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Becker N, Pereyra D, Dingfelder J, Tortopis C, Saffarian Zadeh T, Riha M, Kacar S, Soliman T, Berlakovich GA, Györi G. Immunosuppressive Induction Therapy Using the Antithymocyteglobulin Grafalon: A Single-Center Non-Interventional Study. J Clin Med 2024; 13:4051. [PMID: 39064090 PMCID: PMC11277975 DOI: 10.3390/jcm13144051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 07/07/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
Background: Induction therapy with depleting antibodies in the setting of liver transplantation (LT) is discussed controversially to this day. The rabbit antithymocyteglobulin (ATG) Thymoglobulin (rATG) was introduced as early as 1984 and was frequently used as a standard regime for induction therapy after LT. There are no public reports characterizing Grafalon (ATG-F), a novel ATG, as an induction agent after LT. Objectives: The aim of this observational non-interventional study was to investigate the safety and efficacy of Grafalon induction therapy and characterize its clinical effects in the setting of LT. Methods: A cohort of 80 patients undergoing deceased donor LT at the Medical University of Vienna and receiving Grafalon as part of the clinical standard immunosuppressive regimen was prospectively included between March 2021 and November 2022. Patients were monitored closely for leukocytopenia and thrombocytopenia during the first postoperative week and followed up for incidence and severity of biopsy-proven acute rejection (BPAR), overall survival, and bacterial infections in the first year after LT. Results: The incidences of thrombocytopenia and leukocytopenia following Grafalon treatment peaked on postoperative day four, with 64% and 31%, respectively. However, there were no cases of severe leukocytopenia after the first postoperative week. Induction therapy with Grafalon resulted in a rate of localized bacterial infections and bacteremia of 28% and 21%, respectively. The rate of BPAR was 12.5% in the first year after LT; the one-year survival rate in this cohort was 90%. Conclusions: Overall, this study provides evidence of the safety and efficacy of Grafalon as an induction agent. Further studies investigating the potential long-term effects of Grafalon, as well as comparison studies with different immunosuppressive regimens, are needed in order to draw further conclusions.
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Affiliation(s)
- Nikolaus Becker
- Department of General Surgery, Division of Transplantation, Medical University of Vienna, 1090 Wien, Austria (T.S.); (G.A.B.); (G.G.)
| | - David Pereyra
- Department of General Surgery, Division of Transplantation, Medical University of Vienna, 1090 Wien, Austria (T.S.); (G.A.B.); (G.G.)
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, 1090 Wien, Austria
| | - Jule Dingfelder
- Department of General Surgery, Division of Transplantation, Medical University of Vienna, 1090 Wien, Austria (T.S.); (G.A.B.); (G.G.)
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, 1090 Wien, Austria
| | - Chiara Tortopis
- Department of General Surgery, Division of Transplantation, Medical University of Vienna, 1090 Wien, Austria (T.S.); (G.A.B.); (G.G.)
| | - Tina Saffarian Zadeh
- Department of General Surgery, Division of Transplantation, Medical University of Vienna, 1090 Wien, Austria (T.S.); (G.A.B.); (G.G.)
| | - Moriz Riha
- Department of General Surgery, Division of Transplantation, Medical University of Vienna, 1090 Wien, Austria (T.S.); (G.A.B.); (G.G.)
| | - Sertac Kacar
- Department of General Surgery, Division of Transplantation, Medical University of Vienna, 1090 Wien, Austria (T.S.); (G.A.B.); (G.G.)
| | - Thomas Soliman
- Department of General Surgery, Division of Transplantation, Medical University of Vienna, 1090 Wien, Austria (T.S.); (G.A.B.); (G.G.)
| | - Gabriela A. Berlakovich
- Department of General Surgery, Division of Transplantation, Medical University of Vienna, 1090 Wien, Austria (T.S.); (G.A.B.); (G.G.)
| | - Georg Györi
- Department of General Surgery, Division of Transplantation, Medical University of Vienna, 1090 Wien, Austria (T.S.); (G.A.B.); (G.G.)
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2
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Duizendstra AA, Doukas M, Betjes MGH, van den Bosch TPP, Darwish Murad S, Litjens NHR, Sprengers D, Kwekkeboom J. HLA matching and rabbit antithymocyte globulin as induction therapy to avoid multiple forms of rejection after a third liver transplantation. Clin Res Hepatol Gastroenterol 2021; 45:101539. [PMID: 33109483 DOI: 10.1016/j.clinre.2020.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/18/2020] [Accepted: 08/26/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Despite immunosuppressive drug regimens, T cell-mediated rejection, antibody-mediated rejection with donor-specific antibodies, and chronic rejection occur after liver transplantation (LTx). Rejection may significantly impact allograft survival and often a standard re-LTx is required. However, in some cases rejection recurs. Little is known on how to approach this and which aspects to consider. CASE Here we describe a case in which two successive liver grafts where lost due to T cell-mediated rejection, possible antibody-mediated rejection with de novo donor-specific antibody formation, and chronic rejection that occurred within a month. In an attempt to avoid recurrence with the third graft, we decided to administer a more rigorous immunosuppressive drug induction regimen with rabbit antithymocyte globulin, while applying HLA matching between recipient and donor. This resulted in rejection free survival for 337 days until a mild T cell-mediated rejection occurred, which could then be easily treated with high dose steroids. Graft survival is now at least 683 days without chronic rejection, antibody-mediated rejection or de novo donor-specific antibody formation. CONCLUSION In conclusion, when a liver graft is lost due to multiple forms of rejection short after LTx, the combination applied in this case could be considered as a viable option to improve graft and patient survival instead of a standard re-LTx.
