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Clinical Correlates and Outcomes of Dual Basiliximab and Antithymocyte Globulin Induction in Kidney Transplant Recipients: A National Study. Transplant Direct 2021; 7:e736. [PMID: 35836670 PMCID: PMC9276156 DOI: 10.1097/txd.0000000000001190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 05/19/2021] [Indexed: 11/26/2022] Open
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Ciancio G, Gaynor JJ, Guerra G, Sageshima J, Roth D, Chen L, Kupin W, Mattiazzi A, Tueros L, Flores S, Hanson L, Ruiz P, Vianna R, Burke GW. Randomized trial of rATg/Daclizumab vs. rATg/Alemtuzumab as dual induction therapy in renal transplantation: Results at 8years of follow-up. Transpl Immunol 2016; 40:42-50. [PMID: 27888093 DOI: 10.1016/j.trim.2016.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 11/16/2016] [Accepted: 11/17/2016] [Indexed: 01/28/2023]
Abstract
Our goal in using dual induction therapy is to bring the kidney transplant recipient closer (through more effectively timed lymphodepletion) to an optimally immunosuppressed state. Here, we report long-term results of a prospective randomized trial comparing (Group I,N=100) rATG/Dac (3 rATG, 2 Dac doses) vs. (Group II,N=100) rATG/Alemtuzumab(C1H) (1 dose each), using reduced tacrolimus dosing, EC-MPS, and early corticosteroid withdrawal. Lower EC-MPS dosing was targeted in Group II to avoid severe leukopenia. Median follow-up was 96mo post-transplant. There were no differences in 1st BPAR (including borderline) rates: 10/100 vs. 9/100 in Groups I and II during the first 12mo(P=0.54), and 20/100 vs. 20/100 throughout the study(P=0.90). Equally favorable renal function was maintained in both treatment arms(N.S.). While not significant, more patients in Group II experienced graft loss, 25/100 vs. 18/100 in Group I(P=0.23). Actuarial patient/graft survival at 96mo was 92%/83% vs. 85%/73% in Groups I and II(N.S.). DWFG-due-to-infection(N.S.), EC-MPS withholding-due-to-leukopenia during the first 2mo(P=0.03), and incidence of viral infections(P=0.09) were higher in Group II, whereas EC-MPS withholding-due-to-GI symptoms was higher in Group I(P=0.009). No other adverse event differences were observed. While long-term anti-rejection and renal function efficacy were demonstrated in both treatment arms, slight over-immunosuppression of Group II patients occurred.
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Affiliation(s)
- Gaetano Ciancio
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Jeffrey J Gaynor
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Giselle Guerra
- Division of Nephrology of the Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Junichiro Sageshima
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - David Roth
- Division of Nephrology of the Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Linda Chen
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Warren Kupin
- Division of Nephrology of the Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Adela Mattiazzi
- Division of Nephrology of the Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Lissett Tueros
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Sandra Flores
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Lois Hanson
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Phillip Ruiz
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Rodrigo Vianna
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - George W Burke
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
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Jalalzadeh M, Mousavinasab N, Peyrovi S, Ghadiani MH. The impact of acute rejection in kidney transplantation on long-term allograft and patient outcome. Nephrourol Mon 2015; 7:e24439. [PMID: 25738128 PMCID: PMC4330708 DOI: 10.5812/numonthly.24439] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 11/01/2014] [Accepted: 11/05/2014] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Patients with end stage renal disease (ESRD) can be sustained with dialysis therapy. OBJECTIVES In this study, we followed up the effect of early acute and late acute rejections on survival rates of patients' grafts. PATIENTS AND METHODS We investigated the timing and frequency of acute rejection episodes related to long-term patient-graft survival in Taleghani hospital between 1990 and 2011. Recipients were divided into three groups as Group-1 (no rejection), Group-2 (early acute rejection [EAR]: less than 3-months) and Group-3 (late acute rejection [LAR]: after 3 months of transplant). RESULTS One and five-year patient's survival rates were 94.87% and 93.8%, and graft survival (GS) rates were 92.6% and 81.9%. EAR and LAR occurred in 125 (18.8%) and 77 (11.7%) patients, respectively. Graft and patient survival rates at one and five years were as follows; Group-1 (Graft 96.7% and 94.5% patient: 97.4% and 96.8%), Group-2 (Graft: 72% and 61%, patient: 85.6% and 84%), Group-3 (Graft: 84.4% and 36.8%, patient: 92.2% and 89.4%). Recipient age, type and length of dialysis, number of transplantations and the status of panel reactivity antibody (PRA) had no effect on the type of rejection. LAR was more commonly associated with males (P = 0.001) and donors' age was associated with rejection (P = 0.0002). Five-year GS rate among the three groups was lower in the LAR group (P < 0.0001). CONCLUSIONS LAR had a negative impact on long-term renal allograft survival and the risk of chronic graft dysfunction increased in patients with a history of LAR.
