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Kung CW, Lin YC, Tseng CS, Chou YH. Impact of Renin-Angiotensin System Blockade on Mortality and Allograft Loss among Renal Transplant Recipients: A Systematic Review and Meta-Analysis. Nephron Clin Pract 2024:1-11. [PMID: 39008959 DOI: 10.1159/000540305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 07/08/2024] [Indexed: 07/17/2024] Open
Abstract
INTRODUCTION The blockade of the renin-angiotensin system (RAS) has a beneficial effect on reducing the levels of proteinuria and blood pressure in patients with chronic kidney disease (CKD) and reduces the risk of developing end-stage kidney disease in CKD patients. Nonetheless, a debate persists regarding the impact of RAS inhibitors on outcomes such as mortality and graft survival in renal transplant patients. To assess the effect of RAS inhibitors on graft recipients in the past decade, we conducted a systematic review and meta-analysis. METHODS We searched Embase, PubMed, and the Cochrane Central Register of Clinical Trials from January 1, 2012, to August 1, 2022. We included 14 articles, comprising 5 randomized controlled trials (RCTs) and 9 cohort studies, including 45,377 patients. These studies compared patient or graft survival between an RAS inhibitor treatment arm and a control arm. RESULTS The meta-analysis revealed that RAS blockade was significantly associated with lower mortality in cohort studies (risk ratio [RR] = 0.66, 95% confidence interval [CI]: 0.55-0.79), reduced allograft loss in cohort studies (RR = 0.62, 95% CI: 0.54-0.71), and significant changes in systolic blood pressure in RCTs. Subgroup analysis of the groups of interest (interventions involving RAS blockade, follow-up period of ≥5 years) showed consistently reduced mortality (RR = 0.67, 95% CI: 0.56-0.81) and reduced allograft loss (RR = 0.61, 95% CI: 0.54-0.70). CONCLUSIONS Our results demonstrated that the application of RAS blockade among renal transplant recipients was associated with lower mortality and allograft loss in cohort studies but not in RCTs. More powered clinical trials are needed to evaluate the effects of RAS blockade in renal transplant recipients.
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Affiliation(s)
| | - Yi-Chih Lin
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei City, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital Jin-Shan Branch, New Taipei City, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan
| | - Chi-Shin Tseng
- Department of Urology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Yu-Hsiang Chou
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei City, Taiwan
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Lee J, Jung CY, Kim H, Kim HJ, Ko Y, Kwon H, Shin S, Kim YH, Park SK, Baek CH. Effect of pre-transplantation use of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in kidney transplant recipients-propensity score-matched analysis. J Nephrol 2024:10.1007/s40620-024-01938-3. [PMID: 38684638 DOI: 10.1007/s40620-024-01938-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/24/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers (ACEi/ARBs) can cause acute kidney injury under dehydratation or in hemodynamically unstable conditions. Regarding kidney transplantation (KT), the risk of using ACEi/ARBs before surgery is not well established. Therefore, we evaluated the clinical outcomes to determine the effect of preoperative use of ACEi/ARBs on KT. METHODS We retrospectively collected 1187 patients who received living-donor KT between January 2017 and December 2021. We conducted a propensity score-matched analysis between the ACEi/ARB(+) and ACEi/ARB(-) groups and evaluated the effects of ACEi/ARBs on delayed graft function, post-KT renal function, hyperkalemia events, rejection, and graft survival. RESULTS The ACEi/ARB(+) group showed a similar incidence of delayed graft function as the ACEi/ARB(-) group (1.8% vs. 1.0%, P = 0.362). The risk of delayed graft function was not upregulated in the ACEi/ARB(+) group after propensity score-matching (odds ratio: 0.50, 95% confidence interval (CI) 0.13-2.00). Postoperative creatinine levels and the slope of creatinine levels after KT also were not significantly different between the two groups (creatinine slope from POD#0 to POD#7: - 0.73 ± 0.35 vs. - 0.75 ± 0.32 mg/dL/day, P = 0.464). Hyperkalemia did not occur more often in the ACEi/ARB(+) group than in the ACEi/ARB(-) group during perioperative days. Rejection-free survival (P = 0.920) and graft survival (P = 0.621) were not significantly different between the two groups. CONCLUSIONS In KT, the preoperative use of ACEi/ARBs did not significantly affect clinical outcomes including delayed graft function, postoperative renal function, hyperkalemia events, incidence of rejection, and graft survival rates compared to the patients who did not receive ACEi/ARBs.
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Affiliation(s)
- Jaeyun Lee
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Chan-Young Jung
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hyosang Kim
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hwa Jung Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Youngmin Ko
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyunwook Kwon
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung Shin
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Hoon Kim
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Su-Kil Park
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Chung Hee Baek
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Ofori E, Gyan KF, Gyabaah S, Nguah SB, Sarfo FS. Predictors of rapid progression of estimated glomerular filtration rate among persons living with diabetes and/or hypertension in Ghana: Findings from a multicentre study. J Clin Hypertens (Greenwich) 2022; 24:1358-1369. [PMID: 36067082 PMCID: PMC9581086 DOI: 10.1111/jch.14568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 11/23/2022]
Abstract
In Ghana, the prevalence of chronic kidney disease (CKD) is 28.5% in diabetic hypertensive patients, 26.3% in hypertensives, and 16.1% in those with diabetes only. Trajectories of estimated glomerular filtration rate (eGFR) among patients with hypertension and diabetes are important for monitoring and instituting prompt interventions to prevent the development of CKD, especially in the face of limited access to renal replacement therapy. In this prospective multi‐center study conducted at five hospitals in Ghana, we assessed predictors of rapid eGFR progression among adults with hypertension and/or diabetes. Serum creatinine at baseline and 18 months were taken and eGFR determined using the CKD‐EPI formula. eGFR trajectory was defined as fast when the decline of GFR was ≥ 5 ml/min/1.73 m2 per year. A multivariable logistic regression model was fitted to identify predictors of the fast progression of eGFR. Total 13% of 1261 participants met the criteria for rapid decline in eGFR. The adjusted odds ratio, aOR (95%CI), of four factors adversely associated with fast progression of eGFR were: increasing age 1.20 (1.03–1.14), partial health insurance coverage for medications 1.48 (1.05–2.08), history of smoking 1.91 (1.11–3.27), angiotensin‐receptor blockade use 1.55 (1.06–2.25) while metformin use was protective .56 (.35–.90). Proportion with eGFR <60 ml/min increased from 14% at baseline to 19% at month 18. Effective health insurance policies to improve medication access and avoidance of smoking are interventions that may mitigate the rising burden of CKD in individuals with diabetes mellitus and/or hypertension.
