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Faravardeh A, Akkina S, Villicana R, Guerra G, Moten MA, Meier-Kriesche U, Stevens DR, Patel SJ, Bunnapradist S. Efficacy and Safety of Once-Daily LCP-Tacrolimus Versus Twice-Daily Immediate-Release Tacrolimus in Adult Hispanic Stable Kidney Transplant Recipients: Sub-Group Analysis from a Phase 3 Trial. Ann Transplant 2021; 26:e929535. [PMID: 33859155 PMCID: PMC8056872 DOI: 10.12659/aot.929535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The pharmacokinetics and metabolism of tacrolimus, an immunosuppressant commonly used to prevent transplant rejection, can differ in specific subpopulations. This analysis examined treatment outcomes and safety of immediate-release tacrolimus (IR-Tac) and LCP-tacrolimus (LCPT) in stable Hispanic kidney transplant recipients. MATERIAL AND METHODS This was a post hoc analysis of clinical trial data from Hispanic adult stable kidney transplant recipients randomized to remain on IR-Tac or convert from IR-Tac to a reduced dose of LCPT (NCT00817206). Composite treatment failure was evaluated at 12 months. Estimated glomerular filtration rate and tacrolimus trough concentrations were evaluated over 12 months. RESULTS Fifty-five stable (LCPT n=26, IR-Tac n=29) kidney transplant recipients who self-identified as Hispanic or Latino were included in this analysis. Composite treatment failure occurred in 1 patient (4%) who converted to LCPT and 1 (3%) who remained on IR-Tac. The estimated glomerular filtration rate was stable over time and similar in the 2 treatment groups (P=0.08). Tacrolimus trough levels for both groups were similar over time in the 2 treatment groups (P=0.98). Treatment-emergent adverse events were similar in patients who converted to LCPT and in those who remained on IR-Tac. CONCLUSIONS Efficacy and safety were similar in Hispanic kidney transplant recipients who converted from IR-Tac to LCPT and in those remaining on IR-Tac.
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Affiliation(s)
| | - Sanjeev Akkina
- Loyola Outpatient Center, Loyola University Medical Center, Maywood, IL, USA
| | - Rafael Villicana
- Loma Linda University Transplant Institute, Loma Linda University Health, Loma Linda, CA, USA
| | - Giselle Guerra
- Miami Transplant Institute, University of Miami Health System, Miami, FL, USA
| | - Misbah A Moten
- Department of Medical Affairs, Veloxis Pharmaceuticals, Cary, NC, USA
| | | | - Daniel R Stevens
- Department of Medical Affairs, Veloxis Pharmaceuticals, Cary, NC, USA
| | - Samir J Patel
- Department of Medical Affairs, Veloxis Pharmaceuticals, Cary, NC, USA
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2
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Xu J, Wang G, Tan S, Ge Y, Liu J, Rao M, Deng Y. The clinical effect of Prednisone in combination with Mycophenolate mofetil on idiopathic thrombocytopenic purpura (ITP) and its influence on the level of peripheral blood T lymphocytes and NK lymphocytes. Saudi J Biol Sci 2020; 26:2108-2112. [PMID: 31889803 PMCID: PMC6923462 DOI: 10.1016/j.sjbs.2019.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 11/29/2022] Open
Abstract
Objective To explore he curative effect and safety of Prednisone in combination with Mycophenolate in treating ITP and its influence on the level of peripheral blood T lymphocytes and NK lymphocytes. Method 93 cases of ITP patients were divided into the observation group and the control group by the Random Number Table method, 48 cases for the observation group, 45 for another. Patients in the control group orally took 0.5 mg/kg Prednisone Acetate tablets daily, two times each in the morning and evening. And the observation group, based on the treatment of the control group, orally took Mycophenolate Mofetil Dispersible tablets twice a day, 1 g each time. According to patients’ conditions, 3 to 5 courses were set for treatment with 3 weeks a course. Compared PLT amount and the changing situation of inflammatory factors, CD3+ and CD3+CD95L+ before and after the treatment, the level of CD3+Caspase-3+ and CD3+Caspase-8+, NK+, NK+ CD95L+, NK+Caspase-3+, NK+Caspase-8, the curative effect and adverse events. Result After treatment, PLT amount in both groups increased, and the increase in the observation group was much higher than that of the control group, the difference had statistical significance (P < 0.05). The time needed for PLT amount in the control group to reach the normal and peak values was longer than that of the observation group, whose PLT peak value was higher than another group. The difference had statistical significance (P < 0.05). After the treatment, the levels of TNF-α and IL-6 were lowered, and the value of the observation group was lower than that of another. The difference between and within the group has statistical significance. After the treatment, the level of CD3+, CD3+CD95L+ and CD3+Caspase-8+ is much higher and CD3+Caspase-3+ level lower than that before the treatment. The difference has statistical significance (P < 0.05). After the treatment, the level of NK+ and NK+ CD95L+ is higher and the level of NK+Caspase-8+ lower than that before the treatment. The difference has statistical significance (P < 0.05). After the treatment, the total effective rate 91.67% of the observation group is much higher than that 75.56% of another. The difference has statistical significance (P < 0.05). After the treatment, the incidence rate of adverse events in the control group is 11.11% (5/45), while 4.17% (2/48) in the observation group. The difference between groups has statistical significance (χ2 = 3.890, P < 0.05). Conclusion The curative effect of Prednisone in combination with Mycophenolate on ITP patients is better than orally taking Prednisone tablets. Moreover, when it comes to Prednisone in combination with Mycophenolate, both the PLT amount and immunocompetence are improved without much adverse reaction, and the molecules of peripheral blood T lymphocytes and NK lymphocytes can be effectively adjusted to relieve the symptoms. So the method is trustworthy to be popularized for clinical practices.
