 1 and 5 y posttransplantation was 93.8% and 88.1%, respectively, and was similar between treatment arms. At 1 and 5 y, patient survival was 97.8% and 94.4%, respectively. Five-year graft and patient survival rates in KTPs who remained on PR-T were 91.5% and 98.2%, respectively. Cox proportional hazards analysis demonstrated similar risk of graft loss and death between treatment arms. Five-year biopsy-confirmed acute rejection-free survival was 84.1%. Mean ± standard deviation values of estimated glomerular filtration rate were 52.7 ± 19.5 and 51.1 ± 22.4 mL/min/1.73 m2 at 1 and 5 y, respectively. Fifty adverse drug reactions were recorded, probably tacrolimus-related in 12 patients (1.5%). Conclusions Graft survival and patient survival (overall and for KTPs who remained on PR-T) were numerically high and similar between treatment arms at 5 y posttransplantation.
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Preemptive Second Kidney Transplant Outcomes by Induction Type in the United States. Transplant Proc 2022; 54:2125-2132. [PMID: 36210195 DOI: 10.1016/j.transproceed.2022.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/29/2022] [Indexed: 11/06/2022]
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6
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Gunes H, Bulbuloglu S, Saritaş S. Investigation of adherence to immunosuppressive therapy and spiritual well-being in liver recipients. Transpl Immunol 2022; 72:101585. [DOI: 10.1016/j.trim.2022.101585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 03/19/2022] [Accepted: 03/19/2022] [Indexed: 10/18/2022]
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Kidney Allograft and Recipient Survival After Heart Transplantation by Induction Type in the United States. Transplantation 2022; 106:633-640. [PMID: 33741841 DOI: 10.1097/tp.0000000000003758] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Induction choices for kidney-after-heart transplant recipients are variable. We examined the impact of kidney induction types on kidney graft and patient survival in heart transplant recipients. METHODS We analyzed the Scientific Registry of Transplant Recipient database from inception through the end of 2018 to study kidney and patient outcomes in the United States after heart transplantation. We only included recipients who were discharged on tacrolimus and mycophenolate maintenance. We grouped recipients by induction type into 3 groups: depletional (N = 307), nondepletional (n = 253), and no-induction (steroid only) (n = 57). We studied patients and kidney survival using Cox PH regression, with transplant centers included as a random effect. We adjusted the models for heart induction, recipient and donor age, gender, time between heart and kidney transplant, heart transplant indication, HLA mismatches, payor, live-donor kidney, transplant year, dialysis status, and diabetes mellitus at the time of kidney transplant. RESULTS The 1-y kidney rejection rates and creatinine levels were similar in all groups. The 1-y rehospitalization rate was higher in the depletional group (51.7%) and nondepletional group (50.7%) than in the no-induction group (39.1%) although this was not statistically significant. There were no differences in recipient or kidney survival by kidney induction type. Live-donor kidney was associated with improved patient (hazard ratio, 0.74; 95% confidence interval, 0.54-1.0; P = 0.05) and kidney survival (hazard ratio, 0.45; 95% confidence interval, 0.24-0.84; P = 0.012]. CONCLUSIONS Type of kidney induction did not influence patient or kidney graft survival in heart transplant recipients. No-induction may be the preferred choice due to the lack of clinical benefits associated with induction use.
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Bittner GD, Bushman JS, Ghergherehchi CL, Roballo KCS, Shores JT, Smith TA. Typical and atypical properties of peripheral nerve allografts enable novel strategies to repair segmental-loss injuries. J Neuroinflammation 2022; 19:60. [PMID: 35227261 PMCID: PMC8886977 DOI: 10.1186/s12974-022-02395-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 01/19/2022] [Indexed: 12/20/2022] Open
Abstract
AbstractWe review data showing that peripheral nerve injuries (PNIs) that involve the loss of a nerve segment are the most common type of traumatic injury to nervous systems. Segmental-loss PNIs have a poor prognosis compared to other injuries, especially when one or more mixed motor/sensory nerves are involved and are typically the major source of disability associated with extremities that have sustained other injuries. Relatively little progress has been made, since the treatment of segmental loss PNIs with cable autografts that are currently the gold standard for repair has slow and incomplete (often non-existent) functional recovery. Viable peripheral nerve allografts (PNAs) to repair segmental-loss PNIs have not been experimentally or clinically useful due to their immunological rejection, Wallerian degeneration (WD) of anucleate donor graft and distal host axons, and slow regeneration of host axons, leading to delayed re-innervation and producing atrophy or degeneration of distal target tissues. However, two significant advances have recently been made using viable PNAs to repair segmental-loss PNIs: (1) hydrogel release of Treg cells that reduce the immunological response and (2) PEG-fusion of donor PNAs that reduce the immune response, reduce and/or suppress much WD, immediately restore axonal conduction across the donor graft and re-innervate many target tissues, and restore much voluntary behavioral functions within weeks, sometimes to levels approaching that of uninjured nerves. We review the rather sparse cellular/biochemical data for rejection of conventional PNAs and their acceptance following Treg hydrogel and PEG-fusion of PNAs, as well as cellular and systemic data for their acceptance and remarkable behavioral recovery in the absence of tissue matching or immune suppression. We also review typical and atypical characteristics of PNAs compared with other types of tissue or organ allografts, problems and potential solutions for PNA use and storage, clinical implications and commercial availability of PNAs, and future possibilities for PNAs to repair segmental-loss PNIs.
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Bülbüloğlu S, Demir B. The effect of perceived social support on psychological resilience in liver transplant patients receiving immunosuppression therapy. Transpl Immunol 2021; 69:101475. [PMID: 34600070 DOI: 10.1016/j.trim.2021.101475] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 09/24/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE This study was conducted to investigate the effect of social support on psychological resilience in liver transplant patients receiving immunosuppression therapy. METHOD This study was carried out as a descriptive and cross-sectional study with the participation of 290 liver transplant patients hospitalized in the liver transplant center of a research and application hospital. Personal Information Form, Multidimensional Scale of Perceived Social Support (MSPSS) and Brief Resilience Scale (BRS) were used in data collection. The data analysis was performed with IBM Statistical Package for the Social Sciences Statistics 25. RESULTS According to the data obtained, it was determined that 30.4% of the patients were 58 years old and over, 81% of them were male and 92.8% of them were married. It was found that all of the patients used antimetabolites and corticosteroids, and 82.8% of them used calcineurin inhibitors. It was determined that 32.8% of the patients experienced infection, neuropsychiatric problems and nephrotoxicity at the same time. The psychological resilience of the patients was found to be moderate, and their perceived social support was found to be low. CONCLUSION It is not always possible for liver transplant patients to deal with their situation effectively. The psychological resilience and social support levels of patients who have undergone liver transplantation should be noticed, and social, economic and psychological support should be provided.
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Affiliation(s)
- Semra Bülbüloğlu
- Division of Surgical Nursing, Nursing Department, Erbaa Health Sciences Faculty, Gaziosmanpasa University, Erbaa, Tokat, Turkey.
| | - Bilsev Demir
- Division of Surgical Nursing, Nursing Department, Health Sciences Faculty, Turgut Özal University, Malatya, Turkey
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10
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Demir B, Bulbuloglu S. The effect of immunosuppression therapy on activities of daily living and comfort level after liver transplantation. Transpl Immunol 2021; 69:101468. [PMID: 34536554 DOI: 10.1016/j.trim.2021.101468] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/12/2021] [Accepted: 09/13/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES This study was carried out to investigate the effect of immunosuppression therapy on activities of daily living and comfort level after liver transplantation. MATERIALS AND METHODS This study was conducted in a descriptive and correlational type with the participation of 148 liver transplant patients hospitalized in the liver transplant center of a university hospital. Personal Information Form, Katz Activities of Daily Living Scale and General Comfort Questionnaire were used in data collection. The data analysis was performed with IBM SPSS (Statistical Package for the Social Sciences) Statistics 25. RESULTS According to the results obtained from the study, it was determined that 31.1% of the patients were 58 years old and over, 20.9% of them were between 48- and 57 years old, and 81.8% of them were male. It was found that 61.5% of the patients were between the 11th and 21st days after transplantation and 26.4% of them were given oxygen with a non-invasive catheter. It was determined that the patients were semi-independent in activities of daily living and had a moderate comfort level. CONCLUSIONS It is not always possible for liver transplant patients to effectively deal with their condition. The low comfort level and quality of life of patients who have undergone liver transplantation should be noticed, and social, economic and psychological support should be provided.
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Affiliation(s)
- Bilsev Demir
- Division of Surgical Nursing, Nursing Department, Health Sciences Faculty, Turgut Ozal University, Malatya, Turkey.
| | - Semra Bulbuloglu
- Division of Surgical Nursing, Nursing Department, Erbaa Health Sciences Faculty, Gaziosmanpasa University, Tokat, Turkey.