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Affiliation(s)
- Emmanuel Ofori
- Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Kwadwo Faka Gyan
- Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Solomon Gyabaah
- Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Samuel Blay Nguah
- Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana.,Department of Medicine, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
| | - Fred Stephen Sarfo
- Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana.,Department of Medicine, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
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Kuźmiuk-Glembin I, Heleniak Z, Pięta R, Głyda M, Lizakowski S, Renke M, Konopa J, Chamienia A, Biedunkiewicz B, Rutkowski B, Tylicki L, Dębska-Ślizień A. Short-term Effects of Losartan on Cardiovascular Risk and Allograft Injury Biomarkers in Kidney Transplant Recipients. Transplant Proc 2022; 54:981-988. [PMID: 35346485 DOI: 10.1016/j.transproceed.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 02/03/2022] [Accepted: 02/18/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND There is a controversy over the renoprotective and cardioprotective effects of renin-angiotensin-aldosterone system blockade in kidney transplant recipients (KTRs). The aim of the study was to evaluate the short-term effects of losartan on allograft injury, cardiovascular risk biomarkers and safety of the treatment in KTRs. METHODS An interim analysis of a prospective, open, multicenter, controlled clinical trial CELART (Cardiovascular Effects of Losartan After Renal Transplantation) was performed. KTRs were allocated to losartan (L) 50 to 100 mg or standard hypotensive treatment (ST) group to reach target blood pressure (BP) <140/90 mm Hg. The short-term effects of the therapy were evaluated after 6 months: estimated glomerular filtration rate (eGFR), albuminuria, the intrarenal fibrosis biomarkers: urine excretion of transforming growth factor β-1 (TGFβ-1) and procollagen type III amino terminal propeptide (PIIINP), cardiac biomarker: serum concentration of N-terminal-pro-B-type natriuretic peptide (NT-proBNP), 24-hour ambulatory BP measurement, and hemoglobin and potassium concentrations. RESULTS At baseline the groups did not differ with respect to age, primary nephropathy, comorbidity, immunosuppressive therapy, albuminuria, and graft function. A total of 61 (L group) and 73 (ST group) patients reached the target BP and completed protocol at 6 months. After 6 months of therapy there were no significant differences in changes of eGFR, albuminuria, hemoglobin and potassium concentrations, urine excretion of PIIINP, and TGFβ-1 between groups. There was a trend in the L group to decrease the concentration of serum NT-proBNP. CONCLUSIONS Losartan shows minimal adverse effects and no influence on graft function and biomarkers of graft fibrosis. It may have a positive effect on cardiovascular risk in KTRs. Further interim analyses of the CELART study will be conducted.
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Affiliation(s)
- Izabella Kuźmiuk-Glembin
- Department of Nephrology, Transplantology, and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Zbigniew Heleniak
- Department of Nephrology, Transplantology, and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Renata Pięta
- Department of Transplantology and Surgery, District Public Hospital, Poznań, Poland
| | - Maciej Głyda
- Department of Transplantology and Surgery, District Public Hospital, Poznań, Poland; Collegium Medicum In Bydgoszcz, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Sławomir Lizakowski
- Department of Nephrology, Transplantology, and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Marcin Renke
- Department of Nephrology, Transplantology, and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland; Division of Occupational, Metabolic, and Internal Diseases, National Centre for Maritime Medicine, Medical University of Gdańsk, Gdynia, Poland
| | - Joanna Konopa
- Department of Nephrology, Transplantology, and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Andrzej Chamienia
- Department of Nephrology, Transplantology, and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Bogdan Biedunkiewicz
- Department of Nephrology, Transplantology, and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Bolesław Rutkowski
- Department of Nephrology, Transplantology, and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Leszek Tylicki
- Department of Nephrology, Transplantology, and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland.
| | - Alicja Dębska-Ślizień
- Department of Nephrology, Transplantology, and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
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Viticchi G, Falsetti L, Salvemini S, Bartolini M, Ranghino A, Buratti L, Silvestrini M. Headache changes after kidney transplant. Acta Neurol Belg 2022; 122:83-90. [PMID: 33687728 DOI: 10.1007/s13760-021-01637-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 02/22/2021] [Indexed: 11/25/2022]
Abstract
Headache is considered as a possible complication of dialytic treatment in chronic kidney disease (CKD). The aim of this study was to evaluate possible change in headache characteristics after kidney transplantation in patients with CKD. During a 1-year period, we enrolled 110 subjects submitted to a kidney transplant in the previous 5 years. Headache characteristics before and after the transplant were investigated by a specific questionnaire. Possible effects of pharmacological therapies were also evaluated. 65.5% of patients complained of headache before the transplant (38.2% migraine and 14.5% dialysis headache). After transplant, 53.6% of patients reported changes in headache characteristics. In particular, 27.3% of the patients had a complete resolution, 19.1% presented a headache improvement and 7.2% showed a worsening. In both migraine and dialysis headache subgroups, steroids, beta-blockers and calcium channel blockers were associated with a significant improvement of headache. Kidney transplantation seems to impact significantly headache frequency and severity in patients with CKD. A careful evaluation and use of targeted treatments could improve both patients' compliance to therapies and quality of life.
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Affiliation(s)
- Giovanna Viticchi
- Neurological Clinic, Marche Polytechnic University, Via Conca 1, 60020, Ancona, Italy.
| | - Lorenzo Falsetti
- Internal and Subintesive Medicine, Ospedali Riuniti Ancona, Ancona, Italy
| | - Sergio Salvemini
- Neurological Clinic, Marche Polytechnic University, Via Conca 1, 60020, Ancona, Italy
| | - Marco Bartolini
- Neurological Clinic, Marche Polytechnic University, Via Conca 1, 60020, Ancona, Italy
| | - Andrea Ranghino
- Nephrology, Dialysis and Kidney Transplant Unit, Ospedali Riuniti Ancona, Ancona, Italy
| | - Laura Buratti
- Neurological Clinic, Marche Polytechnic University, Via Conca 1, 60020, Ancona, Italy
| | - Mauro Silvestrini
- Neurological Clinic, Marche Polytechnic University, Via Conca 1, 60020, Ancona, Italy
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Peripheral Vascular Disease and Kidney Transplant Outcomes: Rethinking an Important Ongoing Complication. Transplantation 2021; 105:1188-1202. [PMID: 33148978 DOI: 10.1097/tp.0000000000003518] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Peripheral vascular disease (PVD) is highly prevalent in patients on the waiting list for kidney transplantation (KT) and after transplantation and is associated with impaired transplant outcomes. Multiple traditional and nontraditional risk factors, as well as uremia- and transplant-related factors, affect 2 processes that can coexist, atherosclerosis and arteriosclerosis, leading to PVD. Some pathogenic mechanisms, such as inflammation-related endothelial dysfunction, mineral metabolism disorders, lipid alterations, or diabetic status, may contribute to the development and progression of PVD. Early detection of PVD before and after KT, better understanding of the mechanisms of vascular damage, and application of suitable therapeutic approaches could all minimize the impact of PVD on transplant outcomes. This review focuses on the following issues: (1) definition, epidemiological data, diagnosis, risk factors, and pathogenic mechanisms in KT candidates and recipients; (2) adverse clinical consequences and outcomes; and (3) classical and new therapeutic approaches.
