1
|
Jaksch P, Ankersmit J, Scheed A, Kocher A, Muraközy G, Klepetko W, Lang G. Alemtuzumab in lung transplantation: an open-label, randomized, prospective single center study. Am J Transplant 2014; 14:1839-45. [PMID: 25039364 DOI: 10.1111/ajt.12824] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 03/18/2014] [Accepted: 03/27/2014] [Indexed: 01/25/2023]
Abstract
Induction therapy with alemtuzumab followed by lower maintenance immunosuppression (IS) has been associated with reduced morbidity and mortality in abdominal and heart transplantation (TX). In the current study, alemtuzumab, in combination with reduced levels of maintenance IS, was compared to thymoglobulin in combination with standard IS. Sixty consecutive patients who underwent lung transplantation (LUTX) at a single center were prospectively randomized in two groups: group A received alemtuzumab in conjunction with reduced doses of tacrolimus, steroids and mycophenolate mofetil. Group B received thymoglobulin in association with standard dose IS. Patient and graft survival, freedom from acute cellular rejection (ACR), lymphocytic bronchiolitis, bronchiolitis obliterans syndrome, kidney function, infectious complications and posttransplant lymphoproliferative disorder were analyzed. Alemtuzumab induction therapy resulted in complete the absence of ACR episodes ≥ A2 within the first year post-TX. The difference to thymoglobulin was significant (alemtuzumab 0 vs. ATG 0.33; p = 0.019). All other factors studied did not show any differences between the two groups. Alemtuzumab induction therapy after LUTX in combination with reduced maintenance IS significantly reduces higher-grade rejection rates. This novel therapeutic agent had no impact on survival, infections rates, kidney function and incidence of malignancies.
Collapse
Affiliation(s)
- P Jaksch
- Department of Thoracic Surgery, Medical University of Vienna, Wien, Austria
| | | | | | | | | | | | | |
Collapse
|
2
|
Whitson BA, Lehman A, Wehr A, Hayes D, Kirkby S, Pope-Harman A, Kilic A, Higgins RS. To induce or not to induce: a 21st century evaluation of lung transplant immunosuppression's effect on survival. Clin Transplant 2014; 28:450-61. [DOI: 10.1111/ctr.12339] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Bryan A. Whitson
- Division of Cardiac Surgery; Department of Surgery; Wexner Medical Center; The Ohio State University; Columbus OH USA
| | - Amy Lehman
- Center for Biostatistics; College of Medicine; The Ohio State University; Columbus OH USA
| | - Allison Wehr
- Center for Biostatistics; College of Medicine; The Ohio State University; Columbus OH USA
| | - Don Hayes
- Division of Pulmonary, Allergy, and Critical Care & Sleep Medicine; Department of Internal Medicine; Wexner Medical Center; The Ohio State University; Columbus OH USA
- Department of Pediatrics; Nationwide Children's Hospital; The Ohio State University; Columbus OH USA
| | - Stephen Kirkby
- Division of Pulmonary, Allergy, and Critical Care & Sleep Medicine; Department of Internal Medicine; Wexner Medical Center; The Ohio State University; Columbus OH USA
- Department of Pediatrics; Nationwide Children's Hospital; The Ohio State University; Columbus OH USA
| | - Amy Pope-Harman
- Division of Pulmonary, Allergy, and Critical Care & Sleep Medicine; Department of Internal Medicine; Wexner Medical Center; The Ohio State University; Columbus OH USA
| | - Ahmet Kilic
- Division of Cardiac Surgery; Department of Surgery; Wexner Medical Center; The Ohio State University; Columbus OH USA
| | - Robert S.D. Higgins
- Division of Cardiac Surgery; Department of Surgery; Wexner Medical Center; The Ohio State University; Columbus OH USA
| |
Collapse
|
3
|
Baughman RP, Meyer KC, Nathanson I, Angel L, Bhorade SM, Chan KM, Culver D, Harrod CG, Hayney MS, Highland KB, Limper AH, Patrick H, Strange C, Whelan T. Monitoring of nonsteroidal immunosuppressive drugs in patients with lung disease and lung transplant recipients: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012; 142:e1S-e111S. [PMID: 23131960 PMCID: PMC3610695 DOI: 10.1378/chest.12-1044] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2012] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES Immunosuppressive pharmacologic agents prescribed to patients with diffuse interstitial and inflammatory lung disease and lung transplant recipients are associated with potential risks for adverse reactions. Strategies for minimizing such risks include administering these drugs according to established, safe protocols; monitoring to detect manifestations of toxicity; and patient education. Hence, an evidence-based guideline for physicians can improve safety and optimize the likelihood of a successful outcome. To maximize the likelihood that these agents will be used safely, the American College of Chest Physicians established a committee to examine the clinical evidence for the administration and monitoring of immunosuppressive drugs (with the exception of corticosteroids) to identify associated toxicities associated with each drug and appropriate protocols for monitoring these agents. METHODS Committee members developed and refined a series of questions about toxicities of immunosuppressives and current approaches to administration and monitoring. A systematic review was carried out by the American College of Chest Physicians. Committee members were supplied with this information and created this evidence-based guideline. CONCLUSIONS It is hoped that these guidelines will improve patient safety when immunosuppressive drugs are given to lung transplant recipients and to patients with diffuse interstitial lung disease.