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Chandran MM, Blanchette E, Goebel J, Bock M. Impact of once-daily ER-Tac on trough concentration variability in a stable AYA renal transplant recipient cohort. Pediatr Transplant 2021; 25:e14036. [PMID: 34003550 DOI: 10.1111/petr.14036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND Successful renal transplantation requires complex medication regimens that rely on strict adherence to be effective. Variability in immunosuppression exposure, specifically tacrolimus, is associated with poor allograft outcomes. Wide intra-patient variability of tacrolimus trough concentrations (Vtac) is likely, in part, attributable to regimen complexity and poor medication adherence. Once-daily tacrolimus formulations create opportunity to simplify therapeutic regimens, and this study aims to evaluate their impact on Vtac and ultimately transplant outcomes. METHODS This retrospective cohort study investigated stable (AYA) renal transplant recipients converted from (IR-Tac) to (ER-Tac). Subjects served as their own controls. Vtac was assessed by measuring the (SD) of serial tacrolimus trough concentrations prior to and at four time points post-conversion to ER-Tac over 24-month follow-up. Secondary outcome measures included graft function, infection rates, and effect on modifiable treatment-related factors. RESULTS Twenty-eight AYA subjects were converted from IR-Tac to ER-Tac. Vtac significantly improved following conversion and was sustained for 24 months (Vtac0 2.32 vs. Vtac24 1.11, p .017). Renal function remained stable, and (BPAR) rates were modest (14%). Mean pill burden was reduced by 15%, and 42.9% of subjects achieved a once-daily medication regimen. CONCLUSIONS Conversion from IR-Tac to ER-Tac in this AYA population significantly improved Vtac with sustained effect over 2 years. This effect is likely attributable in part to simplification of the medication regimen and presumably improved medication adherence. Such conversion does not appear to compromise graft function for at least 2 years post-conversion.
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Affiliation(s)
| | - Eliza Blanchette
- Department of Pediatric Nephrology, Children's Hospital Colorado, Aurora, CO, USA
| | - Jens Goebel
- Department of Pediatric Nephrology, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - Margret Bock
- Department of Pediatric Nephrology, Children's Hospital Colorado, Aurora, CO, USA
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12
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Jorgenson MR, Descourouez JL, Brady BL, Chandran MM, Do V, Kim M, Laub MR, Lichvar A, Park JM, Szczepanik A, Alloway RR. A call for transplant stewardship: The need for expanded evidence-based evaluation of induction and biologic-based cost-saving strategies in kidney transplantation and beyond. Clin Transplant 2021; 35:e14372. [PMID: 34033140 DOI: 10.1111/ctr.14372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/15/2021] [Accepted: 05/19/2021] [Indexed: 12/14/2022]
Abstract
Rising expenditures threaten healthcare sustainability. While transplant programs are typically considered profitable, transplant medications are expensive and frequently targeted for cost savings. This review aims to summarize available literature supporting cost-containment strategies used in solid organ transplant. Despite widespread use of these tactics, we found the available evidence to be fairly low quality. Strategies mainly focus on induction, particularly rabbit antithymocyte globulin (rATG), given its significant cost and the lack of consensus surrounding dosing. While there is higher-quality evidence for high single-dose rATG, and dose-rounding protocols to reduce waste are likely low risk, more aggressive strategies, such as dosing rATG by CD3+ target-attainment or on ideal-body-weight, have less robust support and did not always attain similar efficacy outcomes. Extrapolation of induction dosing strategies to rejection treatment is not supported by any currently available literature. Cost-saving strategies for supportive therapies, such as IVIG and rituximab also have minimal literature support. Deferral of high-cost agents to the outpatient arena is associated with minimal risk and increases reimbursement, although may increase complexity and cost-burden for patients and infusion centers. The available evidence highlights the need for evaluation of unique patient-specific clinical scenarios and optimization of therapies, rather than simple blanket application of cost-saving initiatives in the transplant population.
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Affiliation(s)
- Margaret R Jorgenson
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Jillian L Descourouez
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Bethany L Brady
- Department of Pharmacy, Indiana University Health University Hospital, Indianapolis, IN, USA
| | - Mary M Chandran
- Department of Pharmacy, Children's Hospital of Colorado, Aurora, CO, USA
| | - Vincent Do
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Miae Kim
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Melissa R Laub
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | - Alicia Lichvar
- Department of Pharmacy Practice and Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Jeong M Park
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Amanda Szczepanik
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
| | - Rita R Alloway
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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13
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Sahman M, Mugosa S, Rancic N. Utilization of Mycophenolic Acid, Azathioprine, Tacrolimus, Cyclosporin, Sirolimus, and Everolimus: Multinational Study. Front Public Health 2021; 9:671316. [PMID: 33869136 PMCID: PMC8044364 DOI: 10.3389/fpubh.2021.671316] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/08/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Majda Sahman
- Department for Pharmacology, Faculty of Medicine, University of Montenegro, Podgorica, Montenegro.,Institute for Medicines and Medical Devices of Montenegro, Podgorica, Montenegro
| | - Snezana Mugosa
- Department for Pharmacology, Faculty of Medicine, University of Montenegro, Podgorica, Montenegro.,Institute for Medicines and Medical Devices of Montenegro, Podgorica, Montenegro
| | - Nemanja Rancic
- Center for Clinical Pharmacology, Military Medical Academy, Belgrade, Serbia.,Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia
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Nobakht E, Jagadeesan M, Paul R, Bromberg J, Dadgar S. Precision Medicine in Kidney Transplantation: Just Hype or a Realistic Hope? Transplant Direct 2021; 7:e650. [PMID: 33437865 PMCID: PMC7793397 DOI: 10.1097/txd.0000000000001102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 12/17/2022] Open
Abstract
Desirable outcomes including rejection- and infection-free kidney transplantation are not guaranteed despite current strategies for immunosuppression and using prophylactic antimicrobial medications. Graft survival depends on factors beyond human leukocyte antigen matching such as the level of immunosuppression, infections, and management of other comorbidities. Risk stratification of transplant patients based on predisposing genetic modifiers and applying precision pharmacotherapy may help improving the transplant outcomes. Unlike certain fields such as oncology in which consistent attempts are being carried out to move away from the "error and trial approach," transplant medicine is lagging behind in implementing personalized immunosuppressive therapy. The need for maintaining a precarious balance between underimmunosuppression and overimmunosuppression coupled with adverse effects of medications calls for a gene-based guidance for precision pharmacotherapy in transplantation. Technologic advances in molecular genetics have led to increased accessibility of genetic tests at a reduced cost and have set the stage for widespread use of gene-based therapies in clinical care. Evidence-based guidelines available for precision pharmacotherapy have been proposed, including guidelines from Clinical Pharmacogenetics Implementation Consortium, the Pharmacogenomics Knowledge Base National Institute of General Medical Sciences of the National Institutes of Health, and the US Food and Drug Administration. In this review, we discuss the implications of pharmacogenetics and potential role for genetic variants-based risk stratification in kidney transplantation. A single score that provides overall genetic risk, a polygenic risk score, can be achieved by combining of allograft rejection/loss-associated variants carried by an individual and integrated into practice after clinical validation.
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Affiliation(s)
- Ehsan Nobakht
- Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University School of Medicine, Washington, DC
| | - Muralidharan Jagadeesan
- Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University School of Medicine, Washington, DC
| | - Rohan Paul
- Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University School of Medicine, Washington, DC
| | - Jonathan Bromberg
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Sherry Dadgar
- Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University School of Medicine, Washington, DC
- Personalized Medicine Care Diagnostics Laboratory (PMCDx), Inc., Germantown, MD
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15
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Jeong R, Quinn RR, Lentine KL, Ravani P, Ye F, Campbell P, Wen K, Broscheit C, Gourishankar S, Lam NN. Incidence, Risk Factors, and Outcomes of Kidney Transplant Recipients Treated With Both Basiliximab and Antithymocyte Globulin. Can J Kidney Health Dis 2020; 7:2054358120964061. [PMID: 33117549 PMCID: PMC7573718 DOI: 10.1177/2054358120964061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/23/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Kidney transplant recipients are given induction therapy to rapidly reduce the immune response and prevent rejection. Guidelines recommend that an interleukin-2 receptor antibody (basiliximab) be the first-line agent and that a lymphocyte-depleting agent (antithymocyte globulin [ATG]) be reserved for those at high immunologic risk. Objective: To determine the incidence, risk factors, and outcomes for patients who receive both basiliximab and ATG for induction compared to either agent alone. Design: Retrospective cohort study. Setting: We used the transplant electronic medical record at the University of Alberta Hospital in Edmonton, Canada. Patients/samples/participants: We included incident adult kidney transplant recipients from 2013 to 2018. Measurements: We measured baseline characteristics, type, and dose of induction therapy used, estimated glomerular filtration rate (eGFR) at 1-year posttransplant, and outcomes of all-cause graft failure, death-censored graft failure, all-cause mortality, and death with a functioning graft. Methods: Differences between induction groups were compared using chi-square test for categorical variables and Kruskal-Wallis tests for continuous variables. We performed multivariable logistic regression modeling with type of induction therapy as the dependent variable and the case-level factors as the predictors (adjusted odds ratio). We estimated the Kaplan-Meier failure functions and used log-rank tests to assess statistical significance of differences in unadjusted incidence across induction therapy types. We compared cumulative incidence functions using a Fine and Gray competing risk regression model. Results: In all, 430 kidney transplant recipients were followed for a mean of 3.9 years (standard deviation 1.5). Of these, 71% (n = 305) received basiliximab alone, 22% (n = 93) received ATG alone, and 7% (n = 32) received both basiliximab and ATG. After adjusting for age and sex, compared to the basiliximab alone group, patients were more likely to receive dual-induction therapy if they were sensitized (calculated panel reactive antibody ≥80%), had diabetes mellitus or peripheral vascular disease, or experienced delayed graft function. Compared to the ATG alone group, the dual-induction therapy group had worse graft function at 1 year (mean eGFR 42 vs. 59 mL/min/1.73 m2, P = .0008) and an increased risk of all-cause graft failure (31% vs. 13%, P = .02) and death-censored graft failure (16% vs. 4%, P = .03). Limitations: There is a risk of confounding by indication, as patients who received dual-induction therapy likely had worse outcomes due to the indication for dual-induction therapy (such as delayed graft function). Conclusions: In our study, 1 out of 10 recipients who were treated with basiliximab also received ATG for induction therapy. These patients experienced worse outcomes than those treated with ATG alone. Trial registration: Not applicable (cohort study).