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Codina S, Manonelles A, Tormo M, Sola A, Cruzado JM. Chronic Kidney Allograft Disease: New Concepts and Opportunities. Front Med (Lausanne) 2021; 8:660334. [PMID: 34336878 PMCID: PMC8316649 DOI: 10.3389/fmed.2021.660334] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/10/2021] [Indexed: 12/12/2022] Open
Abstract
Chronic kidney disease (CKD) is increasing in most countries and kidney transplantation is the best option for those patients requiring renal replacement therapy. Therefore, there is a significant number of patients living with a functioning kidney allograft. However, progressive kidney allograft functional deterioration remains unchanged despite of major advances in the field. After the first post-transplant year, it has been estimated that this chronic allograft damage may cause a 5% graft loss per year. Most studies focused on mechanisms of kidney graft damage, especially on ischemia-reperfusion injury, alloimmunity, nephrotoxicity, infection and disease recurrence. Thus, therapeutic interventions focus on those modifiable factors associated with chronic kidney allograft disease (CKaD). There are strategies to reduce ischemia-reperfusion injury, to improve the immunologic risk stratification and monitoring, to reduce calcineurin-inhibitor exposure and to identify recurrence of primary renal disease early. On the other hand, control of risk factors for chronic disease progression are particularly relevant as kidney transplantation is inherently associated with renal mass reduction. However, despite progress in pathophysiology and interventions, clinical advances in terms of long-term kidney allograft survival have been subtle. New approaches are needed and probably a holistic view can help. Chronic kidney allograft deterioration is probably the consequence of damage from various etiologies but can be attenuated by kidney repair mechanisms. Thus, besides immunological and other mechanisms of damage, the intrinsic repair kidney graft capacity should be considered to generate new hypothesis and potential therapeutic targets. In this review, the critical risk factors that define CKaD will be discussed but also how the renal mechanisms of regeneration could contribute to a change chronic kidney allograft disease paradigm.
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Affiliation(s)
- Sergi Codina
- Department of Nephrology, Hospital Universitari Bellvitge, Barcelona, Spain
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Anna Manonelles
- Department of Nephrology, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Maria Tormo
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Anna Sola
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Josep M. Cruzado
- Department of Nephrology, Hospital Universitari Bellvitge, Barcelona, Spain
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
- Department of Clinical Sciences, University of Barcelona, Barcelona, Spain
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Update on Treatment of Hypertension After Renal Transplantation. Curr Hypertens Rep 2021; 23:25. [PMID: 33961145 DOI: 10.1007/s11906-021-01151-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW To incorporate novel findings on pathophysiology and treatment of posttransplant hypertension. RECENT FINDINGS (1) The sodium retaining effects of CNIs are mediated by stimulation of the thiazide-sensitive sodium chloride co-transporter in the distal convoluted tubule and in this regard chlorthalidone was proven to be an effective antihypertensive drug in renal transplantation. (2) Local and not systemic activation of the renin-angiotensin-aldosterone system plays a crucial role in the pathogenesis of posttransplant hypertension. (3) Recent randomized controlled trials failed to prove the presumed superiority of renin-angiotensin blockers in kidney transplantation. (4) Steroid-free and mammalian target of rapamycin-based immunosuppressive drug combinations did not show favorable effects on blood pressure control. (5) In a recent report the risk of non-melanoma skin cancer was higher with thiazide diuretics. But the increased cancer risk in transplant recipients is mainly attributed to comorbidities, such as diabetes and hypertension and of course to the transplantation condition itself or the obligatory application of immunosuppression, and has little to do with the antihypertensive medication Actual recommendations about BP targets in adult renal transplant recipients are coming from a post hoc analysis of a large randomized trial with another primary endpoint. Unless convincing studies on treatment of hypertension after renal transplantation are available, the ESC/ESH Guidelines 2018 should apply for these patients.
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Tsuchimoto A, Masutani K, Ueki K, Nakagawa K, Matsukuma Y, Tanaka S, Unagami K, Kakuta Y, Okumi M, Noguchi H, Kaku K, Okabe Y, Nakano T, Kitazono T, Nakamura M, Ishida H, Tanabe K. Effect of renin–angiotensin system blockade on graft survival and cardiovascular disease in kidney transplant recipients: retrospective multicenter study in Japan. Clin Exp Nephrol 2019; 24:369-378. [DOI: 10.1007/s10157-019-01827-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 11/25/2019] [Indexed: 01/13/2023]
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Hernández D, Alonso-Titos J, Armas-Padrón AM, Lopez V, Cabello M, Sola E, Fuentes L, Gutierrez E, Vazquez T, Jimenez T, Ruiz-Esteban P, Gonzalez-Molina M. Waiting List and Kidney Transplant Vascular Risk: An Ongoing Unmet Concern. Kidney Blood Press Res 2019; 45:1-27. [PMID: 31801144 DOI: 10.1159/000504546] [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] [Received: 07/09/2019] [Accepted: 11/01/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is an important independent risk factor for adverse cardiovascular events in patients waitlisted for kidney transplantation (KT). Although KT reduces cardiovascular risk, these patients still have a higher all-cause and cardiovascular mortality than the general population. This concerning situation is due to a high burden of traditional and nontraditional risk factors as well as uremia-related factors and transplant-specific factors, leading to 2 differentiated processes under the framework of CKD, atherosclerosis and arteriosclerosis. These can be initiated by insults to the vascular endothelial endothelium, leading to vascular calcification (VC) of the tunica media or the tunica intima, which may coexist. Several pathogenic mechanisms such as inflammation-related endothelial dysfunction, mineral metabolism disorders, activation of the renin-angiotensin system, reduction of nitric oxide, lipid disorders, and the fibroblast growth factor 23-klotho axis are involved in the pathogenesis of atherosclerosis and arteriosclerosis, including VC. SUMMARY This review focuses on the current understanding of atherosclerosis and arteriosclerosis, both in patients on the waiting list as well as in kidney transplant recipients, emphasizing the cardiovascular risk factors in both populations and the inflammation-related pathogenic mechanisms. Key Message: The importance of cardiovascular risk factors and the pathogenic mechanisms related to inflammation in patients waitlisted for KT and kidney transplant recipients.
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Affiliation(s)
- Domingo Hernández
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain,
| | - Juana Alonso-Titos
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | | | - Veronica Lopez
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Mercedes Cabello
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Eugenia Sola
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Laura Fuentes
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Elena Gutierrez
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Teresa Vazquez
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Tamara Jimenez
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Pedro Ruiz-Esteban
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Miguel Gonzalez-Molina
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
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Ewald H, Ioannidis JPA, Ladanie A, Mc Cord K, Bucher HC, Hemkens LG. Nonrandomized studies using causal-modeling may give different answers than RCTs: a meta-epidemiological study. J Clin Epidemiol 2019; 118:29-41. [PMID: 31704350 DOI: 10.1016/j.jclinepi.2019.10.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 10/25/2019] [Accepted: 10/31/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To evaluate how estimated treatment effects agree between nonrandomized studies using causal modeling with marginal structural models (MSM-studies) and randomized trials (RCTs). STUDY DESIGN Meta-epidemiological study. SETTING MSM-studies providing effect estimates on any healthcare outcome of any treatment were eligible. We systematically sought RCTs on the same clinical question and compared the direction of treatment effects, effect sizes, and confidence intervals. RESULTS The main analysis included 19 MSM-studies (1,039,570 patients) and 141 RCTs (120,669 patients). MSM-studies indicated effect estimates in the opposite direction from RCTs for eight clinical questions (42%), and their 95% CI (confidence interval) did not include the RCT estimate in nine clinical questions (47%). The effect estimates deviated 1.58-fold between the study designs (median absolute deviation OR [odds ratio] 1.58; IQR [interquartile range] 1.37 to 2.16). Overall, we found no systematic disagreement regarding benefit or harm but confidence intervals were wide (summary ratio of odds ratios [sROR] 1.04; 95% CI 0.88 to 1.23). The subset of MSM-studies focusing on healthcare decision-making tended to overestimate experimental treatment benefits (sROR 1.44; 95% CI 0.99 to 2.09). CONCLUSION Nonrandomized studies using causal modeling with MSM may give different answers than RCTs. Caution is still required when nonrandomized "real world" evidence is used for healthcare decisions.
