1
|
Sapir-Pichhadze R, Laprise C, Beauchamp ME, Kaouache M, Zhang X, Della Vecchia A, Azoulay L, Franco EL, Abrahamowicz M, Nicolau B. Immunosuppression and cancer risk in kidney transplant recipients: A retrospective cohort study. Int J Cancer 2024; 154:2043-2053. [PMID: 38345158 DOI: 10.1002/ijc.34875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 01/05/2024] [Accepted: 01/11/2024] [Indexed: 04/14/2024]
Abstract
We assessed whether contemporary immunosuppression agents were associated with cancer among kidney transplant recipients (KTR), and if this association varied by age and sex. We studied a retrospective province-wide cohort of primary KTR (1997-2016). Employing multivariable Cox models, we estimated associations of cumulative doses of prednisone, mycophenolate and tacrolimus administered over the past 10 years, lagged by 2 years, with the incidence of primary malignant neoplasms (PMN). We assessed interactions with age and sex. To assess the impact of exposure recency, we used weighted cumulative exposure (WCE) modeling. Among 1064 KTR, 108 (10.2%) developed PMN over median follow-up of 73 months (interquartile range: 32-120). Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of 0.96 (0.64-1.43), 1.34 (0.96-1.86), and 1.06 (0.88-1.29) were estimated for cumulative daily doses of prednisone (5 mg), mycophenolate (1000 mg), and tacrolimus (2 mg) administered continuously over the past 10 years, respectively. PMN risk associated with cumulative tacrolimus exposure was modified by age (interaction p = .035) and was more pronounced in 15-year and 30-year-old KTR (aHRs of 1.57 [1.08-2.28] and 1.31 [1.03-1.66], respectively) in comparison to older KTR. PMN risk increase associated with higher cumulative mycophenolate dose was more pronounced in females (aHR = 1.86 [1.15-3.00]) than in males (aHR = 1.16 [0.74-1.81]; interaction p = .131). WCE analyses suggested increased PMN risk the higher the mycophenolate doses taken 5-10 years ago. A trend toward increased PMN risk with long-term mycophenolate exposure, particularly in females, and more pronounced risk with long-term tacrolimus exposure in younger KTR, identify opportunities for tailored immunosuppression to mitigate cancer risk.
Collapse
Affiliation(s)
- Ruth Sapir-Pichhadze
- Centre for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics, Occupational Health, McGill University, Montreal, Quebec, Canada
- Division of Nephrology, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Claudie Laprise
- Department of Social and Preventive Medicine, Université de Montréal, Montreal, Quebec, Canada
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Quebec, Canada
- Division of Cancer Epidemiology, McGill University, Montreal, Quebec, Canada
| | - Marie-Eve Beauchamp
- Centre for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada
| | - Mohammed Kaouache
- Centre for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada
| | - Xun Zhang
- Centre for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada
| | - Alexia Della Vecchia
- Centre for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada
| | - Laurent Azoulay
- Department of Epidemiology, Biostatistics, Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Eduardo L Franco
- Department of Epidemiology, Biostatistics, Occupational Health, McGill University, Montreal, Quebec, Canada
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Quebec, Canada
- Division of Cancer Epidemiology, McGill University, Montreal, Quebec, Canada
| | - Michal Abrahamowicz
- Centre for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics, Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Belinda Nicolau
- Department of Epidemiology, Biostatistics, Occupational Health, McGill University, Montreal, Quebec, Canada
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Quebec, Canada
- Division of Cancer Epidemiology, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
2
|
Chen J, Lin J, Weng J, Ju Y, Li Y. Association between trough serum vancomycin concentration and vancomycin-associated acute kidney injury and 30-day mortality in critically ill elderly adults. BMC Infect Dis 2024; 24:330. [PMID: 38509460 PMCID: PMC10953182 DOI: 10.1186/s12879-024-09227-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/14/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Vancomycin-associated acute kidney injury (VA-AKI) is the most clinically relevant side effect of vancomycin. The objective of this study was to investigate the association between VTC and VA-AKI as well as 30-day mortality in critically ill elderly adults. METHOD Elderly patients with trough serum vancomycin concentration records(VTC) in the Medical Information Mart-IV (MIMIC-IV) and eICU databases were retrospectively studied. RESULTS A total of 3,146 critically ill elderly adults were finally enrolled. The incidence of VA-AKI in the elderly population was 76.5%. Logistic regression analysis revealed significant relationships between VA-AKI and various factors, including VTC, comorbidities, and laboratory indicators, and SOFA, and GCS score. For each mg/L increase, the OR for VA-AKI increased by 2.5%. The association between VTC and 30-day mortality was found to be statistically significant (odds ratio (OR): 1.021, 95% CI: 1.010-1.031), P < 0.001). The Restricted cubic splines (RCS) curves revealed that VTC ranged of 19.67 to 35.72 mg/l for AKI and 19.17 to 42.86 mg/l for 30-day mortality exhibit OR with 95% CI above 1, indicating statistically significant associations with an increased risk of AKI and 30-day mortality, respectively. In the subgroup analysis, VTC was identified as a risk factor for VA-AKI in specific patient groups, including white individuals, female patients, those with shock, patients with SOFA > 6, patients with baseline creatinine > 1.2 mg/dl and patients with or without exposed to other nephrotoxic medications. CONCLUSION This study found the significant association between VTC and the incidence of VA-AKI and 30-day mortality in critically ill elderly adults. The RCS curves indicated concentration ranges for AKI (19.67-35.72 mg/L) and 30-day mortality (19.17-42.86 mg/L), signifying increased risk.
Collapse
Affiliation(s)
- Jialong Chen
- Department of Pulmonary and Critical Care Medicine, Beijing Hospital, National Center of Gerontology, the Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
- Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jing Lin
- Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Department of Infectious Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jianzhen Weng
- Department of Pulmonary and Critical Care Medicine, Beijing Hospital, National Center of Gerontology, the Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Yang Ju
- Department of Pulmonary and Critical Care Medicine, Beijing Hospital, National Center of Gerontology, the Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Yanming Li
- Department of Pulmonary and Critical Care Medicine, Beijing Hospital, National Center of Gerontology, the Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China.