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Affiliation(s)
- Aafke A Duizendstra
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Michail Doukas
- Department of Pathology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Michiel G H Betjes
- Section of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Sarwa Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Nicolle H R Litjens
- Section of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Dave Sprengers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jaap Kwekkeboom
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
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3
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Harrington CR, Yang GY, Levitsky J. Advances in Rejection Management: Prevention and Treatment. Clin Liver Dis 2021; 25:53-72. [PMID: 33978583 DOI: 10.1016/j.cld.2020.08.003] [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] [Indexed: 02/06/2023]
Abstract
Extended survival of liver transplant recipients has brought rejection management to the forefront of liver transplant research. This article discusses T-cell-mediated rejection, antibody-mediated rejection, and chronic rejection. We focus on the prevention and then discuss treatment options. Future directions of rejection management include biomarkers of rejection, which may allow for monitoring of patients who are considered high risk for rejection and detection of rejection before there is any clinical evidence to improve graft and patient survival. With improved graft life and survival of liver transplant recipients, the new frontier of rejection management focuses on immunosuppression minimization, withdrawal, and personalization.
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Affiliation(s)
- Claire R Harrington
- Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 2330, Chicago, IL 60611, USA
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University Feinberg School of Medicine, 251 E Huron St. Chicago, IL 60611, USA
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 1400, Chicago, IL 60611, USA; Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 1900, Chicago, IL 60611, USA.
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4
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Uchida H, Sakamoto S, Shimizu S, Takeda M, Yanagi Y, Fukuda A, Uchiyama T, Irie R, Kasahara M. Efficacy of Antithymocyte Globulin Treatment for Severe Centrilobular Injury Following Pediatric Liver Transplant: Clinical Significance of Monitoring Lymphocyte Subset. EXP CLIN TRANSPLANT 2020; 18:325-333. [PMID: 32281527 DOI: 10.6002/ect.2019.0387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Central perivenulitis can occur in association with T-cell-mediated rejection and can sometimes require strong immunosuppressant therapy as refractory rejection. Furthermore, patients with central perivenulitis are more likely to have subsequent episodes of T-cell-mediated rejection and develop chronic rejection than those without central perivenulitis. We retrospectively analyzed clinical data of pediatric patients with episodes of T-cell-mediated rejection according to severity of central perivenulitis and monitored HLA-DR-positive CD8-positive T cells and recent thymic emigrants during treatment for T-cell-mediated rejection. MATERIALS AND METHODS We identified biopsy-proven T-cell-mediated rejection in 50 liver transplant recipients (45 with living-related donors, 5 with deceased donors) between September 2014 and August 2018. Lymphocyte subsets in peripheral blood samples were analyzed. RESULTS Of 50 pediatric patients, 30 were boys and 20 were girls (median age at transplant of 1.1 y; interquartile range, 0.6-6.2 y). Central perivenulitis was found in 46 patients (92%), which was mild in 13, moderate in 16, and severe in 17. Antithymocyte globulin was more frequently administered to patients with severe central perivenulitis than others (P < .05). Patients with antithymocyte globulin treatment were less likely to have subsequent episodes of T-cell-mediated rejection than those without this treatment (P < .05). The absolute number of CD8-positive HLA-DR-positive T cells in patients during treatment was significantly higher than in control patients (P < .05). The absolute number of recent thymic emigrants in patients with active infection was significantly lower than in patients without infection (P < .05). CONCLUSIONS Our results suggest the efficacy and safety of antithymocyte globulin for treating T-cell-mediated rejection with severe central perivenulitis in pediatric liver transplant recipients and suggest that antithymocyte globulin can prevent subsequent episodes of T-cell-mediated rejection. Analyzing lymphocyte subsets during treatment for rejection may help highlight viable therapeutic strategies for achieving a good outcome.
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Affiliation(s)
- Hajime Uchida
- From the Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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5
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Abstract
Passive antibody therapies have a long history of use. In the 19th century, antibodies from xenographic sources of polyclonal antibodies were used to treat infections (diphtheria). They were used often as protection from infectious agents and toxins. Complications related to their use involved development of immune complexes and severe allergic reactions. As a result, human source plasma for polyclonal antibodies became the preferential source for antibodies. They are used to treat infection, remove toxins, prevent hemolytic disease of the newborn, modify inflammatory reactions, and control autoimmune diseases. Continued improvements in processing decreased the transfusion/infusion transmission of infections. In the late 20th century (∼1986), monoclonal antibodies were developed. The first monoclonal antibodies were of xenographic source and were wrought with problems of immunogenicity. These forms of antibodies did not gain favor until chimerization took pace in the mid-1990s and in 1998 two monoclonal antibodies were approved one to treat respiratory syncytial virus and the other for breast cancers. Further development of humanized and then fully human monoclonal antibodies has led to an evolution of therapies with these agents. Monoclonal antibodies are being researched or approved to treat a multitude of diseases to include oncologic, inflammatory, autoimmune, cardiovascular, respiratory, neurologic, allergic, benign hematologic, infections, orthopedic, coagulopathy, metabolic and to decrease morbidity of disease (diminution of pain), modify disease progression, and potentially anatomic development. In this chapter, we will review the history of use of these passive antibody therapies, their mechanism of action, pharmacologic-therapeutic classification, particular medical indication, adverse reactions, and potential future use of these medications.