Collapse
Affiliation(s)
| | - Keith C Meyer
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Luis Angel
- University of Texas Health Sciences, San Antonio, TX
| | | | - Kevin M Chan
- University of Michigan Health Systems, Ann Arbor, MI
| | | | | | - Mary S Hayney
- University of Wisconsin School of Pharmacy, Madison, WI
| | | | | | | | | | | |
Collapse
|
4
|
Elderly Transplant Recipients. PRINCIPLES AND PRACTICE OF GERIATRIC SURGERY 2011. [PMCID: PMC7120546 DOI: 10.1007/978-1-4419-6999-6_98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
While the total number of organs transplanted in this country has increased over the years, there is still an ever-widening gap between the need for organs and our capacity to meet that need as the overall waiting list continues to grow. This is due in part to significant advances in transplant techniques and outcomes such that Americans with organ failure now seek transplants in greater numbers. Additionally, life-expectancy gains in the United States are creating an aging population who are more likely to suffer organ failure than younger Americans. The national transplant waiting list has continued to shift toward older candidates. The Scientific Registry of Transplant Recipients (SRTR) reported that at the end of 2007, 59.7% of all 97,248 candidates on the waiting list for all organs were 50 years old or older, and 14.9% were 65 years or older. These percentages are substantially higher than they were in 1998 (41.5 and 8.1%, respectively) [1].
Collapse
|
5
|
Taylor JL, Palmer SM. Critical care perspective on immunotherapy in lung transplantation. J Intensive Care Med 2006; 21:327-44. [PMID: 17095497 DOI: 10.1177/0885066606292876] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Lung transplantation is now a viable therapeutic option in the care of patients with advanced pulmonary parenchymal or pulmonary vascular disease. Lung transplantation, however, with chronic posttransplant immunosuppression, creates a uniquely vulnerable population of patients likely to experience significant life-threatening complications requiring intensive care. The introduction of several novel immunosuppressive agents, such as sirolimus and mycophenolate mofetil, in conjunction with more established agents such as cyclosporine and tacrolimus, has greatly increased treatment options for lung transplant recipients and likely contributed to improved short-term transplant outcomes. Modern transplant immunosuppression, however, is associated with a host of complications such as opportunistic infections, renal failure, and thrombotic thrombocytopenic purpura. The main focus of this review is to provide a comprehensive summary of modern immunotherapy in lung transplantation and to increase awareness of the serious and potentially life-threatening complications of these medications.
Collapse
|
6
|
Moffatt-Bruce SD, Karamichalis J, Robbins RC, Whyte RI, Theodore J, Reitz BA. Are heart-lung transplant recipients protected from developing bronchiolitis obliterans syndrome? Ann Thorac Surg 2006; 81:286-91; discussion 291. [PMID: 16368382 DOI: 10.1016/j.athoracsur.2005.08.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2004] [Revised: 07/30/2005] [Accepted: 08/15/2005] [Indexed: 11/23/2022]
Abstract
BACKGROUND Heart-lung transplant recipients, when compared with heart transplant recipients, are relatively spared from allograft coronary artery disease. This study was undertaken to investigate whether heart-lung transplant recipients are also spared from experiencing bronchiolitis obliterans syndrome (BOS) when compared with double-lung transplant recipients. In addition, the risk factors for developing BOS after lung transplantation were analyzed. METHODS Heart-lung and bilateral sequential double-lung transplant recipients were reviewed retrospectively from 1990 to 2000 using the Stanford Transplant Database. The heart-lung transplant group consisted of 77 heart-lung transplant recipients and the double-lung transplant group consisted of 51 double-lung transplant recipients. The rates of BOS, survival, acute rejection, and cytomegalovirus infection at 1, 3, and 5 years were measured. RESULTS There were no significant differences in patient demographics between the two groups. Rates of survival and acute rejection were similar in the two transplant groups. The incidence of cytomegalovirus infection was significantly higher in heart-lung transplant recipients. Freedom from BOS was similar in the two transplant groups. Risk factors for the development of BOS in the heart-lung and double-lung transplant recipients included male donor, younger recipient age, a diagnosis other than cystic fibrosis, nonuse of cardiopulmonary bypass, and the use of OKT3 induction therapy. CONCLUSIONS Heart-lung transplant recipients exhibit BOS at a rate similar to double-lung transplant recipients. The immunoprotective effect the lung allograft presumably provides the heart is not reciprocated by the heart in preventing the development of BOS.