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Affiliation(s)
- Rachel Jeong
- Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada
| | - Robert R Quinn
- Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University, MO, USA
| | - Pietro Ravani
- Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Feng Ye
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Patricia Campbell
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Kevin Wen
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Chris Broscheit
- Department of Pharmacy, University of Alberta Hospital, Edmonton, Canada
| | - Sita Gourishankar
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Ngan N Lam
- Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, AB, Canada
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16
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Lodha AR, Pillai A, Sheth K, Hiremath J. A retrospective cohort study exploring diltiazem as a pharmaco-enhancer for tacrolimus, in a post-heart transplant setting. Clin Transplant 2020; 34:e14100. [PMID: 32981136 DOI: 10.1111/ctr.14100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 08/16/2020] [Accepted: 09/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND A significant proportion of heart transplant-associated expenditure are attributable to immunosuppressants. Post-transplant hypertension adds to the pill burden and subsequent costs. In this study, we describe the effect of diltiazem-the antihypertensive and pharmaco-enhancer-on reducing the required oral dose of tacrolimus. METHODS We included 17 recipients who had successfully undergone heart transplants but later developed post-transplant hypertension and were treated with diltiazem. Serum trough levels of the immunosuppressant tacrolimus were measured every 2 weeks. Required doses before and after the introduction of diltiazem were compared. Patients were assessed at each follow-up visit for any evidence of toxicity. Medication-related expenditure was estimated based on government-mandated standardized retail price. RESULTS The power of the study was 98.92% at α = 0.05. The mean tacrolimus dose required prior to initiation of diltiazem was 5.85 ± 1.55 mg. After initiating diltiazem, the mean required doses reduced to 2.88 ± 1.24 mg (p < .0001). Relatively, the required doses reduced by 52.4 ± 10.9%-independently of age, sex, and dose of diltiazem. Medication-related monthly expenditure reduced by 50.3 ± 10.4%. No patient demonstrated evidence of toxicity. CONCLUSIONS Concomitant use of diltiazem and tacrolimus can safely, effectively, and predictably reduce the required dose of tacrolimus and significantly reduce corresponding costs.
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Affiliation(s)
| | - Ashwin Pillai
- Department of Medicine, Ruby Hall Clinic, Pune, India
| | - Kaushik Sheth
- Department of Cardiology, Ruby Hall Clinic, Pune, India
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17
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Mycophenolate Monotherapy in HLA-Matched Kidney Transplant Recipients: A Case Series of 20 Patients. Transplant Direct 2020; 6:e526. [PMID: 32095512 PMCID: PMC7004628 DOI: 10.1097/txd.0000000000000961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/04/2019] [Accepted: 10/26/2019] [Indexed: 11/26/2022] Open
Abstract
The ideal minimizing strategy for maintenance immunosuppression in HLA-matched kidney transplant recipients (KTR) is unknown. We hypothesized that mycophenolate (MPA) monotherapy is a safe and effective approach for maintenance therapy in this group of KTR. Methods Data were abstracted for 6-antigen HLA-matched KTR between 1994 and 2013. Twenty recipients receiving MPA monotherapy secondary to infection, cancer, calcineurin inhibitor (CNI) side effects, or immunosuppression minimization strategies were evaluated in this case series. Results MPA monotherapy had a low incidence of death-censored graft failure (3.19/100 person-y), rejection (0/100 person-y), hospitalization (1.62/100 person-y), malignancy (3.61/100 person-y), and infection (1.75/100 person-y). Further, 12-month mean or median serum creatinine (1.29 mg/dL), estimated glomerular filtration rate (64.3 mL/min/1.73 m2), urine protein creatinine ratio (143.2 mg/g), hemoglobin (13.9 g/dL), platelets (237.8 K/uL), and white blood cell count (9.04 K/uL) were favorable. There was a successful conversion rate of 90% (18 of 20) with 2 patients converting back to CNI-based regimens secondary to recurrence of membranous nephropathy and post-transplant lymphoproliferative disorder. Conclusions Our findings indicate that MPA monotherapy may be a promising immunosuppression minimization strategy for HLA-matched KTR.
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18
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Kuppachi S, Axelrod DA. Desensitization strategies: is it worth it? Transpl Int 2020; 33:251-259. [PMID: 31553805 DOI: 10.1111/tri.13532] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/04/2019] [Accepted: 09/19/2019] [Indexed: 01/10/2023]
Abstract
Preformed donor-specific antibodies (DSAs) limit access to transplantation for thousands of renal transplant patients. While kidney paired donation offers the best strategy for patients with a living donor, for very highly sensitized patients and those without living donors, a strategy of desensitization offers the best hope of transplantation. Removal of DSAs with plasmapheresis, intravenous immunoglobulin and anti-CD20 antibodies can permit successful transplantation. While the clinical outcomes remain inferior to compatible transplant and the costs are significantly greater, when compared with long-term dialysis treatment, these strategies are offer improved survival and are cost-effective given nationally accepted benchmarks.
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Affiliation(s)
- Sarat Kuppachi
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - David A Axelrod
- Department of Surgery, University of Iowa, Iowa City, IA, USA
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19
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Riad S, Goswami U, Jackson S, Hertz M, Matas A. Induction type and outcomes for kidney graft and patient survival in recipients with prior lung transplantation in the United States. J Heart Lung Transplant 2019; 39:157-164. [PMID: 31837899 DOI: 10.1016/j.healun.2019.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Induction immunosuppression regimens for kidney transplants in lung transplant recipients vary widely. We studied the impact of induction types for kidney after lung transplant recipients. METHODS Using the Scientific Registry of Transplant Recipients database between 1994 and 2015, we studied outcomes of patients and kidney grafts for 330 kidney after lung transplant recipients for whom induction before kidney transplant included depletional (n = 115), non-depletional (n = 170), or no induction (steroids only; n = 45). We studied risk factors for recipient and graft survival using Cox proportional hazards model adjusted for kidney and lung induction, kidney donor type, dialysis status, recipient and donor ages, time from lung to kidney transplant, cause of lung disease, bilateral vs single lung transplant, diabetes, and human leukocyte antigen mismatches before kidney transplant, with transplant center as a random effect. RESULTS There was no difference between groups in patient survival or death-censored kidney allograft survival. The 1-year kidney acute rejection rates were 15.5%, 7.14%, and 0% in depletional, non-depletional, and no induction groups, respectively. In the Cox model for patient survival, living kidney donor recipients and bilateral lung transplant recipients were favorable predictors. For death-censored graft survival, kidney induction type did not predict graft survival. Results did not change when models only included recipients on tacrolimus and mycophenolate based maintenance. CONCLUSIONS The type of kidney induction did not influence patient or kidney graft survival following kidney transplants for those with previous lung transplants. No induction may be the preferred choice for kidney after lung transplant because of the lack of benefits from biologic induction in this large cohort.
