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Martin F, Xiao Y, Welten V, Nakamori K, Gizlenci M, Zhou H, Tullius SG. The combinatorial effect of age and biological sex on alloimmunity and transplantation outcome. FRONTIERS IN TRANSPLANTATION 2024; 2:1325232. [PMID: 38993871 PMCID: PMC11235293 DOI: 10.3389/frtra.2023.1325232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/26/2023] [Indexed: 07/13/2024]
Abstract
Both age and biological sex affect transplantation outcomes. We have recently shown in a large volume clinical analysis utilizing the SRTR data that graft survival is inferior in young female kidney transplant recipients. In this multi-factorial analysis, older female recipients presented with a trend towards improved transplant outcomes compared to both young female recipients and male recipients of any age. Those data supported by reports of those of others suggest that sex and age impact alloimmune responses both, individually and synergistically. Biological sex and hormone levels change throughout a lifetime with recognized effects on longevity in addition to an impact on the development and course of several disease preconditions. Detailed mechanisms of those sex and age-specific aspects have thus far been studied outside of transplantation. Effects on alloimmunity are largely unknown. Moreover, the combinatorial impact that both, biological sex and age have on transplant outcomes is not understood. Here, we summarize available data that analyze how age in combination with biological sex may shape alloimmune responses and affect transplant outcomes.
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Affiliation(s)
- Friederike Martin
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
- Department of Surgery, Campus Charité Mitte|Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Yao Xiao
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Vanessa Welten
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Keita Nakamori
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
- Department of Urology, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Merih Gizlenci
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Hao Zhou
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Stefan G Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
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Di Y, Fu R, Xiang Z, Sun H, Dai M, Zhang Q, Si Y. Comparison of Prognosis for Lung Transplantation between Older and Younger Donors: A Systematic Review and Meta-Analysis Based on Cohort Studies. Ann Thorac Cardiovasc Surg 2024; 30:24-00092. [PMID: 39111865 PMCID: PMC11324350 DOI: 10.5761/atcs.ra.24-00092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 07/19/2024] [Indexed: 08/16/2024] Open
Abstract
PURPOSE This meta-analysis aimed to compare the prognosis of lung transplantation recipients based on donor age. METHODS A detailed search was performed in PubMed, Embase, Web of Science, and the Cochrane Library for cohort studies on lung transplantation. The prognosis of lung transplant recipients was investigated based on the donor age, with the primary outcomes being 1-year overall survival (OS), 3-year OS, 5-year OS, and 5-year chronic lung allograft dysfunction (CLAD)-free survival. RESULTS This meta-analysis included 10 cohort studies. Among the short-term outcomes, the older donor group demonstrated no significant difference from the young donor group in primary graft dysfunction within 72 hours, use of extracorporeal membrane oxygenation, length of ventilator use, and intensive care unit hours. However, a longer hospital stay was associated with the older donor group. In terms of long-term outcomes, no difference was found between the two groups in 1-year OS, 3-year OS, and 5-year OS. Notably, patients with older donors exhibited a superior 5-year CLAD-free survival. CONCLUSIONS The results of this meta-analysis indicate that older donors are not inferior to younger donors in terms of long-term and short-term recipient outcomes. Lung transplantation using older donors is a potential therapeutic option after rigorous evaluation.
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Affiliation(s)
- Yongkang Di
- Intensive Care Unit, Hospital of Zhejiang People's Armed Police, Hangzhou, Zhejiang, China
| | - Rongrong Fu
- The First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Zhiyi Xiang
- The First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Huiwen Sun
- The First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Min Dai
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Qiufeng Zhang
- The First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yuexiu Si
- Basic Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
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Shi B, Ying T, Chadban SJ. Survival after kidney transplantation compared with ongoing dialysis for people over 70 years of age: A matched-pair analysis. Am J Transplant 2023; 23:1551-1560. [PMID: 37460010 DOI: 10.1016/j.ajt.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/28/2023] [Accepted: 07/10/2023] [Indexed: 08/01/2023]
Abstract
Kidney transplantation offers improved survival and quality of life compared to dialysis for most recipients; however, benefits for elderly patients (>70 years) remain uncertain. Using the Australia and New Zealand Dialysis and Transplant Registry (2009-2019), elderly transplant recipients were matched to a waitlisted dialysis patient by age, cause of end-stage kidney disease, and dialysis duration (paired controls). We censored dialysis patients at the time of transplant. Survival was compared using stratified Cox regression. Elderly transplant recipients (KTRs) (n = 465) were matched to waitlisted pairs. Transplant group mortality initially exceeded dialysis due to excess infection-related deaths (1.9 transplant versus 0.3 dialysis/100 patient-years, P = .03). Beyond month 9, a progressive survival benefit in favor of transplantation was apparent. Over a median follow-up of 1.7 years, mortality was 38% lower for KTRs (95% confidence interval 0.41-0.94, P = .02), and 5-year survival was 80% KTRs vs 53% dialysis (P < .001). Recipients of living and standard criteria donor kidneys acquired immediate survival advantage compared with dialysis, while recipients of expanded criteria donor's kidneys experienced elevated risk of death for the first 17 months. Compared with remaining on dialysis, elderly KTRs incur an increased risk of early posttransplant mortality but thereafter may anticipate progressively superior survival rates.
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Affiliation(s)
- Bree Shi
- Kidney Node, Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia; Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australia Health and Medicine Research Institute, Adelaide, South Australia, Australia
| | - Tracey Ying
- Kidney Node, Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia; Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australia Health and Medicine Research Institute, Adelaide, South Australia, Australia; Renal Medicine, Kidney Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Steven J Chadban
- Kidney Node, Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia; Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australia Health and Medicine Research Institute, Adelaide, South Australia, Australia; Renal Medicine, Kidney Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
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Merzkani M, Chang SH, Murad H, Lentine KL, Mattu M, Wang M, Hu V, Wang B, Al-Hosni Y, Alzahabi O, Alomar O, Wellen J, Alhamad T. The association of center volume with transplant outcomes in selected high-risk groups in kidney transplantation. BMC Nephrol 2023; 24:61. [PMID: 36941609 PMCID: PMC10029277 DOI: 10.1186/s12882-023-03099-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 02/27/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND In context of increasing complexity and risk of deceased kidney donors and transplant recipients, the impact of center volume (CV) on the outcomes of high-risk kidney transplants(KT) has not been well determined. METHODS We examined the association of CV and outcomes among 285 U.S. transplant centers from 2000-2016. High-risk KT were defined as recipient age ≥ 70 years, body mass index (BMI) ≥ 35 kg/m2, receiving kidneys from donors with kidney donor profile index(KDPI) ≥ 85%, acute kidney injury(AKI), hepatitisC + . Average annual CV for the specific-high-risk KT categorized in tertiles. Death-Censored-Graft-Loss(DCGL) and death at 3 months, 1, 5, and 10 years were compared between CV tertiles using Cox-regression models. RESULTS Two hundred fifty thousand five hundred seventy-four KT were analyzed. Compared to high CV, recipients with BMI ≥ 35 kg/m2 had higher risk of DCGL in low CV(aHR = 1.11,95%CI = 1.03-1.19) at 10 years; recipients with age ≥ 70 years had higher risk of death in low CV(aHR = 1.07,95%CI = 1.01-14) at 10 years. There was no difference of DCGL or death in low CV for donors with KDPI ≥ 85%, hepatitisC + , or AKI. CONCLUSIONS Recipients of high-risk KT with BMI ≥ 35 kg/m2 have higher risk of DCGL and recipients age ≥ 70 years have higher risk of death in low CV, compared to high CV. Future studies should identify care practices associated with CV that support optimal outcomes after KT.
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Affiliation(s)
- Massini Merzkani
- Division of Nephrology, Washington University School of Medicine, 4523 Clayton Ave. CB 8126, St. Louis, MO, 63110, USA
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Haris Murad
- Division of Nephrology, Washington University School of Medicine, 4523 Clayton Ave. CB 8126, St. Louis, MO, 63110, USA
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University, St. Louis, MO, USA
| | - Munis Mattu
- Division of Nephrology, Washington University School of Medicine, 4523 Clayton Ave. CB 8126, St. Louis, MO, 63110, USA
| | - Mei Wang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Vangie Hu
- Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, USA
| | - Bolin Wang
- Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, USA
| | - Yazen Al-Hosni
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Obadah Alzahabi
- Division of Nephrology, Washington University School of Medicine, 4523 Clayton Ave. CB 8126, St. Louis, MO, 63110, USA
| | - Omar Alomar
- Division of Nephrology, Washington University School of Medicine, 4523 Clayton Ave. CB 8126, St. Louis, MO, 63110, USA
| | - Jason Wellen
- Department of Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Tarek Alhamad
- Division of Nephrology, Washington University School of Medicine, 4523 Clayton Ave. CB 8126, St. Louis, MO, 63110, USA.
- Transplant Epidemiology Research Collaboration (TERC), Institute of Public Health, Washington University School of Medicine, St. Louis, MO, USA.
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McGovern KE, Sonar SA, Watanabe M, Coplen CP, Bradshaw CM, Nikolich JŽ. The aging of the immune system and its implications for transplantation. GeroScience 2023:10.1007/s11357-022-00720-2. [PMID: 36626019 PMCID: PMC9838392 DOI: 10.1007/s11357-022-00720-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 12/21/2022] [Indexed: 01/11/2023] Open
Abstract
By the last third of life, most mammals, including humans, exhibit a decline in immune cell numbers, immune organ structure, and immune defense of the organism, commonly known as immunosenescence. This decline leads to clinical manifestations of increased susceptibility to infections, particularly those caused by emerging and reemerging microorganisms, which can reach staggering levels-infection with SARS-CoV-2 has been 270-fold more lethal to older adults over 80 years of age, compared to their 18-39-year-old counterparts. However, while this would be expected to be beneficial to situations where hyporeactivity of the immune system may be desirable, this is not always the case. Here, we discuss the cellular and molecular underpinnings of immunosenescence as they pertain to outcomes of solid organ and hematopoietic transplantation.
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Affiliation(s)
- Kathryn E McGovern
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
- BIO5 Institute, University of Arizona, Tucson, AZ, USA
| | - Sandip A Sonar
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
| | - Makiko Watanabe
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
| | - Christopher P Coplen
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
| | - Christine M Bradshaw
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
| | - Janko Ž Nikolich
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA.
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA.
- BIO5 Institute, University of Arizona, Tucson, AZ, USA.
- The Aegis Consortium for Pandemic-free Future, University of Arizona Health Sciences, University of Arizona, Tucson, 85719, USA.