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Affiliation(s)
- Mojgan Jalalzadeh
- Department of Nephrology, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | | | - Said Peyrovi
- Maraghe University of Medical Sciences, Maraghe, IR Iran
| | - Mohammad Hassan Ghadiani
- Department of Nephrology, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
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Ciancio G, Sageshima J, Chen L, Gaynor JJ, Hanson L, Tueros L, Montenora-Velarde E, Gomez C, Kupin W, Guerra G, Mattiazzi A, Fornoni A, Pugliese A, Roth D, Wolf M, Burke GW. Advantage of rapamycin over mycophenolate mofetil when used with tacrolimus for simultaneous pancreas kidney transplants: randomized, single-center trial at 10 years. Am J Transplant 2012; 12:3363-76. [PMID: 22946986 PMCID: PMC4479274 DOI: 10.1111/j.1600-6143.2012.04235.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Simultaneous pancreas kidney transplantation (SPKT) is the treatment of choice for patients with type 1 diabetes and end-stage renal disease. Rapamycin and mycophenolate mofetil (MMF) have been used for maintenance immunosuppression with tacrolimus in SPKT; however, long-term outcomes are lacking. From September 2000 through December 2009, 170 SPKT recipients were enrolled in a randomized, prospective trial receiving Rapamycin (n = 84) or MMF (n = 86). All patients received dual induction therapy with thymoglobulin and daclizumab, and low-dose maintenance tacrolimus and corticosteroids. Compared to MMF, rates of freedom from first biopsy-proven acute kidney or pancreas rejection were superior for Rapamycin at year 1 (kidney: 100% vs. 88%; P = 0.001; pancreas: 99% vs. 92%; P = 0.04) and at year 10 (kidney: 88% vs. 71%, P = 0.01; pancreas: 99% vs. 89%, P = 0.01). The higher rates of rejection were associated with withholding MMF (vs. Rapamycin, p = 0.009), generally for gastrointestinal or bone marrow toxicity. There was no significant difference in creatinine, proteinuria, c-peptide, viral infections, lymphoproliferative disorders or posttransplant diabetes. HbA1C and lipid levels were normal in both groups, although higher in the Rapamycin arm. There were no significant differences in patient or allograft survival. In this 10-year SPKT study, Rapamycin in combination with tacrolimus was better tolerated and more effective than MMF. Overall, the patient and allograft survival were equivalent.