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6
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Marinelli T, Anagnostou N, Daniel S, Wigg AJ, Teh J. Very early-onset of Cryptococcus neoformans disease following liver transplantation: Report of two cases and a review of the literature. Transpl Infect Dis 2019; 22:e13227. [PMID: 31785187 DOI: 10.1111/tid.13227] [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: 08/19/2019] [Revised: 11/10/2019] [Accepted: 11/24/2019] [Indexed: 01/14/2023]
Abstract
Cryptococcosis is the third most common invasive fungal infection following solid organ transplantation, and mortality is high. Most cases occur late and are due to reactivation of latent infection; however, very early reactivation and donor-derived transmission can occur. Routine screening pre-transplant and antifungal prophylaxis for cryptococcosis post-transplant in solid organ transplantation are not standard practice. We present two cases of very early-onset Cryptococcus neoformans disease following liver transplantation to highlight the need to consider individualized pre-transplant screening and be aware that reactivation of Cryptococcosis neoformans can occur in the immediate post-transplant period.
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Affiliation(s)
- Tina Marinelli
- Department of Infectious Diseases, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Nicholas Anagnostou
- Department of Infectious Diseases, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Santhosh Daniel
- Department of Infectious Diseases, Flinders Medical Centre, Bedford Park, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Alan J Wigg
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia.,Hepatology and Transplantation Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Joanne Teh
- Department of Infectious Diseases, Flinders Medical Centre, Bedford Park, South Australia, Australia
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7
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Ganesh S, Almazroo OA, Tevar A, Humar A, Venkataramanan R. Drug Metabolism, Drug Interactions, and Drug-Induced Liver Injury in Living Donor Liver Transplant Patients. Clin Liver Dis 2017; 21:181-196. [PMID: 27842771 DOI: 10.1016/j.cld.2016.08.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Living donor liver transplant (LDLT) fills a critically needed gap in the number of livers available for transplant. However, little is known about the functional recovery of the liver in the donor and in the recipient after surgery. Given that both donor and recipients are treated with several drugs, it is important to characterize the time course of recovery of hepatic synthetic, metabolic, and excretory function in these patients. In the absence of data from LDLT, information on the effect of liver disease on the pharmacokinetics of medications can be used as guidance for drug dosing in LDLT patients.
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Affiliation(s)
- Swaytha Ganesh
- Thomas Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA 15261, USA.
| | - Omar Abdulhameed Almazroo
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, 731 Salk Hall, 3501 Terrace Street, Pittsburgh, PA 15261, USA
| | - Amit Tevar
- Thomas Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Abhinav Humar
- Thomas Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA 15261, USA.
| | - Raman Venkataramanan
- Thomas Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA 15261, USA; Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, 718 Salk Hall, 3501 Terrace Street, Pittsburgh, PA 15261, USA; Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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8
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Systematic Review and Meta-Analysis of Tacrolimus versus Ciclosporin as Primary Immunosuppression After Liver Transplant. PLoS One 2016; 11:e0160421. [PMID: 27812112 PMCID: PMC5094765 DOI: 10.1371/journal.pone.0160421] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 07/19/2016] [Indexed: 01/24/2023] Open
Abstract
Background and Aims Several meta-analyses comparing ciclosporin with tacrolimus have been conducted since the 1994 publication of the tacrolimus registration trials, but most captured data from randomized controlled trials (RCTs) predating recent improvements in waiting list prioritization, induction protocols and concomitant medications. The present study comprised a systematic review and meta-analysis of ciclosporin and tacrolimus in liver transplant recipients using studies published since January 2000. Methods Searches of PubMed, the Cochrane Library and EMBASE identified RCTs of tacrolimus and ciclosporin as the immunosuppressant in adult primary liver transplant recipients, published between January 2000 and August 6, 2014. A random effects meta-analysis was conducted to evaluate the relative risk of death, graft loss, acute rejection (AR), new-onset diabetes after transplantation (NODAT) and hypertension with tacrolimus relative to ciclosporin at 12 months. Results The literature search identified 11 RCTs comparing ciclosporin with tacrolimus. Relative to ciclosporin, tacrolimus was associated with significantly improved outcomes in terms of patient mortality (risk ratio [RR] with ciclosporin of 1.26; 95% confidence interval [95%CI] 1.01–1.58). Tacrolimus was superior to ciclosporin in terms of hypertension (RR with ciclosporin 1.26; 95%CI 1.07–1.47), but inferior in terms of NODAT (RR with ciclosporin 0.60; 95%CI 0.47–0.77). There were no significant differences between ciclosporin and tacrolimus in terms of graft loss or AR. Conclusions Meta-analysis of RCTs published since 2000 showed tacrolimus to be superior to ciclosporin in terms of patient mortality and hypertension, while ciclosporin was superior in terms of NODAT. No significant differences were identified in terms of graft loss or AR. These findings provide further evidence supporting the use of tacrolimus as the cornerstone of immunosuppressive therapy in liver transplant recipients.