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Affiliation(s)
- Hannah Ewald
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; Swiss Tropical and Public Health Institute, University of Basel, 4051 Basel, Switzerland; University Medical Library, University of Basel, Basel, Switzerland
| | - John P A Ioannidis
- Department of Medicine, Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA 94305, USA; Meta-Research Innovation Center at Stanford (METRICS), Stanford School of Medicine, Palo Alto, CA 94304, USA; Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA 94305, USA; Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA 94305, USA; Department of Statistics, Stanford University School of Humanities and Sciences, Stanford, CA 94305, USA
| | - Aviv Ladanie
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; Swiss Tropical and Public Health Institute, University of Basel, 4051 Basel, Switzerland
| | - Kimberly Mc Cord
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, University of Basel, 4031 Basel, Switzerland; Swiss Tropical and Public Health Institute, University of Basel, 4051 Basel, Switzerland
| | - Heiner C Bucher
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, University of Basel, 4031 Basel, Switzerland
| | - Lars G Hemkens
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, University of Basel, 4031 Basel, Switzerland.
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12
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Abstract
Kidney donors face a small but definite risk of end-stage renal disease 15 to 30 years postdonation. The development of proteinuria, hypertension with gradual decrease in kidney function in the donor after surgical resection of 1 kidney, has been attributed to hyperfiltration. Genetic variations, physiological adaptations, and comorbidities exacerbate the hyperfiltration-induced loss of kidney function in the years after donation. A focus on glomerular hemodynamics and capillary pressure has led to the development of drugs that target the renin-angiotensin-aldosterone system (RAAS), but these agents yield mixed results in transplant recipients and donors. Recent work on glomerular biomechanical forces highlights the differential effects of tensile stress and fluid flow shear stress (FFSS) from hyperfiltration. Capillary wall stretch due to glomerular capillary pressure increases tensile stress on podocyte foot processes that cover the capillary. In parallel, increased flow of the ultrafiltrate due to single-nephron glomerular filtration rate elevates FFSS on the podocyte cell body. Although tensile stress invokes the RAAS, FFSS predominantly activates the cyclooxygenase 2-prostaglandin E2-EP2 receptor axis. Distinguishing these 2 mechanisms is critical, as current therapeutic approaches focus on the RAAS system. A better understanding of the biomechanical forces can lead to novel therapeutic agents to target FFSS through the cyclooxygenase 2-prostaglandin E2-EP2 receptor axis in hyperfiltration-mediated injury. We present an overview of several aspects of the risk to transplant donors and discuss the relevance of FFSS in podocyte injury, loss of glomerular barrier function leading to albuminuria and gradual loss of renal function, and potential therapeutic strategies to mitigate hyperfiltration-mediated injury to the remaining kidney.
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13
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Hernández D, Sánchez E, Armas-Padrón AM. Kidney transplant registries: How to optimise their utility? Nefrologia 2019; 39:581-591. [PMID: 30850219 DOI: 10.1016/j.nefro.2018.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 11/20/2018] [Accepted: 11/28/2018] [Indexed: 11/30/2022] Open
Abstract
The scientific Registries (RE) in renal transplantation (Tx) are very useful since they allow us to identify risk factors in this population and facilitate contrasting the information with other national and international registries, contributing to establishing strategies which improve outcomes in terms of survival. They constitute an organised and planned system that uses observational methods and standardised systematic processes, including adjusted risk models, to essentially evaluate survival outcomes. The scientific RE are complemented with clinical trials providing scientific evidence, but inexcusably need adequate statistical analysis to generate reliable clinical data that contribute to optimising the prognosis of the transplant population. In addition, scientific RE provide valuable information on the performance of Tx programmes and help generate prognostic indexes, which could contribute to improving survival. Under these prerequisites, this review will assess the following aspects related to the scientific RE in the Tx: 1) the concept and importance of implementing RE in Tx; 2) the measures that are needed for the correct execution of the scientific RE; 3) the benefits, quality and limitations of RE; 4) the statistical tools for the adequate analysis of survival; and 5) utility of RE in the evaluation of performance, quality and surveillance of transplant programmes and the generation of comorbidity índices.
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Affiliation(s)
- Domingo Hernández
- Unidad de Gestión Clínica de Nefrología, Hospital Regional Universitario Carlos Haya, Instituto Biomédico de Investigación de Málaga (IBIMA), Universidad de Málaga, REDinREN (RD16/0009/0006), Málaga, España.
| | - Emilio Sánchez
- Área de Gestión Clínica de Nefrología. Hospital Universitario Central de Asturias, REDinREN (RD16/0009/0021), Oviedo, Asturias, España
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14
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Antlanger M, Domenig O, Kovarik JJ, Kaltenecker CC, Kopecky C, Poglitsch M, Säemann MD. Molecular remodeling of the renin-angiotensin system after kidney transplantation. J Renin Angiotensin Aldosterone Syst 2018; 18:1470320317705232. [PMID: 28490223 PMCID: PMC5843863 DOI: 10.1177/1470320317705232] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective: We aimed at assessing the molecular adaptation of the renin-angiotensin system (RAS) after successful kidney transplantation (KTX). Materials and methods: In this prospective, exploratory study we analyzed 12 hemodialysis (HD) patients, who received a KTX and had excellent graft function six to 12 months thereafter. The concentrations of plasma Angiotensin (Ang) peptides (Ang I, Ang II, Ang-(1–7), Ang-(1–5), Ang-(2–8), Ang-(3–8)) were simultaneously quantified with a novel mass spectrometry-based method. Further, renin and aldosterone concentrations were determined by standard immunoassays. Results: Ang values showed a strong inter-individual variability among HD patients. Yet, despite a continued broad dispersion of Ang values after KTX, a substantial improvement of the renin/Ang II correlation was observed in patients without RAS blockade or on angiotensin receptor blocker (HD: renin/Ang II R2 = 0.660, KTX: renin/Ang II R2 = 0.918). Ang-(1–7) representing the alternative RAS axis was only marginally detectable both on HD and after KTX. Conclusions: Following KTX, renin-dependent Ang II formation adapts in non-ACE inhibitor-treated patients. Thus, a largely normal RAS regulation is reconstituted after successful KTX. However, individual Ang concentration variations and a lack of potentially beneficial alternative peptides after KTX call for individualized treatment. The long-term post-transplant RAS regulation remains to be determined.
