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Liu CW, Anih J, Lebedeva V, Gungor A, Wang C, Park L, Roshanov PS. Kidney disease in trials of perioperative tranexamic acid. J Clin Anesth 2024; 94:111417. [PMID: 38387241 DOI: 10.1016/j.jclinane.2024.111417] [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: 10/21/2023] [Revised: 12/31/2023] [Accepted: 02/14/2024] [Indexed: 02/24/2024]
Abstract
STUDY OBJECTIVE To assess how kidney disease is handled in randomized trials evaluating the safety and efficacy of perioperative tranexamic acid, and to evaluate its effects across levels of kidney function. DESIGN Systematic review and meta-analysis of randomized controlled trials. SETTING We screened studies from a previous comprehensive systematic review, and updated its search of PubMed, Embase, and Cochrane CENTRAL to July 31, 2023. PATIENTS Patients undergoing non-obstetric surgery. INTERVENTIONS Intravenous tranexamic acid compared to placebo or usual care without tranexamic acid. MEASUREMENT We summarized the handling of kidney disease in eligibility criteria, dose adjustments for kidney function, and effects of tranexamic acid on thrombotic events, seizures, and bleeding by subgroups of kidney function. MAIN RESULTS We evaluated 300 trials with 53,085 participants; 45,958 participants (86.6%) were enrolled in 228 trials (76.0%) that explicitly excluded patients with kidney disease. Definitions of kidney diseased used for exclusion varied widely. Most were non-specific and some corresponded to mild disease. Only 5 trials adjusted dosing for kidney function. Meta-analysis of two large trials found tranexamic acid unlikely to substantially increase or decrease the occurrence of thrombotic events in patients with eGFR <60 mL/min/1.73m2 (RR, 0.95; 95% CI: 0.83 to 1.07) or ≥ 60 mL/min/1.73m2 (RR, 1.00; 95% CI, 0.91 to 1.11; P for subgroup difference = 0.47), but both trials excluded patients with severe kidney disease. No analysis could be performed regarding seizure risk. One large trial in noncardiac surgery reported similar reduction in bleeding across subgroups of kidney function but excluded patients with creatinine clearance <30 mL/min. CONCLUSIONS The large evidence base supporting perioperative tranexamic acid suffers from broad and unjustified exclusion of patients with kidney disease. Typical perioperative dosing of tranexamic acid is likely safe and effective in patients with creatinine clearance >30 mL/min, but effects in more severe kidney disease are unknown.
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Affiliation(s)
- Cheng-Wei Liu
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
| | - Joshua Anih
- McMaster University, Hamilton, Ontario, Canada
| | | | - Ata Gungor
- Western University, London, Ontario, Canada
| | - Carol Wang
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
| | - Lily Park
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Pavel S Roshanov
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada.
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Schold JD, Tambur AR, Mohan S, Kaplan B. Calibration of Priority Points for Sensitization Status of Kidney Transplant Candidates in the United States. Clin J Am Soc Nephrol 2024; 19:767-777. [PMID: 38509037 PMCID: PMC11168827 DOI: 10.2215/cjn.0000000000000449] [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: 09/28/2023] [Accepted: 03/14/2024] [Indexed: 03/22/2024]
Abstract
Key Points There are multiple factors associated with high sensitization levels among kidney transplant candidates, which differ by candidate sex. Since the initiation of the kidney allocation system, candidates with higher sensitization have higher rates of deceased donor transplantation. Priority points assigned to candidates associated with sensitization have led to inequities in access to deceased donor transplantation. Background A primary change to the national organ allocation system in 2014 for deceased donor kidney offers was to weight candidate priority on the basis of sensitization (i.e ., calculated panel reactive antibody percentage [cPRA%]) using a sliding scale. Increased priority for sensitized patients could improve equity in access to transplantation for disadvantaged candidates. We sought to evaluate the effect of these weights using a contemporary cohort of adult US kidney transplant candidates. Methods We used the national Scientific Registry of Transplant Recipients to evaluate factors associated with sensitization using multivariable logistic models and rates of deceased donor transplantation using cumulative incidence models accounting for competing risks and multivariable Cox models. Results We examined 270,912 adult candidates placed on the waiting list between January 2016 and September 2023. Six-year cumulative incidence of deceased donor transplantation for candidates with cPRA%=80–85 and 90–95 was 48% and 53%, respectively, as compared with 37% for candidates with cPRA%=0–20. In multivariable models, candidates with high cPRA% had the highest adjusted hazards for deceased donor transplantation. There was significant effect modification such that the association of high cPRA% with adjusted rates of deceased donor transplantation varied by region of the country, sex, race and ethnicity, prior dialysis time, and blood type. Conclusions The results indicate that the weighting algorithm for highly sensitized candidates may overinflate the need for prioritization and lead to higher rates of transplantation. Findings suggest recalibration of priority weights for allocation is needed to facilitate overall equity in access to transplantation for prospective kidney transplant candidates. However, priority points should also account for subgroups of candidates who are disadvantaged for access to donor offers.
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Affiliation(s)
- Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Anat R Tambur
- Department of Surgery, Northwestern University, Chicago, Illinois
| | - Sumit Mohan
- Department of Medicine, Columbia University, New York, New York
- Department of Epidemiology, Columbia University, New York, New York
| | - Bruce Kaplan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Johansen KL, Gilbertson DT, Li S, Li S, Liu J, Roetker NS, Ku E, Schulman IH, Greer RC, Chan K, Abbott KC, Butler CR, O'Hare AM, Powe NR, Reddy YNV, Snyder J, St Peter W, Taylor JS, Weinhandl ED, Wetmore JB. US Renal Data System 2023 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis 2024; 83:A8-A13. [PMID: 38519262 DOI: 10.1053/j.ajkd.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
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Li F, Gragert L, Giovanni Biagini D, Patel JK, Kobashigawa JA, Trück J, Rodriguez O, Watson CT, Gibb DR, Zhang X, Kransdorf EP. IgM marks persistent IgG anti-human leukocyte antigen antibodies in highly sensitized heart transplant patients. J Heart Lung Transplant 2024; 43:314-323. [PMID: 37793509 DOI: 10.1016/j.healun.2023.09.022] [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: 02/05/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Sensitization to human leukocyte antigens (HLA) is a persistent problem in heart transplant (HT) candidates. We sought to characterize the anti-HLA antibody and circulating B cell repertoire in a cohort of highly sensitized HT candidates. METHODS We assessed immunoglobulin G (IgG) and immunoglobulin M (IgM) anti-HLA antibodies using Luminex single antigen bead assays in a cohort of 11 highly sensitized (HS; calculated panel reactive antibody ≥ 90%) and 3 mildly sensitized (MS) candidates. We also performed B cell receptor repertoire sequencing (BCRseq) in HS candidates and 33 non-candidate controls. HLA antibody strength was measured by mean fluorescence intensity (MFI). RESULTS We found that IgM anti-HLA antibodies were present in all HS candidates, but with a lower breadth and strength as compared to IgG. When anti-HLA IgG specificities intersected with IgM, binding strength was higher. In contrast, there were IgM but no intersecting IgG specificities for the MS group. In four candidates in the HS group, IgG anti-HLA antibodies decreased in both breadth and strength after HT, but the decrease in strength was smaller if the IgG possessed a specificity that intersected with pre-transplant IgM. BCRseq revealed larger B cell clonotypes in HS candidates but similar diversity as compared to controls. CONCLUSIONS IgM marks IgG anti-HLA antibodies with higher strength before HT and persistence after HT. The presence of IgM intersecting IgG for an anti-HLA specificity may be a useful approach to determine which donor HLA should be avoided for a sensitized candidate.
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Affiliation(s)
- Fang Li
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Loren Gragert
- Department of Pathology, Tulane University School of Medicine, New Orleans, Louisiana
| | - D Giovanni Biagini
- Department of Pathology, Tulane University School of Medicine, New Orleans, Louisiana
| | - Jignesh K Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Johannes Trück
- Division of Immunology, University Children's Hospital and Children's Research Center, University of Zurich (UZH), Zurich, Switzerland
| | - Oscar Rodriguez
- Department of Biochemistry and Molecular Genetics, University of Louisville, Louisville, Kentucky
| | - Corey T Watson
- Department of Biochemistry and Molecular Genetics, University of Louisville, Louisville, Kentucky
| | - David R Gibb
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Xiaohai Zhang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Ranchin B, Schmitt CP, Warady BA, Hataya H, Jones J, Lalji R, Licht C, Mosca M, Stronach L, Vidal E, Walle JV, Shroff R. Technical requirements and devices available for long-term hemodialysis in children-mind the gap! Pediatr Nephrol 2023:10.1007/s00467-023-06233-0. [PMID: 38141144 DOI: 10.1007/s00467-023-06233-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/10/2023] [Accepted: 11/13/2023] [Indexed: 12/24/2023]
Abstract
Children requiring long-term kidney replacement therapy are a "rare disease" cohort. While the basic technical requirements for hemodialysis (HD) are similar in children and adults, key aspects of the child's cardiovascular anatomy and hemodynamic specifications must be considered. In this article, we describe the technical requirements for long-term HD therapy for children and the devices that are currently available around the world. We highlight the characteristics and major technical shortcomings of permanent central venous catheters, dialyzers, dialysis machines, and software available to clinicians who care for children. We show that currently available HD machines are not equipped with appropriately small circuits and sensitive control mechanisms to perform safe and effective HD in the youngest patients. Manufacturers limit their liability, and health regulatory agencies permit the use of devices, only in children according to the manufacturers' pre-specified weight limitations. Although registries show that 6-23% of children starting long-term HD weigh less than 15 kg, currently, there is only one long-term HD device that is cleared for use in children weighing 10 to 15 kg and none is available and labelled for use in children weighing less than 10 kg anywhere in the world. Thus, many children are being treated "off-label" and are subject to interventions delivered by medical devices that lack pediatric safety and efficacy data. Moreover, recent improvements in dialysis technology offered to adult patients are denied to most children. We, in turn, advocate for concerted action by pediatric nephrologists, industry, and health regulatory agencies to increase the development of dedicated HD machines and equipment for children.
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Affiliation(s)
- Bruno Ranchin
- Pediatric Nephrology Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, Lyon, France.