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Kwon JH, Hardy WA, Shorbaji K, Huckaby LV, Welch B, Hashmi ZA, Gibney BC, Bostock IC, Kilic A. Risk of recipient age on 1-year mortality after simultaneous heart-lung transplantation. J Card Surg 2022; 37:4437-4445. [PMID: 36217989 DOI: 10.1111/jocs.17009] [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: 07/27/2022] [Accepted: 09/07/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Heart-lung transplantation (HLTx) is relatively uncommon, and there is a paucity of literature to suggest an age at which older recipients may be exposed to excess risk for mortality. This analysis aimed to identify a threshold of age that predicts adverse outcomes after HLTx. METHODS The United Network of Organ Sharing registry was used to identify adult patients undergoing HLTx from 2005 to 2021. The primary outcome was 1-year mortality. Threshold regression was used to identify the threshold at which age impacts 1-year mortality. Kaplan-Meier analysis was used to model survival, and Cox proportional hazards modeling was used for risk-adjustment. RESULTS We identified 453 patients undergoing HLTx. Threshold analysis identified that the risk for 1-year mortality was significantly elevated beyond an age of 58 years, and 47 (10.38%) patients were older than this threshold. On Kaplan-Meier analysis, 1-year survival was significantly lower in patients > 58 years compared to younger recipients (64.7% vs. 82.0%, p = .007). After risk adjustment, the hazard ratio for 1-year mortality in recipients older than 58 years was 2.27 (95% confidence interval [1.21-4.28], p = .011). CONCLUSION A threshold for recipient age of 58 years of age may avoid excess 1-year mortality after HLTx. However, patients older than this threshold demonstrate acceptable early and midterm survival, and the majority survive to 1 year. Advanced age should be considered in patient selection for HLTx, but may not be a contraindication for candidacy particularly in the absence of other risk factors.
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Affiliation(s)
- Jennie H Kwon
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - William A Hardy
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Khaled Shorbaji
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lauren V Huckaby
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brett Welch
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Zubair A Hashmi
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Barry C Gibney
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ian C Bostock
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Wilk AS, Cummings JR, Plantinga LC, Franch HA, Lea JP, Patzer RE. Racial and Ethnic Disparities in Kidney Replacement Therapies Among Adults With Kidney Failure: An Observational Study of Variation by Patient Age. AMERICAN JOURNAL OF KIDNEY DISEASES 2022; 80:9-19. [DOI: 10.1053/j.ajkd.2021.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/07/2021] [Indexed: 12/13/2022]
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Kim SG, Hong S, Lee H, Eum SH, Kim YS, Jin K, Han S, Yang CW, Park WY, Chung BH. Impact of delayed graft function on clinical outcomes in highly sensitized patients after deceased-donor kidney transplantation. KOREAN JOURNAL OF TRANSPLANTATION 2021; 35:149-160. [PMID: 35769252 PMCID: PMC9235446 DOI: 10.4285/kjt.21.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/18/2021] [Accepted: 09/18/2021] [Indexed: 11/24/2022] Open
Abstract
Background We investigated whether the development of delayed graft function (DGF) in pre-sensitized patients affects the clinical outcomes after deceased-donor kidney transplantation (DDKT). Methods The study included 709 kidney transplant recipients (KTRs) from three transplant centers. We divided KTRs into four subgroups (highly sensitized DGF, highly sensitized non-DGF, low-sensitized DGF, and low-sensitized non-DGF) according to panel reactive antibody level of 50%, or DGF development. We compared post-transplant clinical outcomes among the four subgroups. Results Incidence of biopsy-proven acute rejection (BPAR) was higher in two highly sensitized subgroups than in low-sensitized subgroups. It tended to be higher in highly sensitized DGF subgroups than in the highly sensitized non-DGF subgroups. In addition, the highly sensitized DGF subgroup showed the highest risk for BPAR (hazard ratio, 3.051; P=0.005) and independently predicted BPAR. Allograft function was lower in the two DGF subgroups than in the non-DGF subgroup until one month after transplantation, but thereafter it was similar. Death-censored graft loss rates and patient mortality tended to be low when DGF developed, but it did not reach statistical significance. Conclusions DGF development in highly sensitized patients increases the risk for BPAR in DDKT compared with patients without DGF, suggesting the need for strict monitoring and management of such cases.
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Affiliation(s)
- Seong Gyu Kim
- Division of Nephrology, Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Suyeon Hong
- Transplantation Research Center, Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hanbi Lee
- Transplantation Research Center, Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Hun Eum
- Transplantation Research Center, Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Soo Kim
- Division of Nephrology, Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Kyubok Jin
- Division of Nephrology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Seungyeop Han
- Division of Nephrology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Chul Woo Yang
- Transplantation Research Center, Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Woo Yeong Park
- Division of Nephrology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Byung Ha Chung
- Transplantation Research Center, Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Lentine KL, Cheungpasitporn W, Xiao H, McAdams-DeMarco M, Lam NN, Segev DL, Bae S, Ahn JB, Hess GP, Caliskan Y, Randall HB, Kasiske BL, Schnitzler MA, Axelrod DA. Immunosuppression Regimen Use and Outcomes in Older and Younger Adult Kidney Transplant Recipients: A National Registry Analysis. Transplantation 2021; 105:1840-1849. [PMID: 33214534 PMCID: PMC10576532 DOI: 10.1097/tp.0000000000003547] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Although the population of older transplant recipients has increased dramatically, there are limited data describing the impact of immunosuppression regimen choice on outcomes in this recipient group. METHODS National data for US Medicare-insured adult kidney recipients (N = 67 362; 2005-2016) were examined to determine early immunosuppression regimen and associations with acute rejection, death-censored graft failure, and mortality using multivariable regression analysis in younger (18-64 y) and older (>65 y) adults. RESULTS The use of antithymocyte globulin (TMG) or alemtuzumab (ALEM) induction with triple maintenance immunosuppression (reference) was less common in older compared with younger (36.9% versus 47.0%) recipients, as was TMG/ALEM + steroid avoidance (19.2% versus 20.1%) and mammalian target of rapamycin inhibitor (mTORi)-based (6.7% versus 7.7%) treatments. Conversely, older patients were more likely to receive interleukin (IL)-2-receptor antibody (IL2rAb) + triple maintenance (21.1% versus 14.7%), IL2rAb + steroid avoidance (4.1% versus 1.8%), and cyclosporine-based (8.3% versus 6.6%) immunosuppression. Compared with older recipients treated with TMG/ALEM + triple maintenance (reference regimen), those managed with TMG/ALEM + steroid avoidance (adjusted odds ratio [aOR], 0.440.520.61) and IL2rAb + steroid avoidance (aOR, 0.390.550.79) had lower risk of acute rejection. Older patients experienced more death-censored graft failure when managed with Tac + antimetabolite avoidance (adjusted hazard [aHR], 1.411.782.25), mTORi-based (aHR, 1.702.142.71), and cyclosporine-based (aHR, 1.411.782.25) regimens, versus the reference regimen. mTORi-based and cyclosporine-based regimens were associated with increased mortality in both older and younger patients. CONCLUSIONS Lower-intensity immunosuppression regimens (eg, steroid-sparing) appear beneficial for older kidney transplant recipients, while mTORi and cyclosporine-based maintenance immunosuppression are associated with higher risk of adverse outcomes.
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Affiliation(s)
| | | | | | | | | | | | - Sunjae Bae
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - JiYoon B. Ahn
- Johns Hopkins School of Medicine, Baltimore, MD, USA
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10
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Doucet BP, Cho Y, Campbell SB, Johnson DW, Hawley CM, Teixeira-Pinto ARM, Isbel NM. Kidney Transplant Outcomes in elderly Recipients: An Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry Study. Transplant Proc 2021; 53:1915-1926. [PMID: 34275599 DOI: 10.1016/j.transproceed.2021.06.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 06/14/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND There is an increase in elderly patients receiving kidney transplant internationally. This study describes elderly kidney transplant recipient outcomes in Australia and New Zealand. METHODS The study included all adult first kidney transplant recipients in Australia and New Zealand from 2000 to 2015. Survival and graft outcomes were compared between elderly (≥70 years) and younger (18-69 years) recipients using Cox proportional hazards regression. RESULTS Overall, 10651 kidney transplant recipients were included, of which 279 (2.6%) were elderly adults. The proportion of elderly recipients increased from 0.6 to 4.4% from 2000 to 2015. Compared with younger recipients, elderly recipients were more likely to receive kidneys from deceased donors, elderly donors, and expanded criteria donors. Elderly recipients experienced poorer patient survival with 1- and 5-year survival ranging from 96% to 97% and 79% to 81%, respectively, compared with 97% to 99% and 90% 95% in younger recipients, respectively. Elderly recipients experienced comparable rates of delayed graft function and, in living donor kidney recipients, lower rates of acute rejection. CONCLUSIONS Kidney transplantation in the elderly population is increasing. Although elderly recipients had inferior survival and graft outcomes, elderly recipients generally received poorer quality kidneys. The outcomes achieved in this cohort of elderly adults are encouraging, and improving elderly recipient outcomes should be an important focus for research.
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Affiliation(s)
- Brian Percy Doucet
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; School of Clinical Medicine, The University of Queensland, Brisbane, Queensland, Australia.