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Affiliation(s)
- Samy Riad
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
| | - Umesh Goswami
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | | | - Marshall Hertz
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Arthur Matas
- Division of Transplant Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
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20
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Low JK, Manias E, Crawford K, Williams A. Evaluating the totality of an intervention using qualitative and quantitative methods: The case of the IMAKT study. Res Social Adm Pharm 2019; 16:851-853. [PMID: 31704193 DOI: 10.1016/j.sapharm.2019.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 10/21/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Jac Kee Low
- Monash Nursing & Midwifery, Monash University, Clayton, Victoria, Australia; School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Deakin University, Geelong, Victoria, Australia.
| | - Elizabeth Manias
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Deakin University, Geelong, Victoria, Australia; The Royal Melbourne Hospital, Parkville, Victoria, Australia; Melbourne School of Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
| | - Kimberley Crawford
- Monash Nursing & Midwifery, Monash University, Clayton, Victoria, Australia
| | - Allison Williams
- Monash Nursing & Midwifery, Monash University, Clayton, Victoria, Australia
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21
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Rummo O, Carmellini M, Kamar N, Durrbach A, Mousson C, Caputo F, Mathe Z, Christiaans MHL, Kuypers DRJ, Klempnauer J, Anaokar S, Hurst M, Kazeem G, Undre N, Lehner F. Long-term, prolonged-release tacrolimus-based immunosuppression in de novo kidney transplant recipients: 5-year prospective follow-up of the ADHERE study patients. Transpl Int 2019; 33:161-173. [PMID: 31536654 DOI: 10.1111/tri.13527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/10/2019] [Accepted: 09/17/2019] [Indexed: 12/29/2022]
Abstract
The objectives of this study were to assess long-term graft survival, patient survival, renal function, and acute rejections in de novo kidney transplant recipients, treated with once-daily prolonged-release tacrolimus-based therapy. The study was a 5-year non-interventional prospective follow-up of patients from the ADHERE study, a Phase IV 12-month open-label assessment of patients randomized to receive prolonged-release tacrolimus in combination with mycophenolate mofetil (MMF) (Arm 1) or sirolimus (Arm 2). From 838 patients in the randomized study, 587 were included in the long-term follow-up, of whom 510 completed the study at year 5. At 1 year post-transplant, graft and patient survival rates were 93.0% and 97.8%, respectively, and at 5 years were 84.0% and 90.8%, respectively. Cox proportional hazards analysis showed no association between graft loss, initial randomized treatment arm, donor age, donor type, or sex. The 5-year acute rejection-free survival rate was 77.4%, and biopsy-confirmed acute rejection-free survival rate was 86.0%. Renal function remained stable over the follow-up period: mean ± SD eGFR 4-variable modification diet in renal disease formula (MDRD4) was 52.3 ± 21.6 ml/min/1.73 m2 at 6 months and 52.5 ± 23.0 ml/min/1.73 m2 at 5 years post-transplant. These findings support the role of long-term once-daily prolonged-release tacrolimus-based immunosuppression, in combination with sirolimus or MMF, for renal transplant recipients in routine clinical practice.
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Affiliation(s)
- Oleg Rummo
- Republican Scientific and Practical Center (RSPC) for Organ and Tissue Transplantation, Minsk, Belarus
| | - Mario Carmellini
- Department of Medical, Surgical and Neuroscience, Policlinico Santa Maria alle Scotte, University of Siena, Siena, Italy
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Université Paul Sabatier Toulouse, Toulouse Cedex 9, France
| | - Antoine Durrbach
- Nephrology Service, Centre Hospitalier de Bicetre, Le Kremlin Bicetre, France.,UMRS1197, INSERM, Villejuif, France.,University Paris Sud, Orsay, France
| | - Christiane Mousson
- Department of Nephrology-Transplantation, University Hospital Dijon, Dijon, France
| | - Flavia Caputo
- UOC Nephrology 2, Dialysis and Transplantation, ARNAS Civico Palermo, Palermo, Italy
| | - Zoltan Mathe
- Transplantation and Surgery Clinic, Semmelweis University, Budapest, Hungary
| | - Maarten H L Christiaans
- Department of Internal Medicine/Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dirk R J Kuypers
- Department of Nephrology, and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Jürgen Klempnauer
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | | | | | - Gbenga Kazeem
- Astellas Pharma Europe Ltd, Chertsey, UK.,BENKAZ Consulting Ltd, Cambridge, UK
| | | | - Frank Lehner
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
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22
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Lin YC, Tsai CS, Li IH, Tsai YT, Huang TY, Lee KF, Lin CS, Shih JH, Kao LT. Transplant Recipients Using Tacrolimus Had Higher Utilization of Healthcare Services Than Those Receiving Cyclosporine in Taiwan. Front Pharmacol 2019; 10:1074. [PMID: 31607922 PMCID: PMC6761300 DOI: 10.3389/fphar.2019.01074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 08/23/2019] [Indexed: 12/27/2022] Open
Abstract
To date, population-based studies on the healthcare service utilization among stable heart, kidney, and liver transplant recipients with different calcineurin inhibitors are still scarce. Therefore, we used the Taiwan National Health Insurance Research Database to conduct a nationwide cross-sectional study to estimate the healthcare utilization of stable transplant recipients with tacrolimus or cyclosporine (n = 3,482). The sampled patients in this study comprised 377 heart, 1,693 kidney, and 1,412 liver transplant recipients between 1 January 2011 and 31 December 2011. Each subject was followed for a 1-year period to evaluate his/her healthcare service utilization. Outcome variables of the healthcare service utilization were stated as below: numbers of outpatient visits, outpatient costs, numbers of inpatient days, inpatients costs, and total costs of all healthcare services. As for all healthcare service utilization, stable transplant recipients on tacrolimus had significantly more outpatient visits (40.7 vs. 38.6), outpatient costs (US$10,383 vs. US$8,155), and total costs (US$12,516 vs. US$10,372) of all healthcare services than those on cyclosporine during the 1-year follow-up period. Additionally, further analysis showed that heart transplant recipients receiving tacrolimus incurred 1.7-fold higher inpatient costs compared to patients receiving cyclosporine. We concluded that transplant recipients using tacrolimus had significantly higher utilization of all healthcare services than those receiving cyclosporine as immunosuppressive therapy.
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Affiliation(s)
- Yi-Chang Lin
- Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan.,Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chien-Sung Tsai
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - I-Hsun Li
- Department of Pharmacy Practice, Tri-Service General Hospital, Taipei, Taiwan.,School of Pharmacy, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Ting Tsai
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tien-Yu Huang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Kwai-Fong Lee
- Biobank Management Center, Tri-Service General Hospital, Taipei, Taiwan.,School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Sheng Lin
- Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan
| | - Jui-Hu Shih
- Department of Pharmacy Practice, Tri-Service General Hospital, Taipei, Taiwan.,School of Pharmacy, National Defense Medical Center, Taipei, Taiwan
| | - Li-Ting Kao
- Department of Pharmacy Practice, Tri-Service General Hospital, Taipei, Taiwan.,School of Pharmacy, National Defense Medical Center, Taipei, Taiwan.,School of Public Health, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
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23
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Moal V, Grimbert P, Beauvais A, Dubel L, Le Meur Y. A Prospective, Observational Study of Conversion From Immediate- to Prolonged-Release Tacrolimus in Renal Transplant Recipients in France: The OPALE Study. Ann Transplant 2019; 24:517-526. [PMID: 31477681 PMCID: PMC6752107 DOI: 10.12659/aot.916043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Potential benefits of once-daily, prolonged-release tacrolimus over the immediate-release formulation include improved adherence to immunosuppressives post transplantation. An observational study was performed to characterize real-world practice surrounding conversion from immediate- to prolonged-release tacrolimus in kidney transplant recipients. Material/Methods We performed a prospective, observational study of renal transplant recipients converted from immediate- to prolonged-release tacrolimus capsules. Conversion took place at the baseline visit, within the first 6 months of transplantation (early conversion group) or between 6 and 12 months of transplantation (late conversion group). Data collection was performed at routine follow-up at 6 and 12 months. Endpoints included conversion ratio from immediate- to prolonged-release tacrolimus, reasons for conversion, additional visits due to conversion, safety, and tolerability. Results The analysis population comprised 591 patients. Baseline characteristics were similar between the 2 groups. The mean conversion ratio of the daily dose of tacrolimus was 0.98±0.17 in the early group and 0.99±0.09 in the late group. Time from conversion (mean ±SD) to first measurement of trough tacrolimus blood concentration was 12.1±11.6 and 27.6±26.7 days in the early and late groups, respectively. The highest number of additional visits required was 6 in the early conversion group, in 3 patients (0.7%), and 3 in the late conversion group, in 2 patients (1.6%). Conversion from immediate- to prolonged-release tacrolimus was associated with a very low rate of graft rejection. Conclusions Favorable clinical outcomes and safety profiles were observed with conversion from immediate- to prolonged-release tacrolimus over 1 year following renal transplantation, with no marked differences between the early and late conversion groups.
