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Hollander SA, Barkoff L, Giacone H, Adamson GT, Kaufman BD, Motonaga KS, Dubin AM, Chubb H. Risk factors and outcomes of sudden cardiac arrest in pediatric heart transplant recipients. Am Heart J 2022; 252:31-38. [PMID: 35705134 DOI: 10.1016/j.ahj.2022.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/16/2022] [Accepted: 06/09/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Sudden cardiac arrest (SCA) is a prevailing cause of mortality after pediatric heart transplant (HT) but remains understudied. We analyzed the incidence, outcomes, and risk factors for SCA at our center. METHODS Retrospective review of all pediatric HT patients at our center from January 1, 2009 to January 1, 2021. SCA was defined as an abrupt loss of cardiac function requiring cardiopulmonary resuscitation and/or mechanical circulatory support (MCS). Events that occurred in the setting of limited resuscitative wishes, or while on MCS were excluded. Patient characteristics and risk factors were analyzed. RESULTS Fourteen of 254 (6%) experienced SCA at a median of 3 (1, 4) years post-HT. Seven (50%) events occurred out-of-hospital. Eleven (79%) died from their initial event, 2 (18%) after failure to separate from extracorporeal membrane (ECMO). In univariate analysis, black race, younger donor age, prior acute cellular rejection (ACR) episode, pacemaker and/or ICD in place, and pre-mortem diagnosis of allograft vasculopathy were associated with SCA (P = .003-0.02). In multivariable analysis, history of ACR, younger donor age, and black race retained significance. [OR = 6.3, 95% CI: 1.6-25.4, P = .01], [OR = 0.9, 95% CI: 0.8-1, P = .04], and [OR = 7.3, 95% CI: 1.1-49.9, P = .04], respectively. SCA occurred in 3 patients with a functioning ICD or pacemaker, which failed to restore a perfusing rhythm. CONCLUSIONS SCA occurs relatively early after pediatric HT and is usually fatal. Half of events happen at home. Those who received younger donors, have a history of ACR, or are of black race are at increased risk. ICDs/pacemakers may offer limited protection.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA.
| | - Lynsey Barkoff
- Solid Organ Transplant Services, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
| | - Heather Giacone
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Greg T Adamson
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Beth D Kaufman
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Kara S Motonaga
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Anne M Dubin
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Henry Chubb
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
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Abstract
PURPOSE OF REVIEW Despite advances in medical and device-based therapies for advanced heart failure as well as public policy, disparities by race/ethnicity persist in heart failure clinical outcomes. The purpose of this review is to describe disparities in outcomes by race--ethnicity in patients after receipt of heart transplantation and left ventricular assist device (LVAD), and the current understanding of factors contributing to these disparities. RECENT FINDINGS The proportion of black and Latinx patients receiving advanced heart failure therapies continues to rise, and they have worse hemodynamic profiles at the time of referral for heart transplantation and LVAD. Black patients have lower rates of survival after heart transplantation, in part because of higher rates of cellular and humoral rejection that may be mediated through unique gene pathways, and increased risk for allosensitization and de-novo donor-specific antibodies. Factors that have previously been cited as reasons for worse outcomes in race--ethnic minorities, including psychosocial risk and lower SES, may not be as strongly correlated with outcomes after LVAD. SUMMARY Black and Latinx patients are sicker at the time of referral for advanced heart failure therapies. Despite higher psychosocial risk factors among race--ethnic minorities, outcomes after LVAD appear to be similar to white patients. Black patients continue to have lower posttransplant survival, because of a complex interplay of immunologic susceptibility, clinical and socioeconomic factors. No single factor accounts for the disparities in clinical outcomes for race--ethnic minorities, and thus consideration of these components together is critical in management of these patients.