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Affiliation(s)
- Marlies Antlanger
- 1 Medical University of Vienna, Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Austria
| | - Oliver Domenig
- 1 Medical University of Vienna, Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Austria
| | - Johannes J Kovarik
- 1 Medical University of Vienna, Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Austria
| | - Christopher C Kaltenecker
- 1 Medical University of Vienna, Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Austria
| | - Chantal Kopecky
- 1 Medical University of Vienna, Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Austria
| | | | - Marcus D Säemann
- 1 Medical University of Vienna, Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Austria
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15
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Farmer RE, Kounali D, Walker AS, Savović J, Richards A, May MT, Ford D. Application of causal inference methods in the analyses of randomised controlled trials: a systematic review. Trials 2018; 19:23. [PMID: 29321046 PMCID: PMC5761133 DOI: 10.1186/s13063-017-2381-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 11/21/2017] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Applications of causal inference methods to randomised controlled trial (RCT) data have usually focused on adjusting for compliance with the randomised intervention rather than on using RCT data to address other, non-randomised questions. In this paper we review use of causal inference methods to assess the impact of aspects of patient management other than the randomised intervention in RCTs. METHODS We identified papers that used causal inference methodology in RCT data from Medline, Premedline, Embase, Cochrane Library, and Web of Science from 1986 to September 2014, using a forward citation search of five seminal papers, and a keyword search. We did not include studies where inverse probability weighting was used solely to balance baseline characteristics, adjust for loss to follow-up or adjust for non-compliance to randomised treatment. Studies where the exposure could not be assigned were also excluded. RESULTS There were 25 papers identified. Nearly half the papers (11/25) estimated the causal effect of concomitant medication on outcome. The remainder were concerned with post-randomisation treatment regimens (sequential treatments, n =5 ), effects of treatment timing (n = 2) and treatment dosing or duration (n = 7). Examples were found in cardiovascular disease (n = 5), HIV (n = 7), cancer (n = 6), mental health (n = 4), paediatrics (n = 2) and transfusion medicine (n = 1). The most common method implemented was a marginal structural model with inverse probability of treatment weighting. CONCLUSIONS Examples of studies which exploit RCT data to address non-randomised questions using causal inference methodology remain relatively limited, despite the growth in methodological development and increasing utilisation in observational studies. Further efforts may be needed to promote use of causal methods to address additional clinical questions within RCTs to maximise their value.
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Affiliation(s)
- Ruth E. Farmer
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL School of Life and Medical Sciences, London, UK
- Department of Non-communicable Diseases Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Daphne Kounali
- Bristol Medical School, University of Bristol, Bristol, UK
| | - A. Sarah Walker
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL School of Life and Medical Sciences, London, UK
| | - Jelena Savović
- Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Alison Richards
- Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - Deborah Ford
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL School of Life and Medical Sciences, London, UK
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16
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Jiang YM, Song TR, Qiu Y, Liu JP, Wang XD, Huang ZL, Lin T. Effect of renin-angiotensin system inhibitors on survival in kidney transplant recipients: A systematic review and meta-analysis. Kaohsiung J Med Sci 2018; 34:1-13. [PMID: 29310811 DOI: 10.1016/j.kjms.2017.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 05/10/2017] [Accepted: 07/27/2017] [Indexed: 11/25/2022] Open
Abstract
Renin-angiotensin system inhibitors, specifically angiotensin II converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB), have confirmed renoprotective benefits in patients with proteinuria and hypertension. However, it remains controversial whether these agents are beneficial to kidney recipients. We conducted this meta-analysis to evaluate the effects of ACEI/ARB treatment on patient and allograft survival after kidney transplant. The PubMed, Embase and Cochrane Library databases were searched for eligible articles from before May 2016, and we included 24 articles (9 randomised controlled trials [RCTs] and 15 cohort studies with 54,096 patients), in which patient or graft survival was compared between an ACEI/ARB treatment arm and a control arm. Pooled results showed that ACEI/ARB was associated with decreased risks of patient death (relative risk [RR] = 0.64; 95% confidence interval [CI]:0.49-0.84) and graft loss (RR = 0.59; 95%CI:0.47-0.74). Subgroup analysis of the cohorts revealed significantly reduced patient death (RR = 0.61; 95%CI:0.50-0.74) and graft loss (RR = 0.58; 95%CI:0.46-0.73), but this was not seen in RCTs (patient survival: RR = 0.84, 95%CI:0.39-1.81; graft survival: RR = 0.70, 95%CI:0.17-2.79). Significantly less graft loss was noted among patients with biopsy-proved chronic allograft nephropathy (CAN) (RR = 0.26, 95%CI:0.16-0.44). Furthermore, the benefit of ACEI/ARB on patient survival (RR = 0.62; 95%CI:0.47-0.83) and graft survival (RR = 0.58, 95%CI:0.47-0.71) was limited to those with ≥3years' follow-up. ACEI/ARB decreased proteinuria (P < 0.001) and lowered haemoglobin (P = 0.002), but the haemoglobin change requires no additional treatment (from 119-131 g/L to 107-123 g/L). We therefore concluded that ACEI/ARB treatment may reduce patient death and graft loss, but additional well-designed prospective studies are needed to validate these findings.
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Affiliation(s)
- Ya-Mei Jiang
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tu-Run Song
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yang Qiu
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jin-Peng Liu
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xian-Ding Wang
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhong-Li Huang
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tao Lin
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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17
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Vascular Damage and Kidney Transplant Outcomes: An Unfriendly and Harmful Link. Am J Med Sci 2017; 354:7-16. [DOI: 10.1016/j.amjms.2017.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 12/20/2016] [Accepted: 01/09/2017] [Indexed: 12/31/2022]
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18
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Vanhove T, Goldschmeding R, Kuypers D. Kidney Fibrosis: Origins and Interventions. Transplantation 2017; 101:713-726. [PMID: 27941433 PMCID: PMC7228593 DOI: 10.1097/tp.0000000000001608] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 10/24/2016] [Accepted: 11/10/2016] [Indexed: 02/06/2023]
Abstract
All causes of renal allograft injury, when severe and/or sustained, can result in chronic histological damage of which interstitial fibrosis and tubular atrophy are dominant features. Unless a specific disease process can be identified, what drives interstitial fibrosis and tubular atrophy progression in individual patients is often unclear. In general, clinicopathological factors known to predict and drive allograft fibrosis include graft quality, inflammation (whether "nonspecific" or related to a specific diagnosis), infections, such as polyomavirus-associated nephropathy, calcineurin inhibitors (CNI), and genetic factors. The incidence and severity of chronic histological damage have decreased substantially over the last 3 decades, but it is difficult to disentangle what effects individual innovations (eg, better matching and preservation techniques, lower CNI dosing, BK viremia screening) may have had. There is little evidence that CNI-sparing/minimization strategies, steroid minimization or renin-angiotensin-aldosterone system blockade result in better preservation of intermediate-term histology. Treatment of subclinical rejections has only proven beneficial to histological and functional outcome in studies in which the rate of subclinical rejection in the first 3 months was greater than 10% to 15%. Potential novel antifibrotic strategies include antagonists of transforming growth factor-β, connective tissue growth factor, several tyrosine kinase ligands (epidermal growth factor, platelet-derived growth factor, vascular endothelial growth factor), endothelin and inhibitors of chemotaxis. Although many of these drugs are mainly being developed and marketed for oncological indications and diseases, such as idiopathic pulmonary fibrosis, a number may hold promise in the treatment of diabetic nephropathy, which could eventually lead to applications in renal transplantation.