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Affiliation(s)
- Valérie Moal
- Nephrology and Kidney Transplantation Centre, Aix Marseille University, APHM, Conception's Hospital, Marseille, France
| | - Philippe Grimbert
- Nephrology and Transplantation Unit, Henry Mondor Hospital and UPEC University, Créteil, France
| | | | | | - Yann Le Meur
- Nephrology and Transplantation Unit, Cavale Blanche's Hospital, Brest, France
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24
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Sexton DJ, O'Kelly P, Williams Y, Plant WD, Keogan M, Khalib K, Doyle B, Dorman A, Süsal C, Unterrainer C, Forde J, Power R, Smith G, Mohan P, Denton M, Magee C, de Freitas DG, Little D, O'Seaghdha CM, Conlon PJ. Progressive improvement in short‐, medium‐ and long‐term graft survival in kidney transplantation patients in Ireland – a retrospective study. Transpl Int 2019; 32:974-984. [DOI: 10.1111/tri.13470] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 11/23/2018] [Accepted: 06/12/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Donal J. Sexton
- National Kidney Transplant Service Department of Nephrology and Kidney Transplantation Beaumont Hospital Dublin Ireland
| | - Patrick O'Kelly
- National Kidney Transplant Service Department of Nephrology and Kidney Transplantation Beaumont Hospital Dublin Ireland
| | - Yvonne Williams
- National Kidney Transplant Service Department of Nephrology and Kidney Transplantation Beaumont Hospital Dublin Ireland
- Department of Transplant Urology Beaumont Hospital Dublin Ireland
| | - William D. Plant
- The National Renal Office Health Service Executive of Ireland Cork University Hospital University College Cork Cork Ireland
| | - Marie Keogan
- Department of Immunology Beaumont Hospital Dublin Ireland
| | - Khairin Khalib
- Department of Immunology Beaumont Hospital Dublin Ireland
| | - Brendan Doyle
- Department of Pathology Beaumont Hospital Dublin Ireland
| | - Anthony Dorman
- Department of Pathology Beaumont Hospital Dublin Ireland
| | - Caner Süsal
- Collaborative Transplant Study Institute of Immunology Heidelberg University Heidelberg Germany
| | - Christian Unterrainer
- Collaborative Transplant Study Institute of Immunology Heidelberg University Heidelberg Germany
| | - James Forde
- Department of Transplant Urology Beaumont Hospital Dublin Ireland
| | - Richard Power
- Department of Transplant Urology Beaumont Hospital Dublin Ireland
| | - Gordon Smith
- Department of Transplant Urology Beaumont Hospital Dublin Ireland
| | - Ponnusamy Mohan
- Department of Transplant Urology Beaumont Hospital Dublin Ireland
| | - Mark Denton
- National Kidney Transplant Service Department of Nephrology and Kidney Transplantation Beaumont Hospital Dublin Ireland
| | - Colm Magee
- National Kidney Transplant Service Department of Nephrology and Kidney Transplantation Beaumont Hospital Dublin Ireland
| | - Declan G. de Freitas
- National Kidney Transplant Service Department of Nephrology and Kidney Transplantation Beaumont Hospital Dublin Ireland
| | - Dilly Little
- Department of Transplant Urology Beaumont Hospital Dublin Ireland
| | - Conall M. O'Seaghdha
- National Kidney Transplant Service Department of Nephrology and Kidney Transplantation Beaumont Hospital Dublin Ireland
| | - Peter J. Conlon
- National Kidney Transplant Service Department of Nephrology and Kidney Transplantation Beaumont Hospital Dublin Ireland
- Royal College of Surgeons in Ireland Dublin Ireland
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25
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Akbari M, Saha MN, Telfer S, Ullah S, Mok A, McAlister V, Juriasingani S, Luke PP, Sener A. Reconstitution of T-Cell Subsets Following Thymoglobulin-Induced Depletion in High Immunologic Risk and Donation After Cardiac Death Renal Transplant Recipients. Transplant Proc 2019; 51:1744-1753. [PMID: 31399162 DOI: 10.1016/j.transproceed.2019.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 03/08/2019] [Accepted: 03/23/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Depletion therapy in high immunologic risk (HR) patients by antithymocyte globulin (rATG) induces lymphopenia and subsequent compartmental repopulation of T-cell subsets. rATG is also given to patients receiving kidneys from donations after cardiac death (DCDs) to mitigate innate immune activation associated with the DCD process. METHODS We compared the T-cell response with rATG in both HR and DCD kidney recipients. We examined the reconstitution of T-cell subsets after rATG treatment in HR and DCD recipients (n = 19 per group) by multicolor flow cytometry. RESULTS Following treatment, there was a rapid drop in the frequency of T cells in both groups, which persisted over 28 days. HR patients had an early surge in the frequency of CD4+ naïve, effector-memory, and regulatory T cells. Although we found a significant proliferation of the T cells in both groups, the DCD cohort had a blunted response as well as reduced CD4+ T-cell immune-reactivity compare with the HR group. CONCLUSIONS Our data suggest that there is a lack of significant homeostatic proliferative response in DCD recipients following rATG, and CD4+ T cells may be less reactive in the DCD group than previously thought, indicating that rATG treatment may not have to be considered a first-line induction therapy in DCD recipients.
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Affiliation(s)
- Masoud Akbari
- Department of Surgery, Western University, London, Ontario, Canada; Matthew Mailing Center for Translational Transplant Studies, Western University, London, Ontario, Canada
| | - Manujendra N Saha
- Department of Surgery, Western University, London, Ontario, Canada; Matthew Mailing Center for Translational Transplant Studies, Western University, London, Ontario, Canada
| | - Siobhan Telfer
- Department of Surgery, Western University, London, Ontario, Canada; Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Sha Ullah
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Amy Mok
- Department of Microbiology & Immunology, Western University, London, Ontario, Canada
| | - Vivian McAlister
- Department of Surgery, Western University, London, Ontario, Canada; Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Smriti Juriasingani
- Department of Microbiology & Immunology, Western University, London, Ontario, Canada
| | - Patrick P Luke
- Department of Surgery, Western University, London, Ontario, Canada; Matthew Mailing Center for Translational Transplant Studies, Western University, London, Ontario, Canada; Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Alp Sener
- Department of Surgery, Western University, London, Ontario, Canada; Matthew Mailing Center for Translational Transplant Studies, Western University, London, Ontario, Canada; Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Department of Microbiology & Immunology, Western University, London, Ontario, Canada.
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26
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Tucker EL, Smith AR, Daskin MS, Schapiro H, Cottrell SM, Gendron ES, Hill-Callahan P, Leichtman AB, Merion RM, Gill SJ, Maass KL. Life and expectations post-kidney transplant: a qualitative analysis of patient responses. BMC Nephrol 2019; 20:175. [PMID: 31096942 PMCID: PMC6524208 DOI: 10.1186/s12882-019-1368-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 05/01/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The effect of a kidney transplant on a recipient extends beyond the restoration of kidney function. However, there is limited qualitative analysis of recipient perspectives on life following transplantation, particularly in the United States. To understand the full patient experience, it is necessary to understand recipient views on life adjustments after kidney transplantation, medical management, and quality of life. This could lead to improvements in recipient care and sense of well-being. METHODS We conducted a paper-based survey from March 23 to October 1, 2015 of 476 kidney transplant recipients at the University of Michigan Health System in Ann Arbor, Michigan. We analyzed their open-ended responses using qualitative research methods. This is a companion analysis to a previous quantitative report on the closed-ended responses to that survey. RESULTS Common themes relating to changes following transplantation included: improvements in quality of life, a return to normalcy, better health and more energy. Concerns included: duration of graft survival, fears about one day returning to dialysis or needing to undergo another kidney transplant, comorbidities, future quality of life, and the cost and quality of their healthcare. Many recipients were grateful for their transplant, but some were anxious about the burdens transplantation placed on their loved ones. CONCLUSIONS While most recipients reported meaningful improvements in health and lifestyle after kidney transplantation, a minority of participants experienced declines in energy or health status. Worries about how long the transplant will function, future health, and cost and quality of healthcare are prevalent. Future research could study the effects of providing additional information, programs, and interventions following transplantation that target these concerns. This may better prepare and support kidney recipients and lead to improvements in the patient experience.