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Translational Research Institute, Brisbane, Queensland, Australia; Australasian Kidney Trials Network, The University of Queensland, Brisbane, Queensland, Australia
| | - Scott Bryan Campbell
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Centre for Kidney Disease Research, The University of Queensland, Brisbane, Queensland, Australia
| | - David Wayne Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Translational Research Institute, Brisbane, Queensland, Australia; Centre for Kidney Disease Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Carmel Mary Hawley
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Australasian Kidney Trials Network, The University of Queensland, Brisbane, Queensland, Australia; Centre for Kidney Disease Research, The University of Queensland, Brisbane, Queensland, Australia; Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
| | - Armando Rogerió Martins Teixeira-Pinto
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia; School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Nicole Maree Isbel
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Translational Research Institute, Brisbane, Queensland, Australia; Centre for Kidney Disease Research, The University of Queensland, Brisbane, Queensland, Australia
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Tchantchaleishvili V. Paulo Martins to serve as an Associate Editor of Artificial Organs. Artif Organs 2021; 45:441-442. [PMID: 33871099 DOI: 10.1111/aor.13957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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12
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A Comprehensive Review of Infections in Older Kidney Transplant Recipients. CURRENT TRANSPLANTATION REPORTS 2021. [DOI: 10.1007/s40472-021-00320-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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13
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Staeck A, Khadzhynov D, Kleinsteuber A, Lehner L, Duerr M, Budde K, Lachmann N, Halleck F, Staeck O. Influence of pretransplant class I and II non-donor-specific anti-HLA immunization on immunologic outcome and graft survival in kidney transplant recipients. Transpl Immunol 2020; 63:101333. [PMID: 32919027 DOI: 10.1016/j.trim.2020.101333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 09/03/2020] [Accepted: 09/04/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Anti-HLA immunization determined by Panel Reactive Antibody (PRA) is known to have a negative impact on patient and graft survival. The predictive value of peak PRA (pPRA) on immunologic outcome, however, and the individual effects of anti-HLA class I and II antibodies remain uncertain. METHODS The influence of HLA immunization on immunologic outcome parameters and graft survival was investigated in 1150 adult patients without pretransplant donor-specific antibodies (DSA) and in a subgroup of elderly kidney recipients aged ≥ 65 (n = 264). Anti-HLA immunization was defined as a pPRA > 0%. We investigated the influence of class I and II pPRA by dividing all kidney recipients into four pPRA groups (0%, 1-20%, 21-80%, >80%). RESULTS Patients with non-donor-specific pretransplant anti-HLA immunization were at a higher risk for developing de novo DSA (49.9% vs. 18.7% p < 0.001), antibody mediated rejections (ABMR) (15.7% vs. 5.1%; p < 0.001), had a poorer death censored graft survival (69.2% vs. 86.2%; p < 0.001) and a higher decline of the calculated GFR. In elderly patients anti-HLA immunization only had a significant influence on the development of DSA (40.5% vs. 27.4%; p = 0.004). A multivariate model adjusted for all relevant factors revealed only class I but not class II pretransplant HLA immunization as a significant independent risk factor for de novo DSA, ABMR and death censored graft loss (HR 2.76, p < 0.001, HR 4.16, p < 0.001 and HR 2.07, p < 0.001, respectively). CONCLUSION Mainly non-donor-specific pretransplant HLA class I immunization is an independent risk factor for the development of de novo DSA, ABMR and graft loss.
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Affiliation(s)
- Anja Staeck
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany.
| | - Dmytro Khadzhynov
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Kleinsteuber
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Lukas Lehner
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Duerr
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Nils Lachmann
- HLA Laboratory, Institute of Transfusion Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Staeck
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
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Dickson KM, Martins PN. Implications of liver donor age on ischemia reperfusion injury and clinical outcomes. Transplant Rev (Orlando) 2020; 34:100549. [PMID: 32498978 DOI: 10.1016/j.trre.2020.100549] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 12/11/2022]
Abstract
The aging process causes detrimental changes in a variety of organ systems. These changes include: lesser ability to cope with stress, impaired repair mechanisms and decreased cellular functional reserve capacity. Not surprisingly, aging has been associated with increased susceptibility of donor heart and kidneys grafts to ischemia reperfusion injury (IRI). In the context of liver transplantation, however, the effect of donor age seems to be less influential in predisposing the graft to IRI. In fact, a widely comprehensive understanding of IRI in the aged liver has yet to be agreed upon in the literature. Nevertheless, there have been many reported implications of increased liver donor age with poor clinical outcomes besides IRI. These other poor outcomes include: earlier HCV recurrence, increased rates of acute rejection and greater resistance to tolerance induction. While these other correlations have been identified, it is important to re-emphasize the fact that a unified consensus in regard to liver donor age and IRI has not yet been reached among researchers in this field. Many researchers have even demonstrated that the extent of IRI in aged livers can be ameliorated by careful donor selection, strict allocation or novel therapeutic modalities to decrease IRI. Thus, the goals of this review paper are twofold: 1) To delineate and summarize the conflicting data in regard to liver donor age and IRI. 2) Suggest that careful donor selection, appropriate allocation and strategic effort to minimize IRI can reduce the frequency of a variety of poor outcomes with aged liver donations.
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Affiliation(s)
- Kevin M Dickson
- Department of Surgery, Division of Transplantation, University of Massachusetts Medical School, 55 N Lake Ave, Worcester, MA 01605, USA.
| | - Paulo N Martins
- Department of Surgery, Division of Transplantation, University of Massachusetts Medical School, 55 N Lake Ave, Worcester, MA 01605, USA.
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Süsal C, Kumru G, Döhler B, Morath C, Baas M, Lutz J, Unterrainer C, Arns W, Aubert O, Bara C, Beiras-Fernandez A, Böhmig GA, Bösmüller C, Diekmann F, Dutkowski P, Hauser I, Legendre C, Lozanovski VJ, Mehrabi A, Melk A, Minor T, Mueller TF, Pisarski P, Rostaing L, Schemmer P, Schneeberger S, Schwenger V, Sommerer C, Tönshoff B, Viebahn R, Viklicky O, Weimer R, Weiss KH, Zeier M, Živčić-Ćosić S, Heemann U. Should kidney allografts from old donors be allocated only to old recipients? Transpl Int 2020; 33:849-857. [PMID: 32337766 DOI: 10.1111/tri.13628] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/06/2019] [Accepted: 04/22/2020] [Indexed: 02/05/2023]
Abstract
In several deceased donor kidney allocation systems, organs from elderly donors are allocated primarily to elderly recipients. The Eurotransplant Senior Program (ESP) was implemented in 1999, and since then, especially in Europe, the use of organs from elderly donors has steadily increased. The proportion of ≥60-year-old donors reported to the Collaborative Transplant Study (CTS) by European centers has doubled, from 21% in 2000-2001 to 42% in 2016-2017. Therefore, in the era of organ shortage it is a matter of debate whether kidney organs from elderly donors should only be allocated to elderly recipients or whether <65-year-old recipients can also benefit from these generally as "marginal" categorized organs. To discuss this issue, a European Consensus Meeting was organized by the CTS on April 12, 2018, in Heidelberg, in which 36 experts participated. Based on available evidence, it was unanimously concluded that kidney organs from 65- to 74-year-old donors can also be allocated to 55- to 64-year-old recipients, especially if these organs are from donors with no history of hypertension, no increased creatinine, no cerebrovascular death, and no other reasons for defining a marginal donor, such as diabetes or cancer.
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Affiliation(s)
- Caner Süsal
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Gizem Kumru
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Bernd Döhler
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Morath
- Division of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Marije Baas
- Department of Nephrology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jens Lutz
- Division of Nephrology and Infectious Diseases, Medical Clinic, Gemeinschaftsklinikum Mittelrhein, Koblenz, Germany
| | | | - Wolfgang Arns
- Department of Nephrology and Transplantation, Cologne Merheim Medical Center, Cologne, Germany
| | - Olivier Aubert
- Service de Transplantation Rénale et Unité de Soins Intensifs, AP-HP, Hôpital Necker-Enfants Malades, Paris Descartes University, Paris, France
| | - Christoph Bara
- Division of Thoracic Transplantation and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany
| | - Andres Beiras-Fernandez
- Department of Cardiothoracic and Vascular Surgery, University Hospital of Johannes Gutenberg University, Mainz, Germany
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Claudia Bösmüller
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Fritz Diekmann
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Ingeborg Hauser
- Department of Nephrology, Medinizische Klinik III, UKF, Goethe University, Frankfurt, Germany
| | - Christophe Legendre
- Service de Transplantation Rénale et Unité de Soins Intensifs, AP-HP, Hôpital Necker-Enfants Malades, Paris Descartes University, Paris, France
| | - Vladimir J Lozanovski
- Department of General and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Anette Melk
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Thomas Minor
- Department of Surgical Research, Clinic for General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Germany
| | - Thomas F Mueller
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Przemyslaw Pisarski
- Department for General and Visceral Surgery, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Lionel Rostaing
- Service de Néphrologie, Dialyse, Aphérèses et Transplantation, CHU Grenoble Alpes, Grenoble, France
| | - Peter Schemmer
- Department of Surgery, General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria
| | - Stefan Schneeberger
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Vedat Schwenger
- Department of Nephrology and Autoimmune Diseases, Transplantation Center, Klinikum Stuttgart, Stuttgart, Germany
| | - Claudia Sommerer
- Division of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Richard Viebahn
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Ondrej Viklicky
- Department of Nephrology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Rolf Weimer
- Department of Internal Medicine, University of Giessen, Giessen, Germany
| | - Karl-Heinz Weiss
- Department of Internal Medicine IV, Gastroenterology and Hepatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Zeier
- Division of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stela Živčić-Ćosić
- Department of Nephrology, Dialysis and Kidney Transplantation, Faculty of Medicine, Clinical Hospital Center Rijeka, University of Rijeka, Rijeka, Croatia
| | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Dreyer GJ, de Fijter JW. Transplanting the Elderly: Mandatory Age- and Minimal Histocompatibility Matching. Front Immunol 2020; 11:359. [PMID: 32226428 PMCID: PMC7080649 DOI: 10.3389/fimmu.2020.00359] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/14/2020] [Indexed: 12/16/2022] Open
Abstract
Worldwide over 40% of patients receiving renal replacement therapy (RRT) are aged 65 years or older, a number that is still increasing. Renal transplantation is the preferred RRT, providing substantial survival benefit over those remaining on dialysis, including the elderly. Only 3% of patients aged 65 years or older accepted on the waiting list actually received a kidney transplant offer within the Eurotransplant allocation region. To increase the chance for elderly to receive a timely kidney transplant, the Eurotransplant Senior Program was introduced. The ESP supports local allocation of older kidneys to older donors in order to decrease cold ischemia time, while disregarding former exchange principles based on matching for HLA antigens. As a consequence, more elderly received a kidney transplant and a relative higher incidence of acute rejection resulted in additional courses of high steroids and/or depleting antibody therapy. Since death with a functioning graft due to infections is the dominant reason of graft loss in elderly, more intense clinical immunosuppression to prevent or treat acute rejection is not a very attractive option. Therefore in elderly kidney transplant candidates, we advocate reintroduction of minimal histocompatibility criteria (i.e., HLA-DR matching) followed by age-matching with mandatory local/regional allocation to also facilitate short cold ischemia.