- Centre de référence des maladies rénales rares, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 boulevard Pinel, 69677, Bron Cedex, France.
| | - Claus Peter Schmitt
- Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Bradley A Warady
- Division of Nephrology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Hiroshi Hataya
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
- Department of Pediatrics, School of Medicine, Keio University, Shinjuku-ku, Tokyo, Japan
| | - Joanne Jones
- Queensland Children's Hospital, University of Queensland, Brisbane, Australia
| | - Rowena Lalji
- Centre for Kidney Disease Research, University of Queensland, Brisbane, Australia
- Department of Nephrology, Queensland Children's Hospital, Brisbane, Australia
- Metro South and Integrated Nephrology and Transplant Services, Princess Alexandra Hospital, Brisbane, Australia
| | - Christoph Licht
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Division of Nephrology and Research Institute, Cell Biology Program, The Hospital for Sick Children, Toronto, ON, Canada
| | - Melodie Mosca
- Pediatric Nephrology Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, Lyon, France
| | - Lynsey Stronach
- University College London Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Enrico Vidal
- Pediatric Nephrology Unit, Department for Woman and Child's Health, University-Hospital of Padua, Padua, Italy
| | - Johan Vande Walle
- Department of Pediatric Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Rukshana Shroff
- University College London Great Ormond Street Hospital and Institute of Child Health, London, UK
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O'Connor-Cordova MA, Ortega-Macias AG, Sancen-Herrera JP, Altamirano-Lamarque F, Del Toro AV, Del Campo AIM, Canal-Zarate P, Peddinani BK, Gonzalez-Zorrilla F, O'Connor Juarez M. Living donor robotic-assisted kidney transplant compared to traditional living donor open kidney transplant. Where do we stand now? A systematic review and meta-analysis. Transplant Rev (Orlando) 2023; 37:100789. [PMID: 37604048 DOI: 10.1016/j.trre.2023.100789] [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: 04/17/2023] [Revised: 08/02/2023] [Accepted: 08/06/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Renal transplant is the standard of care for patients with end-stage renal disease (ESRD). Robotic-assisted kidney transplant (RAKT) has emerged as a safe minimally invasive approach with a lower complication rate than open kidney transplant (OKT). Concerns regarding ischemia times and graft function are still a matter of debate. METHODS Following PRISMA guidelines and PROSPERO registration CRD42023413774, a systematic review was performed in March 2023 on RAKT compared to OKT. Primary outcomes of interest were surgical times, ischemia times, blood loss, complication rates, and graft function. Data were analyzed using R version 4.2.2. RESULTS A total of nine studies comparing living donor RAKT to living donor OKT were included, totaling 1477 patients, out of which 508 underwent RAKT and 969 OKT. RAKT cases were highly selected as depicted in the manuscript. Cumulative analysis showed significantly longer total ischemic time (MD = 16.51; 95% CI = [9.86-23.16]) and rewarming ischemia time (MD = 11.24; 95% CI = [-0.46-22.01]) in RAKT group. No differences were found in total procedure time and time to complete anastomoses. Blood loss and transfusion rate were lower in RAKT group (MD = -53.68; 95% CI = [-89.78; -17.58]) and (RR = 0.29; 95% CI = [0.14; 0.57]), respectively. The meta-analysis revealed a lower rate of surgical site infection (SSI) (RR = 0.31; 95% CI = [0.19-0.52]) and symptomatic lymphocele (RR = 0.16; 95% CI = [0.06-0.43]) in RAKT. No difference in ileus rate was found. Pain scores were significantly lower in the RAKT group (MD = -1.14; 95% CI = [-1.59 - -0.69]; p ≤0.01). No difference in length of stay and hospital readmission were evidenced. Delayed graft function (DGF) and acute rejection rates were not different between interventions groups (RR =1.23; 95% CI = [0.40-3.74]) and (RR =0.96; 95% CI = [0.55-1.70]), respectively. No difference between groups in early graft outcomes are evident. CONCLUSIONS Our analysis suggests that RAKT is a minimally invasive, safe, and feasible procedure. It is associated with a lower complication rate and similar intraoperative, perioperative, and postoperative outcomes. Further quality studies are needed to confirm these findings.
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Affiliation(s)
- Mario A O'Connor-Cordova
- Escuela de Medicina del Tecnológico de Monterrey, Av. Morones Prieto 3000, Monterrey, Nuevo León, Mexico.
| | - Alan G Ortega-Macias
- Escuela de Medicina del Tecnológico de Monterrey, Av. Morones Prieto 3000, Monterrey, Nuevo León, Mexico
| | - Juan P Sancen-Herrera
- Escuela de Medicina del Tecnológico de Monterrey, Av. Morones Prieto 3000, Monterrey, Nuevo León, Mexico
| | | | - Alexis Vargas Del Toro
- Escuela de Medicina del Tecnológico de Monterrey, Av. Morones Prieto 3000, Monterrey, Nuevo León, Mexico
| | | | - Pia Canal-Zarate
- Facultad de Medicina Universidad Anahuac, Av. Universidad Anahuac 46, Ciudad de México, Mexico
| | - Bharat Kumar Peddinani
- Escuela de Medicina del Tecnológico de Monterrey, Av. Morones Prieto 3000, Monterrey, Nuevo León, Mexico
| | | | - Mario O'Connor Juarez
- Urology Department, Hospital Ángeles del Carmen, Tarascos 3469 -401, Guadalajara, Jalisco, Mexico
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Kang ZY, Liu C, Liu W, Li D. Association between blood transfusion after kidney transplantation and risk for the development of de novo HLA donor-specific antibodies and poor clinical outcomes: A single-center retrospective study. Transpl Immunol 2023; 81:101930. [PMID: 37730183 DOI: 10.1016/j.trim.2023.101930] [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: 06/21/2023] [Revised: 09/14/2023] [Accepted: 09/16/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Blood transfusion after kidney transplantation may increase the risk of sensitization and development of de novo human leukocyte antigen (HLA) donor-specific antibodies (DSAs). This study aimed to evaluate whether blood transfusion during the first year after kidney transplantation influences the development of de novo DSAs and clinical outcomes of kidney transplantation recipients. METHODS This retrospective cohort study included nonsensitized first-time kidney transplantation recipients at Tianjin First Central Hospital from 2010 to 2022. The incidence of de novo DSA development and clinical outcomes between the groups were compared. Luminex single antigen beads were used to monitor DSAs. RESULTS Of the 538 non-HLA-sensitized kidney transplantation recipients included in the study, 164 patients who received at least one unit of leukoreduced red blood cell transfusion within the first year (the transfused group), whereas the remaining 374 patients received no blood transfusion (the non-transfused group). Our analysis showed that there was a significant difference in the development of de novo DSAs and de novo anti-class I HLA-Ab between the two groups. Indeed, the transfused recipients had a higher serum creatinine and lower estimated glomerular filtration rate (eGFR) at 1-, 6-, and 12-month (all p > 0.05) after transplantation. Futhermore, a higher incidence of CMV infection, antibody-mediated rejection (AMR), hyper acute rejection (HAR), and delayed graft function (DGF) was identified in the transfused group (all p < 0.05). The graft survival was lower in the transfused group compared with patients in the non-transfused group (P = 0.002). Blood transfusion post-transplantation was a risk factor for de novo DSAs development but not an independent predictive factor for AMR and graft loss (odds ratio = 2.064 [1.243-3.429], p = 0.005). CONCLUSIONS Our study showed that blood transfusion after transplantation is associated with the occurrence of de novo DSAs increasing an immunological risk for poor clinical outcomes for kidney transplantation recipients.
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Affiliation(s)
- Zhong-Yu Kang
- Department of Blood Transfusion, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, Nankai, China
| | - Chun Liu
- Department of Blood Transfusion, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, Nankai, China
| | - Wei Liu
- Department of Blood Transfusion, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, Nankai, China
| | - Daihong Li
- Department of Blood Transfusion, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, Nankai, China.
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Kittleson MM. Management of the sensitized heart transplant candidate. Curr Opin Organ Transplant 2023; 28:362-369. [PMID: 37678171 DOI: 10.1097/mot.0000000000001096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
PURPOSE OF REVIEW For sensitized heart transplant candidates who have antibodies to human leukocyte antigens (HLA), finding a suitable donor can be challenging and can lead to adverse waitlist outcomes. In recent years, the number of sensitized patients awaiting heart transplantation has increased likely due to the use of durable and mechanical circulatory support as well as increasing number of candidates with underlying congenital heart disease. RECENT FINDINGS Advances in the assessment of HLA antibodies allow for identification of heart transplant candidates who may benefit from desensitization strategies to widen the donor pool and mitigate the risk of adverse posttransplant outcomes. SUMMARY Antibody sensitization is a barrier to successful heart transplantation and strategies to identify sensitized patients, stratify their risk, and mitigate this risk through desensitization is crucial to optimize the quality of life and survival of HT recipients.
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Affiliation(s)
- Michelle M Kittleson
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Kim Y, Kim B, Kang M, Nam H, Ko DH, Park Y. Associations of Perioperative Red Blood Cell Transfusion With Outcomes of Kidney Transplantation in Korea Over a 16-Year Period. J Korean Med Sci 2023; 38:e212. [PMID: 37463685 DOI: 10.3346/jkms.2023.38.e212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 03/22/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND This study investigated the associations between transfusion of different types of red blood cell (RBC) preparations and kidney allograft outcomes after kidney transplantation (KT) over a 16-year period in Korea using a nationwide population-based cohort. METHODS We investigated the reported use of RBCs during hospitalization for KT surgery, rejection, and graft failure status using nationwide data from the National Health Information Database (2002-2017). The associations between the type of perioperative RBC product and transplant outcomes were evaluated among four predefined groups: no RBC transfusion, filtered RBCs, washed RBCs, and packed RBCs (pRBCs). RESULTS A total of 17,754 KT patients was included, among which 8,530 (48.0%) received some type of RBC transfusion. Of the patients who received RBC transfusion, 74.9%, 19.7%, and 5.4% received filtered RBCs, pRBCs, or washed RBCs, respectively. Regardless of the type of RBC products, the proportions of acute rejection and graft failure was significantly greater in patients receiving transfusion (P < 0.001). Cox proportional hazards regression analyses showed that the filtered RBC and pRBC groups were significantly associated with both rejection and graft failure. The washed RBC group also had hazard ratios greater than 1.0 for rejection and graft failure, but the association was not significant. Rejection-free survival of the pRBC group was significantly lower than that of the other groups (P < 0.001, log-rank test), and graft survival for the no RBC transfusion group was significantly greater than in the other groups (P < 0.001, log-rank test). CONCLUSION Perioperative RBC transfusion was associated with poor graft outcomes. Notably, transfusion of pRBCs significantly increased transplant rejection. Therefore, careful consideration of indications for RBC transfusion and selection of the appropriate type of RBCs is necessary, especially for patients at high risk of rejection or graft failure.
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Affiliation(s)
- Yoonjung Kim
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Banseok Kim
- Department of Laboratory Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Minjin Kang
- Research Institute, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - HyunJun Nam
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dae-Hyun Ko
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Yongjung Park
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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10
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Guo Z, Zhao D, Sa R, Wang L, Li S, Zhao G, Zhu L, Chen G. A modified perioperative regimen for deceased donor kidney transplantation in presensitized recipients without prior desensitization therapy. Front Immunol 2023; 14:1223567. [PMID: 37475867 PMCID: PMC10355838 DOI: 10.3389/fimmu.2023.1223567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 06/16/2023] [Indexed: 07/22/2023] Open
Abstract
Background Renal transplantation in HLA-presensitized recipients entails an increased risk of antibody-mediated rejection (AMR) and graft loss. There is currently no accepted standard treatment protocol that can help transplant surgeons safely perform deceased donor (DD) kidney transplantation in presensitized patients without pretransplant desensitization. Methods Fifty-one panel-reactive antibody (PRA)-positive recipients and 62 PRA-negative retransplant recipients (control) who received DD renal transplantation were included. Patients in the presensitized group (donor-specific antibody [DSA]-positive, n=25; DSA-negative, n=26) without desensitization received a modified perioperative treatment starting on day 0 or -1 with rituximab, thymoglobulin, and low daily doses of intravenous immunoglobulin (IVIG, 10-20 g/d, for 14 days). Plasmapheresis was performed once before surgery in DSA-positive recipients. Results The median follow-up time was 51 months in the presensitized group and 41 months in the control group. The incidence of early acute rejection (AR) and AMR (including mixed rejection) was 35.3% and 13.7% in the presensitized group, respectively, significantly higher than in the control group (14.5% and 1.6%, respectively). Within the presensitized group, the DSA-positive subgroup had more AMR than the DSA-negative subgroup (24.0% vs. 3.8%), but the incidence of T cell-mediated rejection was comparable (20.0% vs. 23.4%). In the presensitized group, all rejections were successfully reversed, and graft function remained stable during follow-up. The 1-year and 3-year survival rates of the grafts and recipients in this group were 98.0%. Conclusion With a modified IVIG-based perioperative regimen, excellent intermediate-term graft and recipient survival outcomes can be achieved in presensitized patients who received DD kidney transplantation without prior desensitization.