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Affiliation(s)
- Jiangwei Xu
- Department of Pediatrics, Department of Western Medicine, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi 445000, China
| | - Gangzuo Wang
- Department of Pediatrics, Department of Western Medicine, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi 445000, China
| | - Sihai Tan
- Department of Pediatrics, Department of Western Medicine, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi 445000, China
| | - Yirong Ge
- Department of Pediatrics, Department of Western Medicine, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi 445000, China
| | - Jingzhen Liu
- Department of Pediatrics, Department of Western Medicine, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi 445000, China
| | - Mei Rao
- Department of Pediatrics, Department of Western Medicine, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi 445000, China
| | - Yufeng Deng
- Department of Pediatrics, Department of Western Medicine, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi 445000, China
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3
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Taber DJ, Gebregziabher M, Posadas A, Schaffner C, Egede LE, Baliga PK. Pharmacist-Led, Technology-Assisted Study to Improve Medication Safety, Cardiovascular Risk Factor Control, and Racial Disparities in Kidney Transplant Recipients. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019; 1:81-88. [PMID: 30714026 DOI: 10.1002/jac5.1024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Introduction Health disparities in African-American (AA) kidney transplant recipients compared with non-AA recipients are well established. Cardiovascular disease (CVD) risk control is a significant mediator of this disparity. Objective To assess the efficacy of improved medication safety, CVD risk control, and racial disparities in kidney transplant recipients. Methods Prospective, pharmacist-led, technology-aided, 6-month interventional clinical trial. A total of 60 kidney recipients with diabetes and hypertension were enrolled. Patients had to be at least one-year post transplant with stable graft function. Primary outcome measured included hypertension, diabetes, and lipid control using intent-to-treat analyses, with differences assessed between AA and non-AA recipients. Results The participants mean age was 59 years, with 42% being female and 68% being AA. Overall, patients demonstrated improvements in blood pressure <140/90 mmHg (baseline 50% vs. end of study 68%, p=0.054) and hemoglobin A1c <7% (baseline 33% vs. end of study 47%, p=0.061). AAs demonstrated a significant reduction from baseline in systolic blood pressure (-0.86 mmHg per month, p=0.026), which was not evident in non-AAs (-0.13 mmHg per month, p=0.865). Mean HgbA1c decreased from baseline in the overall group (-0.12% per month, p=0.003), which was similar within AAs (-0.11% per month, p=0.004) and non-AAs (-0.14% per month, p=0.029). There were no changes in low-density lipoproteins, triglycerides, or high-density lipoproteins over the course of the study. Medication errors were significantly reduced and self-reported medication adherence significantly improved over the course of the study. Conclusion These results demonstrate the potential efficacy of a pharmacist-led, technology-aided, educational intervention in improving medication safety, diabetes, and hypertension and reducing racial disparities in AA kidney transplant recipients. (ClinicalTrials.gov NCT02763943).
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Affiliation(s)
- David J Taber
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC.,Department of Pharmacy Services, Ralph H Johnson VAMC, Charleston, SC
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Aurora Posadas
- Division of Transplant Nephrology, College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Caitlin Schaffner
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Leonard E Egede
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Prabhakar K Baliga
- Department of Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC
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Cole AJ, Johnson RW, Egede LE, Baliga PK, Taber DJ. Improving Medication Safety and Cardiovascular Risk Factor Control to Mitigate Disparities in African-American Kidney Transplant Recipients: Design and Methods. Contemp Clin Trials Commun 2018. [PMID: 29532038 PMCID: PMC5844505 DOI: 10.1016/j.conctc.2017.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
There is a lack of data analyzing the influence of cardiovascular disease (CVD) risk factor control on graft survival disparities in African-American kidney transplant recipients. Studies in the general population indicate that CVD risk factor control is poor in African-Americans, leading to higher rates of renal failure and major acute cardiovascular events. However, with the exception of hypertension, there is no data demonstrating similar results within transplant recipients. Recent analyses conducted by our investigator group indicate that CVD risk factors, especially diabetes, are poorly controlled in African-American recipients, which likely impacts graft loss. This study protocol describes a prospective interventional clinical trial with the goal of demonstrating improved medication safety and CVD risk factor control in adult solitary kidney transplant recipients at least one-year post-transplant with a functioning graft. This is a prospective, interventional, 6-month, pharmacist-led and technology enabled study in adult kidney transplant recipients with the goal of improving CVD risk factor outcomes by improving medication safety and patient self-efficacy. This papers describes the issues related to racial disparities in transplant, the details of this intervention and how we expect this intervention to improve CVD risk factor control in kidney transplant recipients, particularly within African-Americans.
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Affiliation(s)
- Andrew J Cole
- College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Reginald W Johnson
- College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Leonard E Egede
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Prabhakar K Baliga
- Department of Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC
| | - David J Taber
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC.,Department of Pharmacy Services, Ralph H Johnson VAMC, Charleston, SC
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5
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Taber DJ, Gebregziabher M, Srinivas T, Egede LE, Baliga PK. Transplant Center Variability in Disparities for African-American Kidney Transplant Recipients. Ann Transplant 2018; 23:119-128. [PMID: 29449524 PMCID: PMC6019128 DOI: 10.12659/aot.907226] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Disparities research has traditionally focused on patient-level variables to ascertain predominant risk factors driving differences in outcomes for African-American (AA) kidney transplant recipients. Our objectives were to determine the magnitude and impact of transplant center variability for graft outcome disparities. Material/Methods This was a retrospective cohort study analyzing 25 years of U.S. national transplant registry data at both the patient and center levels using univariate descriptive statistics and multivariable modeling. Results A total of 257,024 recipients from 191 centers were analyzed; AAs represented 31.1% of recipients. After adjusting for baseline characteristics, AAs had 42% higher risk of graft loss (aHR 1.42, 95% CI 1.39 to 1.45; p<0.001). Center variability for graft outcome disparities in AAs was significant (race*center interaction term p<0.05), with the aHRs ranging from 0.5 to 4.9; 46% of centers demonstrated a non-statistically significant disparity (aHR p>0.05) and 25% of centers had a large AA disparity (aHR >1.75). In a more recent transplant time period (2000–14), overall racial disparities decreased but center-level disparities increased in variability. Center-level factors significantly associated with increasing disparity included higher acute rejection rates, fewer transplants per year, longer length of stay, lower use of calcineurin inhibitors (CNI), and lower living donor rates. Conclusions There is evidence of significant center-level variability in graft outcome disparities for AA kidney recipients. Further, there appears to be a number of center-level factors associated with this variability, including acute rejection rates, CNI use, number of transplants per year, and, in recent years, low living donor rates.