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Affiliation(s)
- Geertje J Dreyer
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, Netherlands
| | - Johan W de Fijter
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, Netherlands
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17
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Oberbauer R, Bestard O, Furian L, Maggiore U, Pascual J, Rostaing L, Budde K. Optimization of tacrolimus in kidney transplantation: New pharmacokinetic perspectives. Transplant Rev (Orlando) 2020; 34:100531. [PMID: 31955920 DOI: 10.1016/j.trre.2020.100531] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/05/2019] [Accepted: 12/08/2019] [Indexed: 02/07/2023]
Abstract
Tacrolimus is the cornerstone of immunosuppressive therapy after kidney transplantation (KT), but its use is complicated by a narrow therapeutic index and high inter- and intra-patient pharmacokinetic variability. There are three available oral formulations of tacrolimus: immediate-release tacrolimus (IR-Tac), extended-release tacrolimus (ER-Tac) and a MeltDose® (LCPT) formulation, the latter favoring a prolonged drug release and increased bioavailability. The time-concentration curves of these formulations are different. Compared with IR-Tac and ER-Tac, LCPT has a relatively flat pharmacokinetic profile with less fluctuation between trough and peak exposures, and a delayed peak concentration. This translates to a more stable delivery of tacrolimus and may alleviate the risk of underexposure and allograft rejection or overexposure and toxicity. The once-daily formulation of both ER-TAC and LCPT may also offer a potential advantage on patient adherence. Fast metabolizers of tacrolimus, the elderly, and human leukocyte antigen-sensitized patients are at risk of poorer outcomes after KT, possibly associated with a different exhibited pharmacokinetics of tacrolimus or different requirements in terms of exposure. Simple, practical strategies are needed to identify patients at risk of suboptimal KT outcomes and those who would benefit from a more proactively personalized approach to tacrolimus treatment. This review aims to increase awareness of the link between the pharmacokinetics of oral tacrolimus formulations and the clinical needs of patients after KT, particularly among those who have clinically significant pharmacokinetic variation of tacrolimus.
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Affiliation(s)
- Rainer Oberbauer
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Oriol Bestard
- Kidney Transplant Unit, Nephrology department, Bellvitge University Hospital, Barcelona, Spain
| | - Lucrezia Furian
- Kidney and Pancreas Transplantation Unit, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Italy
| | - Umberto Maggiore
- Kidney and Kidney-Pancreas Transplant Unit (Department of Nephrology), Parma University Hospital, Parma, Italy
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Lionel Rostaing
- Nephrology and Transplantation Department, CHU Grenoble, Grenoble, France
| | - Klemens Budde
- Department of Nephrology, Internal Intensive Care Medicine, Campus Charité Mitte, Berlin, Germany.
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18
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Yakubu I, Ravichandran B, Sparkes T, Barth RN, Haririan A, Masters B. Comparison of Alemtuzumab Versus Basiliximab Induction Therapy in Elderly Kidney Transplant Recipients: A Single-Center Experience. J Pharm Pract 2019; 34:199-206. [PMID: 31315501 DOI: 10.1177/0897190019850934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The optimal choice of induction immunosuppression for elderly kidney transplant recipients remains unclear. Although alemtuzumab has been associated with escalating risk of death and graft loss in this population, this risk has not been adequately explored. The purpose of this study was to compare the safety and efficacy of alemtuzumab with basiliximab induction in this population. METHODS This is a retrospective matched cohort study of kidney transplant recipients aged ≥65 years. Patients who received alemtuzumab induction were matched (1:2) to a basiliximab control. The primary outcome was allograft survival. The incidence of acute rejection, infection, and all-cause mortality was measured. RESULTS Fifty-one and 102 patients were included in the alemtuzumab and basiliximab groups, respectively. Baseline demographics were similar between groups, except for more living donor transplant recipients in the alemtuzumab group (26/51 [51%] vs 31/102 [30.4%], P = .02). Acute cellular rejection occurred more frequently within the first year in the basiliximab group (P = .02). There was no difference in rates of infection within the first year. Graft and patient survival rates were similar over the follow-up period. Patients receiving basiliximab had a higher glomerular filtration rate at 2 years posttransplant (59 mL/min/1.73 m2 vs 49 mL/min/1.73 m2, P = .03). CONCLUSIONS Alemtuzumab induction is associated with similar outcomes to basiliximab in elderly kidney transplant recipients.
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Affiliation(s)
- Idris Yakubu
- Pharmacy, 21668University of Maryland Medical Center, Baltimore, MD, USA
| | | | - Tracy Sparkes
- Pharmacy, 21668University of Maryland Medical Center, Baltimore, MD, USA
| | - Rolf N Barth
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Abdolreza Haririan
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brian Masters
- Pharmacy, 21668University of Maryland Medical Center, Baltimore, MD, USA
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Lemoine M, Titeca Beauport D, Lobbedez T, Choukroun G, Hurault de Ligny B, Hazzan M, Guerrot D, Bertrand D. Risk Factors for Early Graft Failure and Death After Kidney Transplantation in Recipients Older Than 70 Years. Kidney Int Rep 2019; 4:656-666. [PMID: 31080920 PMCID: PMC6506713 DOI: 10.1016/j.ekir.2019.01.014] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 01/16/2019] [Accepted: 01/21/2019] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION Although kidney transplantation carries a survival benefit compared with dialysis, mortality, especially the first year after transplantation, is high in recipients older than 70. The aim of this study was to evaluate early death and graft failure, and to determine the risk factors associated with these events in this specific population. METHODS All patients older than 70 years who received a kidney transplant between January 2000 and December 2014 in the North-West of France were included (n = 171). Baseline characteristics and outcomes after transplantation were studied. Kaplan-Meier analysis was performed to assess patient and graft survival, and Cox regression analysis to evaluate risk factors for graft failure and patient death. RESULTS The mean recipient age was 73.3 ± 2.5 years. Death-censored graft survival at 1, 3, and 5 years were 82.6%, 78.7%, and 75.4%, respectively. Patient survival at 1, 3, and 5 years was 90.1%, 82.5%, and 68.1%, respectively. One year after transplantation, 17 patients (9.9%) were dead, mainly from infectious (58.5%) or cardiovascular disease (29.4%). According to the Cox multivariate analysis, the independent risk factors for death or graft failure during the first year were arrhythmia (odds ratio [OR] 2.26; 95% confidence interval [CI] 1.08-4.8), left-ventricular ejection fraction (LVEF) under 56% (OR 2.38; 95% CI 1.18-4.83), human leucocyte antigen (HLA) antibodies (OR 2.1; 95% CI 1.04-4.2), deceased donor from cardiovascular cause (OR 5.18; 95% CI 1.22-6.3), and acute rejection (OR 2.77; 95% CI 1.2-6.3). CONCLUSION In kidney transplant recipients older than 70 years, cardiac evaluation and immunosuppression optimization seem to be crucial to improve short-term patient and graft survival.
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Affiliation(s)
- Mathilde Lemoine
- Department of Nephrology, Centre Hospitalo-Universitaire de Rouen, Rouen, France
| | | | - Thierry Lobbedez
- Department of Nephrology, Centre Hospitalo-Universitaire de Caen, Caen, France
| | - Gabriel Choukroun
- Department of Nephrology, Centre Hospitalo-Universitaire d’Amiens, Amiens, France
| | | | - Marc Hazzan
- Department of Nephrology, Centre Hospitalo-Universitaire de Lille, Lille, France
| | - Dominique Guerrot
- Department of Nephrology, Centre Hospitalo-Universitaire de Rouen, Rouen, France
- INSERM U1096, Rouen, France
| | - Dominique Bertrand
- Department of Nephrology, Centre Hospitalo-Universitaire de Rouen, Rouen, France
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20
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Sharifi F, Htwe SS, Righi M, Liu H, Pietralunga A, Yesil-Celiktas O, Maharjan S, Cha BH, Shin SR, Dokmeci MR, Vrana NE, Ghaemmaghami AM, Khademhosseini A, Zhang YS. A Foreign Body Response-on-a-Chip Platform. Adv Healthc Mater 2019; 8:e1801425. [PMID: 30694616 PMCID: PMC6398437 DOI: 10.1002/adhm.201801425] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 12/17/2018] [Indexed: 11/10/2022]
Abstract
Understanding the foreign body response (FBR) and desiging strategies to modulate such a response represent a grand challenge for implant devices and biomaterials. Here, the development of a microfluidic platform is reported, i.e., the FBR-on-a-chip (FBROC) for modeling the cascade of events during immune cell response to implants. The platform models the native implant microenvironment where the implants are interfaced directly with surrounding tissues, as well as vasculature with circulating immune cells. The study demonstrates that the release of cytokines such as monocyte chemoattractant protein 1 (MCP-1) from the extracellular matrix (ECM)-like hydrogels in the bottom tissue chamber induces trans-endothelial migration of circulating monocytes in the vascular channel toward the hydrogels, thus mimicking implant-induced inflammation. Data using patient-derived peripheral blood mononuclear cells further reveal inter-patient differences in FBR, highlighting the potential of this platform for monitoring FBR in a personalized manner. The prototype FBROC platform provides an enabling strategy to interrogate FBR on various implants, including biomaterials and engineered tissue constructs, in a physiologically relevant and individual-specific manner.