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Affiliation(s)
- G. Ciancio
- Department of Surgery, Lillian Jean Kaplan Renal Transplant Center of the Division of Kidney and Pancreas Transplantation, University of Miami, Leonard M. Miller School of Medicine, Miami, FL
| | - J. Sageshima
- Department of Surgery, Lillian Jean Kaplan Renal Transplant Center of the Division of Kidney and Pancreas Transplantation, University of Miami, Leonard M. Miller School of Medicine, Miami, FL
| | - L. Chen
- Department of Surgery, Lillian Jean Kaplan Renal Transplant Center of the Division of Kidney and Pancreas Transplantation, University of Miami, Leonard M. Miller School of Medicine, Miami, FL
| | - J. J. Gaynor
- Department of Surgery, Lillian Jean Kaplan Renal Transplant Center of the Division of Kidney and Pancreas Transplantation, University of Miami, Leonard M. Miller School of Medicine, Miami, FL
| | - L. Hanson
- Department of Surgery, Lillian Jean Kaplan Renal Transplant Center of the Division of Kidney and Pancreas Transplantation, University of Miami, Leonard M. Miller School of Medicine, Miami, FL
| | - L. Tueros
- Department of Surgery, Lillian Jean Kaplan Renal Transplant Center of the Division of Kidney and Pancreas Transplantation, University of Miami, Leonard M. Miller School of Medicine, Miami, FL
| | - E. Montenora-Velarde
- Department of Surgery, Lillian Jean Kaplan Renal Transplant Center of the Division of Kidney and Pancreas Transplantation, University of Miami, Leonard M. Miller School of Medicine, Miami, FL
| | - C. Gomez
- Department of Surgery, Lillian Jean Kaplan Renal Transplant Center of the Division of Kidney and Pancreas Transplantation, University of Miami, Leonard M. Miller School of Medicine, Miami, FL
| | - W. Kupin
- Department of Medicine, Division of Nephrology and Hypertension, University of Miami, Leonard M. Miller School of Medicine, Miami, FL
| | - G. Guerra
- Department of Medicine, Division of Nephrology and Hypertension, University of Miami, Leonard M. Miller School of Medicine, Miami, FL
| | - A. Mattiazzi
- Department of Medicine, Division of Nephrology and Hypertension, University of Miami, Leonard M. Miller School of Medicine, Miami, FL
| | - A. Fornoni
- Department of Medicine, Division of Nephrology and Hypertension, University of Miami, Leonard M. Miller School of Medicine, Miami, FL,Diabetes Research Institute, University of Miami, Leonard M. Miller School of Medicine, Miami, FL
| | - A. Pugliese
- Diabetes Research Institute, University of Miami, Leonard M. Miller School of Medicine, Miami, FL
| | - D. Roth
- Department of Medicine, Division of Nephrology and Hypertension, University of Miami, Leonard M. Miller School of Medicine, Miami, FL
| | - M. Wolf
- Department of Medicine, Division of Nephrology and Hypertension, University of Miami, Leonard M. Miller School of Medicine, Miami, FL
| | - G. W. Burke
- Department of Surgery, Lillian Jean Kaplan Renal Transplant Center of the Division of Kidney and Pancreas Transplantation, University of Miami, Leonard M. Miller School of Medicine, Miami, FL,Diabetes Research Institute, University of Miami, Leonard M. Miller School of Medicine, Miami, FL,Corresponding author: George W. Burke III,
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Ciancio G, Gaynor JJ, Sageshima J, Guerra G, Zarak A, Roth D, Brown R, Kupin W, Chen L, Hanson L, Tueros L, Ruiz P, Livingstone AS, Burke GW. Randomized Trial of Dual Antibody Induction Therapy With Steroid Avoidance in Renal Transplantation. Transplantation 2011; 92:1348-57. [DOI: 10.1097/tp.0b013e3182384b21] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Prolonged lymphocyte depletion by single-dose rabbit anti-thymocyte globulin and alemtuzumab in kidney transplantation. Transpl Immunol 2011; 25:104-11. [DOI: 10.1016/j.trim.2011.07.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2011] [Revised: 07/06/2011] [Accepted: 07/07/2011] [Indexed: 12/17/2022]
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Ciancio G, Gaynor JJ, Zarak A, Sageshima J, Guerra G, Roth D, Brown R, Kupin W, Chen L, Tueros L, Hanson L, Ruiz P, Burke GW. Randomized trial of mycophenolate mofetil versus enteric-coated mycophenolate sodium in primary renal transplantation with tacrolimus and steroid avoidance: four-year analysis. Transplantation 2011; 91:1198-205. [PMID: 21107305 DOI: 10.1097/tp.0b013e3182003d76] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Our single-center, open-labeled randomized trial of 150 adult, primary kidney transplant recipients receiving 2 g mycophenolate mofetil (group A, n=75) versus 1.440 g enteric-coated mycophenolate sodium (group B, n=75), with reduced maintenance tacrolimus dosing, steroid elimination at 1 week, and combined rabbit antithymocyte globulin/daclizumab induction, previously showed at 1 year posttransplant low biopsy-proven acute rejection (BPAR), acceptably high renal function, and no differences in incidence of symptomatic gastrointestinal (GI) side effects between the two groups. This report includes 3 additional years of follow-up with similar endpoints as in the original study. METHODS Rates of developing first BPAR, graft failure (death censored and uncensored), death, and adverse events (GI toxicity, infections requiring hospitalization, and new onset diabetes mellitus after transplantation) during the first 48 months posttransplant were compared between the two groups using an intent-to-treat approach. RESULTS At 48 months posttransplant, patient/graft survival in groups A and B was 97%/90% vs. 96%/86%, respectively (not significant [NS]). Twenty-seven patients experienced BPAR (including borderline), with actuarial 19% (14/75) vs. 18% (13/75) in groups A and B, respectively (NS). Geometric mean*/standard error serum creatinine level and arithmetic mean calculated glomerular filtration rate (±standard error) at 48 months in groups A and B, respectively, were 1.25*/1.06 and 69.2±3.9 vs. 1.20*/1.05 and 71.2±3.2 (NS). Incidence of new onset diabetes mellitus after transplantation (22% vs. 15%), infections requiring hospitalization (31% vs. 39%), and GI side effects (45% vs. 52%) seemed equivalent. CONCLUSIONS This is the first long-term, randomized trial comparing enteric-coated mycophenolate sodium versus mycophenolate mofetil along with reduced maintenance tacrolimus dosing and steroid avoidance, which resulted in similarly low-BPAR rates, acceptably high renal function at 48 months, and an equivalent side effect profile.