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9
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Rummler S, Bauschke A, Bärthel E, Jütte H, Maier K, Ziehm P, Malessa C, Settmacher U. Current techniques for AB0-incompatible living donor liver transplantation. World J Transplant 2016; 6:548-555. [PMID: 27683633 PMCID: PMC5036124 DOI: 10.5500/wjt.v6.i3.548] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/24/2016] [Accepted: 07/22/2016] [Indexed: 02/05/2023] Open
Abstract
For a long time, it was considered medical malpractice to neglect the blood group system during transplantation. Because there are far more patients waiting for organs than organs available, a variety of attempts have been made to transplant AB0-incompatible (AB0i) grafts. Improvements in AB0i graft survival rates have been achieved with immunosuppression regimens and plasma treatment procedures. Nevertheless, some grafts are rejected early after AB0i living donor liver transplantation (LDLT) due to antibody mediated rejection or later biliary complications that affect the quality of life. Therefore, the AB0i LDLT is an option only for emergency situations, and it requires careful planning. This review compares the treatment possibilities and their effect on the patients’ graft outcome from 2010 to the present. We compared 11 transplant center regimens and their outcomes. The best improvement, next to plasma treatment procedures, has been reached with the prophylactic use of rituximab more than one week before AB0i LDLT. Unfortunately, no standardized treatment protocols are available. Each center treats its patients with its own scheme. Nevertheless, the transplant results are homogeneous. Due to refined treatment strategies, AB0i LDLT is a feasible option today and almost free of severe complications.
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10
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Lee JG, Lee J, Lee JJ, Song SH, Ju MK, Choi GH, Kim MS, Choi JS, Kim SI, Joo DJ. Efficacy of rabbit anti-thymocyte globulin for steroid-resistant acute rejection after liver transplantation. Medicine (Baltimore) 2016; 95:e3711. [PMID: 27281070 PMCID: PMC4907648 DOI: 10.1097/md.0000000000003711] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Acute cellular rejection after liver transplantation (LT) can be treated with steroid pulse therapy, but there is no ideal treatment for steroid-resistant acute rejection (SRAR). We aimed to determine the feasibility and potential complications of rabbit anti-thymocyte globulin (rATG) application to treat SRAR in liver transplant recipients. We retrospectively reviewed medical records of 429 recipients who underwent LT at Severance Hospital between January 2010 and March 2015. We compared clinical features and graft survival between patients with steroid-sensitive acute rejection (SSAR; n = 23) and SRAR (n = 11). We also analyzed complications and changes in laboratory findings after 2.5 mg/kg rATG treatment in patients with SRAR for 6 to 10 days. There were no significant differences in gender, age, model for end-stage liver disease score, Child-Turcotte-Pugh score, or original liver diseases between patients with SSAR and SRAR, although deceased donors were more frequently associated with the SRAR group (P = 0.004). All SRAR patients responded positively to rATG treatment; after treatment, the patients' median AST levels decreased from 138 to 63 IU/L, and their median ALT levels dropped from 327 to 70 IU/L 1 day after rATG treatment (P = 0.022 and 0.017, respectively). Median aspartate aminotransferase (AST), alanine aminotransferase (ALT), and total bilirubin levels significantly decreased 1 month post-treatment (P = 0.038, 0.004, and 0.041, respectively). Median survival after LT was 23 months, and median survival after rATG was 22 months in patients with SRAR. Adverse effects included hepatitis C virus (HCV) reactivation, fungemia, and cytomegalovirus (CMV) infection. Nine SRAR patients survived with healthy liver function, 1 died from a traffic accident during follow-up, and 1 died from graft-versus-host disease and fungemia. Administration of rATG is an effective therapeutic option for SRAR with acceptable complications in liver transplant recipients. However, the occurrence of HCV reactivation and CMV infection in LT patients should be monitored after rATG treatment in these patients.
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Affiliation(s)
- Jae Geun Lee
- Department of Surgery
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul
| | | | - Jung Jun Lee
- Department of Surgery, CHA Bundang Medical Center, CHA University, Bundang, Korea
| | | | | | | | - Myoung Soo Kim
- Department of Surgery
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul
| | | | - Soon Il Kim
- Department of Surgery
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul
| | - Dong Jin Joo
- Department of Surgery
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul
- ∗Correspondence: Dong Jin Joo, Department of Surgery, Yonsei University College of Medicine, Yonsei-ro, Seodaemun-gu, Seoul, Korea (e-mail: )
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11
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Petite SE, Bollinger JE, Eghtesad B. Antithymocyte Globulin Induction Therapy in Liver Transplant: Old Drug, New Uses. Ann Pharmacother 2016; 50:592-8. [PMID: 27147705 DOI: 10.1177/1060028016647974] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To review the use of rabbit antithymocyte globulin (rATG) induction therapy in liver transplant recipients. DATA SOURCES A MEDLINE literature search (inception to March 2016) was conducted using the search terms rabbit antithymocyte globulin, liver transplantation, and induction References from extracted sources were further searched for any relevant, missed data sources. STUDY SELECTION AND DATA EXTRACTION All English-language randomized and observational studies were included. DATA SYNTHESIS A total of 9 studies were included in this review evaluating rATG's use for induction therapy. All studies were single-center analyses. rATG induction is utilized to delay calcineurin inhibitor initiation and to minimize or avoid steroids. Patients receiving rATG induction tended to have improved renal function compared with patients not receiving induction. Overall, rejection rates tended to be lower in recipients administered rATG. Regimens varied in each study, with most recipients receiving 2 to 3 doses of induction therapy. CONCLUSIONS rATG induction therapy may lead to improved renal function and lower rejection rates following liver transplant. The use of this medication can help avoid unwanted adverse effects from other immunosuppression agents. Because of the potential benefits with this induction agent, rATG may have a larger role in induction therapy for liver transplant recipients.