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Affiliation(s)
- Zhiliang Guo
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Daqiang Zhao
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, Chinese Academy of Medical Sciences, Wuhan, China
- NHC Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
- Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Rula Sa
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lu Wang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, Chinese Academy of Medical Sciences, Wuhan, China
- NHC Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
- Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Songxia Li
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guangyuan Zhao
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, Chinese Academy of Medical Sciences, Wuhan, China
- NHC Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
- Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Lan Zhu
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, Chinese Academy of Medical Sciences, Wuhan, China
- NHC Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
- Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Gang Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, Chinese Academy of Medical Sciences, Wuhan, China
- NHC Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
- Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
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11
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Hickey MJ, Singh G, Lum EL. Continuation of immunosuppression vs. immunosuppression weaning in potential repeat kidney transplant candidates: a care management perspective. FRONTIERS IN NEPHROLOGY 2023; 3:1163581. [PMID: 37746029 PMCID: PMC10513023 DOI: 10.3389/fneph.2023.1163581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 05/17/2023] [Indexed: 09/26/2023]
Abstract
Management of immunosuppression in patients with a failing or failed kidney transplant requires a complete assessment of their clinical condition. One of the major considerations in determining immunosuppression is whether or not such an individual is considered a candidate for re-transplantation. Withdrawal of immunosuppression in a re-transplant candidate can result in allosensitization and markedly reduce the chances of a repeat transplant. In this review, we summarize the effects of immunosuppression reduction on HLA sensitization, discuss the impacts of allosensitization in these patients, and explore reduction protocols and future directions. Risks of chronic immunosuppression, medical management of the failing allograft, and the effect of nephrectomy are covered elsewhere in this issue.
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Affiliation(s)
- Michelle J. Hickey
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles (UCLA) Immunogenetics Center, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Gurbir Singh
- Department of Medicine, Division of Nephrology, University of California, Los Angeles (UCLA) David Geffen School of Medicine, Los Angeles, CA, United States
| | - Erik L. Lum
- Department of Medicine, Division of Nephrology, University of California, Los Angeles (UCLA) David Geffen School of Medicine, Los Angeles, CA, United States
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12
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DeFilippis EM, Kransdorf EP, Jaiswal A, Zhang X, Patel J, Kobashigawa JA, Baran DA, Kittleson MM. Detection and management of HLA sensitization in candidates for adult heart transplantation. J Heart Lung Transplant 2023; 42:409-422. [PMID: 36631340 DOI: 10.1016/j.healun.2022.12.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 12/13/2022] [Accepted: 12/17/2022] [Indexed: 12/28/2022] Open
Abstract
Heart transplantation (HT) remains the preferred therapy for patients with advanced heart failure. However, for sensitized HT candidates who have antibodies to human leukocyte antigens , finding a suitable donor can be challenging and can lead to adverse waitlist outcomes. In recent years, the number of sensitized patients awaiting HT has increased likely due to the use of durable and mechanical circulatory support as well as increasing number of candidates with underlying congenital heart disease. This State-of-the-Art review discusses the assessment of human leukocyte antigens antibodies, potential desensitization strategies including mechanisms of action and specific protocols, the approach to a potential donor including the use of complement-dependent cytotoxicity, flow cytometry, and virtual crossmatches, and peritransplant induction management.
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Affiliation(s)
- Ersilia M DeFilippis
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Abhishek Jaiswal
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Xiaohai Zhang
- HLA and Immunogenetics Laboratory, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - David A Baran
- Cleveland Clinic, Heart Vascular and Thoracic Institute, Weston, Florida
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13
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Rao RA, Kransdorf EP, Patel JK, Kobashigawa JA, Kittleson MM. How to Approach HLA Sensitization in Heart Transplant Candidates. JACC: HEART FAILURE 2023; 11:469-475. [PMID: 37019560 DOI: 10.1016/j.jchf.2023.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/16/2022] [Accepted: 01/10/2023] [Indexed: 04/05/2023]
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14
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Choi S, Choi SJ, Shin JW, Yoon YA. Common Data Model-based Analysis of Selective Leukoreduction Protocol Compliance at Three Hospitals. Ann Lab Med 2023; 43:187-195. [PMID: 36281513 PMCID: PMC9618907 DOI: 10.3343/alm.2023.43.2.187] [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: 04/22/2022] [Revised: 07/14/2022] [Accepted: 09/19/2022] [Indexed: 12/27/2022] Open
Abstract
Background The selective leukoreduction protocol (SLP) is limited in that patients who require it can be overlooked. We estimated SLP compliance (SLPC) using the Observational Medical Outcomes Partnership common data model (CDM). Methods Patients were classified into eight groups: pre- and post-hematology disease (A and B), pre- and post-solid organ transplantation (C and D), solid cancer (E), immunodeficiency (F), anticancer therapy (G), and cardiovascular surgery (H). We examined the red blood cell (RBC) transfusion history from three hospital datasets comprising approximately three million patients over 20 years using CDM-based analysis. SLPC was calculated as the percentage of patients who received only leukoreduced RBCs in total patients transfused RBCs. Results In total, 166,641 patients from three hospitals were enrolled in this study. From 2001 to 2021, SLPC in all groups, except H, tended to increase, although there were differences among the hospitals. Based on the most recent values (2017-2021), the SLPC in groups A, B, D, and G was maintained at ≥75% until 1,095 days before or after diagnosis or treatment. Groups E, F, and H had < 50% SLPC one day after diagnosis and treatment. Conclusions CDM analysis supports the review of large datasets for SLPC evaluation. Although SLPC tended to improve in most patient groups, additional education and monitoring are needed for groups that continue to show low SLPC.
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Affiliation(s)
- Sooin Choi
- Department of Laboratory Medicine and Genetics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Soo Jeong Choi
- Division of Nephrology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jeong Won Shin
- Department of Laboratory Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Young Ahn Yoon
- Department of Laboratory Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
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15
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Lim WH, Ho J, Kosmoliaptsis V, Sapir-Pichhadze R. Editorial: Future challenges and directions in determining allo-immunity in kidney transplantation. Front Immunol 2022; 13:1013711. [PMID: 36119031 PMCID: PMC9473680 DOI: 10.3389/fimmu.2022.1013711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Wai H. Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
- Medical School, University of Western Australia, Perth, WA, Australia
- *Correspondence: Wai H. Lim,
| | - Julie Ho
- Department of Internal Medicine University of Manitoba, Winnipeg, MB, Canada
- Department of Immunology, University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba Adult Kidney Program, Transplant Manitoba, Shared Health Manitoba, Winnipeg, MB, Canada
| | - Vasilis Kosmoliaptsis
- Department of Surgery, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke’s Hospital, Cambridge, United Kingdom
- Blood and Transplant Research Unit in Organ Donation and Transplantation, National Institute for Health Research, University of Cambridge, Cambridge, United Kingdom
| | - Ruth Sapir-Pichhadze
- Centre for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montreal, QC, Canada
- Division of Nephrology and Multi-Organ Transplant Program, Department of Medicine, McGill University, Montreal, QC, Canada
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16
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Gaiffe E, Vernerey D, Bardiaux L, Leroux F, Meurisse A, Bamoulid J, Courivaud C, Saas P, Tiberghien P, Ducloux D. Early Post-Transplant Red Blood Cell Transfusion Is Associated With an Increased Risk of Transplant Failure: A Nationwide French Study. Front Immunol 2022; 13:854850. [PMID: 35711440 PMCID: PMC9197232 DOI: 10.3389/fimmu.2022.854850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 04/28/2022] [Indexed: 12/23/2022] Open
Abstract
Background Red blood cell (RBC) transfusions are frequently required in the early period after kidney transplantation. However, the consequences of RBC transfusions on long-term outcomes are largely unrecognized. Methods We conducted a nationwide French cohort study involving all 31 French kidney transplant centers. Patients having received a first kidney transplant between January 1, 2002 and December 31, 2008 were identified through the national registry of the French BioMedecine Agency (Agence de BioMédecine). Number and date of RBC transfusions were collected from the national database of the French transfusion public service. The primary endpoint was transplant failure defined as graft loss or death with a functional graft. Results Among 12,559 patients included during the study period, 3,483 (28%) were transfused during the first 14 days post-transplant. Median follow-up was 7.6 (7.5-7.8) years. Multivariable analysis determined that post-transplant RBC transfusion was associated with an increased risk in transplant failure (HR 1.650, 95%CI [1.538;1.771] p<0.0001). Both sensitivity and propension score analyses confirmed the previous result. Conclusions Early red blood cell transfusion after kidney transplantation is associated with increased transplant failure.