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Affiliation(s)
- Thomas Vanhove
- 1 Department of Microbiology and Immunology, KU Leuven-University of Leuven, Leuven, Belgium. 2 Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium. 3 Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
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19
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Liao RX, Lyu XF, Tang WJ, Gao K. Short- and long-term outcomes with renin-angiotensin-aldosterone inhibitors in renal transplant recipients: A meta-analysis of randomized controlled trials. Clin Transplant 2017; 31. [PMID: 28186357 DOI: 10.1111/ctr.12917] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2017] [Indexed: 02/05/2023]
Affiliation(s)
- Ruo-xi Liao
- Department of Nephrology; West China Hospital; Sichuan University; Chengdu China
| | - Xia-fei Lyu
- Department of Radiology; West China Hospital; Sichuan University; Chengdu China
| | - Wen-jiao Tang
- Department of Hematology; West China Hospital; Sichuan University; Chengdu China
| | - Kai Gao
- Department of Computer Science and Technology; Tsinghua University; Beijing China
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20
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Monfá E, Rodrigo E, Belmar L, Sango C, Moussa F, Ruiz San Millán JC, Piñera C, Fernández-Fresnedo G, Arias M. A high sodium intake reduces antiproteinuric response to renin-angiotensin-aldosterone system blockade in kidney transplant recipients. Nefrologia 2016; 36:545-551. [PMID: 27431273 DOI: 10.1016/j.nefro.2016.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 01/05/2016] [Accepted: 01/28/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Post-transplant proteinuria is associated with lower graft and patient survival. Renin-angiotensin-aldosterone system blockers are used to reduce proteinuria and improve renal outcome. Although it is known that a high salt intake blunts the antiproteinuric effect of ACEI and ARB drugs in non-transplant patients, this effect has not been studied in kidney transplant recipients. OBJECTIVE To analyse the relationship between sodium intake and the antiproteinuric effect of ACEI/ARB drugs in kidney transplant recipients. METHODS We selected 103 kidney transplant recipients receiving ACEI/ARB drugs for more than 6 months due to proteinuria>1 g/day. Proteinuria was analysed at baseline and at 6 months after starting ACEI/ARB treatment. Salt intake was estimated by urinary sodium to creatinine ratio (uNa/Cr). RESULTS Proteinuria fell to less than 1g/day in 46 patients (44.7%). High uNa/Cr was associated with a smaller proteinuria decrease (r=-0.251, P=.011). The percentage proteinuria reduction was significantly lower in patients in the highest uNa/Cr tertile [63.9% (IQR 47.1%), 60.1% (IQR 55.4%), 38.9% (IQR 85.5%), P=.047]. High uNa/Cr independently relates (OR 2.406 per 100 mEq/g, 95% CI: 1.008-5.745, P=.048) to an antiproteinuric response <50% after renin-angiotensin-aldosterone system blockade. CONCLUSIONS A high salt intake results in a smaller proteinuria decrease in kidney transplant recipients with proteinuria treated with ACEI/ARB drugs.
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Affiliation(s)
- Elena Monfá
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España
| | - Emilio Rodrigo
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España.
| | - Lara Belmar
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España
| | - Cristina Sango
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España
| | - Fozi Moussa
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España
| | | | - Celestino Piñera
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España
| | - Gema Fernández-Fresnedo
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España
| | - Manuel Arias
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España
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21
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Hernández D, Muriel A, Abraira V. Current state of clinical end-points assessment in transplant: Key points. Transplant Rev (Orlando) 2016; 30:92-9. [PMID: 26948088 DOI: 10.1016/j.trre.2016.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 02/03/2016] [Indexed: 12/20/2022]
Abstract
Solid organ transplantation is the treatment of choice for patients with end-stage organ disease. However, organ transplantation can stress the cardiovascular system and decrease immune surveillance, leading to early mortality and graft loss due to multiple underlying comorbidities. Clinical end-points in transplant include death and graft failure. Thus, generating accurate predictive models through regression models is crucial to test for definitive clinical post-transplantation end-points. Survival predictive models should assemble efficient surrogate markers or prognostic factors to generate a minimal set of variables derived from a proper modeling strategy through regression models. However, a few critical points should be considered when reporting survival analyses and regression models to achieve proper discrimination and calibration of the predictive models. Additionally, population-based risk scores may underestimate risk prediction in transplant. The application of predictive models in these patients should therefore incorporate both classical and non-classical risk factors, as well as community-based health indicators and transplant-specific factors to quantify the outcomes in terms of survival properly. This review focuses on assessment of clinical end-points in transplant through regression models by combining predictive and surrogate variables, and considering key points in these analyses to accurately predict definitive end-points, which could aid clinicians in decision making.
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Affiliation(s)
- Domingo Hernández
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD12/0021/0015). Avda. Carlos Haya s/n., 29010, Málaga, Spain.
| | - Alfonso Muriel
- Clinical Biostatistic Unit, Hospital Ramón y Cajal, IRYCIS, CIBERESP, Crta. Colmenar km 9.1, 28034, Madrid, Spain
| | - Víctor Abraira
- Clinical Biostatistic Unit, Hospital Ramón y Cajal, IRYCIS, CIBERESP, Crta. Colmenar km 9.1, 28034, Madrid, Spain
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22
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Abstract
Improvements in overall survival early after liver transplantation result in a growing number of patients with the potential for long-term survival. Data available on long-term survival, to date, reflect the situation of patients who received their liver transplant during a very different health-care era. Translating these data into the current medical era of liver transplantation is an important task, as a better understanding of aspects associated with morbidity and mortality is fundamental in improving the long-term outcome of liver transplant recipients. Malignancy screening, optimal treatment of recurrent disease and adequate management of metabolic disease are crucial contributions to advance patient care. In this Review, data specific to the liver transplant recipient will be evaluated and, in the absence of sufficient evidence at this time, recommendations and guidelines for the general population on management of long-term concerns will be assessed for their applicability after liver transplantation. In addition, other preventive strategies relating to pregnancy, contraception and vaccination are reviewed in detail.
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23
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Houri I, Tzukert K, Levi IMY, Aharon M, Bloch A, Gotsman O, Backenroth R, Levi R, Dov IB, Rubinger D, Elhalel MD. Implementation of guidelines for metabolic syndrome control in kidney transplant recipients: results at a single center. Diabetol Metab Syndr 2015; 7:90. [PMID: 26478748 PMCID: PMC4609158 DOI: 10.1186/s13098-015-0083-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 10/01/2015] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Cardiovascular disease is a leading cause of death among kidney transplant recipients. Metabolic syndrome increases the risk for cardiovascular events and decreases graft survival. Lately, guidelines for management of the metabolic syndrome, primarily hypertension, diabetes mellitus (DM) and hypercholesterolemia have dramatically changed in an attempt to decrease cardiovascular risks among kidney transplant recipients. In the present study we examined whether these guideline changes had impact on our management of post-transplantation patients and the subsequent treatment outcomes for these diseases. METHODS Data were obtained from kidney transplant clinic files from two follow-up (FU) periods-between 1994-1997 and between 2008-2011. Demographic data, monitoring and screening frequency for cardiovascular risk factors, immunosuppression regimen, treatment for hypertension, diabetes and hyperlipidemia, treatment outcomes and graft function changes were compared between the two follow-up periods. RESULTS There was a significant increase in the percentage of patients undergoing transplantation due to renal failure secondary to diabetes and/or hypertension. Patient monitoring and screening during the second FU period were less frequent, but more targeted, reflecting changes in clinic routines. Blood pressure was better controlled in the second FU period (p < 0.01), as was hypercholesterolemia (p < 0.001). High fasting glucose levels were more prevalent among patients in the second group (p < 0.005), although more patients received treatment for DM (p < 0.001). Significantly, fewer patients experienced deterioration of kidney functions during the second FU period (p < 0.001). CONCLUSIONS We found that guideline changes had impact on clinical practice, which translated to better control of the metabolic syndrome. DM control is challenging. Overall, stability of kidney function improved.