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Affiliation(s)
- Sarah E Petite
- University of Toledo College of Pharmacy, Toledo, OH, USA
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12
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Herzer K, Strassburg CP, Braun F, Engelmann C, Guba M, Lehner F, Nadalin S, Pascher A, Scherer MN, Schnitzbauer AA, Zimmermann T, Nashan B, Sterneck M. Selection and use of immunosuppressive therapies after liver transplantation: current German practice. Clin Transplant 2016; 30:487-501. [PMID: 26855333 DOI: 10.1111/ctr.12708] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2016] [Indexed: 01/01/2023]
Abstract
In recent years, immunosuppression (IS) after liver transplantation (LT) has become increasingly diversified as the choice of agents has expanded and clinicians seek to optimize the balance of immunosuppressive potency with the risk of adverse events in individual patients. Calcineurin inhibitors (CNIs) are the primary agents used for patients undergoing liver transplantation. Other therapeutic agents like interleukin-2 receptor antagonists are not universally administered, but can be considered for the delay or reduction in CNI exposure. An early addition of mycophenolate mofetil (MMF) or the mTOR inhibitor everolimus also allows for the reduction in the CNI dose. To reduce the risk of malignancy, in particular of skin tumors, as well as to prevent the deterioration of renal function, everolimus-based therapy may be advantageous. Apart from patients with autoimmune hepatitis, steroids are withdrawn within 3-6 months after transplantation. Overall, immunosuppression can only be standardized in a limited proportion of patients due to specific clinical requirements and risk factors. Future studies should attempt to refine accurate individualization of the immunosuppressive regimen in specific difficult-to-treat patient subpopulations.
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Affiliation(s)
- Kerstin Herzer
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Department of Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | | | - Felix Braun
- Department for Transplantation Surgery, University Hospital Kiel, Kiel, Germany
| | - Cornelius Engelmann
- Department for Gastroenterology and Rheumatology, Section Hepatology, University of Leipzig, Leipzig, Germany
| | - Markus Guba
- Department for Transplant Surgery, University Hospital Munich, Munich, Germany
| | - Frank Lehner
- Department for Transplant Surgery, University Hospital Hannover, Hannover, Germany
| | - Silvio Nadalin
- Department for General, Visceral and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Andreas Pascher
- Department of Visceral and Transplant Surgery, Charite-Universitätsmedizin Berlin, Berlin, Germany
| | - Marcus N Scherer
- Department for General-, Visceral- and Transplant Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Andreas A Schnitzbauer
- Clinic for General and Visceral Surgery, Frankfurt University Hospitals, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Tim Zimmermann
- Department for Gastroenterology and Hepatology, University Hospital Mainz, Mainz, Germany
| | - Björn Nashan
- Department for Hepatobiliary Surgery and Transplantation, University Hospital Hamburg, Hamburg, Germany
| | - Martina Sterneck
- University Transplant Center, University Hospital Hamburg, Hamburg, Germany
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13
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Raschzok N, Reutzel-Selke A, Schmuck RB, Morgul MH, Gauger U, Prabowo KA, Tannus LM, Leder A, Struecker B, Boas-Knoop S, Bartels M, Jonas S, Lojewski C, Puhl G, Seehofer D, Bahra M, Pascher A, Pratschke J, Sauer IM. CD44 and CXCL9 serum protein levels predict the risk of clinically significant allograft rejection after liver transplantation. Liver Transpl 2015; 21:1195-207. [PMID: 25950774 DOI: 10.1002/lt.24164] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 04/20/2015] [Indexed: 02/07/2023]
Abstract
The diagnosis of acute cellular rejection (ACR) after liver transplantation is based on histological analysis of biopsies because noninvasive biomarkers for allograft rejection are not yet established for clinical routines. CD31, CD44, and chemokine (C-X-C motif) ligand (CXCL) 9 have previously been described as biomarkers for cross-organ allograft rejection. Here, we assessed the predictive and diagnostic value of these proteins as serum biomarkers for clinically significant ACR in the first 6 months after liver transplantation in a prospective study. The protein levels were measured in 94 patients immediately before transplantation, at postoperative days (PODs) 1, 3, 7, and 14 and when biopsies were performed during episodes of biochemical graft dysfunction. The CD44 serum protein levels were significantly lower at POD 1 in patients who experienced histologically proven ACR in the follow-up compared with patients without ACR (P < 0.001). CXCL9 was significantly higher before transplantation (P = 0.049) and at POD 1 (P < 0.001) in these patients. Low CD44 values (cutoff, <200.5 ng/mL) or high CXCL9 values (cutoff, >2.7 ng/mL) at POD 1 differentiated between rejection and no rejection with a sensitivity of 88% or 60% and a specificity of 61% or 79%, respectively. The combination of both biomarker cutoffs at POD 1 had a positive predictive value of 91% and a negative predictive value of 67% for clinically significant ACR. Moreover, CD44 was significantly lower at the time of ACR (P < 0.001) and differentiated the rejection group from patients with graft dysfunction due to other reasons. Our results suggest that CD44 and CXCL9 may serve as predictive biomarkers to identify liver allograft recipients at risk for clinically significant ACR.