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Affiliation(s)
- Emilie Gaiffe
- Besançon University Hospital, Fédération Hospitalo-Universitaire Integrated Center for REsearch in inflammatory diseASes (FHU INCREASE), Besançon, France.,Univ. Bourgogne Franche-Comté, Institut National De La Santé et de la Recherche Médicale (INSERM), Etablissement Français du Sang Bourgogne Franche-Comté, Unité Mixte De Recherche 1098 (UMR1098), RIGHT Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon, France
| | - Dewi Vernerey
- Univ. Bourgogne Franche-Comté, Institut National De La Santé et de la Recherche Médicale (INSERM), Etablissement Français du Sang Bourgogne Franche-Comté, Unité Mixte De Recherche 1098 (UMR1098), RIGHT Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon, France.,Methodology and Quality of Life in Oncology Unit, Centre Hospitalier Universitaire (CHU) Besançon, Besançon, France
| | | | - Franck Leroux
- Institut National de la santé et de la recherche médicale Centre d'Investigation Clinique (INSERM CIC)-1431, Centre Hospitalier Universitaire Besançon, Besançon, France
| | - Aurelia Meurisse
- Univ. Bourgogne Franche-Comté, Institut National De La Santé et de la Recherche Médicale (INSERM), Etablissement Français du Sang Bourgogne Franche-Comté, Unité Mixte De Recherche 1098 (UMR1098), RIGHT Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon, France.,Methodology and Quality of Life in Oncology Unit, Centre Hospitalier Universitaire (CHU) Besançon, Besançon, France
| | - Jamal Bamoulid
- Univ. Bourgogne Franche-Comté, Institut National De La Santé et de la Recherche Médicale (INSERM), Etablissement Français du Sang Bourgogne Franche-Comté, Unité Mixte De Recherche 1098 (UMR1098), RIGHT Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon, France.,Service de Néphrologie, Centre Hospitalier Universitaire Besançon, Besançon, France
| | - Cécile Courivaud
- Univ. Bourgogne Franche-Comté, Institut National De La Santé et de la Recherche Médicale (INSERM), Etablissement Français du Sang Bourgogne Franche-Comté, Unité Mixte De Recherche 1098 (UMR1098), RIGHT Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon, France.,Service de Néphrologie, Centre Hospitalier Universitaire Besançon, Besançon, France
| | - Philippe Saas
- Univ. Bourgogne Franche-Comté, Institut National De La Santé et de la Recherche Médicale (INSERM), Etablissement Français du Sang Bourgogne Franche-Comté, Unité Mixte De Recherche 1098 (UMR1098), RIGHT Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon, France.,Institut National de la santé et de la recherche médicale Centre d'Investigation Clinique (INSERM CIC)-1431, Centre Hospitalier Universitaire Besançon, Besançon, France
| | - Pierre Tiberghien
- Univ. Bourgogne Franche-Comté, Institut National De La Santé et de la Recherche Médicale (INSERM), Etablissement Français du Sang Bourgogne Franche-Comté, Unité Mixte De Recherche 1098 (UMR1098), RIGHT Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon, France.,Etablissement Français du Sang, La Plaine St Denis, France
| | - Didier Ducloux
- Besançon University Hospital, Fédération Hospitalo-Universitaire Integrated Center for REsearch in inflammatory diseASes (FHU INCREASE), Besançon, France.,Univ. Bourgogne Franche-Comté, Institut National De La Santé et de la Recherche Médicale (INSERM), Etablissement Français du Sang Bourgogne Franche-Comté, Unité Mixte De Recherche 1098 (UMR1098), RIGHT Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon, France.,Service de Néphrologie, Centre Hospitalier Universitaire Besançon, Besançon, France
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17
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HLA Homozygosity and Likelihood of Sensitization in Kidney Transplant Candidates. Transplant Direct 2022; 8:e1312. [PMID: 35415215 PMCID: PMC8989785 DOI: 10.1097/txd.0000000000001312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 02/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background. Homozygosity for HLAs has been associated with adverse outcomes after viral infection as well as pregnancy-induced HLA sensitization. We sought to assess the relationship between HLA locus homozygosity and the level of HLA antibody sensitization. Methods. We measured sensitization using the calculated panel reactive antibody value for a large cohort of 147 461 patients added to the US OPTN/United Network for Organ Sharing kidney transplant waitlist between December 2014 and December 2019. We used multinomial logistic modeling to compare 62 510 sensitized patients to 84 955 unsensitized controls. Results. We found that the number of homozygous HLA loci was strongly associated with the level of sensitization. Within mildly, highly, or extremely sensitized candidates, women displayed a higher relative abundance of HLA homozygosity at multiple HLA loci as compared with men, with attenuation of this effect in Black candidates. In a multivariable logistic model, the number of homozygous HLA loci interacted with female sex but not with other factors associated with sensitization, including recipient ethnicity and a history of prior kidney transplant. Conclusions. This study shows that HLA homozygosity is an innate genetic factor that affects the likelihood of HLA sensitization. Further research is needed to identify the immunologic mechanisms that underlie this observation.
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18
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Khedjat K, Lenain R, Hamroun A, Baes D, Top I, Labalette M, Lopez B, Van Triempont M, Provôt F, Frimat M, Gibier JB, Hazzan M, Maanaoui M. Post-Transplantation Early Blood Transfusion and Kidney Allograft Outcomes: A Single-Center Observational Study. Transpl Int 2022; 35:10279. [PMID: 35368637 PMCID: PMC8971186 DOI: 10.3389/ti.2022.10279] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/07/2022] [Indexed: 11/30/2022]
Abstract
The association between blood transfusion and the occurrence of de novo HLA donor specific antibodies (DSA) after kidney transplantation remains controversial. In this single-center observational study, we examined the association between early blood transfusion, i.e. before 1-month post-transplantation, and the risk of DSA occurrence, using Luminex based-methods. In total, 1,424 patients with a minimum of 1-month follow-up were evaluated between January 2007 and December 2018. During a median time of follow-up of 4.52 years, we observed 258 recipients who had at least one blood transfusion during the first month post-transplantation. At baseline, recipients in the transfused group were significant older, more sensitized against HLA class I and class II antibodies and had a higher 1-month serum creatinine. Cox proportional hazards regression analyses did not show any significant association between blood transfusion and the risk of de novo DSA occurrence (1.35 [0.86–2.11], p = 0.19), the risk of rejection (HR = 1.33 [0.94–1.89], p = 0.11), or the risk of graft loss (HR = 1.04 [0.73–1.50], p = 0.82). These data suggest then that blood transfusion may not be limited when required in the early phase of transplantation, and may not impact long-term outcomes.
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Affiliation(s)
| | - Rémi Lenain
- Department of Nephrology, CHU Lille, Lille, France.,INSERM UMR 1246 -SPHERE, Nantes University, Tours University, Nantes, France
| | - Aghilès Hamroun
- Department of Nephrology, CHU Lille, Lille, France.,Clinical Epidemiology Team, CESP, Centre for Research in Epidemiology and Population Health, Inserm, Paris-Saclay University, Versailles Saint Quentin University, Villejuif, France
| | | | - Isabelle Top
- CHU Lille, Institut d'Immunologie, Bd du Professeur Jules Leclercq, Lille, France.,Lille University, Regional and University Hospital Center of Lille, Lille, France
| | - Myriam Labalette
- CHU Lille, Institut d'Immunologie, Bd du Professeur Jules Leclercq, Lille, France.,Lille University, Regional and University Hospital Center of Lille, Lille, France
| | - Benjamin Lopez
- Laboratoire de Biologie Médicale, CH Dunkerque, Dunkerque, France
| | | | | | - Marie Frimat
- Department of Nephrology, CHU Lille, Lille, France
| | - Jean-Baptiste Gibier
- Department of Pathology, Pathology Institute, Inserm UMR-S1172 Lille, JPARC-Jean-Pierre Aubert Research Center, Team "Mucins, Epithelial Differentiation and Carcinogenesis", Lille, France
| | - Marc Hazzan
- Department of Nephrology, CHU Lille, Lille, France
| | - Mehdi Maanaoui
- Department of Nephrology, CHU Lille, Lille, France.,Univ. Lille, Inserm, CHU Lille, Institut Pasteur Lille, U1190-EGID, Lille, France
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19
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Rijkse E, Kimenai HJAN, Dor FJMF, IJzermans JNM, Minnee RC. Screening, Management, and Acceptance of Patients with Aorto-Iliac Vascular Disease for Kidney Transplantation: A Survey among 161 Transplant Surgeons. Eur Surg Res 2021; 63:77-84. [PMID: 34592735 DOI: 10.1159/000519208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/10/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Aorto-iliac vascular disease (AVD) is frequently found during the workup for kidney transplantation. However, recommendations on screening and management are lacking. We aimed to assess differences in screening, management, and acceptance of these patients for transplantation by performing a survey among transplant surgeons. Second, we aimed to identify center- and surgeon-related factors associated with decline or acceptance of kidney transplant candidates with AVD. METHODS A survey was sent to transplant surgeons and urologists. The survey contained general questions (part I) and 2 patient-based cases (part II) with Trans-Atlantic Inter-Society Consensus (TASC) D and B AVD supported with videos of their CT scans. RESULTS One hundred ninety-one (20.3%) participants responded; 171 were currently involved in kidney transplantation: 161 (94.2%) completed part I and 145 (84.8%) part II. Screening for AVD was often (38.5%) restricted to high-risk patients. The majority of respondents (67.7%) rated "technical problems" as the most important concern in case of AVD, followed by "increased mortality risk because of cardiovascular comorbidity" (29.8%). Pretransplant vascular interventions to facilitate transplantation were infrequently performed (71.4% mentioned <10 per year). Ninety (64.3%) respondents answered that an open vascular procedure should preferably be performed prior to kidney transplantation while 42 (30.0%) respondents preferred a simultaneous open vascular procedure. The decline rate was higher in the TASC D case compared to the TASC B case (26.9% and 9.7%, respectively). Respondents from centers with expertise in pretransplant vascular interventions were more likely to accept both patients with TASC D and B for transplantation. CONCLUSION There is no uniformity in the screening, management, and acceptance of patients with AVD for transplantation. If a center declines a patient with AVD because of technical concerns, the patient should be referred for a second opinion to a tertiary center with expertise in pretransplant vascular interventions. Multidisciplinary meetings including a vascular surgeon and a cardiologist could help optimize these patients for transplantation.
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Affiliation(s)
- Elsaline Rijkse
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Rotterdam, The Netherlands
| | - Hendrikus J A N Kimenai
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Rotterdam, The Netherlands
| | - Frank J M F Dor
- Imperial College Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom.,Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Jan N M IJzermans
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Rotterdam, The Netherlands
| | - Robert C Minnee
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Rotterdam, The Netherlands
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20
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Rossi AP, Alloway RR, Hildeman D, Woodle ES. Plasma cell biology: Foundations for targeted therapeutic development in transplantation. Immunol Rev 2021; 303:168-186. [PMID: 34254320 DOI: 10.1111/imr.13011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/22/2021] [Indexed: 12/20/2022]
Abstract
Solid organ transplantation is a life-saving procedure for patients with end-stage organ disease. Over the past 70 years, tremendous progress has been made in solid organ transplantation, particularly in T-cell-targeted immunosuppression and organ allocation systems. However, humoral alloimmune responses remain a major challenge to progress. Patients with preexisting antibodies to human leukocyte antigen (HLA) are at significant disadvantages in regard to receiving a well-matched organ, moreover, those who develop anti-HLA antibodies after transplantation face a significant foreshortening of renal allograft survival. Historical therapies to desensitize patients prior to transplantation or to treat posttransplant AMR have had limited effectiveness, likely because they do not significantly reduce antibody levels, as plasma cells, the source of antibody production, remain largely unaffected. Herein, we will discuss the significance of plasma cells in transplantation, aspects of their biology as potential therapeutic targets, clinical challenges in developing strategies to target plasma cells in transplantation, and lastly, novel approaches that have potential to advance the field.
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Affiliation(s)
- Amy P Rossi
- Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Immunology Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Medical Scientist Training Program, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rita R Alloway
- Division of Nephrology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - David Hildeman
- Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Immunology Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - E Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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21
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Raichoudhury R, Spinowitz BS. Treatment of anemia in difficult-to-manage patients with chronic kidney disease. Kidney Int Suppl (2011) 2021; 11:26-34. [PMID: 33777493 DOI: 10.1016/j.kisu.2020.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/17/2020] [Accepted: 12/29/2020] [Indexed: 12/14/2022] Open
Abstract
The management of anemia of chronic kidney disease (CKD) is often challenging. In particular, for patients with underlying inflammation, comorbid type 2 diabetes or cancer, those hospitalized, and recipients of a kidney transplant, the management of anemia may be suboptimal. Responsiveness to iron and/or erythropoiesis-stimulating agents, the mainstay of current therapy, may be reduced and the risk of adverse reactions to treatment is increased in these difficult-to-manage patients with anemia of CKD. This review discusses the unique patient and disease characteristics leading to complications and suboptimal treatment response. New treatment options in clinical development, such as hypoxia-inducible factor-prolyl hydroxylase (HIF-PH) inhibitors, may be particularly useful for difficult-to-treat patients. In clinical studies, HIF-PH inhibitors provided increased hemoglobin levels and improved iron utilization in anemic patients with non-dialysis-dependent and dialysis-dependent CKD, and preliminary data suggest that HIF-PH inhibitors may be equally effective in patients with or without underlying inflammation. The availability of new treatment options, including HIF-PH inhibitors, may improve treatment outcomes in difficult-to-manage patients with anemia of CKD.