Collapse
Affiliation(s)
- Susan D Moffatt-Bruce
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA
| | | | | | | | | | | |
Collapse
|
7
|
Moffatt SD, Demers P, Robbins RC, Doyle R, Wienacker A, Henig N, Theodore J, Reitz BA, Whyte RI. Lung transplantation: A decade of experience. J Heart Lung Transplant 2005; 24:145-51. [PMID: 15701428 DOI: 10.1016/j.healun.2003.10.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2003] [Revised: 09/10/2003] [Accepted: 10/22/2003] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Over the past 3 decades, the field of lung transplantation has been refined. However, many barriers exist that limit long-term success. The purpose of this study was to review a single institution's long-term experience with single and double lung transplantation and to assess the effect of different immunosuppressive therapies on outcomes. METHODS Lung transplant recipients, both single and double, were reviewed, retrospectively. Patients were divided into five groups: group I, all lung transplants (n = 127); group II, single lung transplants (n = 73); group III, double lung transplants (n = 54); group IV, OKT3 induction therapy recipients (n = 27); and group V, RATG induction therapy recipients (n = 100). Rates of survival, rejection, bronchiolitis obliterans syndrome (BOS) and infection were analyzed at 1, 3, and 5 years. RESULTS There were no significant differences in survival, acute rejection rate, freedom from BOS, nor infection between single and double lung transplant recipients. Induction therapy with RATG (group V) was associated with significantly improved survival and freedom from acute rejection, BOS, and infection when compared to OKT3 induction therapy (group IV). CONCLUSIONS An earlier impression that RATG is superior to OKT3 induction therapy has borne true in terms of overall survival and incidence of BOS, acute rejection and infection rates. Lung transplantation, using RATG induction therapy, remains an important modality for end-stage pulmonary disease.
Collapse
Affiliation(s)
- Susan D Moffatt
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Roberts DH, Wain JC, Chang Y, Ginns LC. Donor—recipient gender mismatch in lung transplantation: Impact on obliterative bronchiolitis and survival. J Heart Lung Transplant 2004; 23:1252-9. [PMID: 15539123 DOI: 10.1016/j.healun.2003.09.014] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2003] [Revised: 09/08/2003] [Accepted: 09/26/2003] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Because of the shortage of donor lungs, liberalization of donor selection criteria in terms of age, gas exchange, and smoking history has been proposed. METHODS We evaluated a single-institution population of lung transplant recipients (n = 98) for donor-recipient gender matching. We measured overall survival, time to acute allograft rejection, and time to development of obliterative bronchiolitis (OB). RESULTS We found significant improvement in overall survival for gender-mismatched donor and recipient pairs (p = 0.078) and a significantly shorter OB-free period for male donor and female recipient pairs (p = 0.017). CONCLUSION These findings suggest that donor organ allocation based on gender may affect long-term survival and other outcomes after lung transplantation.
Collapse
Affiliation(s)
- David H Roberts
- Pulmonary and Critical Care Unit, General Medical Services, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA
| | | | | | | |
Collapse
|
9
|
Abstract
BOS remains a difficult problem to control following lung transplantation, largely because of uncertainties regarding the underlying mechanisms that are responsible for it. Continued work on the pathogenesis of BOS is essential. The progressive nature and poor outlook when BOS stage 3 is reached indicates that current strategies should be focused on prevention and early intervention. There is a great need for randomized, controlled trials on intervention if the international transplant community is to make progress in this area.