| |
Collapse
|
3
|
Montero N, Rodrigo E, Crespo M, Cruzado JM, Gutierrez-Dalmau A, Mazuecos A, Sancho A, Belmar L, Calatayud E, Mora P, Oliveras L, Solà E, Villanego F, Pascual J. The use of lymphocyte-depleting antibodies in specific populations of kidney transplant recipients: A systematic review and meta-analysis. Transplant Rev (Orlando) 2023; 37:100795. [PMID: 37774445 DOI: 10.1016/j.trre.2023.100795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/07/2023] [Accepted: 09/09/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Recommendations of the use of antibody induction treatments in kidney transplant recipients (KTR) are based on moderate quality and historical studies. This systematic review aims to reevaluate, based on actual studies, the effects of different antibody preparations when used in specific KTR subgroups. METHODS We searched MEDLINE and CENTRAL and selected randomized controlled trials (RCT) and observational studies looking at different antibody preparations used as induction in KTR. Comparisons were categorized into different KTR subgroups: standard, high risk of rejection, high risk of delayed graft function (DGF), living donor, and elderly KTR. Two authors independently assessed the risk of bias. RESULTS Thirty-seven RCT and 99 observational studies were finally included. Compared to anti-interleukin-2-receptor antibodies (IL2RA), anti-thymocyte globulin (ATG) reduced the risk of acute rejection at two years in standard KTR (RR 0.74, 95%CI 0.61-0.89) and high risk of rejection KTR (RR 0.55, 95%CI 0.43-0.72), but without decreasing the risk of graft loss. We did not find significant differences comparing ATG vs. alemtuzumab or different ATG dosages in any KTR group. CONCLUSIONS Despite many studies carried out on induction treatment in KTR, their heterogeneity and short follow-up preclude definitive conclusions to determine the optimal induction therapy. Compared with IL2RA, ATG reduced rejection in standard-risk, highly sensitized, and living donor graft recipients, but not in high DGF risk or elderly recipients. More studies are needed to demonstrate beneficial effects in other KTR subgroups and overall patient and graft survival.
Collapse
Affiliation(s)
- Nuria Montero
- Nephrology Department, Hospital Universitari de Bellvitge, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Emilio Rodrigo
- Nephrology Department, Hospital Universitario Marqués de Valdecilla/IDIVAL, Santander, Spain
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Josep M Cruzado
- Nephrology Department, Hospital Universitari de Bellvitge, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Alex Gutierrez-Dalmau
- Nephrology Department, Hospital Universitario Miguel Servet, Aragon Health Research Institute, Zaragoza, Spain
| | | | - Asunción Sancho
- Nephrology Department, Hospital Universitari Dr Peset, FISABIO, Valencia, Spain
| | - Lara Belmar
- Nephrology Department, Hospital Universitario Marqués de Valdecilla/IDIVAL, Santander, Spain
| | - Emma Calatayud
- Nephrology Department, Hospital Universitari Dr Peset, FISABIO, Valencia, Spain
| | - Paula Mora
- Nephrology Department, Hospital Universitario Miguel Servet, Aragon Health Research Institute, Zaragoza, Spain
| | - Laia Oliveras
- Nephrology Department, Hospital Universitari de Bellvitge, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Eulalia Solà
- Nephrology Department, Consorci Sanitari del Garraf, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | | | - Julio Pascual
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain.
| |
Collapse
|
4
|
Echterdiek F, Döhler B, Latus J, Schwenger V, Süsal C. Influence of Calcineurin Inhibitor Choice on Outcomes in Kidney Transplant Recipients Aged ≥60 Y: A Collaborative Transplant Study Report. Transplantation 2022; 106:e212-e218. [PMID: 35066544 DOI: 10.1097/tp.0000000000004060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients aged ≥60 y represent the fastest growing population among kidney transplant recipients and waitlist patients. They show an elevated infection risk and are frequently transplanted with multiple human leukocyte antigen mismatches. Whether the choice of calcineurin inhibitor influences graft survival, mortality, or key secondary outcomes such as infections in this vulnerable recipient population is unknown. METHODS A total of 31 177 kidney transplants from deceased donors performed between 2000 and 2019 at European centers and reported to the Collaborative Transplant Study were analyzed using multivariable Cox and logistic regression analyses. All recipients were ≥60 y old and received tacrolimus (Tac) or cyclosporine A on an intention-to-treat basis, combined with mycophenolic acid or azathioprine plus/minus steroids. RESULTS The risk of 3-y death-censored graft loss and patient mortality did not differ significantly between Tac- and cyclosporine A-treated patients (hazard ratio 0.98 and 0.95, P = 0.74 and 0.20, respectively). No difference was found in the overall risk of hospitalization for infection (hazard ratio = 0.95, P = 0.19); however, a lower incidence of rejection treatment (hazard ratio = 0.81, P < 0.001) was observed in Tac-treated patients. Assessment of pathogen-specific hospitalizations revealed no difference in the risk of hospitalization due to bacterial infection (odds ratio = 1.00, P = 0.96), but a significantly higher risk of hospitalization due to human polyomavirus infection was found among Tac-treated patients (odds ratio = 2.45, P = 0.002). The incidence of de novo diabetes was higher for Tac-based immunosuppression (odds ratio = 1.79, P < 0.001). CONCLUSIONS Calcineurin inhibitor selection has no significant influence on death-censored graft survival, mortality, and overall infection risk in ≥60-y-old kidney transplant recipients.
Collapse
Affiliation(s)
- Fabian Echterdiek
- Department of Nephrology, Klinikum Stuttgart-Katharinenhospital, Stuttgart, Germany
| | - Bernd Döhler
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Joerg Latus
- Department of Nephrology, Klinikum Stuttgart-Katharinenhospital, Stuttgart, Germany
| | - Vedat Schwenger
- Department of Nephrology, Klinikum Stuttgart-Katharinenhospital, Stuttgart, Germany
| | - Caner Süsal
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
- Transplant Immunology Research Center of Excellence, Koç Üniversitesi, Istanbul, Turkey
| |
Collapse
|
5
|
Cossart AR, Isbel NM, Scuderi C, Campbell SB, Staatz CE. Pharmacokinetic and Pharmacodynamic Considerations in Relation to Calcineurin Usage in Elderly Kidney Transplant Recipients. Front Pharmacol 2021; 12:635165. [PMID: 33912051 PMCID: PMC8072471 DOI: 10.3389/fphar.2021.635165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 02/12/2021] [Indexed: 12/28/2022] Open
Abstract
This review summarizes how possible age-related changes in tacrolimus and cyclosporine pharmacokinetics and pharmacodynamics may influence drug dosing and monitoring in the elderly, and highlights how micro-sampling may be useful in this cohort in the future. Advancing biological age leads to physiological changes that can affect drug absorption, distribution, metabolism and excretion, as well as immune system responsiveness. Some studies have shown that elderly recipients may have higher dose-adjusted exposure and/or lower clearance of the calcineurin inhibitors, suggesting that doses may need to be lowered in elderly recipients. Only one study has examined how aging effects drug target enzyme activity and demonstrated that age does not correlate with the calcineurin inhibitor half-maximal inhibitory concentration. Several studies have shown elderly kidney transplant recipients have increased risk of both morbidity and mortality, compared to younger adults due to increased susceptibility to immunosuppressant side effects, particularly cardiovascular disease, infection and malignancy. Current immunosuppressant dosing and monitoring protocols often make no adjustments for age. Lower maintenance immunosuppressant targets in elderly recipients may decrease patient susceptibility to drug side effects, however, further studies are required and appropriate targets need to be established. Blood draw by micro-sampling may be useful for drug monitoring in this cohort in the future, as blood collection is minimally invasive and less painful than venepuncture. Micro-sampling could also make further pharmacokinetic, pharmacodynamics and outcome studies in the elderly more feasible.