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Affiliation(s)
- Gaetano Ciancio
- The Lillian Jean Kaplan Renal Transplant Center of the Division of Transplantation, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL 33101, USA.
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Webster AC, Ruster LP, McGee RG, Matheson SL, Higgins GY, Willis NS, Chapman JR, Craig JC. Interleukin 2 receptor antagonists for kidney transplant recipients. Cochrane Database Syst Rev 2010; 2010:CD003897. [PMID: 20091551 PMCID: PMC7154335 DOI: 10.1002/14651858.cd003897.pub3] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Interleukin 2 receptor antagonists (IL2Ra) are used as induction therapy for prophylaxis against acute rejection in kidney transplant recipients. Use of IL2Ra has increased steadily since their introduction, but the proportion of new transplant recipients receiving IL2Ra differs around the globe, with 27% of new kidney transplant recipients in the United States, and 70% in Australasia receiving IL2Ra in 2007. OBJECTIVES To systematically identify and summarise the effects of using an IL2Ra, as an addition to standard therapy, or as an alternative to another immunosuppressive induction strategy. SEARCH STRATEGY We searched the Cochrane Renal Group's specialised register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE to identify new records, and authors of included reports were contacted for clarification where necessary. SELECTION CRITERIA Randomised controlled trials (RCTs) in all languages comparing IL2Ra to placebo, no treatment, other IL2Ra or other antibody therapy. DATA COLLECTION AND ANALYSIS Data was extracted and assessed independently by two authors, with differences resolved by discussion. Dichotomous outcomes are reported as relative risk (RR) and continuous outcomes as mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS We included 71 studies (306 reports, 10,537 participants). Where IL2Ra were compared with placebo (32 studies; 5,784 patients) graft loss including death with a functioning graft was reduced by 25% at six months (16 studies: RR 0.75, 95% CI 0.58 to 0.98) and one year (24 studies: RR 0.75, 95% CI 0.62 to 0.90), but not beyond this. At one year biopsy-proven acute rejection was reduced by 28% (14 studies: RR 0.72, 95% CI 0.64 to 0.81), and there was a 19% reduction in CMV disease (13 studies: RR 0.81, 95% CI 0.68 to 0.97). There was a 64% reduction in early malignancy within six months (8 studies: RR 0.36, 95% CI 0.15 to 0.86), and creatinine was lower (7 studies: MD -8.18 micromol/L 95% CI -14.28 to -2.09) but these differences were not sustained.When IL2Ra were compared to ATG (16 studies, 2211 participants), there was no difference in graft loss at any time point, or for acute rejection diagnosed clinically, but the was benefit of ATG therapy over IL2Ra for biopsy-proven acute rejection at one year (8 studies:, RR 1.30 95% CI 1.01 to 1.67), but at the cost of a 75% increase in malignancy (7 studies: RR 0.25 95% CI 0.07 to 0.87) and a 32% increase in CMV disease (13 studies: RR 0.68 95% CI 0.50 to 0.93). Serum creatinine was significantly lower for IL2Ra treated patients at six months (4 studies: MD -11.20 micromol/L 95% CI -19.94 to -2.09). ATG patients experienced significantly more fever, cytokine release syndrome and other adverse reactions to drug administration and more leucopenia but not thrombocytopenia. There were no significant differences in outcomes according to cyclosporine or tacrolimus use, azathioprine or mycophenolate, or to the study populations baseline risk for acute rejection. There was no evidence that effects were different according to whether equine or rabbit ATG was used. AUTHORS' CONCLUSIONS Given a 38% risk of rejection, per 100 recipients compared with no treatment, nine recipients would need treatment with IL2Ra to prevent one recipient having rejection, 42 to prevent one graft loss, and 38 to prevent one having CMV disease over the first year post-transplantation. Compared with ATG treatment, ATG may prevent some experiencing acute rejection, but 16 recipients would need IL2Ra to prevent one having CMV, but 58 would need IL2Ra to prevent one having malignancy. There are no apparent differences between basiliximab and daclizumab. IL2Ra are as effective as other antibody therapies and with significantly fewer side effects.