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Affiliation(s)
- Fatemeh Sharifi
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Cambridge, MA, 02139, USA
- School of Mechanical Engineering, Sharif University of Technology, Tehran, 11155-8639, Iran
| | - Su Su Htwe
- Immunology and Immuno-bioengineering Group, School of Life Science, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Martina Righi
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Cambridge, MA, 02139, USA
| | - Hua Liu
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Cambridge, MA, 02139, USA
| | - Anna Pietralunga
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Cambridge, MA, 02139, USA
| | - Ozlem Yesil-Celiktas
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Cambridge, MA, 02139, USA
- Department of Bioengineering, Faculty of Engineering Ege University, Bornova, 35100, Izmir, Turkey
| | - Sushila Maharjan
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Cambridge, MA, 02139, USA
| | - Byung-Hyun Cha
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Cambridge, MA, 02139, USA
| | - Su Ryon Shin
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Cambridge, MA, 02139, USA
| | - Mehmet Remzi Dokmeci
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Cambridge, MA, 02139, USA
- The BioRobotics Institute, Sant'Anna School of Advanced Studies, Piaggio, 56025, Italy
- Department of Radiology, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, 90095, USA
- Department of Bioengineering, Department of Chemical and Biomolecular Engineering, Henry Samueli School of Engineering and Applied Sciences, University of California, Los Angeles, Los Angeles, CA, 90095, USA
- California NanoSystems Institute (CNSI), University of California, Los Angeles, Los Angeles, CA, 90095, USA
- Department of Bioindustrial Technologies, Konkuk University, Seoul, 05029, Republic of Korea
| | - Nihal Engin Vrana
- Biomatériaux et Bioingénierie, Institut National de la Santé et de la Recherche Médicale (INSERM), 67085, Strasbourg, France
- Protip Medical, 67000, Strasbourg, France
- Fédération de Médecine Translationnelle de Strasbourg, Fédération des Matériaux et Nanoscience d'Alsace (FMNA), Faculté de Chirurgie Dentaire, Université de Strasbourg, 67000, Strasbourg, France
| | - Amir M Ghaemmaghami
- Immunology and Immuno-bioengineering Group, School of Life Science, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Ali Khademhosseini
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Cambridge, MA, 02139, USA
- The BioRobotics Institute, Sant'Anna School of Advanced Studies, Piaggio, 56025, Italy
- Dr. Li Dak Sum & Yip Yio Chin Center for Stem Cells and Regenerative Medicine, Zhejiang University School of Medicine, Hangzhou, 310012, P. R. China
- Key Laboratory of Tissue Engineering and Regenerative Medicine of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, 310012, P. R. China
- Research Institute for Bioscience and Biotechnology, Lalitpur, 44600, Nepal
- Center for Minimally Invasive Therapeutics (C-MIT), University of California-Los Angeles, Los Angeles, CA, 90095, USA
- Department of Radiology, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, 90095, USA
- Department of Bioengineering, Department of Chemical and Biomolecular Engineering, Henry Samueli School of Engineering and Applied Sciences, University of California, Los Angeles, Los Angeles, CA, 90095, USA
- California NanoSystems Institute (CNSI), University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Yu Shrike Zhang
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Cambridge, MA, 02139, USA
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Monitoring cellular immune function of renal transplant recipients based on adenosine triphosphate (ATP) production by mitogen-induced CD4+ T helper cells. Biomed Pharmacother 2018; 107:1402-1409. [PMID: 30257356 DOI: 10.1016/j.biopha.2018.08.110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 08/12/2018] [Accepted: 08/22/2018] [Indexed: 11/21/2022] Open
Abstract
Maintaining the balance between over- and under-immunosuppression has a critical role for successful immunosuppressive therapy after renal transplantation. We studied the predictive value of our functional immune assay, which works based on adenosine triphosphate (ATP) levels, in determining risk of infection and rejection among renal transplant recipients (RTRs). A total of 65 RTRs with less than 1 month (RTRL1) and 48 RTRs with more than 6 months (RTRM6) of post-transplant time, and 56 healthy individuals were included. Upon lymphocyte activation by phytohemagglutinin (PHA), CD4+ T cells were separated using magnetic beads (Dynabeads), the intracellular ATP (iATP) concentrations were measured by luciferin-luciferase reaction, and compared within and between the groups. Activated CD4+ cells iATP production directly correlated with post-transplant time (r = 0.32, P = 0.011). The iATP levels were significantly lower in both RTRL1 and RTRM6 groups compared to control (P < 0.001), and in the RTRL1 group compared to the RTRM6 (P < 0.05). The iATP concentrations were significantly lower in patients who suffered from infection versus the RTRs with stable graft function (SGF). However, the iATP levels were higher in those with allograft rejection episode (ARE). Our optimization experiments showed that best iATP levels cutoffs were 472.5 and 572.5 ng/ml for predicting risk of ARE, and 218.5 and 300.5 ng/ml for predicting risk of developing infection in RTRL1 and RTRM6 patients, respectively. iATP levels measured by immune function assay might be a promising predictive tool for identifying RTRs who are at risk of developing infection or allograft rejection.
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Badawy A, Kaido T, Yoshizawa A, Yagi S, Fukumitsu K, Okajima H, Uemoto S. Human leukocyte antigen compatibility and lymphocyte cross-matching play no significant role in the current adult-to-adult living donor liver transplantation. Clin Transplant 2018; 32:e13234. [DOI: 10.1111/ctr.13234] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Amr Badawy
- Hepato-Biliary-Pancreatic Surgery and Transplantation department; Kyoto University; Kyoto Japan
- General Surgery department; Alexandria University; Alexandria Egypt
| | - Toshimi Kaido
- Hepato-Biliary-Pancreatic Surgery and Transplantation department; Kyoto University; Kyoto Japan
| | - Atsushi Yoshizawa
- Hepato-Biliary-Pancreatic Surgery and Transplantation department; Kyoto University; Kyoto Japan
| | - Shintaro Yagi
- Hepato-Biliary-Pancreatic Surgery and Transplantation department; Kyoto University; Kyoto Japan
| | - Ken Fukumitsu
- Hepato-Biliary-Pancreatic Surgery and Transplantation department; Kyoto University; Kyoto Japan
| | - Hideaki Okajima
- Hepato-Biliary-Pancreatic Surgery and Transplantation department; Kyoto University; Kyoto Japan
| | - Shinji Uemoto
- Hepato-Biliary-Pancreatic Surgery and Transplantation department; Kyoto University; Kyoto Japan
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Forbes RC, Feurer ID, LaNeve D, Concepcion BP, Gamble C, Rega SA, Pinson CW, Shaffer D. Increasing kidney donor profile index sequence does not adversely affect medium-term health-related quality of life after kidney transplantation. Clin Transplant 2018; 32:e13212. [PMID: 29377273 DOI: 10.1111/ctr.13212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The United Network for Organ Sharing system allocates deceased donor kidneys based on the kidney donor profile index (KDPI), stratified as sequences (A ≤ 20%, B > 20-<35%, C ≥ 35-≤85%, and D > 85%), with increasing KDPI associated with decreased graft survival. While health-related quality of life (HRQOL) may improve after transplantation, the effect of donor kidney quality, reflected by KDPI sequence, on post-transplant HRQOL has not been reported. METHODS Health-related quality of life was measured using the eight scales and physical and mental component summaries (PCS, MCS) of the SF-36® Health Survey. Multivariable mixed effects models that adjusted for age, gender, rejection, and previous transplant and analysis of variance methods tested the effects of time and KDPI sequence on post-transplant HRQOL. RESULTS A total of 141 waitlisted adults and 505 recipients (>1700 observations) were included. Pretransplant PCS and MCS averaged, respectively, slightly below and within general population norms (GPN; 40-60). At 31 ± 26 months post-transplant, average PCS (41 ± 11) and MCS (51 ± 11), overall and within each KDPI sequence, were within GPN. KDPI sequence was not related to post-transplant HRQOL (P > .134) or its trajectory (interaction P > .163). CONCLUSION Increasing KDPI does not adversely affect the medium-term values and trajectories of HRQOL after kidney transplantation. This may reassure patients and centers when considering using high KDPI kidneys.
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Affiliation(s)
- Rachel C Forbes
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Irene D Feurer
- Departments of Surgery and Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David LaNeve
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Beatrice P Concepcion
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christianna Gamble
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Scott A Rega
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - C Wright Pinson
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David Shaffer
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA
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24
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[Focusing on kidney transplantation in the elderly]. Nephrol Ther 2017; 14:71-80. [PMID: 29173815 DOI: 10.1016/j.nephro.2017.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 06/14/2017] [Accepted: 06/25/2017] [Indexed: 02/06/2023]
Abstract
Due to the increase in life expectancy and the ageing of end-stage renal disease patients, the number of patients older than 65 years receiving a kidney transplant has been continuously growing over the last fifteen years. The benefits of renal transplantation compared to dialysis in terms of survival and quality of life have been shown in selected recipients over 65, or 70 years. However, the age remains the main limiting factor for the access to the waiting list, and the reluctance of the clinicians can be explained by the multiple comorbidities of these candidates, their limited life expectancy or the shortage of grafts. The challenge is to select the candidates who can benefit from renal transplantation, thanks to rigorous cardiovascular and neoplastic evaluation before enrolment and by taking into account the specific characteristics of elderly patients. The living donor appears to be the ideal option for elderly recipients, the alternative being the extended criteria donor, allowing waiting times to be limited. The choice of immunosuppressive therapy is also crucial in these patients at high risk of infectious and cardiovascular complications in whom the occurrence of acute rejection can have severe consequences. There are currently no specific recommendations for immunosuppression in elderly recipients, and we would need large-scale randomized studies to improve the prognosis of renal transplantation in this population.
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Jackson-Spence F, Gillott H, Tahir S, Nath J, Mytton J, Evison F, Sharif A. Balancing risks for older kidney transplant recipients in the contemporary era: A single-centre observational study. Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2016.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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26
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Mori DN, Shen H, Galan A, Goldstein DR. Aged B cells alter immune regulation of allografts in mice. Eur J Immunol 2016; 46:2650-2658. [PMID: 27546296 DOI: 10.1002/eji.201646353] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 07/04/2016] [Accepted: 08/17/2016] [Indexed: 11/07/2022]
Abstract
Organ transplantation in older people is increasing, but how aging impacts B-cell responses to organ transplantation is still unknown. Here, we show that the depletion of B cells with anti-CD20 antibodies has disparate effects depending on recipient age. In young murine recipients, anti-CD20 treatment impaired the ability of immune modulation to extend skin allograft survival. In contrast, anti-CD20 treatment extended allograft survival in aged recipients treated with immune modulation. Although regulatory B-cell function and the numbers of marginal and follicular B cells were similar between age groups, a subpopulation of B cells, termed age-associated B cells (ABCs), accumulated upon aging. ABCs isolated from aged mice exhibited upregulation of CD73, CD80, CD106, and TLR2 and an increased capacity to augment T-cell alloimmunity compared to ABCs from young mice. Importantly, ABCs from aged, but not young, mice impaired the ability of immune modulation to enhance allograft survival after adoptive transfer into young transplant recipients. Our study indicates that ABCs impair the immune regulation of allografts. Thus, recipient age needs to be considered when proposing B-cell-depleting immune therapy.
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Affiliation(s)
- Daniel N Mori
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.,Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Hua Shen
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.,Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Anjela Galan
- Department of Dermatology, Yale School of Medicine, New Haven, CT, USA.,Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Daniel R Goldstein
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA. .,Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, MI, USA. .,Institute of Gerontology, University of Michigan, Ann Arbor, MI, USA.
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Grow DA, McCarrey JR, Navara CS. Advantages of nonhuman primates as preclinical models for evaluating stem cell-based therapies for Parkinson's disease. Stem Cell Res 2016; 17:352-366. [PMID: 27622596 DOI: 10.1016/j.scr.2016.08.013] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 08/10/2016] [Accepted: 08/22/2016] [Indexed: 01/29/2023] Open
Abstract
The derivation of dopaminergic neurons from induced pluripotent stem cells brings new hope for a patient-specific, stem cell-based replacement therapy to treat Parkinson's disease (PD) and related neurodegenerative diseases; and this novel cell-based approach has already proven effective in animal models. However, there are several aspects of this procedure that have yet to be optimized to the extent required for translation to an optimal cell-based transplantation protocol in humans. These challenges include pinpointing the optimal graft location, appropriately scaling up the graft volume, and minimizing the risk of chronic immune rejection, among others. To advance this procedure to the clinic, it is imperative that a model that accurately and fully recapitulates characteristics most pertinent to a cell-based transplantation to the human brain is used to optimize key technical aspects of the procedure. Nonhuman primates mimic humans in multiple ways including similarities in genomics, neuroanatomy, neurophysiology, immunogenetics, and age-related changes in immune function. These characteristics are critical to the establishment of a relevant model in which to conduct preclinical studies to optimize the efficacy and safety of cell-based therapeutic approaches to the treatment of PD. Here we review previous studies in rodent models, and emphasize additional advantages afforded by nonhuman primate models in general, and the baboon model in particular, for preclinical optimization of cell-based therapeutic approaches to the treatment of PD and other neurodegenerative diseases. We outline current unresolved challenges to the successful application of stem cell therapies in humans and propose that the baboon model in particular affords a number of traits that render it most useful for preclinical studies designed to overcome these challenges.