Collapse
Affiliation(s)
- Amelia R Cossart
- School of Pharmacy, University of Queensland, Brisbane, QLD, Australia
| | - Nicole M Isbel
- Department of Nephrology, University of Queensland at the Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Carla Scuderi
- School of Pharmacy, University of Queensland, Brisbane, QLD, Australia.,Kidney Health Service, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Scott B Campbell
- Department of Nephrology, University of Queensland at the Princess Alexandra Hospital, Brisbane, QLD, Australia
| | | |
Collapse
|
6
|
Cabrera J, Fernández-Ruiz M, Trujillo H, González E, Molina M, Polanco N, Hernández E, Morales E, Gutiérrez E, Rodríguez Mori J, Canon A, Rodríguez-Antolín A, Praga M, Andrés A. Kidney transplantation in the extremely elderly from extremely aged deceased donors: a kidney for each age. Nephrol Dial Transplant 2020; 35:687-696. [PMID: 32049336 DOI: 10.1093/ndt/gfz293] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 12/10/2019] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Advances in life expectancy have led to an increase in the number of elderly people with end-stage renal disease (ESRD). Scarce information is available on the outcomes of kidney transplantation (KT) in extremely elderly patients based on an allocation policy prioritizing donor-recipient age matching. METHODS We included recipients ≥75 years that underwent KT from similarly aged deceased donors at our institution between 2002 and 2015. Determinants of death-censored graft and patient survival were assessed by Cox regression. RESULTS We included 138 recipients with a median follow-up of 38.8 months. Median (interquartile range) age of recipients and donors was 77.5 (76.3-79.7) and 77.0 years (74.7-79.0), with 22.5% of donors ≥80 years. Primary graft non-function occurred in 8.0% (11/138) of patients. Cumulative incidence rates for post-transplant infection and biopsy-proven acute rejection (BPAR) were 70.3% (97/138) and 15.2% (21/138), respectively. One- and 5-year patient survival were 82.1 and 60.1%, respectively, whereas the corresponding rates for death-censored graft survival were 95.6 and 93.1%. Infection was the leading cause of death (46.0% of fatal cases). The occurrence of BPAR was associated with lower 1-year patient survival [hazard ratio (HR) = 4.21, 95% confidence interval (CI) 1.64-10.82; P = 0.003]. Diabetic nephropathy was the only factor predicting 5-year death-censored graft survival (HR = 4.82, 95% CI 1.08-21.56; P = 0.040). CONCLUSIONS ESRD patients ≥75 years can access KT and remain dialysis free for their remaining lifespan by using grafts from extremely aged deceased donors, yielding encouraging results in terms of recipient and graft survival.
Collapse
Affiliation(s)
- Jimena Cabrera
- Programa de Prevención y Tratamiento de las Glomerulopatías, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay.,Department of Nephrology, Hospital Evangélico, Montevideo, Uruguay.,Department of Nephrology, Hospital Militar, Montevideo, Uruguay
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Hernando Trujillo
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Esther González
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - María Molina
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain.,Department of Nephrology, Hospital Universitari "Arnau de Vilanova", Lleida, Spain
| | - Natalia Polanco
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Eduardo Hernández
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Enrique Morales
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Eduardo Gutiérrez
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Juan Rodríguez Mori
- Department of Nephrology, Hospital Nacional "Alberto Sabogal Sologuren", EsSalud, Callao, Peru
| | - Alejandra Canon
- Department of Nephrology, Hospital Evangélico, Montevideo, Uruguay.,Department of Nephrology, Hospital Militar, Montevideo, Uruguay
| | - Alfredo Rodríguez-Antolín
- Department of Urology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Manuel Praga
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain.,School of Medicine, Universidad Complutense, Madrid, Spain
| | - Amado Andrés
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain.,School of Medicine, Universidad Complutense, Madrid, Spain
| |
Collapse
|
7
|
Dujardin A, Lorent M, Foucher Y, Legendre C, Kerleau C, Brouard S, Giral M. Time-dependent lymphocyte count after transplantation is associated with higher risk of graft failure and death. Kidney Int 2020; 99:1189-1201. [PMID: 32891605 DOI: 10.1016/j.kint.2020.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/11/2020] [Accepted: 08/10/2020] [Indexed: 11/18/2022]
Abstract
The transplantation field requires the identification of specific risk factors associated with the level of immunosuppression. Here, our aim was to analyze the association between the number of circulating lymphocytes, monitored routinely by complete blood cell counts during outpatient visits, and patient and graft survival. In total, 2,999 kidney or combined kidney-pancreas recipients transplanted between 2000 and 2016, from two University hospitals, were enrolled. We investigated the etiological relationship between time-dependent lymphocyte count beyond one year after transplantation and patient and graft survival, viral infection and cancer risk using time-dependent multivariate Cox models. Model 1 considered kidney function at one year and model 2 as time-dependent variable. At the time of inclusion (one year after transplantation), 584 patients (19.4%) had deep lymphopenia (under 750 /mm3) and 1,072 (35.7%) had a normal count (over 1,500 /mm3). A patient with deep lymphopenia at a given follow-up time had significantly higher risks of graft failure, death and viral infection than comparable patients with a normal lymphocyte count at the same time point. Thus, after the first year of transplantation, the occurrence of deep lymphopenia within a patient's follow-up is a risk factor for long-term graft failure, death and viral infection.
Collapse
Affiliation(s)
- Amaury Dujardin
- CRTI UMR 1064, Inserm, Université de Nantes, ITUN, CHU Nantes, RTRS Centaure, Nantes, France; Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Marine Lorent
- Centre Hospitalier Universitaire de Nantes, Nantes, France; Inserm UMR 1246-SPHERE, Université de Nantes, Université de Tours, Nantes, France
| | - Yohann Foucher
- Centre Hospitalier Universitaire de Nantes, Nantes, France; Inserm UMR 1246-SPHERE, Université de Nantes, Université de Tours, Nantes, France
| | - Christophe Legendre
- Kidney Transplant Center, Necker University Hospital, APHP, RTRS Centaure, Paris Descartes and Sorbonne Paris Cité Universities, Paris, France
| | | | - Sophie Brouard
- CRTI UMR 1064, Inserm, Université de Nantes, ITUN, CHU Nantes, RTRS Centaure, Nantes, France; Centre Hospitalier Universitaire de Nantes, Nantes, France.