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Affiliation(s)
- Angela C Webster
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
| | - Lorenn P Ruster
- The Children's Hospital at WestmeadCentre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
| | - Richard G McGee
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
| | - Sandra L Matheson
- The Children's Hospital at WestmeadCentre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
| | - Gail Y Higgins
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2045
| | - Narelle S Willis
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2045
| | - Jeremy R Chapman
- Westmead Millennium Institute, The University of Sydney at WestmeadCentre for Transplant and Renal ResearchDarcy RdWestmeadNSWAustralia2145
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
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Ciancio G, Burke GW, Gaynor JJ, Roth D, Sageshima J, Kupin W, Tueros L, Hanson L, Rosen A, Ruiz P, Miller J. Randomized Trial of Mycophenolate Mofetil Versus Enteric-Coated Mycophenolate Sodium in Primary Renal Transplant Recipients Given Tacrolimus and Daclizumab/Thymoglobulin: One Year Follow-Up. Transplantation 2008; 86:67-74. [DOI: 10.1097/tp.0b013e3181734b4a] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Burke GW, Ciancio G, Figueiro J, Buigas R, Olson L, Roth D, Kupin W, Miller J. Hypercoagulable state associated with kidney-pancreas transplantation. Thromboelastogram-directed anti-coagulation and implications for future therapy. Clin Transplant 2004; 18:423-8. [PMID: 15233820 DOI: 10.1111/j.1399-0012.2004.00183.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The clinical consequences of type 1 diabetes mellitus (IDDM) include diabetic triopathy: retinopathy, nephropathy, and neuropathy, as well as microangiopathy, accelerated atherosclerotic disease, and hypercoagulability. The etiology of the hypercoagulability is multifactorial, involving various clotting factors or pathways (for example platelets, fibrinogen, individual components of the clotting system and/or fibrinolysis in different studies). The development of end-stage renal disease (ESRD), with the uremia-related platelet effect has the potential to protect from the existing hypercoagulable state. This has important implications for surgery, particularly simultaneous pancreas-kidney (SPK) transplantation, where the pancreas has historically been prone to thrombosis. This has led us to perform intra-operative thromboelastograms (TEG's) to evaluate the patient's current coagulation status. METHODS A TEG was performed in 85 SPK recipients along with a control group of 54 non-diabetic kidney transplant (KT) recipients. RESULTS For each of the 4 TEG coagulation parameters, the SPK recipients were significantly more hypercoagulable than the non-diabetic KT recipients. The use of intra-operative heparin is based on the degree of hypercoagulability by TEG and degree of operative hemostasis. There has been one PT lost to thrombosis (1%) in the first week following transplantation during this time. CONCLUSION The use of TEG is a helpful adjunct to SPK surgery, demonstrating the patient's current coagulation status. Nearly all SPK recipients (type 1 IDDM with ESRD) have been demonstrated to be hypercoagulable. The TEG allows the judicious use of anti-coagulation at the time of surgery, and beyond.
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Affiliation(s)
- George W Burke
- Department of Surgery, Division of Transplantation, University of Miami School of Medicine, Miami, FL 33101, USA.
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