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Affiliation(s)
- Emily L. Tucker
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI USA
| | | | - Mark S. Daskin
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI USA
| | - Hannah Schapiro
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI USA
| | - Sabrina M. Cottrell
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI USA
| | - Evelyn S. Gendron
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI USA
| | | | - Alan B. Leichtman
- Arbor Research Collaborative for Health, Ann Arbor, MI USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA
| | - Robert M. Merion
- Arbor Research Collaborative for Health, Ann Arbor, MI USA
- Department of Surgery, University of Michigan, Ann Arbor, MI USA
| | | | - Kayse Lee Maass
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI USA
- Department of Mechanical and Industrial Engineering, Northeastern University, Boston, MA USA
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Abstract
BACKGROUND Despite significant changes in the past decade for children undergoing heart transplantation, including the evolution of mechanical circulatory support and increasing patient complexity, costs and resource utilization have not been reassessed. We sought to use a novel linkage of clinical-registry and administrative data to examine changes in hospitalization costs over time in this population. METHODS We identified all pediatric heart transplant recipients in a unique linked Pediatric Health Information System/Scientific Registry of Transplant Recipients data set (2002-2016). Hospital costs were estimated from charges using cost-to-charge ratios, inflated to 2016 dollars. Severity-adjusted costs were calculated using generalized linear mixed-effects models. Costs were compared across 3 eras (era 1, 2002-2006; era 2, 2007-2011; and era 3, 2012-2016). RESULTS A total of 2896 pediatric heart transplant recipients were included: era 1, 649 (22.4%); era 2, 1028 (35.5%); and era 3, 1219 (42.1%). Extracorporeal membrane oxygenation support at transplant decreased over time, concurrent with an increase in ventricular assist device-supported patients. Between era 1 and era 2, there was an increase in pretransplant hospitalization costs (US $343 692 vs US $435 554; P < 0.001). However, between era 2 and era 3, there was a decline in total (US $906 454 vs US $767 221; P < 0.001), pretransplant (US $435 554 vs US $353 364; P < 0.001), and posttransplant (US $586 133 vs US $508 719; P = 0.002) hospitalization costs. CONCLUSIONS Concurrent with the increase in utilization of ventricular assist device support, there has been an increase in pretransplant costs associated with pediatric heart transplantation. However, in the most recent era, costs have declined. These findings suggest the evolution of more cost-effective management strategies, which may be related to shifts in the approach to pediatric mechanical circulatory support.
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28
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Kanate AS, Szabo A, Raj RV, Bower K, Grulke R, Shah N, Ross KG, Cumpston A, Craig M, Pasquini MC, Shah N, Hari P, Hamadani M, Chhabra S. Comparison of Graft Acquisition and Early Direct Charges of Haploidentical Related Donor Transplantation versus Umbilical Cord Blood Transplantation. Biol Blood Marrow Transplant 2019; 25:1456-1464. [PMID: 30878605 DOI: 10.1016/j.bbmt.2019.03.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 03/10/2019] [Indexed: 11/18/2022]
Abstract
Alternative donor allogeneic hematopoietic cell transplants (HCTs), such as double umbilical cord blood transplants (dUCBT) and haploidentical related donor transplants (haplo-HCT), have been shown to be safe and effective in adult patients who do not have an HLA-identical sibling or unrelated donor available. Most transplant centers have committed to 1 of the 2 alternative donor sources, even with a lack of published randomized data directly comparing outcomes and comparative data on the cost-effectiveness of dUCBT versus haplo-HCT. We conducted a retrospective study to evaluate and compare the early costs and charges of haplo-HCT and dUCBT in the first 100 days at 2 US transplant centers. Forty-nine recipients of haplo-HCT (at 1 center) and 37 with dUCBT (at another center) were included in the analysis. We compared graft acquisition, inpatient/outpatient, and total charges in the first 100 days. The results of the analysis showed a significantly lower cost of graft acquisition and lower total charges (for 100-day HCT survivors) in favor of haplo-HCT. Importantly, to control for the obvious shortcomings of comparing costs at 2 different transplant centers, adjustments were made based on the current (2018) local wage index and inflation rate. In the absence of further guidance from a prospective study, the cost analysis in this study suggests that haplo-HCT may result in early cost savings over dUCBT and may be preferred by transplant centers and for patients with more limited resources.
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Affiliation(s)
- Abraham S Kanate
- Osborn Hematopoietic Malignancy and Cellular Therapy Program, West Virginia University, Morgantown, West Virginia
| | - Aniko Szabo
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Renju V Raj
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kathryn Bower
- Osborn Hematopoietic Malignancy and Cellular Therapy Program, West Virginia University, Morgantown, West Virginia
| | - Rachel Grulke
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nilay Shah
- Osborn Hematopoietic Malignancy and Cellular Therapy Program, West Virginia University, Morgantown, West Virginia
| | - Kelly G Ross
- Osborn Hematopoietic Malignancy and Cellular Therapy Program, West Virginia University, Morgantown, West Virginia
| | - Aaron Cumpston
- Osborn Hematopoietic Malignancy and Cellular Therapy Program, West Virginia University, Morgantown, West Virginia
| | - Michael Craig
- Osborn Hematopoietic Malignancy and Cellular Therapy Program, West Virginia University, Morgantown, West Virginia
| | - Marcelo C Pasquini
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nirav Shah
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Parameswaran Hari
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mehdi Hamadani
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Saurabh Chhabra
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Helmuth ME, Liu Q, Turenne MN, Park JM, Oguntimein M, Dutcher SK, Balkrishnan R, Sharma P, Zee J, Leichtman AB, Smith AR. Secular Trends in the Cost of Immunosuppressants after Solid Organ Transplantation in the United States. Clin J Am Soc Nephrol 2019; 14:421-430. [PMID: 30819667 PMCID: PMC6419280 DOI: 10.2215/cjn.10590918] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/16/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Immunosuppressive medications are critical for maintenance of graft function in transplant recipients but can represent a substantial financial burden to patients and their insurance carriers. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS To determine whether availability of generic immunosuppressive medications starting in 2009 may have alleviated some of that burden, we used Medicare Part D prescription drug events between 2008 and 2013 to estimate the average annualized per-patient payments made by patients and Medicare in a large national sample of kidney, liver, and heart transplant recipients. Repeated measures linear regression was used to determine changes in payments over the study period. RESULTS Medicare Part D payments for two commonly used immunosuppressive medications, tacrolimus and mycophenolic acid (including mycophenolate mofetil and mycophenolate sodium), decreased overall by 48%-67% across organs and drugs from 2008 to 2013, reflecting decreasing payments for brand and generic tacrolimus (21%-54%), and generic mycophenolate (72%-74%). Low-income subsidy payments, which are additional payments made under Medicare Part D, also decreased during the study period. Out-of-pocket payments by patients who did not receive the low-income subsidy decreased by more than those who did receive the low-income subsidy (63%-79% versus 24%-44%). CONCLUSIONS The decline in payments by Medicare Part D and by transplant recipients for tacrolimus and mycophenolate between 2008 and 2013 suggests that the introduction of generic immunosuppressants during this period has resulted in substantial cost savings to Medicare and to patients, largely reflecting the transition from brand to generic products.
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Affiliation(s)
| | - Qian Liu
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Marc N. Turenne
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Jeong M. Park
- College of Pharmacy, University of Michigan, Ann Arbor, Michigan
| | - Murewa Oguntimein
- Center for Drug Evaluation and Research, US Food and Drug Administration, Washington, DC; and
| | - Sarah K. Dutcher
- Center for Drug Evaluation and Research, US Food and Drug Administration, Washington, DC; and
| | - Rajesh Balkrishnan
- Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Pratima Sharma
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
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30
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AbdulRahim N, Anderson L, Kotla S, Liu H, Ariyamuthu VK, Ghanta M, MacConmara M, Tujios SR, Mufti A, Mohan S, Marrero JA, Vagefi PA, Tanriover B. Lack of Benefit and Potential Harm of Induction Therapy in Simultaneous Liver-Kidney Transplants. Liver Transpl 2019; 25:411-424. [PMID: 30506870 DOI: 10.1002/lt.25390] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 11/04/2018] [Indexed: 02/07/2023]
Abstract
The number of simultaneous liver-kidney transplantations (SLKTs) and use of induction therapy for SLKT have increased recently, without much published evidence, especially in the context of maintenance immunosuppression containing tacrolimus (TAC) and mycophenolic acid (MPA). We queried the Organ Procurement and Transplant Network registry for SLKT recipients maintained on TAC/MPA at discharge in the United States for 2002-2016. The cohort was divided into 3 groups on the basis of induction type: rabbit antithymocyte globulin (r-ATG; n = 831), interleukin 2 receptor antagonist (IL2RA; n = 1558), and no induction (n = 2333). Primary outcomes were posttransplant all-cause mortality and acute rejection rates in kidney and liver allografts at 12 months. Survival rates were analyzed by the Kaplan-Meier method. A propensity score analysis was used to control potential selection bias. Multivariate inverse probability weighted Cox proportional hazard and logistic regression models were used to estimate the hazard ratios (HRs) and odds ratios. Among SLKT recipients, survival estimates at 3 years were lower for recipients receiving r-ATG (P = 0.05). Compared with no induction, the multivariate analyses showed an increased mortality risk with r-ATG (HR, 1.29; 95% confidence interval [CI], 1.10-1.52; P = 0.002) and no difference in acute liver or kidney rejection rates at 12 months across all induction categories. No difference in outcomes was noted with IL2RA induction over the no induction category. In conclusion, there appears to be no survival benefit nor reduction in rejection rates for SLKT recipients who receive induction therapy, and r-ATG appears to increase mortality risk compared with no induction.