| | - Magali Giral
- CRTI UMR 1064, Inserm, Université de Nantes, ITUN, CHU Nantes, RTRS Centaure, Nantes, France; Centre Hospitalier Universitaire de Nantes, Nantes, France; Centre d'Investigation Clinique en Biothérapie, Labex IGO, Nantes, France
| |
Collapse
|
8
|
Camilleri B, Pararajasingam R, Buttigieg J, Halawa A. Immunosuppression strategies in elderly renal transplant recipients. Transplant Rev (Orlando) 2020; 34:100529. [DOI: 10.1016/j.trre.2020.100529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/09/2019] [Accepted: 12/18/2019] [Indexed: 01/23/2023]
|
9
|
Oberbauer R, Bestard O, Furian L, Maggiore U, Pascual J, Rostaing L, Budde K. Optimization of tacrolimus in kidney transplantation: New pharmacokinetic perspectives. Transplant Rev (Orlando) 2020; 34:100531. [PMID: 31955920 DOI: 10.1016/j.trre.2020.100531] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/05/2019] [Accepted: 12/08/2019] [Indexed: 02/07/2023]
Abstract
Tacrolimus is the cornerstone of immunosuppressive therapy after kidney transplantation (KT), but its use is complicated by a narrow therapeutic index and high inter- and intra-patient pharmacokinetic variability. There are three available oral formulations of tacrolimus: immediate-release tacrolimus (IR-Tac), extended-release tacrolimus (ER-Tac) and a MeltDose® (LCPT) formulation, the latter favoring a prolonged drug release and increased bioavailability. The time-concentration curves of these formulations are different. Compared with IR-Tac and ER-Tac, LCPT has a relatively flat pharmacokinetic profile with less fluctuation between trough and peak exposures, and a delayed peak concentration. This translates to a more stable delivery of tacrolimus and may alleviate the risk of underexposure and allograft rejection or overexposure and toxicity. The once-daily formulation of both ER-TAC and LCPT may also offer a potential advantage on patient adherence. Fast metabolizers of tacrolimus, the elderly, and human leukocyte antigen-sensitized patients are at risk of poorer outcomes after KT, possibly associated with a different exhibited pharmacokinetics of tacrolimus or different requirements in terms of exposure. Simple, practical strategies are needed to identify patients at risk of suboptimal KT outcomes and those who would benefit from a more proactively personalized approach to tacrolimus treatment. This review aims to increase awareness of the link between the pharmacokinetics of oral tacrolimus formulations and the clinical needs of patients after KT, particularly among those who have clinically significant pharmacokinetic variation of tacrolimus.
Collapse
Affiliation(s)
- Rainer Oberbauer
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Oriol Bestard
- Kidney Transplant Unit, Nephrology department, Bellvitge University Hospital, Barcelona, Spain
| | - Lucrezia Furian
- Kidney and Pancreas Transplantation Unit, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Italy
| | - Umberto Maggiore
- Kidney and Kidney-Pancreas Transplant Unit (Department of Nephrology), Parma University Hospital, Parma, Italy
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Lionel Rostaing
- Nephrology and Transplantation Department, CHU Grenoble, Grenoble, France
| | - Klemens Budde
- Department of Nephrology, Internal Intensive Care Medicine, Campus Charité Mitte, Berlin, Germany.
| |
Collapse
|
10
|
Fragoso YD, Ruocco HH, Dias RM, Cabeça H, Gonçalves R, de Carvalho Sousa NA, Spessotto CV, Tauil CB, Alves-Leon SV, Gomes S, Gonçalves MVM, Machado SCN, Anacleto A, Correa EC, Pimentel MLV, Santos GAC. Late Onset of Neuromyelitis Optica Spectrum Disorders. Neurol Ther 2019; 8:477-482. [PMID: 31267407 PMCID: PMC6858916 DOI: 10.1007/s40120-019-0143-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune demyelinating disease of the central nervous system. NMOSD starting after the age of 50 years is considered a "late onset" (LO-NMOSD) and seems to be particularly aggressive. The objective of this paper is to present a series of 37 Brazilian patients with LO-NMOSD. METHODS Retrospective data collection from medical records of patients with LO-NMOSD seen at 14 Brazilian specialized units. RESULTS The ratio of women to men in the sample was 4.3 to 1. The patients were followed up for a median period of 4 years. Sex, age at disease onset, and ethnic background were not associated with the number of relapses or disability outcomes. Extensive longitudinal myelitis affected 86% of patients, while optic neuritis affected 70%, and brainstem syndromes were present in only 16% of these patients. Six patients are currently using some type of support for walking or are wheelchair-bound. Three have died. Therapeutic options for NMOSD were particularly complicated for these elderly patients, since medications for controlling NMOSD are, in essence, immunosuppressive. Long-term use of corticosteroids can be an issue when the patients have high blood pressure, diabetes mellitus, or dyslipidemia (conditions often seen in elderly individuals). CONCLUSION This series of LO-NMOSD cases highlights the importance of prompt diagnosis and treatment for these patients.
Collapse
Affiliation(s)
- Yara Dadalti Fragoso
- Department of Neurology, Universidade Metropolitana de Santos, Santos, SP, Brazil.
- MS and Headache Research, Santos, SP, Brazil.
| | - Heloisa Helena Ruocco
- Department of Neurology, Pontificia Universidade Catolica de Campinas, Campinas, SP, Brazil
| | - Ronaldo Maciel Dias
- Department of Neurology, Hospital de Base do Distrito Federal, Brasilia, DF, Brazil
| | - Hideraldo Cabeça
- Department of Neurology, Hospital Ophir Loyola, Belem, PA, Brazil
| | - Ricardo Gonçalves
- Department of Neurology, Hospital Pompeia, Caxias do Sul, RS, Brazil
| | | | | | | | | | - Sidney Gomes
- Department of Neurology, Hospital Beneficencia Portuguesa de Sao Paulo and Hospital Paulistano, Sao Paulo, SP, Brazil
| | | | | | - Andrea Anacleto
- Department of Neurology, Universidade Metropolitana de Santos, Santos, SP, Brazil
| | - Eber Castro Correa
- Department of Neurology, Hospital de Base do Distrito Federal, Brasilia, DF, Brazil
| | - Maria Lucia V Pimentel
- Department of Neurology, Santa Casa de Misericordia do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | |
Collapse
|
11
|
Everolimus in de novo kidney transplant recipients participating in the Eurotransplant senior program: Results of a prospective randomized multicenter study (SENATOR). PLoS One 2019; 14:e0222730. [PMID: 31536556 PMCID: PMC6752944 DOI: 10.1371/journal.pone.0222730] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 09/05/2019] [Indexed: 01/17/2023] Open
Abstract
Early conversion to everolimus was assessed in kidney transplant recipients participating in the Eurotransplant Senior Program (ESP), a population in whom data are lacking. The SENATOR multicenter study enrolled 207 kidney transplant recipients undergoing steroid withdrawal at week 2 post-transplant (ClinicalTrials.gov [NCT00956293]). At week 7, patients were randomized (1:2 ratio) to continue the previous calcineurin inhibitor (CNI)-based regimen with mycophenolic acid (MPA) and cyclosporine or switch to a CNI-free regimen with MPA, everolimus (5–10 ng/mL) and basiliximab at weeks 7 and 12, then followed for 18 weeks to month 6 post-transplant. The primary endpoint was estimated GFR (eGFR). At week 7, 77/207 (37.2%) patients were randomized (53 everolimus, 24 control). At month 6, eGFR was comparable: 36.5±10.8ml/min with everolimus versus 42.0±13.0ml/min in the control group (p = 0.784). Discontinuation due to adverse events occurred in 27.8% of everolimus-treated patients and 0.0% of control patients (p = 0005). Efficacy profiles showed no difference. In conclusion, eGFR, safety and efficacy outcomes at month 6 post-transplant showed no difference between groups. The everolimus group experienced a higher rate of discontinuation due to adverse events. However, the high rate of non-randomization is highly relevant, indicating this to be a somewhat unstable patient population regardless of treatment.