Collapse
Affiliation(s)
- Paul A Corris
- University of Newcastle upon Tyne and Regional Cardiothoracic Centre, Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK.
| |
Collapse
|
10
|
Pinderski LJ, Fonarow GC, Hamilton M, Fishbein MC, Marelli D, Moriguchi J, Cohen B, Kobashigawa JA. Giant cell myocarditis in a young man responsive to T-lymphocyte cytolytic therapy. J Heart Lung Transplant 2002; 21:818-21. [PMID: 12100910 DOI: 10.1016/s1053-2498(01)00396-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We describe a case of a 40-year-old man who presented with recent-onset, rapidly decompensating heart failure, and who was found to have giant cell myocarditis (GCM) on biopsy. The patient responded to myocardial rest on a biventricular assist device, as well as immunosuppression that included eradication of T cells using OKT3 therapy, coupled with high-dose steroids. The patient was successfully weaned off mechanical support, and ultimately discharged home, where he continues to do well. Based on a review of the clinical and experimental literature, we believe treatment with T-lymphocytic cytolytic therapy may be beneficial. Further studies using this therapy in the treatment of GCM are warranted.
Collapse
Affiliation(s)
- Laura J Pinderski
- Division of Cardiology, UCLA Medical Center, Los Angeles, California, USA.
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Duarte AG, Lick S. Perioperative care of the lung transplant patient. CHEST SURGERY CLINICS OF NORTH AMERICA 2002; 12:397-416. [PMID: 12122831 DOI: 10.1016/s1052-3359(02)00007-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Improvements in the perioperative management of lung transplant recipients have produced a 90% survival in the first 30 days following surgery. Detailed attention to donor organ procurement and preservation of the allograft are important in ensuring an early successful outcome. Early antibacterial administration based on donor or pretransplant cultures and antiviral therapy in CMV-negative recipients assist in avoiding early infectious complications. Development of hypoxemia or hemodynamic instability in the perioperative period requires a rapid, systematic evaluation with attention to mechanical, immunologic, or infectious causes. Nonpulmonary complications are not infrequent in lung transplant recipients.
Collapse
Affiliation(s)
- Alexander G Duarte
- Division of Pulmonary & Critical Care Medicine, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0561, USA.
| | | |
Collapse
|
12
|
Affiliation(s)
- D L DeMeo
- Lung Transplant Program, Pulmonary and Critical Care Unit, Bigelow 808, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | | |
Collapse
|
13
|
Brock MV, Borja MC, Ferber L, Orens JB, Anzcek RA, Krishnan J, Yang SC, Conte JV. Induction therapy in lung transplantation: a prospective, controlled clinical trial comparing OKT3, anti-thymocyte globulin, and daclizumab. J Heart Lung Transplant 2001; 20:1282-90. [PMID: 11744411 DOI: 10.1016/s1053-2498(01)00356-4] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Because acute rejection is associated with inferior outcomes in lung transplantation, we have routinely employed OKT3, anti-thymocyte globulin (ATG), or daclizumab as adjuncts to reduce rejection. METHOD We performed a 4-year prospective, controlled clinical trial of these 3 therapies to determine differences in post-operative infection, rejection, survival, and bronchiolitis obliterans syndrome (BOS). Eighty-seven consecutive lung transplant patients received OKT3 (n = 30), ATG (n = 34), and daclizumab (n = 23) as induction agents. The groups had similar demographics and immunosuppression protocols differing only in induction agents used. RESULTS No differences were observed in immediate post-operative outcomes such as length of hospitalization, ICU stay, or time on ventilators. Twelve months post-transplant, OKT3 had more infections per patient than the other agents, a difference that only became significant 2 months post-operatively (p = 0.009). The most common infection was bacterial and OKT3 had more bacterial infections than any other agent. Daclizumab had more patients remain infection free in the first year (p = 0.02), having no fungal infections and a low rate of viral infections. No patient receiving daclizumab developed drug specific side-effects. Only those patients with episodes of acute rejection developed BOS. There were no significant differences in the freedom from acute rejection or BOS between the groups. The 2-year survival for the entire cohort was 68%, with no differences observed in patient survival. CONCLUSIONS This study again reveals the importance of acute rejection in the subsequent development of BOS. Although daclizumab offers a low risk of post-transplant infection and drug specific side-effects, no drug is superior in delaying rejection or BOS or in prolonging long-term survival.
Collapse
Affiliation(s)
- M V Brock
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Dupuis RE, Taber DJ, Fann AL, Lumbert KP. Medical Management Considerations for Patients With Lung Transplantation. J Pharm Pract 2001. [DOI: 10.1106/7yoj-rukc-p7gv-v1uv] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Lung transplantation has become an accepted modality for the treatment of end-stage lung disease. Adult and pediatric patients with a variety of lung diseases, including cystic fibrosis, chronic obstructive pulmonary disease, and idiopathic pulmonary fibrosis are candidates for lung transplantation. Lung transplantation can extend survival and improve quality of life for these patients. With the introduction of new immunosuppressive agents and enhanced surgical and medical care, both short- and long-term morbidity and mortality in these populations, although not as good as other transplant types, are improving. After lung transplantation, recipients continue to face a number of obstacles including post-operative complications, complex drug regimens, drug-induced toxicities, infection, and rejection. An understanding of the management and monitoring issues after lung transplantation is the focus of this review.