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Affiliation(s)
- David J Taber
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.,Department of Pharmacy Services, Ralph H Johnson Va Medical Center, Charleston, SC, USA
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Titte Srinivas
- Department of Transplant Nephrology, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Leonard E Egede
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Prabhakar K Baliga
- Department of Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
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6
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Baron PW, Infante S, Peters R, Tilahun J, Weissman J, Delgado L, Kore AH, Beeson WL, de Vera ME. Post-Transplant Diabetes Mellitus After Kidney Transplant in Hispanics and Caucasians Treated with Tacrolimus-Based Immunosuppression. Ann Transplant 2017; 22:309-314. [PMID: 28533501 PMCID: PMC6248042 DOI: 10.12659/aot.903079] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Development of post-transplant diabetes mellitus after kidney transplant (PTDM) significantly increases kidney graft loss and mortality. Several risk factors for PTDM have been reported, including Hispanic ethnicity and the use of calcineurin inhibitors and corticosteroids. The incidence and impact of PTDM in the Hispanic kidney transplant population is unknown. Material/Methods We retrospectively reviewed the medical records of 155 Hispanic and 124 Caucasian patients, who were not diabetics and underwent kidney transplant between January 2006 and December 2011. We analyzed their clinical outcomes at 12 months post-transplant, including the incidence of PTDM, acute rejection rates, and patient and graft survival. Results Hispanics who developed PTDM (n=22) were more than 10 years older and had higher body mass index (BMI) than Hispanics without PTDM (p<0.001 and p=0.001, respectively). Caucasians with PTDM (n=13) were non-significantly older (2.5 years) and had higher BMI than Caucasians without PTDM (p=0.526, p=0.043, respectively). The incidence of PTDM was not significantly different between Hispanics and Caucasians treated with tacrolimus-based immunosuppression (14.2% and 10.5%, respectively). Conclusions PTDM did not cause significant difference in short-term outcomes after kidney transplant in Hispanics or Caucasians. Larger multicenter prospective and long-term clinical trials are needed to validate these findings.
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Affiliation(s)
- Pedro W Baron
- Transplantation Institute, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Sergio Infante
- Department of Internal Medicine, Division of Nephrology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Regina Peters
- School of Pharmacy, Loma Linda University, Loma Linda, CA, USA
| | - Jerusalem Tilahun
- Department of Internal Medicine, Division of Nephrology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Jill Weissman
- School of Pharmacy, Loma Linda University, Loma Linda, CA, USA.,Department of Pharmacy, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Lauren Delgado
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | | | - W Lawrence Beeson
- Center for Nutrition, Healthy Lifestyle and Disease Prevention, School of Public Health, Loma Linda University, Loma Linda, CA, USA
| | - Michael E de Vera
- Transplantation Institute, Loma Linda University Medical Center, Loma Linda, CA, USA
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7
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Everly MJ, Briley KP, Haisch CE, Dieplinger G, Bolin P, Kendrick SA, Morgan C, Maldonado AQ, Rebellato LM. Racial differences in incident de novo
donor-specific anti-HLA antibody among primary renal allograft recipients: results from a single center cohort study. Transpl Int 2017; 30:566-578. [DOI: 10.1111/tri.12937] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 11/14/2016] [Accepted: 02/13/2017] [Indexed: 12/16/2022]
Affiliation(s)
| | - Kimberly P. Briley
- Department of Pathology; Brody School of Medicine at East Carolina University; Greenville NC USA
| | - Carl E. Haisch
- Department of Surgery; Brody School of Medicine at East Carolina University; Greenville NC USA
| | | | - Paul Bolin
- Department of Medicine; Brody School of Medicine at East Carolina University; Greenville NC USA
| | | | - Claire Morgan
- Department of Medicine; Brody School of Medicine at East Carolina University; Greenville NC USA
| | | | - Lorita M. Rebellato
- Department of Pathology; Brody School of Medicine at East Carolina University; Greenville NC USA
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8
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Taber DJ, Gebregziabher M, Hunt KJ, Srinivas T, Chavin KD, Baliga PK, Egede LE. Twenty years of evolving trends in racial disparities for adult kidney transplant recipients. Kidney Int 2016; 90:878-87. [PMID: 27555121 PMCID: PMC5026578 DOI: 10.1016/j.kint.2016.06.029] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 06/01/2016] [Accepted: 06/02/2016] [Indexed: 02/04/2023]
Abstract
Disparities in outcomes for African American (AA) kidney transplant recipients have persisted for 40 years without a comprehensive analysis of evolving trends in the risks associated with this disparity. Here we analyzed U.S. transplant registry data, which included adult Caucasian or AA solitary kidney recipients undergoing transplantation between 1990 and 2009 comprising 202,085 transplantations. During this 20-year period, the estimated rate of 5-year graft loss decreased from 27.6% to 12.8%. Notable trends in baseline characteristics that significantly differed by race over time included the following: increased prevalence of diabetes from 2001 to 2009 in AAs (5-year slope difference: 3.4%), longer time on the waiting list (76.5 more days per 5 years in AAs), fewer living donors in AAs from 2003 to 2009 (5-year slope difference: -3.36%), more circulatory death donors in AAs from 2000-09 (5-year slope difference: 1.78%), and a slower decline in delayed graft function in AAs (5-year slope difference: 0.85%). The absolute risk difference between AAs and Caucasians for 5-year graft loss significantly declined over time (-0.92% decrease per 5 years), whereas the relative risk difference actually significantly increased (3.4% increase per 5 years). These results provide a mixed picture of both promising and concerning trends in disparities for AA kidney transplant recipients. Thus, although the disparity for graft loss has significantly improved, equity is still far off, and other disparities, including living donation rates and delayed graft function rates, have widened during this time.
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Affiliation(s)
- David J Taber
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA; Department of Pharmacy Services, Ralph H. Johnson VAMC, Charleston, South Carolina, USA.