Collapse
|
12
|
Santos AH, Chen C, Alquadan K, Wen X. Outcomes of sirolimus regimens in 65-year-old and older kidney transplant recipients: a registry-based observational study. Int Urol Nephrol 2019; 51:2063-2072. [PMID: 31385180 DOI: 10.1007/s11255-019-02251-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 07/29/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE In large observational studies of adult kidney transplant recipients (KTRs) where older adults (65 years old and older) were not well represented, the mammalian target of rapamycin inhibitors (mTOR inhibitors) has poorer outcomes than the standard tacrolimus-mycophenolate-steroids (TAC-MPA-S) regimen. We conducted this study to compare the outcomes of regimens containing the common mTOR inhibitor, sirolimus (SRL) against TAC-MPA-S in older adult KTRs. METHODS Using the 2000-2016 Scientific Registry of Transplant Recipients, Cox multivariable regression models were conducted to analyze the patient and graft outcomes associated with regimens containing SRL, steroids (S) and cyclosporine (CSA), tacrolimus (TAC), or mycophenolate (MPA) vs. the standard (TAC-MPA-S) regimen in older adult KTRs. RESULTS Included in the analysis were 15,008 (95.19%) older adult KTRs on standard (TAC-MPA-S) regimen, 242 (1.53%) on SRL-MPA-S, 300 (1.90%) on SRL-TAC-S, and 217 (1.38%) on SRL-CSA-S. Compared with the standard regimen, the adjusted risks of all-cause death and overall graft loss over a maximum 5-year follow-up were highest with SRL-MPA-S, intermediate with SRL-TAC-S and not significantly different with SRL-CSA-S. The adjusted risks of all-cause death and overall graft loss were modified by a pre-transplant history of malignancy in older adult KTRs on SRL-TAC-S, not in those on SRL-MPA-S or SRL-CSA-S. CONCLUSIONS In older adult kidney transplant recipients, SRL-TAC-S or SRL-MPA-S, but not SRL-CSA-S is associated with higher risks of death and allograft loss than standard TAC-MPA-S regimen and a pre-transplant malignancy history worsens these risks in patients on SRL-TAC-S. Confirmation of our findings by a prospective randomized trial is needed before translation into clinical practice can be recommended.
Collapse
Affiliation(s)
- Alfonso H Santos
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Medical Science Bldg, NG-4, Gainesville, FL, 32610, USA.
| | - Chao Chen
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Kawther Alquadan
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Medical Science Bldg, NG-4, Gainesville, FL, 32610, USA
| | - Xuerong Wen
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
| |
Collapse
|
13
|
Michielsen LA, van Zuilen AD, Verhaar MC, Wisse BW, Kamburova EG, Joosten I, Allebes WA, van der Meer A, Baas MC, Spierings E, Hack CE, van Reekum FE, Bots ML, Drop ACAD, Plaisier L, Seelen MAJ, Sanders JSF, Hepkema BG, Lambeck AJ, Bungener LB, Roozendaal C, Tilanus MGJ, Voorter CE, Wieten L, van Duijnhoven EM, Gelens MACJ, Christiaans MHL, van Ittersum FJ, Nurmohamed SA, Lardy NM, Swelsen W, van der Pant KA, van der Weerd NC, Ten Berge IJM, Bemelman FJ, Hoitsma A, van der Boog PJM, de Fijter JW, Betjes MGH, Heidt S, Roelen DL, Claas FH, Otten HG, Hilbrands LB. Effect of initial immunosuppression on long-term kidney transplant outcome in immunological low-risk patients. Nephrol Dial Transplant 2019; 34:1417-1422. [PMID: 30561730 DOI: 10.1093/ndt/gfy377] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 11/10/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Few studies have evaluated the effect of different immunosuppressive strategies on long-term kidney transplant outcomes. Moreover, as they were usually based on historical data, it was not possible to account for the presence of pretransplant donor-specific human-leukocyte antigen antibodies (DSA), a currently recognized risk marker for impaired graft survival. The aim of this study was to evaluate to what extent frequently used initial immunosuppressive therapies increase graft survival in immunological low-risk patients. METHODS We performed an analysis on the PROCARE cohort, a Dutch multicentre study including all transplantations performed in the Netherlands between 1995 and 2005 with available pretransplant serum (n = 4724). All sera were assessed for the presence of DSA by a luminex single-antigen bead assay. Patients with a previous kidney transplantation, pretransplant DSA or receiving induction therapy were excluded from the analysis. RESULTS Three regimes were used in over 200 patients: cyclosporine (CsA)/prednisolone (Pred) (n = 542), CsA/mycophenolate mofetil (MMF)/Pred (n = 857) and tacrolimus (TAC)/MMF/Pred (n = 811). Covariate-adjusted analysis revealed no significant differences in 10-year death-censored graft survival between patients on TAC/MMF/Pred therapy (79%) compared with patients on CsA/MMF/Pred (82%, P = 0.88) or CsA/Pred (79%, P = 0.21). However, 1-year rejection-free survival censored for death and failure unrelated to rejection was significantly higher for TAC/MMF/Pred (81%) when compared with CsA/MMF/Pred (67%, P < 0.0001) and CsA/Pred (64%, P < 0.0001). CONCLUSION These results suggest that in immunological low-risk patients excellent long-term kidney graft survival can be achieved irrespective of the type of initial immunosuppressive therapy (CsA or TAC; with or without MMF), despite differences in 1-year rejection-free survival.