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Affiliation(s)
- Ritesh Raichoudhury
- Division of Nephrology, Department of Medicine, NewYork-Presbyterian Queens, New York, New York, USA
| | - Bruce S Spinowitz
- Division of Nephrology, Department of Medicine, NewYork-Presbyterian Queens, New York, New York, USA
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22
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Fishbane S, El-Shahawy MA, Pecoits-Filho R, Van BP, Houser MT, Frison L, Little DJ, Guzman NJ, Pergola PE. Roxadustat for Treating Anemia in Patients with CKD Not on Dialysis: Results from a Randomized Phase 3 Study. J Am Soc Nephrol 2021; 32:737-755. [PMID: 33568383 PMCID: PMC7920165 DOI: 10.1681/asn.2020081150] [Citation(s) in RCA: 99] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 12/01/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Current anemia therapies for patients with non-dialysis-dependent CKD may require injection and medical visits. Roxadustat, an oral hypoxia-inducible factor prolyl hydroxylase inhibitor, stimulates erythropoiesis and improves iron homeostasis. METHODS In this double-blind phase 3 study, we randomized patients with non-dialysis-dependent CKD stages 3-5 and hemoglobin <10.0 g/dl (1:1) to thrice-weekly 70-mg oral roxadustat or placebo. Doses were titrated throughout the study based on hemoglobin levels. The primary efficacy end point was mean change from baseline in hemoglobin averaged over weeks 28-52 versus placebo, irrespective of rescue therapy use. We assessed patients for adverse events. RESULTS The study included 2781 patients, 1393 who received roxadustat and 1388 who received placebo. Mean baseline hemoglobin was 9.1 g/dl for both groups. The mean change in hemoglobin from baseline was 1.75 g/dl (95% confidence interval [95% CI], 1.68 to 1.81) with roxadustat versus 0.40 g/dl (95% CI, 0.33 to 0.47) with placebo, (P<0.001). Among 411 patients with baseline elevated high-sensitivity C-reactive protein, mean change in hemoglobin from baseline was 1.75 g/dl (95% CI, 1.58 to 1.92) with roxadustat versus 0.62 g/dl (95% CI, 0.44 to 0.80) with placebo, (P<0.001). Roxadustat reduced the risk of red blood cell transfusion by 63% (hazard ratio, 0.37; 95% CI, 0.30 to 0.44). The most common adverse events with roxadustat and placebo, respectively, were ESKD (21.0% versus 20.5%), urinary tract infection (12.8% versus 8.0%), pneumonia (11.9% versus 9.4%), and hypertension (11.5% versus 9.1%). CONCLUSIONS Roxadustat effectively increased hemoglobin in patients with non-dialysis-dependent CKD and reduced the need for red blood cell transfusion, with an adverse event profile comparable to that of placebo. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Safety and Efficacy Study of Roxadustat to Treat Anemia in Patients With CKD, Not on Dialysis, NCT02174627.
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Affiliation(s)
- Steven Fishbane
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, New York
| | - Mohamed A. El-Shahawy
- Department of Medicine, Keck-University of Southern California School of Medicine, Los Angeles, California
| | - Roberto Pecoits-Filho
- School of Medicine, Pontifical Catholic University of Parana, Curitiba, Brazil,Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Bui Pham Van
- Department of Medicine, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Mark T. Houser
- Global Medicines Development, Biopharmaceuticals Research & Development, AstraZeneca Gaithersburg, Gaithersburg, Maryland
| | - Lars Frison
- Biostatistics, Biopharmaceuticals Research & Development, AstraZeneca Gothenburg, Mölndal, Sweden
| | - Dustin J. Little
- Global Medicines Development, Biopharmaceuticals Research & Development, AstraZeneca Gaithersburg, Gaithersburg, Maryland
| | - Nicolas J. Guzman
- Global Medicines Development, Biopharmaceuticals Research & Development, AstraZeneca Gaithersburg, Gaithersburg, Maryland
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Toto R, Petersen J, Berns JS, Lewis EF, Tran Q, Weir MR. A Randomized Trial of Strategies Using Darbepoetin Alfa To Avoid Transfusions in CKD. J Am Soc Nephrol 2021; 32:469-478. [PMID: 33288629 PMCID: PMC8054895 DOI: 10.1681/asn.2020050556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 09/26/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Exposure to high doses or a high cumulative dose of erythropoiesis-stimulating agents (ESAs) may contribute to cardiovascular events in patients with CKD and anemia. Whether using a low fixed ESA dose versus dosing based on a hemoglobin-based, titration-dose algorithm in such patients might reduce risks associated with high ESA doses and decrease the cumulative exposure-while reducing the need for red blood cell transfusions-is unknown. METHODS In this phase-3, randomized trial involving 756 adults with stage-3 to -5 CKD and anemia, we evaluated incidence of red blood cell transfusions for participants randomized to receive darbepoetin given as a fixed dose (0.45 µg/kg every 4 weeks) versus administered according to a hemoglobin-based, titration-dose algorithm, for up to 2 years. Participants received transfusions as deemed necessary by the treating physician. RESULTS There were 379 patients randomized to the fixed-dose group, and 377 to the titration-dose group. The percentage of participants transfused did not differ (24.1% and 24.4% for the fixed-dose and titration-dose group, respectively), with similar time to first transfusion. The titration-dose group achieved significantly higher median hemoglobin (9.9 g/dl) compared with the fixed-dose group (9.4 g/dl). The fixed-dose group had a significantly lower median cumulative dose of darbepoetin (median monthly dose of 30.9 µg) compared with the titration-dose group (53.6 µg median monthly dose). The FD and TD group received a median (Q1, Q3) cumulative dose per 4 weeks of darbepoetin of 30.9 (21.8, 40.0) µg and 53.6 (31.1, 89.9) µg, respectively; the median of the difference between treatment groups was -22.1 (95% CI, -26.1 to -18.1) µg. CONCLUSIONS These findings indicate no evidence of difference in incidence of red blood cell transfusion for a titration-dose strategy versus a fixed-dose strategy for darbepoetin. This suggests that a low fixed dose of darbepoetin may be used as an alternative to a dose-titration approach to minimize transfusions, with less cumulative dosing.
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Affiliation(s)
- Robert Toto
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Jeffrey S. Berns
- Perelman School of Medicine at the University of Pennsylvania and Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Qui Tran
- Amgen Inc., Thousand Oaks, California
| | - Matthew R. Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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Daloul R, Braga JR, Diez A, Logan A, Pesavento T. Early Posttransplant Blood Transfusion and Risk for Worse Graft Outcomes. Kidney Int Rep 2021; 6:986-994. [PMID: 33912748 PMCID: PMC8071616 DOI: 10.1016/j.ekir.2020.12.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 12/14/2020] [Accepted: 12/30/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Blood transfusion is a risk factor for allosensitization. Nevertheless, blood transfusion posttransplant remains a common practice. We evaluated the effect of posttransplant blood transfusion on graft outcomes. Methods We included nonsensitized, first-time, kidney-alone recipients transplanted between 1 July 2015 and 31 December 2017. Patients were grouped based on receiving blood transfusion in the first 30 days posttransplant. The primary end point was a composite outcome of biopsy-proven acute rejection, death of any cause, or graft failure in the first year posttransplant. Secondary outcomes included the individual components of the primary outcome and the cumulative incidence of de novo donor-specific antibodies (DSAs). Results Two hundred seventy-three patients were included. One hundred twenty-seven (47%) received blood transfusion. Patients in the transfusion group were more likely to be older, have had a deceased donor, and have received induction with basiliximab. There was no difference between groups in the composite primary outcome (adjusted hazard ratio = [HR] 1.34; 95% confidence interval [CI], 0.83–2.17; P = 0.23). The cumulative incidence of de novo DSAs during the first year posttransplant was similar between groups (12.8% transfusion vs. 10.9% no transfusion, P = 0.48). Conclusion Early transfusion of blood products in kidney transplant recipients receiving induction with lymphocyte depletion was not associated with an increased hazard of experiencing acute rejection, death from any cause, or graft loss.
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Affiliation(s)
- Reem Daloul
- The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Juarez R Braga
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Alejandro Diez
- The Ohio State University Medical Center, Columbus, Ohio, USA
| | - April Logan
- The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Todd Pesavento
- The Ohio State University Medical Center, Columbus, Ohio, USA
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25
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Abstract
Anemia is a frequent complication of kidney disease. When severe, it causes symptoms that can be debilitating. The course of anemia tends to track the decline in kidney function, with prevalence increasing in more advanced disease. Although the most common cause is relative erythropoietin deficiency, other factors such as reduced iron availability contribute to the pathobiology. In this review, we use cases to explore the surprising complexity of decision-making in management of renal anemia.
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Seay T, Guinn N, Maisonave Y, Fuller M, Poisson J, Pollak A, Bryner B, Haney J, Klapper J, Hartwig M, Bottiger B. The Association of Increased FFP:RBC Transfusion Ratio to Primary Graft Dysfunction in Bleeding Lung Transplantation Patients. J Cardiothorac Vasc Anesth 2020; 34:3024-3032. [PMID: 32622711 DOI: 10.1053/j.jvca.2020.05.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/17/2020] [Accepted: 05/29/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Lung transplantation is associated with a significant risk of needed transfusion. Although algorithm-based transfusion strategies that promote a high fresh frozen plasma:red blood cells (FFP:RBC) ratio have reduced overall blood product requirements in other populations, large-volume transfusions have been linked to primary graft dysfunction (PGD) in lung transplantation, particularly use of platelets and plasma. The authors hypothesized that in lung transplant recipients requiring large-volume transfusions, a higher FFP:RBC ratio would be associated with increased PGD severity at 72 hours. DESIGN Observational retrospective review. SETTING Single tertiary academic center. PARTICIPANTS Adult patients undergoing bilateral or single orthotopic lung transplantation and receiving >4 U PRBC in the first 72 hours from February 2014 to March 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patient demographics, operative characteristics, blood transfusions, and outcomes including PGD scores and length of stay were collected. Eighty-nine patients received >4U PRBC, had available 72-hour PGD data, and were included in the study. These patients were grouped into a high-ratio (>1:2 units of FFP:RBC, N = 38) or low-ratio group (<1:2 units of FFP:RBC, N = 51). Patients in the high-ratio group received more transfusions and factor concentrates and had significantly longer case length. The high-ratio group had a higher rate of severe PGD at 72 hours (60.5% v 23.5%, p = 0.0013) and longer hospital length of stay (40 v 32 days, p = 0.0273). CONCLUSIONS In bleeding lung transplantation patients at high risk for PGD, a high FFP:RBC transfusion ratio was associated with worsened 72-hour PGD scores when compared with the low-ratio cohort.