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kelly J Hunt
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Titte Srinivas
- Division of Transplant Nephrology, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kenneth D Chavin
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Prabhakar K Baliga
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Leonard E Egede
- Veteran Affairs HSR&D Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson VAMC, Charleston, South Carolina, USA
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9
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Taber DJ, Hunt KJ, Fominaya CE, Payne EH, Gebregziabher M, Srinivas TR, Baliga PK, Egede LE. Impact of Cardiovascular Risk Factors on Graft Outcome Disparities in Black Kidney Transplant Recipients. Hypertension 2016; 68:715-25. [PMID: 27402921 DOI: 10.1161/hypertensionaha.116.07775] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 06/05/2016] [Indexed: 12/25/2022]
Abstract
Although outcome inequalities for non-Hispanic black (NHB) kidney transplant recipients are well documented, there is paucity in data assessing the impact of cardiovascular disease (CVD) risk factors on this disparity in kidney transplantation. This was a longitudinal study of a national cohort of veteran kidney recipients transplanted between January 2001 and December 2007. Data included baseline characteristics acquired through the United States Renal Data System linked to detailed clinical follow-up information acquired through the Veterans Affairs electronic health records. Analyses were conducted using sequential multivariable modeling (Cox regression), incorporating blocks of variables into iterative nested models; 3139 patients were included (2095 non-Hispanic whites [66.7%] and 1044 NHBs [33.3%]). NHBs had a higher prevalence of hypertension (100% versus 99%; P<0.01) and post-transplant diabetes mellitus (59% versus 53%; P<0.01) with reduced control of hypertension (blood pressure <140/90 60% versus 69%; P<0.01), diabetes mellitus (A1c <7%, 35% versus 47%; P<0.01), and low-density lipoprotein (<100 mg/dL, 55% versus 61%; P<0.01). Adherence to medications used to manage CVD risk was significantly lower in NHBs. In the fully adjusted models, the independent risk of graft loss in NHBs was substantially reduced (unadjusted hazard ratio, 2.00 versus adjusted hazard ratio, 1.49). CVD risk factors and control reduced the influence of NHB race by 9% to 18%. Similar trends were noted for mortality, and estimates were robust across in sensitivity analyses. These results demonstrate that NHB kidney transplant recipients have significantly higher rates of CVD risk factors and reduced CVD risk control. These issues are likely partly related to medication nonadherence and meaningfully contribute to racial disparities for graft outcomes.
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Affiliation(s)
- David J Taber
- From the Division of Transplant Surgery (D.J.T., P.K.B.), Department of Public Health Sciences (K.J.H., E.H.P., M.G.), and Division of Transplant Nephrology (T.R.S.), College of Medicine, Medical University of South Carolina, Charleston, SC; and Department of Pharmacy Services (D.J.T., C.E.F.) and Veteran Affairs HSR&D Health Equity and Rural Outreach Innovation Center (L.E.E.), Ralph H Johnson VAMC, Charleston, SC.
| | - Kelly J Hunt
- From the Division of Transplant Surgery (D.J.T., P.K.B.), Department of Public Health Sciences (K.J.H., E.H.P., M.G.), and Division of Transplant Nephrology (T.R.S.), College of Medicine, Medical University of South Carolina, Charleston, SC; and Department of Pharmacy Services (D.J.T., C.E.F.) and Veteran Affairs HSR&D Health Equity and Rural Outreach Innovation Center (L.E.E.), Ralph H Johnson VAMC, Charleston, SC
| | - Cory E Fominaya
- From the Division of Transplant Surgery (D.J.T., P.K.B.), Department of Public Health Sciences (K.J.H., E.H.P., M.G.), and Division of Transplant Nephrology (T.R.S.), College of Medicine, Medical University of South Carolina, Charleston, SC; and Department of Pharmacy Services (D.J.T., C.E.F.) and Veteran Affairs HSR&D Health Equity and Rural Outreach Innovation Center (L.E.E.), Ralph H Johnson VAMC, Charleston, SC
| | - Elizabeth H Payne
- From the Division of Transplant Surgery (D.J.T., P.K.B.), Department of Public Health Sciences (K.J.H., E.H.P., M.G.), and Division of Transplant Nephrology (T.R.S.), College of Medicine, Medical University of South Carolina, Charleston, SC; and Department of Pharmacy Services (D.J.T., C.E.F.) and Veteran Affairs HSR&D Health Equity and Rural Outreach Innovation Center (L.E.E.), Ralph H Johnson VAMC, Charleston, SC
| | - Mulugeta Gebregziabher
- From the Division of Transplant Surgery (D.J.T., P.K.B.), Department of Public Health Sciences (K.J.H., E.H.P., M.G.), and Division of Transplant Nephrology (T.R.S.), College of Medicine, Medical University of South Carolina, Charleston, SC; and Department of Pharmacy Services (D.J.T., C.E.F.) and Veteran Affairs HSR&D Health Equity and Rural Outreach Innovation Center (L.E.E.), Ralph H Johnson VAMC, Charleston, SC
| | - Titte R Srinivas
- From the Division of Transplant Surgery (D.J.T., P.K.B.), Department of Public Health Sciences (K.J.H., E.H.P., M.G.), and Division of Transplant Nephrology (T.R.S.), College of Medicine, Medical University of South Carolina, Charleston, SC; and Department of Pharmacy Services (D.J.T., C.E.F.) and Veteran Affairs HSR&D Health Equity and Rural Outreach Innovation Center (L.E.E.), Ralph H Johnson VAMC, Charleston, SC
| | - Prabhakar K Baliga
- From the Division of Transplant Surgery (D.J.T., P.K.B.), Department of Public Health Sciences (K.J.H., E.H.P., M.G.), and Division of Transplant Nephrology (T.R.S.), College of Medicine, Medical University of South Carolina, Charleston, SC; and Department of Pharmacy Services (D.J.T., C.E.F.) and Veteran Affairs HSR&D Health Equity and Rural Outreach Innovation Center (L.E.E.), Ralph H Johnson VAMC, Charleston, SC
| | - Leonard E Egede
- From the Division of Transplant Surgery (D.J.T., P.K.B.), Department of Public Health Sciences (K.J.H., E.H.P., M.G.), and Division of Transplant Nephrology (T.R.S.), College of Medicine, Medical University of South Carolina, Charleston, SC; and Department of Pharmacy Services (D.J.T., C.E.F.) and Veteran Affairs HSR&D Health Equity and Rural Outreach Innovation Center (L.E.E.), Ralph H Johnson VAMC, Charleston, SC
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10