Collapse
Affiliation(s)
- Laura A Michielsen
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arjan D van Zuilen
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Bram W Wisse
- Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Elena G Kamburova
- Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Irma Joosten
- Laboratory Medicine, Lab. Medical Immunology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wil A Allebes
- Laboratory Medicine, Lab. Medical Immunology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arnold van der Meer
- Laboratory Medicine, Lab. Medical Immunology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marije C Baas
- Radboud Institute for Health Sciences, Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eric Spierings
- Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Cornelis E Hack
- Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Franka E van Reekum
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Adriaan C A D Drop
- Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Loes Plaisier
- Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marc A J Seelen
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan-Stephan F Sanders
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bouke G Hepkema
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Annechien J Lambeck
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Laura B Bungener
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Caroline Roozendaal
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marcel G J Tilanus
- Department of Transplantation Immunology, Tissue Typing Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Christien E Voorter
- Department of Transplantation Immunology, Tissue Typing Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Lotte Wieten
- Department of Transplantation Immunology, Tissue Typing Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Elizabeth M van Duijnhoven
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Mariëlle A C J Gelens
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Maarten H L Christiaans
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Frans J van Ittersum
- Department of Nephrology, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Shaikh A Nurmohamed
- Department of Nephrology, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Neubury M Lardy
- Department of Immunogenetics, Sanquin, Amsterdam, The Netherlands
| | - Wendy Swelsen
- Department of Immunogenetics, Sanquin, Amsterdam, The Netherlands
| | - Karlijn A van der Pant
- Renal Transplant Unit, Department of Internal Medicine, Amsterdam UMC, Academic Medical Center, Amsterdam, The Netherlands
| | - Neelke C van der Weerd
- Renal Transplant Unit, Department of Internal Medicine, Amsterdam UMC, Academic Medical Center, Amsterdam, The Netherlands
| | - Ineke J M Ten Berge
- Renal Transplant Unit, Department of Internal Medicine, Amsterdam UMC, Academic Medical Center, Amsterdam, The Netherlands
| | - Frederike J Bemelman
- Renal Transplant Unit, Department of Internal Medicine, Amsterdam UMC, Academic Medical Center, Amsterdam, The Netherlands
| | - Andries Hoitsma
- Dutch Organ Transplant Registry (NOTR), Dutch Transplant Foundation (NTS), Leiden, The Netherlands
| | | | - Johan W de Fijter
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Michiel G H Betjes
- Department of Nephrology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Sebastiaan Heidt
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
| | - Dave L Roelen
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
| | - Frans H Claas
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
| | - Henderikus G Otten
- Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Luuk B Hilbrands
- Radboud Institute for Health Sciences, Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
14
|
Induction Therapy in Elderly Kidney Transplant Recipients With Low Immunological Risk. Transplantation 2019; 104:613-622. [PMID: 31283665 DOI: 10.1097/tp.0000000000002804] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND In nonimmunized patients, similar rejection rates are observed for patients who have undergone thymoglobulin (antithymocyte globulins [ATG]) or basiliximab (BSX) therapy. While ATG may improve delayed graft function, it may also be associated with higher infection rates and malignancy risk. We compared survival and clinical outcomes in elderly recipients with low immunological risk according to their induction therapy. METHODS We conducted a multicentric study on nonimmunized patients ≥65 years of age receiving a first kidney transplant between 2010 and 2017. The principal outcome was patient and graft survival. Secondary outcomes were cumulative probabilities of infection, first acute rejection episode, malignancy, de novo donor specific antibody, posttransplant diabetes (PTD), cardiac complications, estimated glomerular filtration rate, and occurrence of delayed graft function. Cox, logistic, or linear statistical models were used depending on the outcome studied, and models were weighted on the propensity scores. RESULTS Two hundred and four patients were included in the BSX group and 179 in the ATG group with the average age of 71.0 and 70.5 years, respectively. Patient and graft survival at 3 years posttransplantation were 74% (95% CI, 65%-84%) and 68% (95% CI, 60%-78%) in ATG and BSX group, respectively, without significant difference. Occurrence of PTD was significatively higher in BSX group (23% versus 15%, P = 0.04) due to higher trough levels of Tacrolimus on month 3 (9.48 versus 7.30 ng/mL, P = 0.023). There was no difference in other evaluated outcomes. CONCLUSIONS In elderly recipients, ATG does not lead to poorer outcomes compared with BSX and could permit lower trough levels of Tacrolimus, thus reducing occurrence of PTD.
Collapse
|
15
|
Usefulness of Delayed Introduction of Tacrolimus in Kidney Transplants Using Type-III Donors After Circulatory Death. Transplant Proc 2019; 51:337-340. [DOI: 10.1016/j.transproceed.2018.10.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 10/23/2018] [Indexed: 11/24/2022]
|
16
|
Zmonarski SC, Madziarska K, Golebiowski T, Banasik M, Mazanowska O, Madziarski M, Krajewska M. Can the Toll-like receptors 4 expression in peripheral blood mononuclear cells help assess the effectiveness of immunosuppression and the chance of a future good renal transplant function? Transpl Immunol 2018; 53:43-50. [PMID: 30592973 DOI: 10.1016/j.trim.2018.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 12/24/2018] [Accepted: 12/24/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND A small percentage of peripheral blood mononuclear cells (PBMCs) circulating during the kidney transplantation (KT) period remain in the blood long after transplantation. A part of the PBMCs penetrates the graft. AIM To examine if the choice of immunosuppression may change TLR4ex and how TLR4ex affects the transplant function in the future. MATERIAL The study population-143 transplanted patients (pts) (55 females, 88 males), mean age on recruitment day 50.33 ± 12.8 years old, mean BMI 25.04 ± 4.18. 41 pts. experienced delayed graft function (DGF+). 55 pts. were treated with cyclosporine A (CsA) and 88 with tacrolimus (Tac). All were treated with mofetil mycophenolate (MMF). The PBMCs acquisition and starting point of the follow-up (TLR-day) was at least one month after KT. METHOD We investigated averaged mRNA expression of Toll-like receptors 4 (TLR4ex) in non-stimulated peripheral blood mononuclear cells with the use of real-time polymerase chain reaction. The KT pts. (All, Tac, CsA, DGF+) were divided by the respective median of their TLR4ex (lower: L-TLR4ex, higher: H-TLR4ex). Main clinical parameters and transplant biopsy files (if available) were assessed on TLR-day and post follow-up. RESULTS We found that TLR4ex was reduced for a long time in patients who experienced delayed graft function. L-TLR4ex had a higher proportion of DGF+ patients, and patients treated with CsA but lower of those treated with Tac than in H-TLR4ex. The amplitude of changes in renal function parameters (ΔEGFR%/ΔsCr/ΔsCr%) was clearly less favorable for L-TLR4ex. Tacrolimus expressed a stabilizing effect. Both the positive vasculitis score and chronic graft nephropathy were more frequent in the L-TLR4ex group. On TLR-day an association of renal function and Tac concentration with TLR4ex was clear only in the tacrolimus population. The TLR4ex was lower in patients with a future deterioration of the graft function. CONCLUSION In kidney transplant recipients the occurrence of DGF results in a long-term reduction of the averaged TLR4ex in PBMC. Tacrolimus exerts a clear, stabilizing, positive and dose-dependent effect on TLR4ex. An improvement in renal transplant function may be expected in KT patients with high TLR4ex. Evaluation of the averaged TLR4ex can be used to assess the efficacy of immunosuppression in the treatment with tacrolimus and to estimate the likelihood of deterioration in renal function.