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Affiliation(s)
- Nathanael Raschzok
- General, Visceral, and Transplantation Surgery, Experimental Surgery and Regenerative Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Anja Reutzel-Selke
- General, Visceral, and Transplantation Surgery, Experimental Surgery and Regenerative Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Rosa Bianca Schmuck
- General, Visceral, and Transplantation Surgery, Experimental Surgery and Regenerative Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Mehmet Haluk Morgul
- Visceral, Transplantation, Thoracic, and Vascular Surgery, University of Leipzig, Leipzig, Germany
| | | | - Kukuh Aji Prabowo
- General, Visceral, and Transplantation Surgery, Experimental Surgery and Regenerative Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Laura-Marie Tannus
- General, Visceral, and Transplantation Surgery, Experimental Surgery and Regenerative Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Annekatrin Leder
- General, Visceral, and Transplantation Surgery, Experimental Surgery and Regenerative Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Benjamin Struecker
- General, Visceral, and Transplantation Surgery, Experimental Surgery and Regenerative Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sabine Boas-Knoop
- General, Visceral, and Transplantation Surgery, Experimental Surgery and Regenerative Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Bartels
- Visceral, Transplantation, Thoracic, and Vascular Surgery, University of Leipzig, Leipzig, Germany
| | - Sven Jonas
- Centre Hépato-Biliaire, Hôpital Paul Brousse, Université Paris Sud, Villejuif, France
| | - Christian Lojewski
- General, Visceral, and Transplantation Surgery, Experimental Surgery and Regenerative Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gero Puhl
- General, Visceral, and Transplantation Surgery, Experimental Surgery and Regenerative Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Daniel Seehofer
- General, Visceral, and Transplantation Surgery, Experimental Surgery and Regenerative Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Marcus Bahra
- General, Visceral, and Transplantation Surgery, Experimental Surgery and Regenerative Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Pascher
- General, Visceral, and Transplantation Surgery, Experimental Surgery and Regenerative Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Johann Pratschke
- General, Visceral, and Transplantation Surgery, Experimental Surgery and Regenerative Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Igor Maximilian Sauer
- General, Visceral, and Transplantation Surgery, Experimental Surgery and Regenerative Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Mohty M, Bacigalupo A, Saliba F, Zuckermann A, Morelon E, Lebranchu Y. New directions for rabbit antithymocyte globulin (Thymoglobulin(®)) in solid organ transplants, stem cell transplants and autoimmunity. Drugs 2015; 74:1605-34. [PMID: 25164240 PMCID: PMC4180909 DOI: 10.1007/s40265-014-0277-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In the 30 years since the rabbit antithymocyte globulin (rATG) Thymoglobulin® was first licensed, its use in solid organ transplantation and hematology has expanded progressively. Although the evidence base is incomplete, specific roles for rATG in organ transplant recipients using contemporary dosing strategies are now relatively well-identified. The addition of rATG induction to a standard triple or dual regimen reduces acute cellular rejection, and possibly humoral rejection. It is an appropriate first choice in patients with moderate or high immunological risk, and may be used in low-risk patients receiving a calcineurin inhibitor (CNI)-sparing regimen from time of transplant, or if early steroid withdrawal is planned. Kidney transplant patients at risk of delayed graft function may also benefit from the use of rATG to facilitate delayed CNI introduction. In hematopoietic stem cell transplantation, rATG has become an important component of conventional myeloablative conditioning regimens, following demonstration of reduced acute and chronic graft-versus-host disease. More recently, a role for rATG has also been established in reduced-intensity conditioning regimens. In autoimmunity, rATG contributes to the treatment of severe aplastic anemia, and has been incorporated in autograft projects for the management of conditions such as multiple sclerosis, Crohn’s disease, and systemic sclerosis. Finally, research is underway for the induction of tolerance exploiting the ability of rATG to induce immunosuppresive cells such as regulatory T-cells. Despite its long history, rATG remains a key component of the immunosuppressive armamentarium, and its complex immunological properties indicate that its use will expand to a wider range of disease conditions in the future.
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Affiliation(s)
- Mohamad Mohty
- Department of Hematology and Cellular Therapy, CHU Hôpital Saint Antoine, 184, rue du Faubourg Saint Antoine, 75571, Paris Cedex 12, France,
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15
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Bolton EM, Bradley JA. Avoiding immunological rejection in regenerative medicine. Regen Med 2015; 10:287-304. [DOI: 10.2217/rme.15.11] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
One of the major goals of regenerative medicine is repair or replacement of diseased and damaged tissues by transfer of differentiated stem cells or stem cell-derived tissues. The possibility that these tissues will be destroyed by immunological rejection remains a challenge that can only be overcome through a better understanding of the nature and expression of potentially immunogenic molecules associated with cell replacement therapy and the mechanisms and pathways resulting in their immunologic rejection. This review draws on clinical experience of organ and tissue transplantation, and on transplantation immunology research to consider practical approaches for avoiding and overcoming the possibility of rejection of stem cell-derived tissues.
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Affiliation(s)
- Eleanor M Bolton
- Department of Surgery, University of Cambridge, Box 202, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - John Andrew Bradley
- Department of Surgery, University of Cambridge, Box 202, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
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16
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Is minimal, [almost] steroid-free immunosuppression a safe approach in adult liver transplantation? Long-term outcome of a prospective, double blind, placebo-controlled, randomized, investigator-driven study. Ann Surg 2015; 260:886-91; discussion 891-2. [PMID: 25379858 DOI: 10.1097/sla.0000000000000969] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To investigate the safety of minimal immunosuppression (IS) in liver transplantation (LT). BACKGROUND The lack of long-term follow-up studies, including pathologic data, has led to a protean handling of IS in LT. METHODS Between February 2000 and September 2004, 156 adults were enrolled in a prospective, randomized, double-blind, placebo-controlled minimization trial comparing tacrolimus placebo (TAC-PLAC) and TAC short-term steroid (TAC-STER) IS. All patients had a minimum clinical, biochemical, and histological follow-up of 5 years. RESULTS Five-year actual patient and graft survival rates in TAC-PLAC and TAC-STER groups were 78.1% and 82.1% (P=0.89) and 74.2% and 76.9% (P=0.90), respectively. Five-year biopsies were available in 112 (89.6%) of 125 survivors. Twelve patients refused a biopsy because of their excellent evolution; tissue material was insufficient in 1 patient; 11 had normal liver tests; and 2 patients had developed alcoholic and secondary biliary cirrhosis. Histology was normal in 44 (39.3%) patients; 35 (31.3%) had disease recurrence. The remaining biopsies showed nonspecific chronic hepatitis (14.3%), mild inflammatory infiltrates (10.7%), and steatosis (3.5%). All findings were equally distributed between both groups. In each group, 3 patients (4.8%) presented with acute cellular rejection after the first year and only 1 (0.9%) TAC-PLAC patient developed chronic rejection after IS withdrawal because of pneumonitis. Arterial hypertension, diabetes mellitus, renal insufficiency, hypercholesterolemia, gout, and obesity were equally low in both groups. CONCLUSIONS Excellent long-term results can be obtained under minimal IS and absence of steroids. TAC-based monotherapy is feasible in most adult liver recipients until 5 years of follow-up.