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Affiliation(s)
- Nashila AbdulRahim
- Divisions of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Lee Anderson
- Divisions of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Suman Kotla
- Divisions of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Hao Liu
- Divisions of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Mythili Ghanta
- Divisions of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Malcolm MacConmara
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Shannan R Tujios
- Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX
| | - Arjmand Mufti
- Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX
| | - Sumit Mohan
- Division of Nephrology, Columbia University Medical Center, New York, NY
| | - Jorge A Marrero
- Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX
| | - Parsia A Vagefi
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Bekir Tanriover
- Divisions of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX
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31
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Katsumata H, Miyairi S, Ikemiyagi M, Hirai T, Fukuda H, Kanzawa T, Ishii R, Saiga K, Ishii Y, Omoto K, Okumi M, Yokoo T, Tanabe K. Evaluation of the impact of conventional immunosuppressant on the establishment of murine transplantation tolerance - an experimental study. Transpl Int 2019; 32:443-453. [PMID: 30561097 DOI: 10.1111/tri.13390] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 12/11/2018] [Indexed: 12/17/2022]
Abstract
Regulatory T cells (Tregs) play a significant role in immune tolerance. Since Treg function deeply depends on Interleukin-2 signaling, calcineurin inhibitors could affect their suppressive potentials, whereas mammalian target of rapamycin (mTOR) inhibitors may have less impact, as mTOR signaling is not fundamental to Treg proliferation. We previously reported a novel mixed hematopoietic chimerism induction regimen that promotes Treg proliferation by stimulating invariant natural killer T cells under CD40 blockade. Here, we use a mouse model to show the impact of tacrolimus (TAC) or everolimus (EVL) on the establishment of chimerism and Treg proliferation in the regimen. In the immunosuppressive drug-dosing phase, peripheral blood chimerism was comparably enhanced by both TAC and EVL. After dosing was discontinued, TAC-treated mice showed gradual graft rejection, whereas EVL-treated mice sustained long-term robust chimerism. Tregs of TAC-treated mice showed lower expression of both Ki67 and cytotoxic T lymphocyte antigen-4 (CTLA-4), and lower suppressive activity in vitro than those of EVL-treated mice, indicating that TAC negatively impacted the regimen by interfering with Treg proliferation and activation. Our results suggest that the usage of calcineurin inhibitors should be avoided if utilizing the regimen to induce Tregs in vivo for the establishment of mixed hematopoietic chimerism.
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Affiliation(s)
- Haruki Katsumata
- Department of Urology, Tokyo Women's Medical University, Kawadacho, Shinjuku-ku, Tokyo, Japan.,Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Satoshi Miyairi
- Department of Urology, Tokyo Women's Medical University, Kawadacho, Shinjuku-ku, Tokyo, Japan.,Department of Cardiovascular Surgery, Tokyo Women's Medical University, Kawadacho, Shinjuku-ku, Tokyo, Japan
| | - Masako Ikemiyagi
- Department of Urology, Tokyo Women's Medical University, Kawadacho, Shinjuku-ku, Tokyo, Japan
| | - Toshihito Hirai
- Department of Urology, Tokyo Women's Medical University, Kawadacho, Shinjuku-ku, Tokyo, Japan
| | - Hironori Fukuda
- Department of Urology, Tokyo Women's Medical University, Kawadacho, Shinjuku-ku, Tokyo, Japan
| | - Taichi Kanzawa
- Department of Urology, Tokyo Women's Medical University, Kawadacho, Shinjuku-ku, Tokyo, Japan
| | - Rumi Ishii
- Department of Urology, Tokyo Women's Medical University, Kawadacho, Shinjuku-ku, Tokyo, Japan
| | - Kan Saiga
- Department of Urology, Tokyo Women's Medical University, Kawadacho, Shinjuku-ku, Tokyo, Japan.,Department of Urology, Jyoban Hosipital of Tokiwa Foundation, Fukushima, Japan
| | - Yasuyuki Ishii
- Vaccine Innovation Laboratory, RIKEN Cluster for Science, Technology and Innovation Hub (RCSTI), RIKEN, Suehirocho, Tsurumi-ku, Yokohama, Kanagawa, Japan.,REGiMMUNE Corporation, Nihonbashi-Hakozakicho, Chuou-ku, Tokyo, Japan
| | - Kazuya Omoto
- Department of Urology, Tokyo Women's Medical University, Kawadacho, Shinjuku-ku, Tokyo, Japan
| | - Masayoshi Okumi
- Department of Urology, Tokyo Women's Medical University, Kawadacho, Shinjuku-ku, Tokyo, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Kawadacho, Shinjuku-ku, Tokyo, Japan
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32
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Mukdad L, Toppen W, Nguyen S, Kim K, Mendelsohn AH, Zarrinpar A, Benharash P. A Targeted Swallow Screen for the Detection of Postoperative Dysphagia in Liver Transplant Patients. Prog Transplant 2018; 29:4-10. [DOI: 10.1177/1526924818817035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Postoperative dysphagia leads to aspiration pneumonia, prolonged hospital stay, and is associated with increased mortality. We have demonstrated the validity of a bedside targeted swallow evaluation following cardiac surgery. Since dysphagia following liver transplantation is not well examined, we evaluated the efficacy of this swallow screen method in postoperative liver transplant patients. Methods: This was a prospective trial involving adult patients who underwent liver transplant surgery at our institution over a 5-month period. Within 24 hours of extubation and prior to the initiation of oral intake, all patients were evaluated using the targeted swallow screen, which is a direct assessment of mental status and laryngeal sensation/elevation upon swallowing of progressively larger amounts of water. A fiberoptic endoscopic evaluation of swallowing was requested for failed screenings. Results: During the study, 50 patients were screened. Twenty (40%) failed the targeted swallow screen, while 18 (90%)/20 failed the subsequent fiberoptic endoscopic examination (overall dysphagia incidence = 40%). Patients with dysphagia were older and had significantly longer intensive care unit and hospital stays. The screening test had a 90% sensitivity and a specificity of 83% for detecting dysphagia. Conclusion: The true incidence of dysphagia following liver transplantation appears to be significantly higher than previously recognized. A simple bedside swallow screen can efficiently screen these patients for dysphagia. Our findings require further validation and may support programs for reduction and early detection of dysphagia.
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Affiliation(s)
- Laith Mukdad
- Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - William Toppen
- Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Son Nguyen
- Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Kwang Kim
- Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Abie H. Mendelsohn
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ali Zarrinpar
- Department of Transplantation Surgery, University of Florida Health, Gainesville, FL, USA
| | - Peyman Benharash
- Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Long-term Immunosuppression Adherence After Kidney Transplant and Relationship to Allograft Histology. Transplant Direct 2018; 4:e392. [PMID: 30498769 PMCID: PMC6233670 DOI: 10.1097/txd.0000000000000824] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 07/10/2018] [Indexed: 01/27/2023] Open
Abstract
Background Nonadherence to immunosuppression after kidney transplant is an important contributor to graft failure. Little is known about how nonadherence changes 3 years posttransplant when Medicare coverage of immunosuppression ends and how that nonadherence impacts allograft histology. The goal of this study was to compare rates of nonadherence during posttransplant years 1 to 3 to years 3 to 5 and examine the relationship between nonadherence during years 3 to 5 and 5-year allograft histology. Methods We retrospectively analyzed 552 conventional kidney allografts in patients transplanted at our center between January 1, 1999, and June 1, 2010, who used the Mayo Clinic Specialty Pharmacy for the first 5 years posttransplant. Nonadherence was defined as less than 80% proportion of days covered. Overall adherence to immunosuppression appeared to be higher during years 3 and 5 compared to between years 1 and 3 (89.4% vs 82.9%, respectively; P < 0.0001 [paired t test]). Results Overall nonadherence during posttransplant years 3 to 5 appeared to be associated with fibrosis and inflammation on 5-year allograft biopsy but not with transplant glomerulopathy (16.9% vs 5.9%, P = 0.004; 10.4% vs 8.5%, P = 0.61, respectively). After adjusting for nonadherence to calcineurin inhibitor and prednisone therapy, only nonadherence to antimetabolite therapy remained significantly associated with 5-year fibrosis and inflammation (odds ratio, 10.6; 95% confidence interval, 1.5-76.1; P = 0.02). Conclusions Efforts to improve long-term adherence, possibly through the use of specialty pharmacies and increased adherence to antimetabolite therapy, may improve long-term allograft histology and survival, although further studies are needed to confirm these findings.
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34
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Freeman LM, Rose SL, Youngner SJ. Poverty: Not a Justification for Banning Physician‐Assisted Death. Hastings Cent Rep 2018; 48:38-46. [DOI: 10.1002/hast.937] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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35
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Cajanding R. Immunosuppression following organ transplantation. Part 1: mechanisms and immunosuppressive agents. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2018; 27:920-927. [PMID: 30187798 DOI: 10.12968/bjon.2018.27.16.920] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Solid organ transplantation has revolutionised medical care by providing a definitive cure for a wide spectrum of end-stage medical conditions. This treatment, however, does not come without complications and poses the risks of rejection, life-threatening infection, malignancies and recurrent organ failure, with significant impacts on patient outcomes. One of the major challenges involved in optimising post-transplant outcomes is managing the immune system's response to the transplanted graft and preventing organ rejection. This is mainly accomplished through the use of immunosuppressant agents, which have become a mainstay of treatment for a majority of post-transplant patients. This article, the first of two parts, discusses the concept of immunosuppression and its importance in the care of patients who have received an organ transplant. It focuses on the pathophysiologic mechanisms involved in transplant rejection and discusses the pharmacologic aspects of immunosuppression and its implications for patient care.