Collapse
Affiliation(s)
- Robert E. Dupuis
- School of Pharmacy, Beard Hall CB#7360, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7360,
| | - David J. Taber
- Department of Pharmacy, UNC Hospitals, 101 Manning Drive, Chapel Hill, NC 27514
| | - Amy L. Fann
- Department of Pharmacy, UNC Hospitals, 101 Manning Drive, Chapel Hill, NC 27514
| | - Kevin P. Lumbert
- University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7360
| |
Collapse
|
15
|
Abstract
Lung transplantation has become a viable treatment option for patients with end-stage lung disease. Donor selection and organ allocation must follow specific guidelines. Single, bilateral, and living-donor lobar transplantation have all been performed successfully for a variety of diseases. Complications include reimplantation response and airway complications. Rejection may occur in the hyperacute, acute, or chronic settings and requires judicious management with immunosuppression. Infection and malignancy remain potential complications of the commitment to lifelong systemic immunosuppression. Survival statistics have remained encouraging and continue to improve with experience. Improved exercise tolerance and quality of life have been demonstrated in the years following transplantation. Remaining obstacles include limited donor organ availability, long-term graft function, and patient survival. However, ongoing advances in immune tolerance and standardized training of physicians in the care of transplant patients should carry lung transplant forward in the twenty-first century.
Collapse
Affiliation(s)
- D L DeMeo
- Pulmonary and Critical Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114, USA.
| | | |
Collapse
|
16
|
Bronchiolitis obliterans syndrome in lung transplantation: risk factors and markers for development of the disease. Curr Opin Organ Transplant 2000. [DOI: 10.1097/00075200-200012000-00015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
17
|
|
18
|
Strahilevitz J, Sugar AM, Engelhard D. Fluconazole in transplant recipients: options and limitations. Transpl Infect Dis 2000; 2:62-71. [PMID: 11429014 DOI: 10.1034/j.1399-3062.2000.020204.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Fluconazole is currently a first-line agent used for therapy of non-critically ill patients with candidal infection. Its efficacy, the availability of an oral formula, and its relatively low toxicity make it a very attractive drug for use in many clinical situations. The advisability of prophylaxis and empirical treatment in transplant patients is a difficult issue for the following reasons: the potential emergence of resistance to the azoles, the lack of solid data establishing its advantage over placebo and/or oral nonabsorbable antifungal agents in some of the clinical conditions encountered, its ineffectiveness against molds, and its cost. Judicious use of fluconazole where its efficacy has been well established would provide the best therapy for patients and would limit the emergence of potential pathogens. As new antifungal agents are approved for clinical use, appropriate clinical trials will need to be designed and conducted in order for clinicians to make rational decisions in selecting the most appropriate drug for the specific indication. Prophylaxis and treatment with fluconazole in various transplant situations is reviewed.
Collapse
Affiliation(s)
- J Strahilevitz
- The Department of Clinical Microbiology and Infectious Diseases, Hadassah University Hospital, Jerusalem, Israel
| | | | | |
Collapse
|
19
|
Laroche-Traineau J, Clofent-Sanchez G, Santarelli X. Three-step purification of bacterially expressed human single-chain Fv antibodies for clinical applications. JOURNAL OF CHROMATOGRAPHY. B, BIOMEDICAL SCIENCES AND APPLICATIONS 2000; 737:107-17. [PMID: 10681047 DOI: 10.1016/s0378-4347(99)00441-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We have obtained a cell line which secretes a human monoclonal IgM (B7) reacting with the myosin heavy chain of human heart. We have constructed single-chain fragments (scFv) of B7. The scFv may be useful for the imaging of myocardial necrosis after myocarditis, cardiac drug toxicosis or graft rejection. The aim of our work was to purify the scFv for immunoscintigraphy. We describe several purification steps including immobilized metal affinity chromatography (IMAC), anti-c-myc monoclonal antibody affinity chromatography, size-exclusion chromatography with Superdex 75 HR 10/30 and ion-exchange chromatography (mini Q TM 30Q).
Collapse
Affiliation(s)
- J Laroche-Traineau
- Laboratoire de Pathologie Cellulaire de l'Hémostase, CNRS, UMR 5533, Hôpital du Haut-Lévêque, Pessac, France
| | | | | |
Collapse
|
20
|
|