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Mengelle C, Rostaing L, Weclawiak H, Rossignol C, Kamar N, Izopet J. Prophylaxis versus pre-emptive treatment for prevention of cytomegalovirus infection in CMV-seropositive orthotopic liver-transplant recipients. J Med Virol 2015; 87:836-44. [PMID: 25655981 DOI: 10.1002/jmv.23964] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2014] [Indexed: 12/19/2022]
Abstract
This study compared the pre-emptive and the prophylactic strategies used to prevent cytomegalovirus (CMV) infection and disease in CMV-seropositive orthotopic liver-transplant recipients and searched for associated predictive factors. Seventy-three orthotopic liver-transplant recipients who had received a transplant before November 2005 were given ganciclovir IV pre-emptively (group I) and 56 recipients who had received a transplant after November 2005 were given prophylactic valganciclovir for 3 months (group II). Demographic and biochemical parameters did not statistically vary between the groups at baseline. Monitoring of CMV DNAemia was similar in both groups. Forty-two (57.5%) patients presented with CMV infection in group I and 18 (32.1%) in group II (P < 0.004). CMV DNAemia was first detected at a median of 33 days post-transplant in group I and at 98.5 days in group II (P < 0.003), but viral loads were not significantly different. The overall incidence of CMV disease was 9.6% in group I versus 7.1% in group II (ns). Thirty-five (47.9%) patients presented with biopsy-proven acute rejection in group I and 13 (23.2%) in group II (P = 0.004). Forty (55%) patients in group I and 25 (44.6%) in group II presented with de novo post-transplant diabetes (P = 0.057). At 1-year post-transplant, global survival curves were not significantly different. Independent factors associated with CMV reactivation were an absence of CMV prophylaxis, CMV serological status of the donor, cold ischemia time, and HLA A + B + DR compatibility. CMV prophylaxis is efficacious and can prevent safely the direct and indirect effects of CMV infection in CMV-seropositive orthotopic liver-transplant recipients.
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18
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Lee SD, Kim SH, Kong SY, Kim YK, Park SJ. Kinetics of B, T, NK lymphocytes and isoagglutinin titers in ABO incompatible living donor liver transplantation using rituximab and basiliximab. Transpl Immunol 2014; 32:29-34. [PMID: 25449537 DOI: 10.1016/j.trim.2014.11.216] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Revised: 11/11/2014] [Accepted: 11/11/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND The kinetics of isoagglutinin titers and lymphocyte subpopulations including B, T, and natural killer (NK) cells after ABO incompatible (ABO-I) living donor liver transplantation (LDLT) have not been evaluated. METHODS From January 2012 to July 2013, consecutive ABO-I LDLT patients were enrolled at the National Cancer Center. Our desensitizing protocol included rituximab, plasma exchanges, basiliximab, and intravenous immune globulin without splenectomy. RESULTS Twenty patients (14 males, 6 females) underwent ABO-I LDLT due to HCC (n=15) or liver cirrhosis (n=5). There was no hyperacute and antibody-mediated rejection. The isoagglutinin titers were effectively lowered less than 1:16 before operation. CD 19+ B cells were rapidly eliminated after rituximab and suppressed during 6months postoperatively. CD3+ and CD4+ T cells were elevated higher than CD8+ T cells. CD4/CD8 ratio was increased during first 1month postoperatively and decreased thereafter. CD16+CD56+ NK cells were lowered and restored after 4months of LDLT. Among 15 patients with HCC, 5 patients (33.3%) experienced early tumor recurrence (1/8 within Milan and 4/7 beyond Milan). CONCLUSIONS Our protocol showed effective results in preventing antibody-mediated rejection and suppressing B lymphocytes. Application to advanced hepatocellular carcinoma should be considered due to decreased natural immunity after ABO-I LDLT.
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Affiliation(s)
- Seung Duk Lee
- Center for Liver Cancer, National Cancer Center, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Seong Hoon Kim
- Center for Liver Cancer, National Cancer Center, Goyang-si, Gyeonggi-do, Republic of Korea.