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Affiliation(s)
- Douglas A Grow
- Department of Biology, University of Texas at San Antonio, San Antonio Cellular Therapeutics Institute, PriStem, United States
| | - John R McCarrey
- Department of Biology, University of Texas at San Antonio, San Antonio Cellular Therapeutics Institute, PriStem, United States
| | - Christopher S Navara
- Department of Biology, University of Texas at San Antonio, San Antonio Cellular Therapeutics Institute, PriStem, United States.
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Montero N, Pérez-Sáez MJ, Pascual J, Abramowicz D, Budde K, Dudley C, Hazzan M, Klinger M, Maggiore U, Oberbauer R, Pascual J, Sorensen SS, Viklicky O. Immunosuppression in the elderly renal allograft recipient: a systematic review. Transplant Rev (Orlando) 2016; 30:144-53. [PMID: 27279024 DOI: 10.1016/j.trre.2016.05.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 05/17/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Elderly are the fastest growing part of kidney transplant recipients. The best immunosuppressive strategy is unknown. METHODS We performed a systematic search of randomized controlled trials and observational studies focused on safety and efficacy of different immunosuppression strategies in elderly kidney recipients. Data extraction and risk of bias evaluation were systematically performed. RESULTS Ten studies were included: 2 randomized clinical trials and 8 observational. A marginal benefit was found for early renal function with delayed tacrolimus or complete tacrolimus avoidance using mycophenolate mofetil (MMF). Observational cohort studies looked at different antibody induction strategies, calcineurin-inhibitors based maintenance immunosuppression, calcineurin-inhibitor-free sirolimus-based therapy and use of MMF versus azathioprine. Treatment with interleukin-2 receptor antibody induction, calcineurin-inhibitor minimization with MMF and steroid minimization is advisable in the low immunologic risk elderly recipient, considering the increased risk of toxicities, infection and malignancies. In the high immunologic risk elderly recipient, taking into account the morbid consequences of acute rejection in the elderly, observational studies support antibody induction with depletive antibodies, calcineurin-inhibitor, MMF and steroids; calcineurin-inhibitor-minimization is not recommended. CONCLUSIONS There is very limited evidence for the benefits and harms of different immunosuppression strategies in the elderly. Most of the published literature are observational studies, and randomized controlled trials are urgently needed.
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Affiliation(s)
- Nuria Montero
- Department of Nephrology, Hospital Universitari Bellvitge, Barcelona, Spain
| | - María José Pérez-Sáez
- Red de Investigación Renal (Redinren) Instituto Carlos III, Madrid, Spain; Department of Nephrology, Hospital del Mar, Barcelona, Spain; Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Julio Pascual
- Red de Investigación Renal (Redinren) Instituto Carlos III, Madrid, Spain; Department of Nephrology, Hospital del Mar, Barcelona, Spain; Universitat Autonoma de Barcelona, Barcelona, Spain.
| | - Daniel Abramowicz
- Department of Nephrology, Antwerp University Hospital, Antwerp, Belgium
| | - Klemens Budde
- Department of Nephrology Campus Charité Mitte, Berlin, Germany
| | | | - Mark Hazzan
- Service de Néphrologie, Univ Lille Nord de France, Lille, France
| | - Marian Klinger
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland
| | - Umberto Maggiore
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Rainer Oberbauer
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Soren S Sorensen
- Department of Nephrology P, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ondrej Viklicky
- Department of Nephrology, Transplant Centre, Prague, Czech Republic
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Abstract
CD8+ T cells play a cardinal feature in response to alloantigens and are able to generate effector/memory T cells independently from CD4+ T cells. To investigate the impact of aging on CD8 T cells, we used a fully mismatched mouse skin transplant model. Our findings showed a prolonged allograft survival in older recipients associated with a significant increase of CD4+ and CD8+ CD44high CD62Llow effector/memory T cells and a reduced systemic IFNγ production. When reconstituting young CBA Rag-1 mice that lack mature T and B cells with old CD8+ T cells expressing clonal anti-H2K T cell receptor (TCR) alloreactive for MHC I, graft survival was significantly prolonged and comparable to those receiving young CD8+ T cells. Moreover, our data showed that reduced systemic IFNγ levels observed in old recipients had been linked to a compromised expression of the IL-2R β subunit (CD122) by old CD8+ T cells. In addition, we observed an impaired IFNγ production on IL-2 receptor activation. At the same time, gene profiling analysis of old CD8 T cells demonstrated reduced chemokine ligand-3 and CD40L expression that resulted in compromised CD8+ T cell/dendritic cell communication, leading to impaired migratory and phagocytic activity of CD11c cells.Collectively, our study demonstrated that aging delays allograft rejection. CD8 T cells play a critical role in this process linked to a compromised production of IFNγ, in addition to a defective IL-2 receptor signaling machinery and a defective communication between CD8 T cells and dendritic cells.
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Filiopoulos V, Boletis JN. Renal transplantation with expanded criteria donors: Which is the optimal immunosuppression? World J Transplant 2016; 6:103-114. [PMID: 27011908 PMCID: PMC4801786 DOI: 10.5500/wjt.v6.i1.103] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 11/03/2015] [Accepted: 01/04/2016] [Indexed: 02/05/2023] Open
Abstract
The growing gap between demand and supply for kidney transplants has led to renewed interest in the use of expanded criteria donor (ECD) kidneys in an effort to increase the donor pool. Although most studies of ECD kidney transplantation confirm lower allograft survival rates and, generally, worse outcomes than standard criteria donor kidneys, recipients of ECD kidneys generally have improved survival compared with wait-listed dialysis patients, thus encouraging the pursuit of this type of kidney transplantation. The relative benefits of transplantation using kidneys from ECDs are dependent on patient characteristics and the waiting time on dialysis. Because of the increased risk of poor graft function, calcineurin inhibitor (CNI)-induced nephrotoxicity, increased incidence of infections, cardiovascular risk, and malignancies, elderly recipients of an ECD kidney transplant are a special population that requires a tailored immunosuppressive regimen. Recipients of ECD kidneys often are excluded from transplant trials and, therefore, the optimal induction and maintenance immunosuppressive regimen for them is not known. Approaches are largely center specific and based upon expert opinion. Some data suggest that antithymocyte globulin might be the preferred induction agent for elderly recipients of ECD kidneys. Maintenance regimens that spare CNIs have been advocated, especially for older recipients of ECD kidneys. CNI-free regimens are not universally accepted due to occasionally high rejection rates. However, reduced CNI exposure and CNI-free regimens based on mammalian target of rapamycin inhibitors have shown acceptable outcomes in appropriately selected ECD transplant recipients.
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Gu XQ, Zheng WP, Teng DH, Sun JS, Zheng H. Impact of non-oncological factors on tumor recurrence after liver transplantation in hepatocellular carcinoma patients. World J Gastroenterol 2016; 22:2749-2759. [PMID: 26973413 PMCID: PMC4777997 DOI: 10.3748/wjg.v22.i9.2749] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 12/13/2015] [Accepted: 12/30/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common primary neoplasm of the liver and is one of the leading causes of cancer-related death worldwide. Liver transplantation (LT) has become one of the best curative therapeutic options for patients with HCC, although tumor recurrence after LT is a major and unaddressed cause of mortality. Furthermore, the factors that are associated with recurrence are not fully understood, and most previous studies have focused on the biological properties of HCC, such as the number and size of the HCC nodules, the degree of differentiation, the presence of hepatic vascular invasion, elevated serum levels of alpha-fetoprotein, and the tumor stage outside of the Milan criteria. Thus, little attention has been given to factors that are not directly related to HCC (i.e., “non-oncological factors”), which have emerged as predictors of tumor recurrence. This review was performed to assess the effects of non-oncological factors on tumor recurrence after LT. The identification of these factors may provide new research directions and clinical strategies for the prophylaxis and surveillance of tumor recurrence after LT, which can help reduce recurrence and improve patient survival.
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Singh P, Ng YH, Unruh M. Kidney Transplantation Among the Elderly: Challenges and Opportunities to Improve Outcomes. Adv Chronic Kidney Dis 2016; 23:44-50. [PMID: 26709062 DOI: 10.1053/j.ackd.2015.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 11/01/2015] [Accepted: 11/02/2015] [Indexed: 01/08/2023]
Abstract
Elderly patients (>65 years old) represent the fastest growing population among the ESRD patients and those awaiting kidney transplantation. There is ample evidence to suggest that kidney transplant in the elderly population offers the best chance of survival and improves health-related quality of life compared to remaining on dialysis. Although all these emerging facts are encouraging, this population brings with them complex medical problems including frailty, cognitive impairment, and multiple comorbidities. These issues can be barriers to transplantation and threaten the well-being of the patients after transplantation. Furthermore, aging results in changes to the immune system and affects the pharmacokinetics of immunosuppressants. All these changes can increase risk of complications such as infections and malignancy. Because death with a functioning graft is a common cause of graft loss, the new kidney allocation system has been implemented in an attempt to maximize allograft utilization and minimize unrealized graft years. This may result in longer wait-times for the elderly. In this review, we will highlight the barriers to kidney transplant, characterize transplant-related issues in the elderly, and propose alternative strategies under the new allocation system.
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Oberhuber R, Liu G, Heinbokel T, Tullius SG. Emerging issues in transplantation. Transpl Immunol 2015. [DOI: 10.1002/9781119072997.ch14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Le Meur Y. What immunosuppression should be used for old-to-old recipients? Transplant Rev (Orlando) 2015; 29:231-6. [PMID: 26409505 DOI: 10.1016/j.trre.2015.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 08/25/2015] [Accepted: 08/31/2015] [Indexed: 12/18/2022]
Abstract
Elderly patients receiving a kidney from old donors (old-to-old) are a growing population of transplant recipients. This population cumulates risks of complications due to the co-morbidities and the immunodeficiency state and the frailty of the recipients together with the kidney senescence of the donors. In this context, the choice of immunosuppression is complicated and must take into account some contradictory principles explaining why no consensus exists today.
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Affiliation(s)
- Yannick Le Meur
- Department of Nephrology, University Hospital La Cavale Blanche, European University of Brittany, Brest, France.