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Taber DJ, Douglass K, Srinivas T, McGillicuddy JW, Bratton CF, Chavin KD, Baliga PK, Egede LE. Significant racial differences in the key factors associated with early graft loss in kidney transplant recipients. Am J Nephrol 2014; 40:19-28. [PMID: 24969370 DOI: 10.1159/000363393] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 05/02/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND There is continued and significant debate regarding the salient etiologies associated with graft loss and racial disparities in kidney transplant recipients. METHODS This was a longitudinal cohort study of all adult kidney transplant recipients, comparing patients with early graft loss (<5 years) to those with graft longevity (surviving graft with at least 5 years of follow-up) across racial cohorts [African-American (AA) and non-AA] to discern risk factors. RESULTS 524 patients were included, 55% AA, 151 with early graft loss (29%) and 373 with graft longevity (71%). Consistent within both races, early graft loss was significantly associated with disability income [adjusted odds ratio (AOR) 2.2, 95% CI 1.1-4.5], Kidney Donor Risk Index (AOR 3.2, 1.4-7.5), rehospitalization (AOR 2.1, 1.0-4.4) and acute rejection (AOR 4.4, 1.7-11.6). Unique risk factors in AAs included Medicare-only insurance (AOR 8.0, 2.3-28) and BK infection (AOR 5.6, 1.3-25). Unique protective factors in AAs included cardiovascular risk factor control: AAs with a mean systolic blood pressure <150 mm Hg had 80% lower risk of early graft loss (AOR 0.2, 0.1-0.7), while low-density lipoprotein <100 mg/dl (AOR 0.4, 0.2-0.8), triglycerides <150 mg/dl (AOR 0.4, 0.2-1.0) and hemoglobin A1C <7% (AOR 0.2, 0.1-0.6) were also protective against early graft loss in AA, but not in non-AA recipients. CONCLUSIONS AA recipients have a number of unique risk factors for early graft loss, suggesting that controlling cardiovascular comorbidities may be an important mechanism to reduce racial disparities in kidney transplantation.
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Affiliation(s)
- David J Taber
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, S.C., USA
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11
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Wang CJ, Tuffaha A, Zhang D, Diederich DA, Wetmore JB. A CD3+ count-based thymoglobulin induction regimen permits delayed introduction of calcineurin inhibitors in kidney transplantation. Clin Transplant 2012; 26:900-9. [PMID: 22672562 DOI: 10.1111/j.1399-0012.2012.01656.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2012] [Indexed: 12/01/2022]
Abstract
BACKGROUND Withholding calcineurin inhibitors (CNIs) can be considered when graft function is inadequate following kidney transplantation (KT). Thymoglobulin (rATG) can be used to prevent acute rejection while CNIs are being withheld. Here, we report our results of a novel CNI-sparing induction protocol, which utilizes a CD3+ cell count-based rATG treatment regimen when delayed graft function (DGF) develops in the immediate postoperative period. METHODS In a cohort of 153 consecutive deceased-donor KT recipients, all received a single intraoperative dose of basiliximab; 84 subsequently developed DGF and therefore received rATG (rATG+ group), while 69 demonstrated immediate graft function and received CNIs (rATG- group). RESULTS In the rATG+ group, mean duration of therapy was 8.5±6.0 d, permitting CNI initiation to be delayed until postoperative day 10.3±6.2. Cumulative dose of rATG was only 5.1±4.5 mg/kg while targeting CD3+ counts of ≤30 cells/mm3. CD3+ counts were reduced to a mean of 16.7±17.0 cells/mm3 during therapy. At one yr, patient and graft survival rates were 97.6% and 92.9%, respectively, while the frequency of infections and malignancies were not significantly increased compared to the rATG- group. CONCLUSION A unique induction regimen successfully delayed CNI initiation by using modest doses of rATG to deplete CD3+ cells, while yielding excellent long-term graft outcome without increased risk of infection or malignancy.
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Affiliation(s)
- Connie J Wang
- Division of Nephrology and Hypertension, Department of Pathology, University of Kansas Medical Center, Kansas City, KS 66160, USA.
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12
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Malat GE, Culkin C, Palya A, Ranganna K, Kumar MSA. African American kidney transplantation survival: the ability of immunosuppression to balance the inherent pre- and post-transplant risk factors. Drugs 2010; 69:2045-62. [PMID: 19791826 DOI: 10.2165/11318570-000000000-00000] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Among organ transplant recipients, the African American population historically has received special attention. This is because secondary to their disposition to certain disease states, for example hypertension, an African American patient has a propensity to reach end-stage renal disease and require renal replacement earlier than a Caucasian patient. Regardless of the initiative to replace dialysis therapy with organ transplantation, the African American patient has many barriers to kidney transplantation, thus extending their time on dialysis and waiting time on the organ transplant list. These factors are among the many negative causes of decreased kidney graft survival, realized before kidney transplantation. Unfortunately, once the African American recipient receives a kidney graft, the literature documents that many post-transplant barriers exist which limit successful outcomes. The primary post-transplant barrier relates to designing proper immunosuppression protocols. The difficulty in designing protocols revolves around (i) altered genetic metabolism/lower absorption, (ii) increased immuno-active cytokines and (iii) detrimental effects of noncompliance. Based on the literature, dosing of immunosuppression must be aggressive and requires a diligent practitioner. Research has indicated that, despite some success with proven levels of immunosuppression, the African American recipient usually requires a higher 'dose per weight' regimen. However, even with aggressive immunosuppressant dosing, African Americans still have worse outcomes than Caucasian recipients. Additionally, many of the targeted sites of action that immunosuppression exerts its effects on have been found to be amplified in the African American population. Finally, noncompliance is the most discouraging inhibitor of long-term success in organ transplantation. The consequences of noncompliance are biased by ethnicity and affect the African American population more severely. All of these factors are discussed further in this review in the hope of identifying an ideal healthcare model for caring for the African American transplant recipient, from diagnosing chronic kidney disease through to successful kidney graft outcomes. An indepth review of the literature is described and organized in a fashion that highlights all of the issues affecting success in African Americans. The compilation of the literature in this review will enable the reader to get closer to understanding the caveats of kidney transplantation in the African American patient, but falls short of delivering an actual 'equation' for post-transplant care in an African American kidney recipient.