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3
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Black race and outcomes in children with a heart transplant. J Heart Lung Transplant 2019; 38:1323-1324. [PMID: 31628005 DOI: 10.1016/j.healun.2019.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 09/13/2019] [Accepted: 09/19/2019] [Indexed: 11/21/2022] Open
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Lamour JM, Mason KL, Hsu DT, Feingold B, Blume ED, Canter CE, Dipchand AI, Shaddy RE, Mahle WT, Zuckerman WA, Bentlejewski C, Armstrong BD, Morrison Y, Diop H, Iklé DN, Odim J, Zeevi A, Webber SA. Early outcomes for low-risk pediatric heart transplant recipients and steroid avoidance: A multicenter cohort study (Clinical Trials in Organ Transplantation in Children - CTOTC-04). J Heart Lung Transplant 2019; 38:972-981. [PMID: 31324444 PMCID: PMC8359669 DOI: 10.1016/j.healun.2019.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 06/12/2019] [Accepted: 06/16/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Immunosuppression strategies have changed over time in pediatric heart transplantation. Thus, comorbidity profiles may have evolved. Clinical Trials in Organ Transplantation in Children-04 is a multicenter, prospective, cohort study assessing the impact of pre-transplant sensitization on outcomes after pediatric heart transplantation. This sub-study reports 1-year outcomes among recipients without pre-transplant donor-specific antibodies (DSAs). METHODS We recruited consecutive candidates (<21 years) at 8 centers. Sensitization status was determined by a core laboratory. Immunosuppression was standardized as follows: Thymoglobulin induction with tacrolimus and/or mycophenolate mofetil maintenance. Steroids were not used beyond 1 week. Rejection surveillance was by serial biopsy. RESULTS There were 240 transplants. Subjects for this sub-study (n = 186) were non-sensitized (n = 108) or had no DSAs (n = 78). Median age was 6 years, 48.4% were male, and 38.2% had congenital heart disease. Patient survival was 94.5% (95% confidence interval, 90.1-97.0%). Freedom from any type of rejection was 67.5%. Risk factors for rejection were older age at transplant and presence of non-DSAs pre-transplant. Freedom from infection requiring hospitalization/intravenous anti-microbials was 75.4%. Freedom from rehospitalization was 40.3%. New-onset diabetes mellitus and post-transplant lymphoproliferative disorder (PTLD) occurred in 1.6% and 1.1% of subjects, respectively. There was no decline in renal function over the first year. Corticosteroids were used in 14.5% at 1 year. CONCLUSIONS Pediatric heart transplantation recipients without DSAs at transplant and managed with a steroid avoidance regimen have excellent short-term survival and a low risk of first-year diabetes mellitus and PTLD. Rehospitalization remains common. These contemporary observations allow for improved caregiver and/or patient counseling and provide the necessary outcomes data to help design future randomized controlled trials.
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Affiliation(s)
- Jacqueline M Lamour
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Bronx, New York, New York.
| | | | - Daphne T Hsu
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Bronx, New York, New York
| | - Brian Feingold
- Departments of Pediatrics and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Elizabeth D Blume
- Department of Pediatric Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Charles E Canter
- Division of Pediatric Cardiology, Washington University School of Medicine, St. Louis, Missouri
| | - Anne I Dipchand
- Department of Paediatrics, Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robert E Shaddy
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - William T Mahle
- Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Warren A Zuckerman
- Division of Pediatric Cardiology, Columbia University Medical Center, New York, New York
| | - Carol Bentlejewski
- Division of Pediatric Cardiology, Columbia University Medical Center, New York, New York
| | | | | | - Helena Diop
- Rho Federal Systems Division, Chapel Hill, North Carolina
| | - David N Iklé
- Rho Federal Systems Division, Chapel Hill, North Carolina
| | - Jonah Odim
- Transplantation Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Steven A Webber
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
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Morris AA. Utilizing gene expression profiling to understand immunologic mechanisms that impact racial disparities after heart transplant. J Heart Lung Transplant 2019; 38:830-832. [PMID: 31352998 DOI: 10.1016/j.healun.2019.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 06/16/2019] [Indexed: 11/29/2022] Open