Collapse
Affiliation(s)
- Slawomir C Zmonarski
- Dept. of Nephrology and Transplantation Medicine, Medical University Wroclaw, Poland
| | - Katarzyna Madziarska
- Dept. of Nephrology and Transplantation Medicine, Medical University Wroclaw, Poland.
| | - Tomasz Golebiowski
- Dept. of Nephrology and Transplantation Medicine, Medical University Wroclaw, Poland
| | - Miroslaw Banasik
- Dept. of Nephrology and Transplantation Medicine, Medical University Wroclaw, Poland
| | - Oktawia Mazanowska
- Faculty of Medicine and Dentistry, Dept. of Nephrology and Transplantation Medicine, Medical University Wroclaw, Poland
| | - Marcin Madziarski
- Dept. of Nephrology and Transplantation Medicine, Medical University Wroclaw, Poland
| | - Magdalena Krajewska
- Dept. of Nephrology and Transplantation Medicine, Medical University Wroclaw, Poland
| |
Collapse
|
17
|
Gao L, Xu F, Cheng H, Liu J. Comparison of Sirolimus Combined With Tacrolimus and Mycophenolate Mofetil Combined With Tacrolimus in Kidney Transplantation Recipients: A Meta-Analysis. Transplant Proc 2018; 50:3306-3313. [DOI: 10.1016/j.transproceed.2018.08.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 08/03/2018] [Accepted: 08/29/2018] [Indexed: 12/17/2022]
|
18
|
Gandolfini I, Crespo E, Baweja M, Jarque M, Donadei C, Luque S, Montero N, Allesina A, Perin L, Maggiore U, Cravedi P, Bestard O. Impact of preformed T-cell alloreactivity by means of donor-specific and panel of reactive T cells (PRT) ELISPOT in kidney transplantation. PLoS One 2018; 13:e0200696. [PMID: 30059561 PMCID: PMC6066206 DOI: 10.1371/journal.pone.0200696] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 07/02/2018] [Indexed: 01/09/2023] Open
Abstract
Donor-specific (d-sp) interferon gamma enzyme-linked immunosorbent spot (d-sp ELISPOT) and Panel of reactive T-cell (PRT) ELISPOT assays have been developed to detect alloreactive memory T (Tmem) cells in order to estimate the risk of acute rejection after kidney transplantation. Adding IL15 to the PRT assay (PRT+IL15) may uncover the presence of pathogenic alloreactive CD28-Tmem. Face-to-face comparisons of these assays have not been done yet. We performed pre-transplant d-sp ELISPOT and PRT assays (±IL15, against six B-cell lines) in 168 consecutive kidney transplant recipients and evaluated the multivariable-adjusted associations with biopsy-proven acute rejection (BPAR), de novo donor-specific antibodies (DSA), and eGFR decline over a 48-month follow-up period. D-sp ELISPOT was positive in 81 (48%) subjects, while 71 (42%) and 81 (48%) subjects displayed positive PRT and PRT+IL15, respectively. Their median [interquartile range] numerical test result was 23 [6–65], 18 [8–37], and 26 [10–45] spots/3x105 PBMCs, respectively. The number of PRT spots were weakly correlated with those of d-sp ELISPOT, but highly correlated with PRT+IL15 (rho = 0.96, P<0.001). d-sp ELISPOT, but not PRT (±IL15) was independently associated with BPAR (adjusted Odds Ratio of BPAR associated with d-sp ELISPOT positivity: 4.20 [95%CI: 1.06 to 21.73; P = 0.041]). Unlike d-sp ELISPOT, median PRT and PRT+IL15 were independently associated with higher Δ3-48month eGFR decline post-transplantation (for both assays, about -3mL/min/1.73m2 per one standard deviation unit increase in the spot number). Pre-transplant T-cell immune-monitoring using d-sp ELISPOT and PRT assays identifies kidney transplant candidates at high risk of BPAR and worse kidney allograft progression.
Collapse
Affiliation(s)
- Ilaria Gandolfini
- Department of Medicine, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
- Kidney and Kidney-Pancreas Transplant Unit (Department of Nephrology), Parma University Hospital, Parma, Italy
| | - Elena Crespo
- Experimental Nephrology Laboratory, IDIBELL, Barcelona University, Barcelona, Spain
| | - Mukta Baweja
- Department of Medicine, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Marta Jarque
- Experimental Nephrology Laboratory, IDIBELL, Barcelona University, Barcelona, Spain
| | - Chiara Donadei
- Department of Medicine, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Sergio Luque
- Experimental Nephrology Laboratory, IDIBELL, Barcelona University, Barcelona, Spain
| | - Núria Montero
- Kidney Transplant Unit, Bellvitge University Hospital, IDIBELL, Barcelona University, Barcelona, Spain
| | - Anna Allesina
- Experimental Nephrology Laboratory, IDIBELL, Barcelona University, Barcelona, Spain
| | - Laura Perin
- GOFARR Laboratory, Saban Research Institute, Division of Urology, Children's Hospital Los Angeles, Los Angeles, California, United States of America
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Umberto Maggiore
- Kidney and Kidney-Pancreas Transplant Unit (Department of Nephrology), Parma University Hospital, Parma, Italy
| | - Paolo Cravedi
- Department of Medicine, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Oriol Bestard
- Experimental Nephrology Laboratory, IDIBELL, Barcelona University, Barcelona, Spain
- Kidney Transplant Unit, Bellvitge University Hospital, IDIBELL, Barcelona University, Barcelona, Spain
- * E-mail:
| |
Collapse
|
19
|
Sitruk L, Couchoud C, Hourmant M, Tuppin P, Macher MA, Legeai C. [Description of immunosuppressive maintenance treatments post kidney transplant through the National System of Health Insurance]. Nephrol Ther 2018; 14:523-530. [PMID: 29887268 DOI: 10.1016/j.nephro.2018.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 03/02/2018] [Accepted: 03/18/2018] [Indexed: 01/08/2023]
Abstract
The aim of this study was to describe the drug dispensing of maintenance immunosuppression treatment in 2014 for patients who received a kidney transplant in 2012, based on the data of the French national health insurance and to compare those results with the information collected in the national database for kidney recipients. For each patient, are considered all drugs dispensing with their dates of issue, the molecules and their presentations (number of pills and dosage). Among 2463 transplanted adults in 2012, 73% have received tacrolimus monohydrate, 59% mycophenolate mofetil, 54% prednisone and 20% cyclosporin in 2014. The daily doses but not the number of tablets per day declined with age. The most frequent association was tacrolimus monohydrate-mycophenolate mofetil-steroids in 34% of the cases. The use of mTOR inhibitors, rare generally (7%), is more common in patients aged 66-85 years. Associations did not differ significantly according to diabetic status, for patients with a kidney from an elderly donor or according to the number of mismatch. The daily doses estimated from the deliverance in pharmacy are respectively similar, understated and over-estimate for tacrolimus, mycophenolate mofetil and cyclosporin compared to the national database. This study confirms the difficulty of apprehending drug consumption based only on dispensing in pharmacies or punctual recording even if it allows a fairly comprehensive view of French practices.