| | - Sun-Young Kong
- Department of Laboratory Medicine, National Cancer Center, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Young-Kyu Kim
- Department of Surgery, Graduate School of Medicine, Kangwon National University, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Sang-Jae Park
- Center for Liver Cancer, National Cancer Center, Goyang-si, Gyeonggi-do, Republic of Korea
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19
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Garcia-Saenz-de-Sicilia M, Olivera-Martinez MA, Grant WJ, Mercer DF, Baojjang C, Langnas A, McCashland T. Impact of anti-thymocyte globulin during immunosuppression induction in patients with hepatitis C after liver transplantation. Dig Dis Sci 2014; 59:2804-12. [PMID: 24865255 DOI: 10.1007/s10620-014-3215-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 05/12/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Induction immunosuppression with anti-thymocyte globulin (ATG) provides potential benefits after liver transplantation (LT). However, its use in patients with LT and hepatitis C (HCV) is controversial. AIM To evaluate the 1- and 2-year patient survival and HCV recurrence rate in patients receiving ATG during the induction phase of immunosuppression (IPI) after LT. METHODS A total of 49 patients undergoing their first LT for HCV were randomized to receive ATG during IPI. Patient survival and HCV recurrence were determined at 1 and 2 years. The frequency of acute cellular rejection (ACR), infections, and neoplasms was also evaluated. RESULTS Twenty-six patients were randomized to receive ATG (Arm-1) and 23 to standard induction therapy (Arm-2). Those given ATG had lower HCV recurrence (26.9 vs 73.9 %, p = 0.001). The 1- and 2-year patient survival rates were similar for both arms (p = 0.33). Infections occurred in 46.1 % subjects in Arm-1 and 34.7 % in Arm-2 (p = 0.562). There was a greater proportion of fungal infections in Arm-1 (19.2 vs 0 %, p = 0.032). CONCLUSIONS ATG during the IPI was associated with lower frequency of recurrence of HCV in patients undergoing LT. This, however, did not affect the 1- and 2-year survival and the frequency of ACR, infections, or neoplasms.
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Affiliation(s)
- Mauricio Garcia-Saenz-de-Sicilia
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arkansas for Medical Sciences, 4301 W Markham St #567, Little Rock, AR, 72205, USA,
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20
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A Single-Center Experience of the Use of Interleukin-2 Receptor Antagonists for Various Situations in Liver Transplant Recipients. Transplant Proc 2014; 46:739-43. [DOI: 10.1016/j.transproceed.2013.11.075] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 11/22/2013] [Indexed: 12/12/2022]
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Abstract
In this article the medications that have been shown to increase rates of drug-induced liver injury in patients with cirrhosis and the important drug-drug interactions in recipients of liver transplantation are reviewed. In general, the risk of drug-induced liver injury in patients with cirrhosis does not seem to be higher when compared with the noncirrhotic population. There are, however, 2 classes of agents that have been implicated-medications used to treat tuberculosis and medications used to treat human immunodeficiency virus infection. However, with careful monitoring, even significant interactions can be effectively managed.
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22
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23
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Safer U, Tasci I, Binay Safer V, Doruk H. Re. Pre- and perioperative factors affecting infection after living donor liver transplantation. Nutrition 2013; 30:241-2. [PMID: 24035055 DOI: 10.1016/j.nut.2013.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 05/05/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Umut Safer
- Department of Geriatrics, Gulhane School of Medicine, Ankara, Turkey
| | - Ilker Tasci
- Department of Geriatrics, Gulhane School of Medicine, Ankara, Turkey
| | - Vildan Binay Safer
- Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Research and Training Hospital, Ankara, Turkey
| | - Huseyin Doruk
- Department of Geriatrics, Gulhane School of Medicine, Ankara, Turkey
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Orlicka K, Barnes E, Culver EL. Prevention of infection caused by immunosuppressive drugs in gastroenterology. Ther Adv Chronic Dis 2013; 4:167-85. [PMID: 23819020 PMCID: PMC3697844 DOI: 10.1177/2040622313485275] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Immunosuppressive therapy is frequently used to treat gastrointestinal diseases such as inflammatory bowel disease, autoimmune hepatitis, IgG4-related disease (autoimmune pancreatitis and sclerosing cholangitis) and in the post-transplantation setting. These drugs interfere with the immune system. The main safety concern with their use is the risk of infections. Certain infections can be prevented or their impact minimized. Physicians must adopt preventative strategies and should have a high degree of suspicion to recognize infections early and treat appropriately. This article reviews the risk factors for infections, the mechanism of action of immunosuppressive therapy and proposes preventive strategies.
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Affiliation(s)
- Katarzyna Orlicka
- Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
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25
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Aliabadi A, Grömmer M, Cochrane A, Salameh O, Zuckermann A. Induction therapy in heart transplantation: where are we now? Transpl Int 2013; 26:684-95. [DOI: 10.1111/tri.12107] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 03/20/2013] [Accepted: 04/04/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Arezu Aliabadi
- Department of Cardiothoracic Surgery; Medical University of Vienna; Vienna; Austria
| | - Martina Grömmer
- Department of Cardiothoracic Surgery; Medical University of Vienna; Vienna; Austria
| | | | - Olivia Salameh
- Department of Cardiothoracic Surgery; Medical University of Vienna; Vienna; Austria
| | - Andreas Zuckermann
- Department of Cardiothoracic Surgery; Medical University of Vienna; Vienna; Austria
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26
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Turner AP, Knechtle SJ. Induction immunosuppression in liver transplantation: a review. Transpl Int 2013; 26:673-83. [PMID: 23651083 DOI: 10.1111/tri.12100] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 10/30/2012] [Accepted: 03/18/2013] [Indexed: 12/15/2022]
Abstract
Antibody therapy for induction is seldom used in liver transplantation in the United States, but continues to be used in approximately 10% of patients. The most commonly used antibody at the current time is basiliximab (Simulect, Novartis) and is used in adults with renal dysfunction at the time of liver transplantation with the intention of delaying introduction of calcineurin-inhibitors. In children, the same antibody is commonly used in order to reduce rates of acute rejection. Most patients, adult and pediatric, are treated with initially higher levels of tacrolimus rather than antibody induction.
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