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35
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Dreyer GJ, Hemke AC, Reinders MEJ, de Fijter JW. Transplanting the elderly: Balancing aging with histocompatibility. Transplant Rev (Orlando) 2015; 29:205-11. [PMID: 26411382 DOI: 10.1016/j.trre.2015.08.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 08/30/2015] [Accepted: 08/30/2015] [Indexed: 01/10/2023]
Abstract
Across the world, the proportions of senior citizens (i.e. those ≥65years) increase rapidly and are predicted to constitute over 25% of the general population by 2050. In 2012 already 48% of the population with end stage renal disease (ESRD) was aged 65years or older. Transplantation is considered the preferred treatment option for ESRD offering survival advantage over long-term dialysis in the majority of patients. Indeed, acceptable outcomes have been documented for selected patients over the age of 70years or even cases over 80years. The reality of organ scarcity and prolonged waiting times for a deceased donor kidney transplantation, however, indicate that at best 50% of the selected elderly may have realistic expectations to receive a timely transplant offer. By choice or medical selection, access to transplantation also decreases with increasing age. In order to expedite the chance for elderly to receive a kidney transplant dedicated allocation systems have been developed. These allocation systems, like the Eurotransplant Senior Program (ESP), support preferential local allocation of kidneys from older donors to older patients in order to match recipient and graft life while disregarding histocompatibility for HLA antigens. The consequence has been more acute rejection episodes and an increase in immunosuppressive load. In the elderly, the most common cause of graft loss is death with functioning graft and death from infectious diseases is one of the dominant causes. The Eurotransplant Senior DR-compatible Program (ESDP) was designed to further improve the perspective of successful transplantation in the elderly in terms of life and quality of life by re-introducing matching criteria for HLA-DR in the old-for-old algorithm.
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Affiliation(s)
- G J Dreyer
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - A C Hemke
- Nefrovision/Renine, Dutch Transplant Foundation, Leiden, The Netherlands
| | - M E J Reinders
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - J W de Fijter
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands.
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Outcomes following renal transplantation in older renal transplant recipients: a single-center experience and “Croatian senior program”. Int Urol Nephrol 2015; 47:1415-22. [DOI: 10.1007/s11255-015-1034-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 06/11/2015] [Indexed: 10/23/2022]
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37
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Shi YY, Hesselink DA, van Gelder T. Pharmacokinetics and pharmacodynamics of immunosuppressive drugs in elderly kidney transplant recipients. Transplant Rev (Orlando) 2015; 29:224-30. [PMID: 26048322 DOI: 10.1016/j.trre.2015.04.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 04/29/2015] [Accepted: 04/30/2015] [Indexed: 02/05/2023]
Abstract
Elderly patients are a fast growing population among transplant recipients over the past decades. Both the innate and adaptive immune reactivity decrease with age, which is believed to contribute to the decreased incidence of acute rejection and increased infectious death rate in elderly transplant recipients. In contrast to recipient age, donor age is associated with a higher incidence of acute rejection. Pharmacokinetic studies in renal transplant recipients show that CNI troughs are >5% higher in elderly compared to younger patients given the same dose normalized by body weight. This may impact the starting dose of tacrolimus and cyclosporine. Possibly in elderly patients the intracellular (in lymphocyte) concentrations are relatively high in relation to the whole blood concentration, resulting in a stronger pharmacodynamic effect at the same whole blood trough concentration. For cyclosporine this has been shown, but it is not clear if the same is true for other immunosuppressive drugs. Pharmacodynamic studies have compared the inhibition of target enzymes, or more downstream effects of immunosuppressive drugs, in younger and older patients. Measurement of nuclear factor of activated T-cell (NFAT)-regulated gene expression (RGE), a pharmacodynamic read-out of CNI, is a promising biomarker of immunosuppression. Low levels of NFAT RGE are associated with increased risk of infection and non-melanoma skin cancer in elderly patients. Clinical trials to evaluate the safety and efficacy of immunosuppression regimens in this specific patient population, which is underrepresented in published trials, are lacking. More studies in elderly patients are needed to investigate the impact of age on the pharmacokinetics or pharmacodynamics of immunosuppressive drugs, and to decide on the optimal regimen and target levels for elderly transplant recipients.
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Affiliation(s)
- Yun-Ying Shi
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Dennis A Hesselink
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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Struijk G, Lammers A, Brinkman R, Lombarts M, van Vugt M, van der Pant K, ten Berge I, Bemelman F. Immunization after renal transplantation: current clinical practice. Transpl Infect Dis 2015; 17:192-200. [DOI: 10.1111/tid.12368] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 11/30/2014] [Accepted: 02/01/2015] [Indexed: 01/22/2023]
Affiliation(s)
- G.H. Struijk
- Renal Transplant Unit; Department of Nephrology; Division of Internal Medicine; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - A.J.J. Lammers
- Department of Infectious Diseases, Tropical Medicine and AIDS; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - R.J. Brinkman
- Renal Transplant Unit; Department of Nephrology; Division of Internal Medicine; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - M.J.M.H. Lombarts
- Professional Performance Research Group; Center of Evidence-Based Education; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - M. van Vugt
- Department of Infectious Diseases, Tropical Medicine and AIDS; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - K.A.M.I. van der Pant
- Renal Transplant Unit; Department of Nephrology; Division of Internal Medicine; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - I.J.M. ten Berge
- Renal Transplant Unit; Department of Nephrology; Division of Internal Medicine; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - F.J. Bemelman
- Renal Transplant Unit; Department of Nephrology; Division of Internal Medicine; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
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Iwai T, Uchida J, Kuwabara N, Kabei K, Yukimatsu N, Okamura M, Yamasaki T, Naganuma T, Kumada N, Nakatani T. Clinical Outcome of Elderly Kidney Transplant Recipients from Spousal Donors. Urol Int 2015; 95:99-105. [PMID: 25633349 DOI: 10.1159/000368324] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 09/11/2014] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Patients aged 60 years and older stand for the fastest growing group of patients with end-stage renal disease worldwide, and the need for kidney transplants among this population is rising. In Japan, living donor kidney transplantation is mainly performed to deal with the severe shortage of deceased donors, and the number of spousal transplants is currently increasing. PATIENTS AND METHODS A total of 164 patients with ESRD underwent living donor kidney transplantation at our institution, of whom 21 patients aged 60 years and older had spousal kidney transplantation. ABO-incompatible kidney transplantation was performed in 5 of the 21 cases. We analyzed these recipients. RESULTS Patient and graft survival rates were 100%. The incidence of acute rejection was 23.8%. Eight patients experienced cytomegalovirus viremia, two patients experienced Pneumocystis jiroveci infection, and one experienced bacterial pneumonia. Two patients developed cancers and underwent curative operation after transplantation. CONCLUSIONS Elderly kidney transplantation from spousal donors is associated with age-related immune dysfunction, which may develop infections and malignancies and could be immunologically high risk due to the high rate of ABO-incompatibility and poor histocompatibility. An effort to minimize the adverse effect of immunosuppression and to reduce the risk of acute rejection may be needed for an excellent long-term outcome.
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Affiliation(s)
- Tomoaki Iwai
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
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Vittoraki AG, Boletis JN, Darema MN, Kostakis AJ, Iniotaki AG. Adenosine triphosphate production by peripheral blood CD4⁺T cells in clinically stable renal transplant recipients. Transplant Proc 2015; 46:108-14. [PMID: 24507034 DOI: 10.1016/j.transproceed.2013.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 03/12/2013] [Accepted: 04/23/2013] [Indexed: 12/19/2022]
Abstract
Previous studies have shown that intracellular adenosine triphosphate (iATP) in activated CD4 T cells in vitro may identify patients at risk of infection or rejection post-transplantation. In this study, we evaluated whether this test could identify the level of risk in 656 renal transplant recipients (RTRs) with good and stable graft function. Therefore, 1095 blood samples from RTRs and 200 from healthy blood donors (normal controls [NCs]) were collected in 2 years and analyzed using the Cylex(®) ImmuKnow™ assay (Cylex, Inc., Columbia, MD, USA). The classification of T cell responses into strong, moderate, and low revealed significant differences between patients and NCs in low and strong responses (P < .001 and P = .021, respectively). The majority of patient samples exhibited moderate immune response (72.2%) in comparison with NC (75%). One hundred twenty-eight patients had fluctuated T cell responses between the three response zones. All patients were clinically stable for at least 1 month after the test. T cell response was increased after time post-transplantation (P < .001) and was found higher in protocols using azathioprine versus other immunosuppression (P < .001) and cyclosporine instead of tacrolimus (P = .012). According to the results of this study, we are not able to support this assay as an immune monitoring test post-transplantation in clinically stable RTRs. In contrast, measuring of iATP in CD4 T cells is a valuable tool for estimating T cell activation capacity. Because T cell activation is mainly affected by immunosuppression, this test may give information regarding the strength of different immunosuppressive protocols or the strength of immunosuppression as it is associated with longer follow-up periods.
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Affiliation(s)
- A G Vittoraki
- National Tissue Typing Center, General Hospital of Athens "G.Gennimatas", Athens, Greece.
| | - J N Boletis
- Transplantation Unit, "Laiko Hospital", Athens, Greece
| | - M N Darema
- Transplantation Unit, "Laiko Hospital", Athens, Greece
| | - A J Kostakis
- Biomedical Research Foundation, Academy of Athens, Athens, Greece
| | - A G Iniotaki
- National Tissue Typing Center, General Hospital of Athens "G.Gennimatas", Athens, Greece
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41
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Recipient-related risk factors for graft failure and death in elderly kidney transplant recipients. PLoS One 2014; 9:e112938. [PMID: 25389964 PMCID: PMC4229296 DOI: 10.1371/journal.pone.0112938] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 10/17/2014] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Elderly patients with end-stage renal disease have become the fastest growing population of kidney transplant candidates in recent years. However, the risk factors associated with long-term outcomes in these patients remain unclear. METHODS We retrospectively analyzed 166 recipients aged 60 years or older who underwent primary deceased kidney transplantation between 2002 and 2013 in our center. The main outcomes included 1-, 3- and 5-year patient survival as well as overall and death-censored graft survival. The independent risk factors affecting graft and patient survival were analyzed using Cox regression analysis. RESULTS The 1-, 3-, 5-year death-censored graft survival rates were 93.6%, 89.4% and 83.6%, respectively. Based on the Cox multivariate analysis, panel reactive antibody (PRA)>5% [hazard ratio (HR) 4.295, 95% confidence interval (CI) 1.321-13.97], delayed graft function (HR 4.744, 95% CI 1.611-13.973) and acute rejection (HR 4.971, 95% CI 1.516-16.301) were independent risk factors for graft failure. The 1-, 3-, 5-year patient survival rates were 84.8%, 82.1% and 77.1%, respectively. Longer dialysis time (HR 1.011 for 1-month increase, 95% CI 1.002-1.020), graft loss (HR 3.501, 95% CI 1.559-7.865) and low-dose ganciclovir prophylaxis (1.5 g/d for 3 months) (HR 3.173, 95% CI 1.063-9.473) were risk factors associated with patient death. CONCLUSIONS The five-year results show an excellent graft and patient survival in elderly kidney transplant recipients aged ≥60 years. PRA>5%, delayed graft function, and acute rejection are risk factors for graft failure, while longer duration of dialysis, graft loss and low-dose ganciclovir prophylaxis are risk factors for mortality in elderly recipients. These factors represent potential targets for interventions aimed at improving graft and patient survival in elderly recipients.