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Affiliation(s)
- Inbal Houri
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
| | - Keren Tzukert
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
| | - Irit Mor-Yosef Levi
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
| | - Michal Aharon
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
| | - Aharon Bloch
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
| | - Olga Gotsman
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
| | - Rebecca Backenroth
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
| | - Ronen Levi
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
| | - Iddo Ben Dov
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
| | - Dvora Rubinger
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
| | - Michal Dranitzki Elhalel
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
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Xiao Y, Abrahamowicz M, Moodie EEM, Weber R, Young J. Flexible Marginal Structural Models for Estimating the Cumulative Effect of a Time-Dependent Treatment on the Hazard: Reassessing the Cardiovascular Risks of Didanosine Treatment in the Swiss HIV Cohort Study. J Am Stat Assoc 2014. [DOI: 10.1080/01621459.2013.872650] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Hošková L, Málek I, Kautzner J, Honsová E, van Dokkum RPE, Husková Z, Vojtíšková A, Varcabová Š, Červenka L, Kopkan L. Tacrolimus-induced hypertension and nephrotoxicity in Fawn-Hooded rats are attenuated by dual inhibition of renin–angiotensin system. Hypertens Res 2014; 37:724-32. [DOI: 10.1038/hr.2014.79] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 02/03/2014] [Accepted: 03/01/2014] [Indexed: 01/13/2023]
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Issa N, Ortiz F, Reule S, Kukla A, Kasiske B, Mauer M, Jackson S, Matas AJ, Ibrahim HN. The renin-aldosterone axis in kidney transplant recipients and its association with allograft function and structure. Kidney Int 2014; 85:404-15. [PMID: 23965522 PMCID: PMC3946607 DOI: 10.1038/ki.2013.278] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 05/14/2013] [Accepted: 05/23/2013] [Indexed: 12/27/2022]
Abstract
The level of the renin-angiotensin-aldosterone system (RAAS) activity in kidney transplant recipients has not been extensively studied or serially profiled. To describe this axis and to determine its association with glomerular filtration rate (GFR) change, interstitial expansion, and end-stage renal disease (ESRD), we measured plasma renin activity (PRA) and plasma aldosterone levels annually for 5 years in 153 kidney transplant recipients randomly assigned to losartan or placebo. PRA and plasma aldosterone levels were in the normal range at all times and did not vary by immunosuppression regimen. Those on losartan exhibited higher PRA but similar plasma aldosterone levels. Neither baseline nor serial PRA or plasma aldosterone levels were associated with GFR decline, proteinuria, or interstitial expansion. Losartan use (hazard ratio (HR) 0.48 (95% confidence interval (CI) 0.21-1.0), insignificant) and Caucasian donor (HR 0.18 (95% CI 0.07-0.4) significant) were associated with less doubling of serum creatinine, death, or ESRD. Hypertension, <3 human leukocyte antigen matches, the combination of tacrolimus-rapamycin, and acute rejection were associated with more events. Neither PRA nor plasma aldosterone levels were independently associated with this outcome. Higher serial plasma aldosterone levels were associated, however, with a significantly higher risk of ESRD (HR 1.01 (95% CI 1.00-1.02)). Thus, systemic RAAS is not overly activated in kidney transplant recipients, but this may not reflect the intrarenal system. Importantly, plasma aldosterone levels may be associated with more ESRD.
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Affiliation(s)
- Naim Issa
- Division of Renal Diseases and Hypertension, University of Minnesota
| | - Fernando Ortiz
- Division of Renal Diseases and Hypertension, University of Minnesota
| | - Scott Reule
- Division of Renal Diseases and Hypertension, University of Minnesota
| | - Aleksandra Kukla
- Division of Renal Diseases and Hypertension, University of Minnesota
| | | | | | - Scott Jackson
- Division of Renal Diseases and Hypertension, University of Minnesota
| | - Arthur J. Matas
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Hassan N. Ibrahim
- Division of Renal Diseases and Hypertension, University of Minnesota
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Yang S, Eaton CB, Lu J, Lapane KL. Application of marginal structural models in pharmacoepidemiologic studies: a systematic review. Pharmacoepidemiol Drug Saf 2014; 23:560-71. [PMID: 24458364 DOI: 10.1002/pds.3569] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 12/08/2013] [Accepted: 12/17/2013] [Indexed: 11/11/2022]
Abstract
PURPOSE We systematically reviewed pharmacoepidemiologic studies published in 2012 that used inverse probability weighted (IPW) estimation of marginal structural models (MSM) to estimate the effect from a time-varying treatment. METHODS Potential studies were retrieved through a citation search within Web of Science and a keyword search within PubMed. Eligibility of retrieved studies was independently assessed by at least two reviewers. One reviewer performed data extraction, and a senior epidemiologist confirmed the extracted information for all eligible studies. RESULTS Twenty pharmacoepidemiologic studies were eligible for data extraction. The majority of reviewed studies did not report whether the positivity assumption was checked. Six studies performed intention-to-treat analyses, but none of them reported adherence levels after treatment initiation. Eight studies chose an as-treated analytic strategy, but only one of them reported modeling the multiphase of treatment use. Almost all studies performing as-treated analyses chose the most recent treatment status as the functional form of exposure in the outcome model. Nearly half of the studies reported that the IPW estimate was substantially different from the estimate derived from a standard regression model. CONCLUSIONS The use of IPW method to control for time-varying confounding is increasing in medical literature. However, reporting of the application of the technique is variable and suboptimal. It may be prudent to develop best practices in reporting complex methods in epidemiologic research.
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Affiliation(s)
- Shibing Yang
- Department of Family Medicine and Population Health, Division of Epidemiology, Virginia Commonwealth University, Richmond, VA, USA
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Salzberg DJ, Karadsheh FF, Haririan A, Reddivari V, Weir MR. Specific management of anemia and hypertension in renal transplant recipients: influence of renin-angiotensin system blockade. Am J Nephrol 2014; 39:1-7. [PMID: 24356394 DOI: 10.1159/000357205] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 11/12/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Renin-angiotensin system (RAS) inhibition has proven to be helpful in reducing cardiovascular and kidney disease progression in the general population; whether kidney transplant patients would derive similar benefits is unknown. RAS inhibition also reduces posttransplantation erythrocytosis in kidney transplant recipients, but its effect on hemoglobin (Hb) levels in patients without posttransplantation erythrocytosis is unclear. METHODS The Specific Management of Anemia and Hypertension in Renal Transplant (SMAhRT) recipients study was designed to examine the cardiovascular benefits of RAS blockade with telmisartan 80 mg versus placebo, and Hb management with darbepoetin α in a randomized, double-blind, single-center controlled trial in 2,000 patients over 3 years. The primary efficacy variable was a composite of all-cause mortality, myocardial infarction or stroke. RESULTS The SMAhRT study was stopped prematurely due to a lower than expected event rate. At that point, 136 patients were enrolled and were followed for a mean duration of 15 months. The use of RAS blockade was not associated with an increased risk of adverse events such as worsening anemia or hyperkalemia. Likewise, the correction of Hb with darbepoetin was not associated with any increase in thrombotic events. CONCLUSIONS This study provides insight into the safety of RAS inhibition and Hb correction with an erythrocyte-stimulating agent in kidney transplant recipients.