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Affiliation(s)
- Theresa Seay
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC.
| | - Nicole Guinn
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Yasmin Maisonave
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Matt Fuller
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Jessica Poisson
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Angela Pollak
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Ben Bryner
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - John Haney
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jacob Klapper
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Matthew Hartwig
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Brandi Bottiger
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
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27
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Geoghegan L, Al-Khalil M, Scarborough A, Murray A, Issa F. Pre-transplant management and sensitisation in vascularised composite allotransplantation: A systematic review. J Plast Reconstr Aesthet Surg 2020; 73:1593-1603. [PMID: 32475735 DOI: 10.1016/j.bjps.2020.05.010] [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: 09/26/2019] [Revised: 04/11/2020] [Accepted: 05/09/2020] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Vascularised composite allotransplantation (VCA) permits like-for-like reconstruction following extensive soft tissue injuries. The initial management of extensive soft tissue injury can lead to the development of anti-HLA antibodies through injury-related factors, transfusion and cadaveric grafting. The role of antibody-mediated rejection, donor-specific antibody formation and graft rejection in the context of VCA remains unclear. This systematic review aimed to determine whether pre-transplant management strategies influence immunological outcome following VCA. METHODS A systematic review of MEDLINE, EMBASE and CINAHL using a PRISMA-compliant methodology up to February 2019 was conducted. Pre-transplant, procedural and long-term outcome data were collected and recorded for all VCA recipients on an individual patient basis. RESULTS The search revealed 3,847 records of which 114 met inclusion criteria and reported clinical data related to 100 patients who underwent 129 VCA transplants. Trauma (50%) and burns (15%) were the most frequent indications for VCA. Of all 114 studies, only one reported acute resuscitative management. Fifteen patients were sensitised prior to reconstructive transplantation with an 80%%incidence of acute rejection in the first post-operative year. Seven patients demonstrated graft vasculopathy, only one of whom had demonstrated panel reactive antibodies. CONCLUSIONS Currently employed acute management strategies may predispose to the development of anti-HLA antibodies, adding to the already complex immunological challenge of VCA. To determine whether association between pre-transplant management and outcomes exists, further refinement of international registries is required.
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Affiliation(s)
- Luke Geoghegan
- Imperial College NHS Trust, London, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK
| | | | | | - Alexandra Murray
- Department of Plastic and Reconstructive Surgery, Stoke Mandeville Hospital, Aylesbury, UK
| | - Fadi Issa
- Department of Plastic and Reconstructive Surgery, Stoke Mandeville Hospital, Aylesbury, UK; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
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28
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Abstract
Purpose of review Since the discovery of human leukocyte antigen (HLA) in the 1950s, there has been great interest in the role of antibodies in posttransplant rejection. The development of the lymphocyte toxicity test by Terasaki et al. in the 1960s was the first step toward understanding the role of antibodies in posttransplant rejection. Recent findings Subsequently, various organs have been transplanted and improving posttransplant outcomes have become a focus of research. In particular, methods to measure antibodies that affect posttransplant outcomes, including anti-HLA antibodies, and methods to desensitize patients from specific antibodies have been explored. One recent method for measuring antibodies is called the solid-phase assay, which uses purified HLA fixed to microbeads. This assay does not use donor lymphocytes and allows clinicians to test the reactivity of patient serum against a panel of antibodies. It has also enabled the identification of specific anti-HLA antibodies using a single HLA. Summary In addition to advances in methods to measure and analyze anti-HLA antibodies, the clinical impact of non-HLA antibodies has also received much attention recently.
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29
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Nickel RS, Horan JT, Abraham A, Qayed M, Haight A, Ngwube A, Liang H, Luban NLC, Hendrickson JE. Human leukocyte antigen (HLA) class I antibodies and transfusion support in paediatric HLA‐matched haematopoietic cell transplant for sickle cell disease. Br J Haematol 2019; 189:162-170. [DOI: 10.1111/bjh.16298] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 08/19/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Robert S. Nickel
- Division of Hematology Children's National Hospital WashingtonDCUSA
- The George Washington University School of Medicine and Health Sciences Washington DCUSA
| | - John T. Horan
- Aflac Cancer and Blood Disorders Center Emory University Atlanta GAUSA
| | - Allistair Abraham
- Division of Hematology Children's National Hospital WashingtonDCUSA
- The George Washington University School of Medicine and Health Sciences Washington DCUSA
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center Emory University Atlanta GAUSA
| | - Ann Haight
- Aflac Cancer and Blood Disorders Center Emory University Atlanta GAUSA
| | - Alexander Ngwube
- Center for Cancer and Blood Disorders Phoenix Children's Hospital Phoenix AZUSA
| | - Hua Liang
- Department of Statistics The George Washington University Washington DCUSA
| | - Naomi L. C. Luban
- Division of Hematology Children's National Hospital WashingtonDCUSA
- The George Washington University School of Medicine and Health Sciences Washington DCUSA
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30
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Jackson AM, Manook M. Tracking HLA Antibody Changes among Kidney Waitlist Candidates: One Protocol May Not Fit All. J Am Soc Nephrol 2019; 30:2042-2044. [PMID: 31653785 DOI: 10.1681/asn.2019090946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
| | - Miriam Manook
- Department of Surgery, Duke University, Durham, North Carolina; and.,Renal and Transplant Department, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
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31
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Nelson KA, Aldea GS, Warner P, Latchman Y, Gunasekera D, Tamir A, Gernsheimer T, Bolgiano D, Slichter SJ. Transfusion‐related immunomodulation: gamma irradiation alters the effects of leukoreduction on alloimmunization. Transfusion 2019; 59:3396-3404. [DOI: 10.1111/trf.15555] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 08/21/2019] [Accepted: 08/21/2019] [Indexed: 12/28/2022]
Affiliation(s)
| | - Gabriel S. Aldea
- Department of Surgery, Division of Cardiothoracic Surgery University of Washington Seattle Washington
| | | | - Yvette Latchman
- Bloodworks Northwest Seattle Washington
- Silverback Therapeutics Seattle Washington
| | - Devi Gunasekera
- Bloodworks Northwest Seattle Washington
- Uniformed Services University of Health Sciences Bethesda Maryland
| | | | - Terry Gernsheimer
- Bloodworks Northwest Seattle Washington
- Division of Hematology University of Washington School of Medicine Seattle Washington
- Seattle Cancer Care Alliance Seattle Washington
| | | | - Sherrill J. Slichter
- Bloodworks Northwest Seattle Washington
- Division of Hematology University of Washington School of Medicine Seattle Washington
- Seattle Cancer Care Alliance Seattle Washington
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32
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Abstract
Cancer and kidney disease are linked by causality and comorbidities. Observational data show an increased risk of malignancy as renal function declines. Erythropoietin stimulating agents (ESAs), which are the cornerstone therapy for anemia patients with chronic kidney disease and cancer, are associated with increased risks for cancer, cancer-related mortality, progression of disease, and thromboembolic events. This article examines the recently published guidelines for ESA use in cancer patients from the American Society of Clinical Oncology and American Society of Hematology and attempts to contextualize them to the care of patients with coexistent CKD, cancer, and anemia.
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Affiliation(s)
- Sheron Latcha
- Renal Division, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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33
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Brief Normothermic Machine Perfusion Rejuvenates Discarded Human Kidneys. Transplant Direct 2019; 5:e502. [PMID: 31773055 PMCID: PMC6831120 DOI: 10.1097/txd.0000000000000944] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 08/24/2019] [Indexed: 12/30/2022] Open
Abstract
Supplemental Digital Content is available in the text. Normothermic machine perfusion (NMP) may allow resuscitation and improved assessment of kidneys before transplantation. Using discarded human kidneys, we investigated the mechanistic basis and translational potential of NMP compared with cold static storage (CS).
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34
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Jung CW, Park KT, Gwon JG, Ko SY, Kim MG. Immunologic Characteristics of Mongolian Patients Receiving Kidney Transplantation in a Single Center in Korea. Transplant Proc 2019; 51:2555-2558. [PMID: 31447191 DOI: 10.1016/j.transproceed.2019.03.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/18/2019] [Accepted: 03/04/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Among foreigners undergoing kidney transplantation (KT) in Korea, Mongolians are the most common, and most of these cases are conducted at our center. We report the immunologic characteristics and clinical outcomes of these patients. METHODS Consecutive Mongolian patients who underwent KT from September 2009 to August 2017 in our center were retrospectively analyzed. Pre- and post-transplant HLA antibody status and clinical data of the Mongolian patients were collected and compared with the Korean patients who underwent living donor KT during the same period. RESULTS Sixty-two Mongolian and 85 Korean patients received KT and were followed up for 20.9 and 50.8 months (P = .01), respectively. Before transplantation, 17.7% of the Mongolian patients and 7.1% of the Korean patients were highly sensitized (P = .05). The patients were monitored consistently throughout the entire post-transplant period. Follow-up loss occurred in some cases. Of the patients, 32 Mongolian patients and 79 Korean patients were monitored for post-transplant HLA antibodies at any time point. Estimated glomerular filtration rates were comparable between Mongolian and Korean patients at 1 month (77.1 vs 71.5 mL/min/1.73m2, P = .21) and 1 year (64.6 vs 68.7 mL/min/1.73m2, P = .25) after transplantation but tended to be different at 3 years (57.2 vs 67.3 mL/min/1.73m2, P = .06) and 5 years (56.9 vs 73.1 mL/min/1.73m2, P = .04) post transplant. CONCLUSIONS Mongolian patients undergoing KT in Korea were often highly sensitized. Mean follow-up time was short and follow-up loss was common in Mongolian patients compared with Korean patients. Cautious follow-up is needed for foreigner transplant recipients, especially for those at high-risk immunologically, to achieve better outcomes.
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Affiliation(s)
- Cheol Woong Jung
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Kwan Tae Park
- Department of Surgery, Mongolian National University of Medical Science, Ulan Bator, Mongolia
| | - Jun Gyo Gwon
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Sun-Young Ko
- Department of Laboratory Medicine, Korea University College of Medicine, Seoul, Korea.
| | - Myung-Gyu Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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35
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Desensitization in the Era of Precision Medicine: Moving From the Bench to Bedside. Transplantation 2019; 103:1574-1581. [DOI: 10.1097/tp.0000000000002737] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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36
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Hassan S, Regan F, Brown C, Harmer A, Anderson N, Beckwith H, Roufosse CA, Santos-Nunez E, Brookes P, Taube D, Willicombe M. Shared alloimmune responses against blood and transplant donors result in adverse clinical outcomes following blood transfusion post-renal transplantation. Am J Transplant 2019; 19:1720-1729. [PMID: 30582278 DOI: 10.1111/ajt.15233] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 01/25/2023]
Abstract
De novo HLA donor-specific antibodies (DSA) following transplantation are associated with alloimmune injury and allograft failure. Blood transfusions are allogeneic, and when given posttransplant (PTBT) they may independently increase the risk of HLA antibody development. This study aims to analyze the development of HLA transfusion-specific antibodies (TSA) to blood donors of transfusions given posttransplant and examine the impact on clinical outcomes. A total of 244 blood donors of transfusions received by 86 transplant patients (46 who developed a DSA post transfusion and 40 who remained DSA negative) were HLA typed. De novo TSA developed against 150/244 (61.5%) blood donors. In 70/150 (46.7%) cases the TSA was of shared HLA antibody specificity with a DSA response in the recipient (DSA+ = TSA+). This occurred when there was a greater overall HLA match between the blood and transplant donor. DSA+ = TSA+ patients had increased risk of allograft failure (P = .0025) and AMR (P = .02) compared with the DSA+ ≠ TSA+ patients. To conclude, PTBT may elicit de novo HLA antibodies. Enhanced HLA matching between the blood and transplant donor is more likely to result in a DSA and TSA of shared antibody specificities. Transfusion avoidance or the use of HLA matched or selected blood may reduce this risk and improve outcomes.