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Distinct phenotypes of cardiac allograft vasculopathy after heart transplantation: A histopathological study. Atherosclerosis 2014; 236:353-9. [DOI: 10.1016/j.atherosclerosis.2014.07.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 06/12/2014] [Accepted: 07/17/2014] [Indexed: 11/22/2022]
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Malinis MF, Chen S, Allore HG, Quagliarello VJ. Outcomes among older adult liver transplantation recipients in the model of end stage liver disease (MELD) era. Ann Transplant 2014; 19:478-87. [PMID: 25256592 DOI: 10.12659/aot.890934] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Since 2002, the Model of End Stage Liver Disease (MELD) score has been the basis of the liver transplant (LT) allocation system. Among older adult LT recipients, short-term outcomes in the MELD era were comparable to the pre-MELD era, but long-term outcomes remain unclear. MATERIAL AND METHODS This is a retrospective cohort study using the UNOS data on patients age ≥ 50 years who underwent primary LT from February 27, 2002 until October 31, 2011. RESULTS A total of 35,686 recipients met inclusion criteria. The cohort was divided into 5-year interval age groups. Five-year over-all survival rates for ages 50-54, 55-59, 60-64, 65-69, and 70+ were 72.2%, 71.6%, 69.5%, 65.0%, and 57.5%, respectively. Five-year graft survival rates after adjusting for death as competing risk for ages 50-54, 55-59,60-64, 65-69 and 70+ were 85.8%, 87.3%, 89.6%, 89.1% and 88.9%, respectively. By Cox proportional hazard modeling, age ≥ 60, increasing MELD, donor age ≥ 60, hepatitis C, hepatocellular carcinoma (HCC), dialysis and impaired pre-transplant functional status (FS) were associated with increased 5-year mortality. Using Fine and Gray sub-proportional hazard modeling adjusted for death as competing risk, 5-year graft failure was associated with donor age ≥ 60, increasing MELD, hepatitis C, HCC, and impaired pre-transplant FS. CONCLUSIONS Among older LT recipients in the MELD era, long-term graft survival after adjusting for death as competing risk was improved with increasing age, while over-all survival was worse. Donor age, hepatitis C, and pre-transplant FS represent potentially modifiable risk factors that could influence long-term graft and patient survival.
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Affiliation(s)
- Maricar F Malinis
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, USA
| | - Shu Chen
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, USA
| | - Heather G Allore
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, USA
| | - Vincent J Quagliarello
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, USA
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Piselli P, Verdirosi D, Cimaglia C, Busnach G, Fratino L, Ettorre GM, De Paoli P, Citterio F, Serraino D. Epidemiology of de novo malignancies after solid-organ transplantation: immunosuppression, infection and other risk factors. Best Pract Res Clin Obstet Gynaecol 2014; 28:1251-65. [PMID: 25209964 DOI: 10.1016/j.bpobgyn.2014.08.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 08/13/2014] [Accepted: 08/14/2014] [Indexed: 12/18/2022]
Abstract
Organ transplantation is an increasingly used medical procedure for treating otherwise fatal end-stage organ diseases, and a large number of anti-rejection drugs have been developed to prolong long-term survival of both the individual and the transplanted organ. However, the prolonged use of immunosuppressive drugs is well known to increase the risk of opportunistic diseases, particularly infections and virus-related malignancies. Although transplant recipients experience a nearly twofold elevated risk for all types of de novo cancers, persistent infections with oncogenic viruses are associated with up to hundredfold increased risks. Women of the reproductive age are growing in number among the recipients of solid-organ transplants, but specific data on cancer outcomes are lacking. This article updates evidences linking iatrogenic immunosuppression, persistent infections with oncogenic viruses, other risk factors and post-transplant malignancies. Epidemiological aspects, tumourigenesis related to oncogenic viruses, clinical implications, as well as primary and secondary prevention issues are discussed to offer clinicians and researchers alike an update of an increasingly important topic.
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Affiliation(s)
- Pierluca Piselli
- National Institute for Infectious Diseases "L. Spallanzani", Rome, Italy.
| | - Diana Verdirosi
- National Institute for Infectious Diseases "L. Spallanzani", Rome, Italy
| | - Claudia Cimaglia
- National Institute for Infectious Diseases "L. Spallanzani", Rome, Italy
| | | | - Lucia Fratino
- IRCCS Centro di Riferimento Oncologico, Aviano, Italy
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46
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Kohei N, Sawada Y, Hirai T, Omoto K, Ishida H, Tanabe K. Influence of Dialysis Duration on the Outcome of Living Kidney Transplantation. Ther Apher Dial 2014; 18:481-8. [DOI: 10.1111/1744-9987.12169] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Naoki Kohei
- Department of Urology; Tokyo Women's Medical University; Tokyo Japan
| | - Yugo Sawada
- Department of Urology; Tokyo Women's Medical University; Tokyo Japan
| | - Toshihito Hirai
- Department of Urology; Tokyo Women's Medical University; Tokyo Japan
| | - Kazuya Omoto
- Department of Urology; Tokyo Women's Medical University; Tokyo Japan
| | - Hideki Ishida
- Department of Urology; Tokyo Women's Medical University; Tokyo Japan
| | - Kazunari Tanabe
- Department of Urology; Tokyo Women's Medical University; Tokyo Japan
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47
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Harhay M, Lin E, Pai A, Harhay MO, Huverserian A, Mussell A, Abt P, Levine M, Bloom R, Shea J, Troxel A, Reese P. Early rehospitalization after kidney transplantation: assessing preventability and prognosis. Am J Transplant 2013; 13:3164-72. [PMID: 24165498 PMCID: PMC4108077 DOI: 10.1111/ajt.12513] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 09/17/2013] [Accepted: 09/17/2013] [Indexed: 01/25/2023]
Abstract
Early rehospitalization after kidney transplantation (KT) is common and may predict future adverse outcomes. Previous studies using claims data have been limited in identifying preventable rehospitalizations. We assembled a cohort of 753 adults at our institution undergoing KT from January 1, 2003 to December 31, 2007. Two physicians independently reviewed medical records of 237 patients (32%) with early rehospitalization and identified (1) primary reason for and (2) preventability of rehospitalization. Mortality and graft failure were ascertained through linkage to the Scientific Registry of Transplant Recipients. Leading reasons for rehospitalization included surgical complications (15%), rejection (14%), volume shifts (11%) and systemic and surgical wound infections (11% and 2.5%). Reviewer agreement on primary reason (85% of cases) was strong (kappa = 0.78). Only 19 rehospitalizations (8%) met preventability criteria. Using logistic regression, weekend discharge (odds ratio [OR] 1.59, p = 0.01), waitlist time (OR 1.10, p = 0.04) and longer initial length of stay (OR 1.42, p = 0.03) were associated with early rehospitalization. Using Cox regression, early rehospitalization was associated with mortality (hazard ratio [HR] 1.55; p = 0.03) but not graft loss (HR 1.33; p = 0.09). Early rehospitalization has diverse causes and presents challenges as a quality metric after KT. These results should be validated prospectively at multiple centers to identify vulnerable patients and modifiable processes-of-care.
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Affiliation(s)
- M. Harhay
- Center for Clinical Epidemiology and Biostatistics, University of
Pennsylvania, Philadelphia, PA,Renal Division, Department of Medicine, University of Pennsylvania,
Philadelphia, PA
| | - E. Lin
- Department of Medicine, University of Pennsylvania, Philadelphia,
PA
| | - A. Pai
- Renal Division, Pennsylvania Hospital, Philadelphia, PA
| | - M. O. Harhay
- Center for Clinical Epidemiology and Biostatistics, University of
Pennsylvania, Philadelphia, PA
| | - A. Huverserian
- School of Medicine, Washington University, St. Louis, MO
| | - A. Mussell
- Center for Clinical Epidemiology and Biostatistics, University of
Pennsylvania, Philadelphia, PA
| | - P. Abt
- Department of Surgery, Transplant Institute, University of
Pennsylvania, Philadelphia, PA
| | - M. Levine
- Department of Surgery, Transplant Institute, University of
Pennsylvania, Philadelphia, PA
| | - R. Bloom
- Renal Division, Department of Medicine, University of Pennsylvania,
Philadelphia, PA
| | - J.A. Shea
- Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA
| | - A.B. Troxel
- Center for Clinical Epidemiology and Biostatistics, University of
Pennsylvania, Philadelphia, PA
| | - P.P. Reese
- Center for Clinical Epidemiology and Biostatistics, University of
Pennsylvania, Philadelphia, PA,Renal Division, Department of Medicine, University of Pennsylvania,
Philadelphia, PA,Department of Surgery, Transplant Institute, University of
Pennsylvania, Philadelphia, PA
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Clinical and Histopathologic Comparative Analysis Between Kidney Transplant Recipients From Expanded-Criteria Donors and Standard-Criteria Donors. Transplant Proc 2013; 45:3234-8. [DOI: 10.1016/j.transproceed.2013.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 05/09/2013] [Indexed: 11/21/2022]
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49
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Martins PN, Markmann JF. Age-related differences in hepatic ischemia/reperfusion: gene activation, liver injury, and protective effect of melatonin. J Surg Res 2013; 185:e19-21. [DOI: 10.1016/j.jss.2012.08.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 08/09/2012] [Accepted: 08/09/2012] [Indexed: 10/27/2022]
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Martins PNA, Tullius SG, Markmann JF. Immunosenescence and immune response in organ transplantation. Int Rev Immunol 2013; 33:162-73. [PMID: 24127845 DOI: 10.3109/08830185.2013.829469] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The immune system undergoes a complex and continuous remodeling with aging. Immunosenescence results into both quantitative and qualitative changes of specific cellular subpopulations that have major impact on allorecognition and alloresponse, and consequently on graft rejection and tolerance. Here, we are going to review the immunological changes associated with the aging process relevant for transplantation. Interventions to selectively target changes associated with the senescence process seem promising therapeutic strategies to improve transplantation outcome.
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Affiliation(s)
- Paulo Ney Aguiar Martins
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School , Boston, MA , USA
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