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Affiliation(s)
- Gregory E Malat
- Department of Pharmacy, Hahnemann University Hospital/Drexel University, Philadelphia, Pennsylvania, USA
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Sageshima J, Ciancio G, Chen L, Burke GW. Anti-interleukin-2 receptor antibodies-basiliximab and daclizumab-for the prevention of acute rejection in renal transplantation. Biologics 2009; 3:319-36. [PMID: 19707418 PMCID: PMC2726067 DOI: 10.2147/btt.2009.3257] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The use of antibody induction after kidney transplantation has increased from 25% to 63% in the past decade and roughly one half of the induction agent used is anti-interleukin-2 receptor antibody (IL-2RA, ie, basiliximab or daclizumab). When combined with calcineurin inhibitor (CNI)-based immunosuppression, IL-2RAs have been shown to reduce the incidence of acute rejection, one of the predictors of poor graft survival, without increasing risks of infections and malignancies in kidney transplantation. For low-immunological-risk patients, IL-2RAs, as compared with lymphocyte-depleting antibodies, are equally efficacious and have better safety profiles. For high-risk patients, however, IL-2RAs may be inferior to lymphocyte-depleting antibodies for the prophylaxis of acute rejection. In an effort to reduce toxicities of other immunosuppressive medications without increasing the risk of acute rejection and chronic graft loss, IL-2RAs have often been combined with steroid- and CNI-sparing immunosuppression protocols. More data support the benefits of early steroid withdrawal with IL-2RA in low-risk patients, but preferred induction therapy for high-risk patients has yet to be determined. Although CNI-sparing protocols with IL-2RA may preserve renal function and improve long-term survival in selected patients, further studies are needed to identify those who benefit most from this strategy.
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Affiliation(s)
- Junichiro Sageshima
- DeWitt Daughtry Family Department of Surgery, Division of Kidney and Pancreas Transplantation, Lillian Jean Kaplan Renal Transplant Center, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
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14
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Golshayan D, Pascual M, Vogt B. Mycophenolic acid formulations in adult renal transplantation - update on efficacy and tolerability. Ther Clin Risk Manag 2009; 5:341-51. [PMID: 19753127 PMCID: PMC2690976 DOI: 10.2147/tcrm.s3496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The description more than 30 years ago of the role of de novo purine synthesis in T and B lymphocytes clonal proliferation opened the possibility for selective immunosuppression by targeting specific enzymatic pathways. Mycophenolic acid (MPA) blocks the key enzyme inosine monophosphate dehydrogenase and the production of guanosine nucleotides required for DNA synthesis. Two MPA formulations are currently used in clinical transplantation as part of the maintenance immunosuppressive regimen. Mycophenolate mofetil (MMF) was the first MPA agent to be approved for the prevention of acute rejection following renal transplantation, in combination with cyclosporine and steroids. Enteric-coated mycophenolate sodium (EC-MPS) is an alternative MPA formulation available in clinical transplantation. In this review, we will discuss the clinical trials that have evaluated the efficacy and safety of MPA in adult kidney transplantation for the prevention of acute rejection and their use in new combination regimens aiming at minimizing calcineurin inhibitor toxicity and chronic allograft nephropathy. We will also discuss MPA pharmacokinetics and the rationale for therapeutic drug monitoring in optimizing the balance between efficacy and safety in individual patients.
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15
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Ciancio G, Burke GW, Gaynor JJ, Sageshima J, Herrada E, Tueros L, Roth D, Kupin W, Rosen A, Esquenazi V, Miller J. Campath-1H induction therapy in African American and Hispanic first renal transplant recipients: 3-year actuarial follow-up. Transplantation 2008; 85:507-16. [PMID: 18347528 DOI: 10.1097/tp.0b013e318163619f] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In a retrospective study of the first 75 primary renal transplant patients given alemtuzumab induction at our center, 20 were African American (27%), 32 were Hispanic (43%), and 23 were non-African American, non-Hispanic (31%). METHODS Alemtuzumab was given intraoperatively and 4 days later (0.3 mg/kg), with planned low-dose maintenance mycophenolate mofetil (500 mg twice daily) and tacrolimus (targeted trough levels of 5 to 7 ng/ml) and no corticosteroid therapy after the first week. Median follow-up among ongoing survivors with a functioning graft was 45 months. RESULTS Three-year actuarial patient and graft survival rates were 95% and 85% in African Americans, 89% and 78% in Hispanics, and 96% and 96% in non-African Americans, non-Hispanics, respectively (not significant). Bioavailability of tacrolimus was significantly lower among African Americans in comparison with the other patient subgroups (P CONCLUSIONS This immunosuppressive protocol appears reasonably safe for 3 years after renal transplantation but suggests higher incidences of biopsy-proven acute rejection, chronic allograft dysfunction, and borderline poorer renal function among African Americans in comparison with the other patient subgroups.
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Affiliation(s)
- Gaetano Ciancio
- Lillian Jean Kaplan Renal Transplant Center, Division of Transplantation, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL 33101, USA.