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Affiliation(s)
- Sevda Hassan
- Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Fiona Regan
- Haematology, NHS Blood and Transplant, London, UK.,Haematology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Colin Brown
- Histocompatibility and Immunogenetics, NHS Blood and Transplant, London, UK
| | - Andrea Harmer
- Histocompatibility and Immunogenetics, NHS Blood and Transplant, London, UK
| | - Nicky Anderson
- Haematology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Hannah Beckwith
- Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Candice A Roufosse
- Department of Cellular Pathology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK.,Centre for Inflammatory Disease, Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London, UK
| | - Eva Santos-Nunez
- Histocompatibility and Immunogenetics, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Paul Brookes
- Histocompatibility and Immunogenetics, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - David Taube
- Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Michelle Willicombe
- Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK.,Centre for Inflammatory Disease, Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London, UK
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37
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Wanek MR, Hodges K, Persaud RA, Lam SW, Soltesz EG, Tong MZ, Moazami N. Prothrombin Complex Concentrates for Warfarin Reversal Before Heart Transplantation. Ann Thorac Surg 2019; 107:1409-1415. [DOI: 10.1016/j.athoracsur.2018.10.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 09/20/2018] [Accepted: 10/10/2018] [Indexed: 10/27/2022]
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Moledina DG, Luciano RL, Kukova L, Chan L, Saha A, Nadkarni G, Alfano S, Wilson FP, Perazella MA, Parikh CR. Kidney Biopsy-Related Complications in Hospitalized Patients with Acute Kidney Disease. Clin J Am Soc Nephrol 2018; 13:1633-1640. [PMID: 30348813 PMCID: PMC6237071 DOI: 10.2215/cjn.04910418] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 08/23/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients are informed of the risk of kidney biopsy-related complications using data from nonhospitalized patients, which may underestimate the risk for hospitalized patients. We evaluated the rate and risk factors of kidney biopsy-related complications in hospitalized patients with acute kidney disease (AKD) to better estimate the risk in this population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We used data from the Yale biopsy cohort to evaluate rates of kidney biopsy-related complications including adjudicated procedure-related bleeding requiring blood transfusions or angiographic interventions, medium- or large-sized hematomas, reimaging after biopsy including abdominal ultrasonography or computed tomography, and death in hospitalized patients with AKD (including AKI). We evaluated univariable and multivariable association of risk factors with transfusions. We compared rates of complications between hospitalized and nonhospitalized patients. RESULTS Between 2015 and 2017, 159 hospitalized patients underwent a kidney biopsy for AKD evaluation, of which 80 (51%) had stage 1 AKI, 42 (27%) had stage 2 (or higher) AKI, and 27 (17%) had AKD (without AKI). Of these, 12 (8%; 95% confidence interval [95% CI], 5% to 15%) required a transfusion, three (2%; 95% CI, 1% to 5%) required an intervention, 11 (7%; 95% CI, 4% to 12%) had hematoma, and 31 (20%; 95% CI, 14% to 26%) required reimaging after biopsy. Of the four (3%; 95% CI, 1% to 6%) deaths during hospitalization, none were related to the biopsy. Female sex, lower platelet count, and higher BUN were associated with postbiopsy transfusions on univariable and multivariable analyses. Trainee as proceduralist and larger needle gauge were associated with transfusions in univariable, but not multivariable, analysis. Nonhospitalized patients had lower rates of transfusion than hospitalized patients, although the latter also had lower prebiopsy hemoglobin and greater surveillance after biopsy. CONCLUSIONS Hospitalized patients experience higher risk of postbiopsy complications than previously reported and several factors, such as lower platelet count, female sex, and higher BUN, are associated with this risk.
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Affiliation(s)
- Dennis G. Moledina
- Sections of Nephrology and
- Program of Applied Translational Research, Yale School of Medicine, New Haven, Connecticut
| | | | - Lidiya Kukova
- Sections of Nephrology and
- Program of Applied Translational Research, Yale School of Medicine, New Haven, Connecticut
| | - Lili Chan
- Division of Nephrology, Department of Medicine, and
| | - Aparna Saha
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | | | | | - F. Perry Wilson
- Sections of Nephrology and
- Program of Applied Translational Research, Yale School of Medicine, New Haven, Connecticut
| | | | - Chirag R. Parikh
- Division of Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Bynum JP, Zachary A, Ness PM, Luo X, Bagnasco S, King KE, Segev DL, Orandi BJ, Warren DS, Fuller A, Ciappi A, Montgomery R, Tobian AAR. Transfusion of leukoreduced blood products and risk of antibody-mediated rejection of renal allografts. Transfusion 2018; 58:1951-1957. [PMID: 30171817 PMCID: PMC6131050 DOI: 10.1111/trf.14800] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 04/11/2018] [Accepted: 04/13/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) is a major barrier to the long-term function of renal allografts. White blood cells, which may be present in red blood cell (RBC) units, and platelets (PLTs) express HLA antigens that may increase the risk of AMR by inducing or increasing humoral sensitization to HLA. STUDY DESIGN AND METHODS A retrospective cohort study of HLA-incompatible (HLAi) renal transplant recipients between 2004 and 2015 was conducted. Data on apheresis PLT and leukoreduced RBC transfusions within 4 weeks of transplantation, demographic information, and biopsy-proven AMR were collected from medical records and the Scientific Registry of Transplant Recipients. Patients were evaluated until they showed evidence of AMR or until 1 year posttransplant, whichever came first. Multivariable analysis with Cox modeling was performed. RESULTS Of 244 individuals, 182 (74.6%) received RBCs and 20 (8.2%) of those also received PLTs. During the first year posttransplant, 97 (39.8%) had AMR. RBC-alone or RBC and PLT transfusions were not associated with increased risk of AMR after adjustment for panel-reactive antibody, years on dialysis, HLA antibody strength, and number of therapeutic plasma exchange treatments (adjusted hazard ratio [adjHR] 1.00, 95% confidence interval [95% CI] 0.59-1.69; and adjHR 0.68, 95% CI 0.28-1.68, respectively). For each 1-unit increase in RBC transfusions, there was no association with AMR (adjHR 0.94, 95% CI 0.85-1.05). Only HLA antibody strength before transplantation was associated with AMR (adjHR 2.23, 95% CI 1.10-4.52; cytotoxic crossmatch compared to crossmatch negative but detectable donor-specific HLA antibodies). CONCLUSIONS Patients who receive an HLAi transplant who are transfused with leukoreduced RBCs or PLTs in the peritransplant period are at no higher risk of AMR than nontransfused patients.
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Affiliation(s)
| | | | | | - Xun Luo
- Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | | | | | - Dorry L Segev
- Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Babak J Orandi
- Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Daniel S Warren
- Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | | | | | - Robert Montgomery
- Transplant Institute, New York University Langone Medical Center, New York, New York
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Prevalence, treatment patterns, and healthcare resource utilization in Medicare and commercially insured non-dialysis-dependent chronic kidney disease patients with and without anemia in the United States. BMC Nephrol 2018; 19:67. [PMID: 29544446 PMCID: PMC5856223 DOI: 10.1186/s12882-018-0861-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 03/01/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Anemia is common in non-dialysis-dependent chronic kidney disease (NDD-CKD) patients, but detailed information on prevalence and treatment is lacking. METHODS We evaluated anemia prevalence and treatment using two datasets: the Medicare 20% random sample (ages 66-85 years), and the Truven Health MarketScan database (ages 18-63 years). We selected stage 3-5 NDD-CKD patients with and without anemia from both databases during 2011-2013. We evaluated anemia prevalence and treatment (erythropoietin stimulating agents [ESAs], intravenous [IV] iron, red blood cell [RBC] transfusions) following anemia diagnosis during a 1-year baseline period, and healthcare utilization during a 1-year follow-up period. We used Poisson regression models to compare healthcare utilization in patients with and without anemia, adjusting for demographics, baseline comorbid conditions, inflammatory conditions, and CKD stage. RESULTS We identified 218,079 older and 56,188 younger stage 3-5 NDD-CKD patients. Anemia prevalence increased with age in both datasets; was higher in women, black patients (Medicare only), and patients with comorbid conditions; and rose sharply with increasing CKD stage. Of 15,716 younger anemic patients, 11.7%, 10.8%, and 9.4% were treated with RBC transfusion, ESAs, and IV iron, respectively. Corresponding proportions of 109,251 older anemic patients were 22.2%, 12.7%, and 6.7%. Regardless of age, anemic patients were more likely than non-anemic patients to use healthcare resources, including hospitalizations and emergency department, hematologist, nephrologist, and outpatient visits. Anemic NDD-CKD patients were more likely to be treated with RBC transfusion than with ESAs or IV iron. CONCLUSION More research is necessary to determine best approaches to anemia management in CKD.
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Katalinić N, Starčević A, Mavrinac M, Balen S. Complement-dependent cytotoxicity and Luminex technology for human leucocyte antigen antibody detection in kidney transplant candidates exposed to different sensitizing events. Clin Kidney J 2017; 10:852-858. [PMID: 29225816 PMCID: PMC5716092 DOI: 10.1093/ckj/sfx050] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 04/27/2017] [Indexed: 01/02/2023] Open
Abstract
Background The aim of this study was to determine the frequency of exposure to different sensitizing events (SEs) and to assess their effects on human leucocyte antigen (HLA) alloimmunization in transplant candidates using two different HLA antibody screening techniques: complement-dependent cytotoxicity (CDC) and Luminex. Methods This retrospective study included HLA antibody screening results for 163 patients on the kidney transplant waiting list (WL) tested from March 2012 until the end of December 2015 at the Tissue Typing Laboratory, Rijeka, Croatia. All sera samples were tested using the CDC and Luminex techniques in parallel. Results Two-thirds of the patients [114 (70%)] on the WL were exposed to transfusions, pregnancies and/or kidney transplant. The pre-transplant sera of 104 (63.80%) patients were negative for antibodies. In the sera of 23 (14.11%) patients, HLA antibodies were detected by CDC and Luminex and in the sera of 36 (22.09%) patients by Luminex only. Conclusion In patients on kidney WL, previous organ transplantation represents the strongest immunogenic stimulus, followed by blood transfusions (the most frequent SE) and pregnancies. Although Luminex is more sensitive than CDC in HLA antibody detection, the decision on unacceptable HLA antigens in WL patients has to be based on the results of both assays and the patient's immunization history.
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Affiliation(s)
- Nataša Katalinić
- Tissue Typing Laboratory, Clinical Institute for Transfusion Medicine, Clinical Hospital Centre Rijeka, Croatia.,Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Croatia
| | - Alma Starčević
- Tissue Typing Laboratory, Clinical Institute for Transfusion Medicine, Clinical Hospital Centre Rijeka, Croatia
| | - Martina Mavrinac
- Department of Medical Informatics, Faculty of Medicine, University of Rijeka, Croatia
| | - Sanja Balen
- Tissue Typing Laboratory, Clinical Institute for Transfusion Medicine, Clinical Hospital Centre Rijeka, Croatia.,Department of Clinical Laboratory Diagnostics, Faculty of Medicine, University of Rijeka, Croatia
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Abstract
Purpose of review Accurate and timely detection and characterization of human leukocyte antigen (HLA) antibodies are critical for pre-transplant and post-transplant immunological risk assessment. Solid phase immunoassays have provided increased sensitivity and specificity, but test interpretation is not always straightforward. This review will discuss the result interpretation considering technical limitations; assessment of relative antibody strength; and the integration of data for risk stratification from complementary testing and the patient's immunological history. Recent findings Laboratory and clinical studies have provided insight into causes of test failures – false positive reactions because of antibodies to denatured HLA antigens and false negative reactions resulting from test interference and/or loss of native epitopes. Test modifications permit detection of complement-binding antibodies and determination of the IgG subclasses. The high degree of specificity of single antigen solid phase immunoassays has revealed the complexity and clinical relevance of antibodies to HLA-C, HLA-DQ, and HLA-DP antigens. Determination of antibody specificity for HLA epitopes enables identification of incompatible antigens not included in test kits. Summary Detection and characterization of HLA antibodies with solid phase immunoassays has led to increased understanding of the role of those antibodies in graft rejection, improved treatment of antibody-mediated rejection, and increased opportunities for transplantation. However, realization of these benefits requires careful and accurate interpretation of test results.