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Affiliation(s)
- Daniel J Salzberg
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Md., USA
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Ueno T, Dutta P, Keliher E, Leuschner F, Majmudar M, Marinelli B, Iwamoto Y, Figueiredo JL, Christen T, Swirski FK, Libby P, Weissleder R, Nahrendorf M. Nanoparticle PET-CT detects rejection and immunomodulation in cardiac allografts. Circ Cardiovasc Imaging 2013; 6:568-73. [PMID: 23771986 DOI: 10.1161/circimaging.113.000481] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Macrophages predominate among the inflammatory cells in rejecting allografts. These innate immune cells, in addition to allospecific T cells, can damage cardiomyocytes directly. METHODS AND RESULTS We explored whether sensitive positron emission tomography-computed tomography (PET-CT) imaging of macrophages-avid nanoparticles detects rejection of heart allografts in mice. In addition, we used the imaging method to follow the immunomodulatory impact of angiotensin-converting enzyme inhibitor therapy on myeloid cells in allografts. Dextran nanoparticles were derivatized with the PET isotope copper-64 and imaged 7 days after transplantation. C57BL/6 recipients of BALB/c allografts displayed robust positron emission tomography signal (standard uptake value allograft, 2.8±0.3; isograft control, 1.7±0.2; P<0.05). Autoradiography and scintillation counting confirmed the in vivo findings. We then imaged the effects of angiotensin-converting enzyme inhibitor (5 mg/kg enalapril). Angiotensin-converting enzyme inhibitor significantly decreased nanoparticle signal (P<0.05). Histology and flow cytometry showed a reduced number of myeloid cells in the graft, blood, and lymph nodes and diminished antigen presentation (P<0.05 versus untreated allografts). Angiotensin-converting enzyme inhibitor also significantly prolonged allograft survival (12 versus 7 days; P<0.0001). CONCLUSIONS Nanoparticle macrophage PET-CT detects heart transplant rejection and predicts organ survival by reporting on myeloid cells.
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Affiliation(s)
- Takuya Ueno
- Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Blanca L, Jiménez T, Cabello M, Sola E, Gutierrez C, Burgos D, Lopez V, Hernandez D. Cardiovascular risk in recipients with kidney transplants from expanded criteria donors. Transplant Proc 2013; 44:2579-81. [PMID: 23146460 DOI: 10.1016/j.transproceed.2012.09.086] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Posttransplant cardiovascular disease (CVD) is the leading cause of death in renal transplant (RT) recipients and is more evident in recipients with transplants from expanded criteria donors (ECD). OBJECTIVES We analyzed the evolution of cardiovascular risk factors and their association with patient mortality. MATERIALS AND METHODS We undertook a single-center, prospective study of RT patients (n = 360) between 1999 and 2006. These were 180 recipients with transplants from ECD and 180 controls. We analyzed the baseline characteristics and the cardiovascular risk factors: hypertension, diabetes, dyslipidemia, CVD, and anemia. Posttransplant analyses included the evolution of cardiovascular risk factors and causes of death. RESULTS The mean age of the ECD was 63.5 ± 5.4 versus 32.0 ± 13.2 years in the non-ECD (P < .001) and the recipient ages were 58.4 ± 8.7 versus 40.8 ± 13.3 years, respectively (P < .001). The median interquartile range [IQR] dialysis time was 25 months (15-39) versus 20 months (12-44; P = .017). The pretransplant body mass index was 26.89 ± 3.91 versus 25.43 ± 4.72 kg/m(2) (P = .002); the median (IQR) number of antihypertensive drugs was two (1-2) versus two (1-2.75; P = .015); dyslipidemia was present in 32.5% versus 21.6% (P = .024), diabetes in 10.6% versus 5.6% (P = .087), and CVD in 13.3% versus 7.8% (P = .086). Treatment with erythropoiesis-stimulating agents (ESA) was received by 84.9% versus 83.9% (P = .857). Concerning transplantation, the mean follow-up was 64.3 ± 33.7 months. Hypertension was present at 3 and 5 years in 85.6% versus 69.5% (P = .001) and 87.9% versus 72.8% (P = .009), respiratory. Treatment with angiotensin-converting enzyme inhibitors/angiotensin-II receptor blockers at 3 and 5 years was 79.8% versus 64.5% and 85.6% versus 65%. Dyslipidemia was present at 5 years in 63.1% versus 58.0% (P = .482). De novo diabetes occurred in 16.7% versus 11.1% (P = .128), and CVD in 13.5% versus 4.5% (P = .003). Univariate and multivariate Cox regression proportional hazards models were constructed to analyze the factors associated with patient death. CONCLUSIONS CVD is the most common cause of death in recipients of ECD, RT, 40% in the ECD group versus 28.6% in the control group. Tight control of cardiovascular risk factors and a good pretransplant patient selection contributed to the good results obtained.
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Affiliation(s)
- L Blanca
- Nephrology and Pathology Departments, H.U. Carlos Haya, Malaga, Spain.
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Zhang R, Laguardia H, Paramesh A, Mills K, Killackey M, McGee J, Alper B, Simon E, Lee Hamm L, Slakey D. Early inhibition of the renin-angiotensin system improves the long-term graft survival of single pediatric donor kidneys transplanted in adult recipients. Transpl Int 2013; 26:601-7. [PMID: 23506676 DOI: 10.1111/tri.12087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 12/31/2012] [Accepted: 02/13/2013] [Indexed: 11/29/2022]
Abstract
Transplanting single pediatric donor kidneys into adult recipients has an increased risk of hyperfiltration injury and graft loss. It is unknown if renin-angiotensin system (RAS) blockers are beneficial in this setting. We retrospectively analyzed 94 adults who received single kidneys from donors <10 years old during 1996-2009. The recipients were divided into group 1 with RAS blockers (n = 40) and group 2 without RAS blockers (n = 54) in the first year of transplant. There was no significant difference in any donor/recipient demographic between the two groups. Graft function, incidence of delayed graft function, acute rejection, and persistent proteinuria were not statistically different either. Kaplan-Meier estimated death-censored graft survivals were significantly better in group 1 than in group 2: 95 vs. 81.2%, 82.4 vs. 61.2%, 72.6 vs. 58.5%, and 68.5 vs. 47.2% at 1, 3, 5, and 7 years, respectively (log rank P = 0.043). Multivariable analysis found persistent proteinuria was a risk factor for graft loss (OR 2.70, 95% CI 1.33-5.49, P = 0.006), while RAS blockers reduced the risk of graft loss (OR 0.38, 95% CI 0.18-0.79, P = 0.009). Early RAS blockade therapy in the first year of transplant is associated with superior long-term graft survival among adults transplanted with single pediatric donor kidneys.
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Affiliation(s)
- Rubin Zhang
- Department of Medicine, School of Medicine, School of Public Health and Tropic Medicine, Tulane University, New Orleans, LA 70112, USA.
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