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16
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Wang J, Yang JW, Zeevi A, Webber SA, Girnita DM, Selby R, Fu J, Shah T, Pravica V, Hutchinson IV, Burckart GJ. IMPDH1 gene polymorphisms and association with acute rejection in renal transplant patients. Clin Pharmacol Ther 2007; 83:711-7. [PMID: 17851563 DOI: 10.1038/sj.clpt.6100347] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Inosine 5'-monophosphate dehydrogenase 1 (IMPDH1) catalyzes the rate-limiting step of the de novo pathway for purine synthesis and is a major target of the immunosuppressive drug mycophenolic acid (MPA). Few variants of the IMPDH1 gene have been reported. The objective of this study was to identify and characterize IMPDH1 variants to determine whether genetic variation contributes to differences in MPA response and toxicity in transplant patients. Seventeen genetic variants were identified in the IMPDH1 gene with allele frequencies ranging from 0.2 to 42.7%. In this study, 191 kidney transplant patients who received mycophenolate mofetil were genotyped for IMPDH1. Two single-nucleotide polymorphisms, rs2278293 and rs2278294, were significantly associated with the incidence of biopsy-proven acute rejection in the first year post-transplantation. Future studies of the multifactorial nature of acute rejection must consider IMPDH1 polymorphisms in MPA-treated patients.
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Affiliation(s)
- J Wang
- Department of Pharmacy, University of Southern California, Los Angeles, California, USA
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17
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Ciancio G, Burke GW, Gaynor JJ, Ruiz P, Roth D, Kupin W, Rosen A, Miller J. A randomized long-term trial of tacrolimus/sirolimus versus tacrolimums/mycophenolate versus cyclosporine/sirolimus in renal transplantation: three-year analysis. Transplantation 2006; 81:845-52. [PMID: 16570006 DOI: 10.1097/01.tp.0000203894.53714.27] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND We report three-year (interim) effects of combining sirolimus (Siro) vs. mycophenolate mofetil (MMF) as adjunctive therapy with calcineurin inhibitors (CI) in renal transplantation in the three different CI-based regimens. METHODS Between May 2000 and December 2001, 150 recipients of deceased donor (DD) and living donor (LD) kidney transplants were randomized into three groups (n=50/group): Group A (Tacro/Siro), Group B (Tacro/MMF) and Group C (CsA/Siro). This report details drug dosing and monitoring, protocol discontinuance, biopsy-proven rejection, graft failure, other adverse events, and death at 36 months postoperatively. RESULTS Actual patient and graft survival respectively in Group A was 90% and 82%, in Group B was 92% and 88%, and in Group C was 96% and 88% (not significant). Biopsy-confirmed acute rejection incidents showed a trend in favor of Group B (10%) vs. Group A (26%) and Group C (20%) combined (P=0.07). The geometric mean */SE serum creatinine concentration and arithmetic mean +/- SE Cockroft-Gault creatinine clearance calculations, respectively, were 1.39*/1.1 and 72.8+/-4.3 for Group A, 1.36*/1.1 and 72.1+/-4.1 for Group B, and 1.60*/1.1 and 61.8+/-3.8 for Group C, a statistically favorable difference for Group B over Group C (P=0.04). There was also less de novo development of posttransplant diabetes mellitus and lipid disorders in Group B vs. A and C (P<0.04). CONCLUSIONS This three-year (interim) analysis has indicated a trend towards better graft function, fewer endocrine disorders, and fewer acute rejection episodes comparing adjunctive MMF and Tacro vs. Siro and Tacro or Siro and CsA, in the dosages used.
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Affiliation(s)
- Gaetano Ciancio
- The Lillian Jean Kaplan Renal Transplant Center, Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, PO Box 012440, Miami, FL 33101, USA.
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19
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Provan D, Moss AJ, Newland AC, Bussel JB. Efficacy of mycophenolate mofetil as single-agent therapy for refractory immune thrombocytopenic purpura. Am J Hematol 2006; 81:19-25. [PMID: 16369979 DOI: 10.1002/ajh.20515] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Refractory disease occurs in 25% or more of adults with idiopathic (immune) thrombocytopenic purpura (ITP). Therapy to elevate the platelet count may be required in a proportion of these patients. Immunosuppressive agents such as prednisone, azathioprine, cyclophosphamide, and cyclosporin have been shown to be effective treatments in a proportion of patients with refractory ITP. A newer immunosuppressive medication, mycophenolate mofetil (MMF), has been used successfully with acceptable toxicity in solid organ transplant patients to reduce the risk of organ rejection. The goal of this study was to determine whether MMF is an effective treatment for refractory ITP. Efficacy, defined as a sustained platelet increase to a level greater than 50 x 10(9)/L, was seen in 7 of 18 patients with refractory ITP. Three of these 7 patients have had intermittent thrombocytopenic episodes while continuing the medication. No severe toxicity was seen, although two of the 18 patients discontinued MMF within the first month of treatment because of side effects, i.e., headache. In summary, MMF may be a useful component of a combination protocol but does not appear to be highly effective as sole therapy in patients with refractory ITP. The data suggests that response rates to MMF may be higher in patients who have had a shorter duration of their ITP.
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Affiliation(s)
- Drew Provan
- Bart's and The London, Queen Mary's School of Medicine & Dentistry, London, United Kingdom
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20
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Ciancio G, Miller J, Gonwa TA. Review of Major Clinical Trials with Mycophenolate Mofetil in Renal Transplantation. Transplantation 2005; 80:S191-200. [PMID: 16251852 DOI: 10.1097/01.tp.0000187035.22298.ba] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Mycophenolate mofetil (MMF) was approved for the prevention of acute rejection following renal transplantation based on the results of three groundbreaking, large, clinical trials that demonstrated a significantly reduced risk of acute rejection in patients receiving MMF when compared with those receiving placebo or azathioprine. These three multicenter, prospective, double-blind trials performed at 55 transplant centers on three continents were the largest immunosuppressive drug trials ever attempted and the first prospective, randomized, double-blind trials ever performed in transplantation. These pivotal trials established a foundation for widespread acceptance of MMF in combination with cyclosporine and steroids as a maintenance regimen for renal transplant patients. The findings of these initial trials that led to the approval of MMF for renal transplantation, including long-term follow-up data, will be reviewed in this paper. The expanding scope of major trials of MMF, including trials in pediatric patients, combination regimens with novel induction therapies or other maintenance agents, and trials in special patient populations such as those at high immunological risk or with deteriorating kidney function, will also be discussed.
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Affiliation(s)
- Gaetano Ciancio
- Department of Surgery, Division of Transplantation, Lillian Jean Kaplan Renal Transplant Center, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33101, USA.