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Abstract
PURPOSE OF REVIEW The review outlines the diagnosis, clinical implications, and treatment strategies for acute and chronic antibody-mediated rejection (AMR) after orthotopic liver transplantation (OLT). RECENT FINDINGS A combination of clinical work-up, histopathology, C4d staining, and donor-specific antibody (DSA) should be used to diagnose AMR. The differential diagnosis for idiopathic fibrosis now includes chronic AMR. Characterization of pathogenic DSA continues to progress. De-novo and persistent DSA, particularly of the IgG3 subtype, are associated with inferior long-term outcomes.The liver allograft may confer long-term immunologic benefits to the kidney allograft after simultaneous liver-kidney transplant.The more widespread use of rituximab has improved outcomes in ABO-incompatible OLT.Although larger long-term studies of treatment options are needed, compliance with tacrolimus-based immunosuppression and transfusion minimization are agreed upon preventive strategies. SUMMARY AMR has evolved into an established pathology in OLT recipients. Acute AMR may lead to early graft loss whereas chronic AMR results in progressive fibrosis if unrecognized. DSAs, likely in the setting of predisposing environmental factors, appear to play a role in T cell-mediated rejection and long-term graft outcomes.
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Persaud SP, Duffy B, Phelan DL, Mohanakumar T, Delos Santos R, Gaut JP, Liu C. Accelerated humoral renal allograft rejection due to HLA-C14 mediated allosensitization to HLA-Bw6. Hum Immunol 2017; 78:692-698. [DOI: 10.1016/j.humimm.2017.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/25/2017] [Accepted: 09/28/2017] [Indexed: 10/18/2022]
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Sieg AC, Moretz JD, Horn E, Jennings DL. Pharmacotherapeutic Management of Gastrointestinal Bleeding in Patients with Continuous-Flow Left Ventricular Assist Devices. Pharmacotherapy 2017; 37:1432-1448. [DOI: 10.1002/phar.2016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Adam C. Sieg
- Department of Pharmacy; University of Kentucky; Lexington Kentucky
| | - Jeremy D. Moretz
- Department of Pharmacy; Vanderbilt University Medical Center; Nashville Tennessee
| | - Edward Horn
- Department of Pharmacy; Allegheny General Hospital; Pittsburgh Pennsylvania
| | - Douglas L. Jennings
- Department of Pharmacy; New York-Presbyterian Hospital - Columbia University Medical Center; New York New York
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Abbes S, Metjian A, Gray A, Martinu T, Snyder L, Chen DF, Ellis M, Arepally GM, Onwuemene O. Human Leukocyte Antigen Sensitization in Solid Organ Transplantation: A Primer on Terminology, Testing, and Clinical Significance for the Apheresis Practitioner. Ther Apher Dial 2017; 21:441-450. [PMID: 28880430 DOI: 10.1111/1744-9987.12570] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 03/24/2017] [Accepted: 04/25/2017] [Indexed: 01/02/2023]
Abstract
The human leukocyte antigen (HLA) system is an important immunologic barrier that must be considered for successful solid organ transplantation. Formation of donor-specific HLA antibodies in solid organ transplantation is an important cause of allograft injury and may contribute to recipient morbidity and mortality. Therapeutic plasma exchange is often requested to lower HLA antibody levels prior to or after transplantation and for management of HLA antibodies in the context of organ rejection. In this review, we summarize the current terminology, laboratory testing, and clinical significance of HLA sensitization in the solid organ transplant population. Furthermore, to illustrate applications of HLA testing in clinical practice, we summarize our own lung and kidney institutional protocols for managing HLA antibodies in the peri-transplant setting.
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Affiliation(s)
- Sarah Abbes
- Institut du thorax, Service de pneumologie et unite de transplantation thoracique, Centre Hospitalier Universitaire, Nantes, France.,Department of Medicine, Division of Hematology, Duke University School of Medicine, Durham, NC, USA
| | - Ara Metjian
- Department of Medicine, Division of Hematology, Duke University School of Medicine, Durham, NC, USA
| | - Alice Gray
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Tereza Martinu
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA.,Department of Medicine, Division of Respirology, University of Toronto, Toronto, ON, Canada
| | - Laurie Snyder
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Dong-Feng Chen
- Department of Pathology, Division of Pathology Clinical Services, Duke University School of Medicine, Durham, NC, USA
| | - Matthew Ellis
- Department of Medicine, Division of Nephrology, Duke University School of Medicine, Durham, NC, USA
| | - Gowthami M Arepally
- Department of Medicine, Division of Hematology, Duke University School of Medicine, Durham, NC, USA
| | - Oluwatoyosi Onwuemene
- Department of Medicine, Division of Hematology, Duke University School of Medicine, Durham, NC, USA
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Yoshioka D, Li B, Takayama H, Garan RA, Topkara VK, Han J, Kurlansky P, Yuzefpolskaya M, Colombo PC, Naka Y, Takeda K. Outcome of heart transplantation after bridge-to-transplant strategy using various mechanical circulatory support devices. Interact Cardiovasc Thorac Surg 2017; 25:918-924. [DOI: 10.1093/icvts/ivx201] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 05/25/2017] [Indexed: 11/13/2022] Open
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Jetton JG, Sorenson M. Pharmacological management of acute kidney injury and chronic kidney disease in neonates. Semin Fetal Neonatal Med 2017; 22:109-115. [PMID: 27720664 DOI: 10.1016/j.siny.2016.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Both acute kidney injury (AKI) and chronic kidney disease (CKD) are seen more frequently in the neonatal intensive care unit (NICU) as advances in supportive care improve the survival of critically ill infants as well as those with severe, congenital kidney and urinary tract anomalies. Many aspects of the infant's care, including fluid balance, electrolyte and mineral homeostasis, acid-base balance, and growth and nutrition require close monitoring by and collaboration among neonatologists, nephrologists, dieticians, and pharmacologists. This educational review summarizes the therapies widely used for neonates with AKI and CKD. Use of these therapies is extrapolated from data in older children and adults or based on clinical experience and case series. There is a critical need for more research on the use of therapies in infants with kidney disease as well as for the development of drug delivery systems and preparations scaled more appropriately for these small patients.
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Affiliation(s)
- Jennifer G Jetton
- Division of Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa Children's Hospital, Iowa City, IA, USA.
| | - Mark Sorenson
- Department of Pharmaceutical Care, University of Iowa Children's Hospital, Iowa City, IA, USA
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Zachary AA, Leffell MS. HLA Mismatching Strategies for Solid Organ Transplantation - A Balancing Act. Front Immunol 2016; 7:575. [PMID: 28003816 PMCID: PMC5141243 DOI: 10.3389/fimmu.2016.00575] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 11/23/2016] [Indexed: 12/24/2022] Open
Abstract
HLA matching provides numerous benefits in organ transplantation including better graft function, fewer rejection episodes, longer graft survival, and the possibility of reduced immunosuppression. Mismatches are attended by more frequent rejection episodes that require increased immunosuppression that, in turn, can increase the risk of infection and malignancy. HLA mismatches also incur the risk of sensitization, which can reduce the opportunity and increase waiting time for a subsequent transplant. However, other factors such as donor age, donor type, and immunosuppression protocol, can affect the benefit derived from matching. Furthermore, finding a well-matched donor may not be possible for all patients and usually prolongs waiting time. Strategies to optimize transplantation for patients without a well-matched donor should take into account the immunologic barrier represented by different mismatches: what are the least immunogenic mismatches considering the patient’s HLA phenotype; should repeated mismatches be avoided; is the patient sensitized to HLA and, if so, what are the strengths of the patient’s antibodies? This information can then be used to define the HLA type of an immunologically optimal donor and the probability of such a donor occurring. A probability that is considered to be too low may require expanding the donor population through paired donation or modifying what is acceptable, which may require employing treatment to overcome immunologic barriers such as increased immunosuppression or desensitization. Thus, transplantation must strike a balance between the risk associated with waiting for the optimal donor and the risk associated with a less than optimal donor.
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Affiliation(s)
- Andrea A Zachary
- Department of Medicine, Johns Hopkins University School of Medicine , Baltimore, MD , USA
| | - Mary S Leffell
- Department of Medicine, Johns Hopkins University School of Medicine , Baltimore, MD , USA
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Chiu P, Schaffer JM, Oyer PE, Pham M, Banerjee D, Joseph Woo Y, Ha R. Influence of durable mechanical circulatory support and allosensitization on mortality after heart transplantation. J Heart Lung Transplant 2016; 35:731-42. [PMID: 26856669 DOI: 10.1016/j.healun.2015.12.023] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 11/22/2015] [Accepted: 12/21/2015] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Allosensitization has been shown to negatively affect post-heart transplant (HTx) survival even with a negative crossmatch. Whether allosensitization related to mechanical circulatory support (MCS) is associated with worse post-HTx survival remains controversial. METHODS Adult HTx recipients listed in the United Network for Organ Sharing database (July 2006-December 2012) were identified. Multivariate Cox regression assessed the effect of allosensitization on survival. Propensity matching was performed to compare patients who were and were not allosensitized. Kaplan-Meier survival analysis compared matched and unmatched patients in the MCS and medically managed cohorts. RESULTS We identified 11,840 HTx recipients, of whom 4,167 had MCS. MCS was associated with allosensitization in multivariate logistic regression. Each different MCS device was associated with worse post-HTx survival in multivariate Cox regression. Allosensitization did not predict post-HTx mortality in MCS patients (hazard ratio, 1.07; 95% confidence interval, 0.89-1.28; p = 0.48. Among patients without MCS, allosensitization was associated with post-HTx mortality (hazard ratio, 1.19; 95% confidence interval, 1.03-1.39; p = 0.02). Kaplan-Meier analysis revealed equivalent survival in unmatched and matched cohorts when MCS patients who were allosensitized were compared with non-allosensitized MCS patients. Among non-MCS patients, allosensitization was associated with worse survival in unmatched and matched analysis. CONCLUSIONS MCS was associated with allosensitization. For MCS patients, allosensitization did not independently predict worse post-HTx outcome. Among non-MCS patients, allosensitization was associated with worse post-HTx survival. Allosensitization appears to be a heterogeneous process influenced by presence of MCS.
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Affiliation(s)
- Peter Chiu
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California
| | - Justin M Schaffer
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California
| | - Philip E Oyer
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California
| | - Michael Pham
- Division of Cardiovascular Medicine, Stanford University, School of Medicine, Stanford, California
| | - Dipanjan Banerjee
- Division of Cardiovascular Medicine, Stanford University, School of Medicine, Stanford, California
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California
| | - Richard Ha
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California.
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