Collapse
Affiliation(s)
- Lola Sitruk
- Agence de la biomédecine, 1, avenue du Stade-de-France, 93212 Saint-Denis-La-Plaine cedex, France
| | - Cécile Couchoud
- Agence de la biomédecine, 1, avenue du Stade-de-France, 93212 Saint-Denis-La-Plaine cedex, France
| | - Maryvonne Hourmant
- Service de néphrologie et d'immunologie clinique, CHU, 30, boulevard Jean-Monnet, immeuble Jean-Monnet, 44093 Nantes cedex 1, France
| | - Philippe Tuppin
- Caisse nationale de l'Assurance maladie des travailleurs salariés, Direction de la stratégie des études et des statistiques, 26-50, avenue du Professeur-André-Lemierre, 75986 Paris cedex 20, France
| | - Marie-Alice Macher
- Agence de la biomédecine, 1, avenue du Stade-de-France, 93212 Saint-Denis-La-Plaine cedex, France
| | - Camille Legeai
- Agence de la biomédecine, 1, avenue du Stade-de-France, 93212 Saint-Denis-La-Plaine cedex, France.
| |
Collapse
|
20
|
Montero N, Redondo-Pachón D, Pérez-Sáez MJ, Crespo M, Cruzado JM, Pascual J. Dual kidney transplantation as a strategy to use expanded criteria donors: a systematic review. Transpl Int 2018; 31:838-860. [DOI: 10.1111/tri.13157] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 01/29/2018] [Accepted: 03/19/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Nuria Montero
- Department of Nephrology; Hospital Universitari de Bellvitge; L'Hospitalet del Llobregat; Barcelona Spain
| | | | | | - Marta Crespo
- Department of Nephrology; Hospital del Mar; Barcelona Spain
| | - Josep M. Cruzado
- Department of Nephrology; Hospital Universitari de Bellvitge; L'Hospitalet del Llobregat; Barcelona Spain
| | - Julio Pascual
- Department of Nephrology; Hospital del Mar; Barcelona Spain
| |
Collapse
|
21
|
Hernández D, Alonso-Titos J, Armas-Padrón AM, Ruiz-Esteban P, Cabello M, López V, Fuentes L, Jironda C, Ros S, Jiménez T, Gutiérrez E, Sola E, Frutos MA, González-Molina M, Torres A. Mortality in Elderly Waiting-List Patients Versus Age-Matched Kidney Transplant Recipients: Where is the Risk? Kidney Blood Press Res 2018; 43:256-275. [PMID: 29490298 DOI: 10.1159/000487684] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/15/2018] [Indexed: 11/19/2022] Open
Abstract
The number of elderly patients on the waiting list (WL) for kidney transplantation (KT) has risen significantly in recent years. Because KT offers a better survival than dialysis therapy, even in the elderly, candidates for KT should be selected carefully, particularly in older waitlisted patients. Identification of risk factors for death in WL patients and prediction of both perioperative risk and long-term post-transplant mortality are crucial for the proper allocation of organs and the clinical management of these patients in order to decrease mortality, both while on the WL and after KT. In this review, we examine the clinical results in studies concerning: a) risk factors for mortality in WL patients and KT recipients; 2) the benefits and risks of performing KT in the elderly, comparing survival between patients on the WL and KT recipients; and 3) clinical tools that should be used to assess the perioperative risk of mortality and predict long-term post-transplant survival. The acknowledgment of these concerns could contribute to better management of high-risk patients and prophylactic interventions to prolong survival in this particular population, provided a higher mortality is assumed.
Collapse
Affiliation(s)
- Domingo Hernández
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Juana Alonso-Titos
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | | | - Pedro Ruiz-Esteban
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Mercedes Cabello
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Verónica López
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Laura Fuentes
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Cristina Jironda
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Silvia Ros
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Tamara Jiménez
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Elena Gutiérrez
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Eugenia Sola
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Miguel Angel Frutos
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Miguel González-Molina
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Armando Torres
- Nephrology Department, Hospital Universitario de Canarias, CIBICAN, University of La Laguna, Tenerife and Instituto Reina Sofía de Investigación Renal, IRSIN, Tenerife, Spain
| |
Collapse
|
22
|
Jin P, Chen H, Xie J, Zhou C, Zhu X. Essential role of microRNA-650 in the regulation of B-cell CLL/lymphoma 11B gene expression following transplantation: A novel mechanism behind the acute rejection of renal allografts. Int J Mol Med 2017; 40:1840-1850. [PMID: 29039465 PMCID: PMC5716404 DOI: 10.3892/ijmm.2017.3194] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 10/06/2017] [Indexed: 12/14/2022] Open
Abstract
Kidney transplantation is an effective final therapeutic procedure for patients with end-stage kidney failure. Although advanced immunosuppressive therapy is administered following transplantation, certain patients still suffer from acute allograft rejection. MicroRNAs (miRs) have a potential diagnostic and therapeutic value for acute renal allograft rejection; however, their underlying mechanism of action is largely unknown. In the present study, an increased level of miR-650 was identified to be associated with the downregulation of B-cell CLL/lymphoma 11B (BCL11B) expression in acute renal allograft rejection. Furthermore, in vitro study using human renal glomerular endothelial cells (HRGECs) transfected with a miR-650 mimic revealed that key characteristics of acute renal allograft rejection were observed, including apoptosis, the release of cytokines and the chemotaxis of macrophages, while the effects were reduced in HRGECs transfected with a miR-650 inhibitor. The existence of a conserved miR-650 binding site on the 3'-untranslated region of BCL11B mRNA was predicted by computational algorithms and confirmed by a luciferase reporter assay. Knockdown of BCL11B with small interfering RNA (siRNA) significantly increased the apoptotic rate and significantly decreased the proliferation ability of HRGECs compared with the negative control group. HRGECs transfected with a combination of BCL11B siRNA and the miR-650 mimic demonstrated a significant increase in the rate of apoptosis compared with the control. These results suggest that the upregulation of miR-650 contributes to the development of acute renal allograft rejection by suppression of BCL11B, which leads to apoptosis and inflammatory responses. Thus, miR-650 and BCL11B may represent potential therapeutic targets for the prevention of acute renal allograft rejection.
Collapse
Affiliation(s)
- Peng Jin
- Centre of Organ Transplantation, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
| | - Hongxi Chen
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
| | - Jinliang Xie
- Centre of Organ Transplantation, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
| | - Cheng Zhou
- Centre of Organ Transplantation, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
| | - Xiangrong Zhu
- Centre of Organ Transplantation, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
| |
Collapse
|
23
|
Abstract
The old-for-old allocation policy used for kidney transplantation (KT) has confirmed the survival benefit compared to remaining listed on dialysis. Shortage of standard donors has stimulated the development of strategies aimed to expand acceptance criteria, particularly of kidneys from elderly donors. We have systematically reviewed the literature on those different strategies. In addition to the review of outcomes of expanded criteria donor or advanced age kidneys, we assessed the value of the Kidney Donor Profile Index policy, preimplantation biopsy, dual KT, machine perfusion and special immunosuppressive protocols. Survival and functional outcomes achieved with expanded criteria donor, high Kidney Donor Profile Index or advanced age kidneys are poorer than those with standard ones. Outcomes using advanced age brain-dead or cardiac-dead donor kidneys are similar. Preimplantation biopsies and related scores have been useful to predict function, but their applicability to transplant or refuse a kidney graft has probably been overestimated. Machine perfusion techniques have decreased delayed graft function and could improve graft survival. Investing 2 kidneys in 1 recipient does not make sense when a single KT would be enough, particularly in elderly recipients. Tailored immunosuppression when transplanting an old kidney may be useful, but no formal trials are available.Old donors constitute an enormous source of useful kidneys, but their retrieval in many countries is infrequent. The assumption of limited but precious functional expectancy for an old kidney and substantial reduction of discard rates should be generalized to mitigate these limitations.
Collapse
|