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Singh N, Wannstedt C, Keyes L, Wagener MM, Cacciarelli TV. Who among cytomegalovirus-seropositive liver transplant recipients is at risk for cytomegalovirus infection? Liver Transpl 2005; 11:700-4. [PMID: 15915496 DOI: 10.1002/lt.20417] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
A vast majority of the transplant recipients are cytomegalovirus (CMV)-seropositive (R+). We sought to assess variables predictive of CMV infection, specifically in R+ liver transplant recipients. Study patients comprised 182 consecutive liver transplant recipients who survived at least 14 days after transplantation. Surveillance testing was used to detect CMV infection. Pre-emptive therapy was employed for the prevention of CMV disease, however, no antiviral prophylaxis was used for CMV infection. CMV infection developed in 32.5% (38 of 117) of R+ patients, 84.6% (33 of 39) of R-/D+, and 3.8% (1 of 26) of R-/D- patients. In R+ patients, Hispanic race (21.6% vs. 7.8%, P = 0.06), donor CMV seropositivity (73.7% vs. 45.6%, P = 0.005), and hepatocellular carcinoma (23.7% vs. 6.3%, P = 0.05) correlated with a higher risk of CMV infection. In a multivariate model, Hispanic race (OR: 3.5, 95% CI: 1.03-11.6, P = 0.045), donor CMV serostatus (OR: 4.0, 95% CI: 1.6-10.2, P = 0.003) and hepatocellular carcinoma (OR: 5.8, 95% CI: 1.6-20.5, P = 0.006) were all significant independent predictors of CMV infection. The aforementioned variables did not portend a higher risk of CMV infection in R-/D+ patients; donor CMV seropositivity overwhelmed all other risk factors in R- patients (P < 0.00001). In conclusion, CMV-seropositive liver transplant recipients at risk for CMV infection can be identified based on readily assessable variables. Preventive strategies may be selectively targeted toward these patients.
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Affiliation(s)
- Nina Singh
- Infectious Disease Section, Veterans Affairs Medical Center, Pittsburgh, PA 15240, USA. nis5+@pitt.edu
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Wilson CH, Brook NR, Gok MA, Asher JF, Nicholson ML, Talbot D. Randomized clinical trial of daclizumab induction and delayed introduction of tacrolimus for recipients of non-heart-beating kidney transplants. Br J Surg 2005; 92:681-7. [DOI: 10.1002/bjs.4976] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Kidneys from non-heart-beating donors (NHBDs) have high rates of delayed graft function (DGF). Use of calcineurin inhibitors is associated with a reduction in renal blood flow, which may delay graft recovery from ischaemic acute tubular necrosis.
Methods
To assess whether daclizumab (DZB) could safely replace tacrolimus in the immediate postoperative period, patients were randomized to receive DZB induction and daily mycophenolate mofetil with steroids (DZB group) or standard tacrolimus-based triple therapy (control group). Tacrolimus was given to patients in the DZB group when the serum creatinine level dropped below 350 µmol/l.
Results
Fifty-one patients were recruited at two centres over a 2-year interval between 2000 and 2003. The overall rate of immediate function was 28 per cent (13 of 46 grafts), with the highest rate in recipients of machine-perfused kidneys treated with DZB (eight of 15 patients).
Conclusion
Induction with DZB and delayed introduction of tacrolimus reduced the incidence of DGF in recipients of machine-perfused NHBD kidneys.
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Affiliation(s)
- C H Wilson
- Liver/Renal Unit, The Freeman Hospital, Newcastle upon Tyne, UK
| | - N R Brook
- Division of Transplant Surgery, Leicester General Hospital, Leicester, UK
| | - M A Gok
- Liver/Renal Unit, The Freeman Hospital, Newcastle upon Tyne, UK
| | - J F Asher
- Liver/Renal Unit, The Freeman Hospital, Newcastle upon Tyne, UK
| | - M L Nicholson
- Division of Transplant Surgery, Leicester General Hospital, Leicester, UK
| | - D Talbot
- Liver/Renal Unit, The Freeman Hospital, Newcastle upon Tyne, UK
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Kobashigawa J, David K, Morris J, Chu AH, Steffen BJ, Gotz VP, Gordon RD. Daclizumab is Associated With Decreased Rejection and No Increased Mortality in Cardiac Transplant Patients Receiving MMF, Cyclosporine, and Corticosteroids. Transplant Proc 2005; 37:1333-9. [PMID: 15848713 DOI: 10.1016/j.transproceed.2004.12.135] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Sparse published data exist on outcomes in daclizumab-treated cardiac transplant patients. One trial observed an increased mortality risk 6 and 12 months posttransplant in patients receiving daclizumab plus mycophenolate mofetil (MMF), cyclosporine, and steroids. This study further investigates the safety profile of daclizumab with this same immunosuppressive regimen from a large registry. METHODS Data obtained at hospital discharge on all adult cardiac transplants performed in the USA between January 1998 and October 2003 for patients receiving MMF plus cyclosporine and steroids were accessed from the Scientific Registry of Transplant Recipients. Patients were selected based on induction treatment: daclizumab (n = 684) or no induction (n = 2525). Outcomes were evaluated at 6 months, 12 months, and 3 years posttransplant. Univariate Kaplan-Meier and multivariate Cox models were used to evaluate the effect of treatment on outcomes. Patient survival and infectious death were the primary endpoints. Secondary endpoints included rejection within the first year posttransplant (acute rejection; AR) and total rejection episodes over time. The two treatment groups shared similar demographics and transplant procedure details. RESULTS Daclizumab (vs no induction) patients had no increased risk of patient death nor infectious death. Daclizumab patients had a lower incidence of AR at 6 months (P = .005) and 12 months (P < .001); the adjusted risk for AR at 12 months (hazards ratio [HR] = 0.77; P = .89) and over 3 years (HR 0.83, P = .006) was also lower in daclizumab-treated patients. CONCLUSIONS In cardiac transplant patients, daclizumab (vs no induction) does not result in increased mortality or infectious death, and is associated with a lower incidence of AR.
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Affiliation(s)
- J Kobashigawa
- University of California, Los Angeles, Los Angeles, California 90095, USA.
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