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Affiliation(s)
- Ruff Cajanding
- Staff Nurse, Liver Intensive Therapy Unit, Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London
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36
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Rancic N, Vavic N, Obrencevic K, Pilipovic F, Dragojevic-Simic V. Tacrolimus Utilization and Expenditure in Serbia. Front Public Health 2017; 5:291. [PMID: 29164097 PMCID: PMC5673994 DOI: 10.3389/fpubh.2017.00291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 10/20/2017] [Indexed: 11/27/2022] Open
Abstract
Background Increasing immunosuppressant consumption and expenditure is a quite a challenge in transplantation medicine. The aim of the study was to characterize the utilization and expenditure of tacrolimus, backbone, and standard of care in immunosuppression regimen in Serbian solid organ transplant recipients. Methods This study was performed as retrospective cross-sectional study during a 3-year period (from 2013 to 2015) in Serbia. The Anatomical Therapeutic Chemical Classification/Defined Daily Doses (ATC/DDD) international system was used for consumption evaluation. Results Two hundred and sixty-nine patients were transplanted in Serbia from 2013 to 2015 (185 recipients from deceased donors and 84 recipients from living donors). Total number of deceased donors in this period was 81. The consumption of tacrolimus increased (from 0.051 DDD/1,000 inhabitants/day to 0.069 DDD/1,000 inhabitants/day in 2013 and 2015, respectively). The total cost of tacrolimus was also increased; from 1,206,816€ to 1,483,472€ in 2013 and 2015, respectively. On the other hand, the number of all new solid organ transplants (from deceased and living donors) per million population per year was decreased from 17.39 to 10.02, from 2013 to 2015, respectively. Conclusion In spite downward trend in the number of solid organ transplants, tacrolimus consumption and expenditure in the examined 3-year period in Serbia increased. Since tacrolimus is a high-cost and life-preserving drug, its increasing utilization and expenditure will most likely continue consuming an enhancing share of Serbian pharmaceutical expenditure, as well as its health care, as a whole.
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Affiliation(s)
- Nemanja Rancic
- Centre for Clinical Pharmacology, Medical Faculty of the Military Medical Academy, University of Defence, Belgrade, Serbia
| | - Neven Vavic
- Solid Organ Transplantation Center, Military Medical Academy, Belgrade, Serbia
| | - Katarina Obrencevic
- Solid Organ Transplantation Center, Military Medical Academy, Belgrade, Serbia
| | - Filip Pilipovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Viktorija Dragojevic-Simic
- Centre for Clinical Pharmacology, Medical Faculty of the Military Medical Academy, University of Defence, Belgrade, Serbia
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Dharnidharka VR, Naik AS, Axelrod DA, Schnitzler MA, Zhang Z, Bae S, Segev DL, Brennan DC, Alhamad T, Ouseph R, Lam NN, Nazzal M, Randall H, Kasiske BL, McAdams-Demarco M, Lentine KL. Center practice drives variation in choice of US kidney transplant induction therapy: a retrospective analysis of contemporary practice. Transpl Int 2017; 31:198-211. [PMID: 28987015 DOI: 10.1111/tri.13079] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 08/29/2017] [Accepted: 09/28/2017] [Indexed: 01/27/2023]
Abstract
To assess factors that influence the choice of induction regimen in contemporary kidney transplantation, we examined center-identified, national transplant registry data for 166 776 US recipients (2005-2014). Bilevel hierarchical models were constructed, wherein use of each regimen was compared pairwise with use of interleukin-2 receptor blocking antibodies (IL2rAb). Overall, 82% of patients received induction, including thymoglobulin (TMG, 46%), IL2rAb (22%), alemtuzumab (ALEM, 13%), and other agents (1%). However, proportions of patients receiving induction varied widely across centers (0-100%). Recipients of living donor transplants and self-pay patients were less likely to receive induction treatment. Clinical factors associated with use of TMG or ALEM (vs. IL2rAb) included age, black race, sensitization, retransplant status, nonstandard deceased donor, and delayed graft function. However, these characteristics explained only 10-33% of observed variation. Based on intraclass correlation analysis, "center effect" explained most of the variation in TMG (58%), ALEM (66%), other (51%), and no induction (58%) use. Median odds ratios generated from case-factor adjusted models (7.66-11.19) also supported large differences in the likelihood of induction choices between centers. The wide variation in induction therapy choice across US transplant centers is not dominantly explained by differences in patient or donor characteristics; rather, it reflects center choice and practice.
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Affiliation(s)
- Vikas R Dharnidharka
- Department of Pediatrics, Division of Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Abhijit S Naik
- Department of Medicine, Division of Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - David A Axelrod
- Department of Surgery, Division of Transplantation, Lahey Clinic, Burlington, MA, USA
| | - Mark A Schnitzler
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Zidong Zhang
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Sunjae Bae
- Center for Transplantation, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Center for Transplantation, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Daniel C Brennan
- Center for Transplantation, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Tarek Alhamad
- Transplant Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Rosemary Ouseph
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Ngan N Lam
- Division of Nephrology, University of Alberta, Edmonton, AB, Canada
| | - Mustafa Nazzal
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Henry Randall
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Bertram L Kasiske
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Mara McAdams-Demarco
- Center for Transplantation, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO, USA
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Gillespie H, Smith MA, O'Neil TA. Transplant Medication Management for Patients Nearing End of Life #333. J Palliat Med 2017; 20:895-896. [DOI: 10.1089/jpm.2017.0247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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39
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Koyawala N, Silber JH, Rosenbaum PR, Wang W, Hill AS, Reiter JG, Niknam BA, Even-Shoshan O, Bloom RD, Sawinski D, Nazarian S, Trofe-Clark J, Lim MA, Schold JD, Reese PP. Comparing Outcomes between Antibody Induction Therapies in Kidney Transplantation. J Am Soc Nephrol 2017; 28:2188-2200. [PMID: 28320767 DOI: 10.1681/asn.2016070768] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 01/24/2017] [Indexed: 12/24/2022] Open
Abstract
Kidney transplant recipients often receive antibody induction. Previous studies of induction therapy were often limited by short follow-up and/or absence of information about complications. After linking Organ Procurement and Transplantation Network data with Medicare claims, we compared outcomes between three induction therapies for kidney recipients. Using novel matching techniques developed on the basis of 15 clinical and demographic characteristics, we generated 1:1 pairs of alemtuzumab-rabbit antithymocyte globulin (rATG) (5330 pairs) and basiliximab-rATG (9378 pairs) recipients. We used paired Cox regression to analyze the primary outcomes of death and death or allograft failure. Secondary outcomes included death or sepsis, death or lymphoma, death or melanoma, and healthcare resource utilization within 1 year. Compared with rATG recipients, alemtuzumab recipients had higher risk of death (hazard ratio [HR], 1.14; 95% confidence interval [95% CI], 1.03 to 1.26; P<0.01) and death or allograft failure (HR, 1.18; 95% CI, 1.09 to 1.28; P<0.001). Results for death as well as death or allograft failure were generally consistent among elderly and nonelderly subgroups and among pairs receiving oral prednisone. Compared with rATG recipients, basiliximab recipients had higher risk of death (HR, 1.08; 95% CI, 1.01 to 1.16; P=0.03) and death or lymphoma (HR, 1.12; 95% CI, 1.01 to 1.23; P=0.03), although these differences were not confirmed in subgroup analyses. One-year resource utilization was slightly lower among alemtuzumab recipients than among rATG recipients, but did not differ between basiliximab and rATG recipients. This observational evidence indicates that, compared with alemtuzumab and basiliximab, rATG associates with lower risk of adverse outcomes, including mortality.
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Affiliation(s)
| | - Jeffrey H Silber
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics
| | - Paul R Rosenbaum
- Department of Statistics, Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wei Wang
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alexander S Hill
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph G Reiter
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bijan A Niknam
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Orit Even-Shoshan
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Roy D Bloom
- Renal Electrolyte and Hypertension Division, Department of Medicine, and
| | - Deirdre Sawinski
- Renal Electrolyte and Hypertension Division, Department of Medicine, and
| | | | - Jennifer Trofe-Clark
- Renal Electrolyte and Hypertension Division, Department of Medicine, and.,Pharmacy Services, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Mary Ann Lim
- Renal Electrolyte and Hypertension Division, Department of Medicine, and
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Peter P Reese
- Renal Electrolyte and Hypertension Division, Department of Medicine, and .,Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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