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Non-HLA Genetic Factors and Their Influence on Heart Transplant Outcomes: A Systematic Review. Transplant Direct 2019; 5:e422. [PMID: 30882026 PMCID: PMC6415970 DOI: 10.1097/txd.0000000000000859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 11/25/2018] [Indexed: 12/15/2022] Open
Abstract
Supplemental digital content is available in the text. Background Improvement of immunosuppressive therapies and surgical techniques has increased the survival rate after heart transplantation. Nevertheless, a large number of patients still experience complications, such as allograft rejection, vasculopathy, kidney dysfunction, and diabetes in response to immunosuppressive therapy. Variants in HLA genes have been extensively studied for their role in clinical outcomes after transplantation, whereas the knowledge about non-HLA genetic variants in this setting is still limited. Non-HLA polymorphisms are involved in the metabolism of major immunosuppressive therapeutics and may play a role in clinical outcomes after cardiac transplantation. This systematic review summarizes the existing knowledge of associations between non-HLA genetic variation and heart transplant outcomes. Methods The current evidence available on genetic polymorphisms associated with outcomes after heart transplantation was identified by a systematic search in PubMed and Embase. Studies reporting on polymorphisms significantly associated with clinical outcomes after cardiac transplantation were included. Results A total of 56 studies were included, all were candidate gene studies. These studies identified 58 polymorphisms in 36 genes that were associated with outcomes after cardiac transplantation. Variants in TGFB1, CYP3A5, and ABCB1 are consistently replicated across multiple studies for various transplant outcomes. Conclusions The research currently available supports the hypothesis that non-HLA polymorphisms are associated with clinical outcomes after heart transplantation. However, many genetic variants were only identified in a single study, questioning their true effect on the clinical outcomes tested. Further research in larger cohorts with well-defined phenotypes is warranted.
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Kleinmahon JA, Gralla J, Kirk R, Auerbach SR, Henderson HT, Wallis GA, Ramakrishnan K, Singh RK, Caldwell RL, Savage AJ, Everitt MD. Cardiac allograft vasculopathy and graft failure in pediatric heart transplant recipients after rejection with severe hemodynamic compromise. J Heart Lung Transplant 2019; 38:277-284. [DOI: 10.1016/j.healun.2018.12.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 11/14/2018] [Accepted: 12/18/2018] [Indexed: 11/25/2022] Open
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Watanabe K, Karimpour-Fard A, Michael A, Miyamoto SD, Nakano SJ. Elevated serum vascular endothelial growth factor and development of cardiac allograft vasculopathy in children. J Heart Lung Transplant 2018; 37:1075-1082. [PMID: 29954686 PMCID: PMC6261433 DOI: 10.1016/j.healun.2018.04.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 04/19/2018] [Accepted: 04/25/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is a leading cause of retransplantation and death in pediatric heart transplant recipients. Our aim was to evaluate the association between serum vascular endothelial growth factor-A (VEGF) and CAV development in the pediatric heart transplant population. METHODS In this retrospective study performed at a university hospital, VEGF concentrations were measured by enzyme-linked immunosorbent assay in banked serum from pediatric heart transplant recipients undergoing routine cardiac catheterization. In subjects with CAV (n = 29), samples were obtained at 2 time-points: before CAV diagnosis (pre-CAV) and at the time of initial CAV diagnosis (CAV). In subjects without CAV (no-CAV, n = 16), only 1 time-point was used. VEGF concentrations (n = 74) were assayed in duplicate. RESULTS Serum VEGF is elevated in pediatric heart transplant recipients before catheter-based diagnosis of CAV (no-CAV mean: 144.0 ± 89.05 pg/ml; pre-CAV mean: 316.2 ± 118.3 pg/ml; p = 0.0002). Receiver-operating characteristic curve analysis of pre-CAV VEGF levels demonstrated an area under the curve of 87.7% (p = 0.0002), with a VEGF level of 226.3 pg/ml predicting CAV development with 77.8% sensitivity and 91.7% specificity. VEGF is similarly elevated in subjects with angiographically diagnosed CAV and in those with normal angiography but intravascular ultrasound (IVUS) evidence of CAV. CONCLUSIONS The increase in serum VEGF before onset of detectable CAV is fundamental to its utility as a predictive biomarker and suggests further investigations of VEGF in the pathogenesis of CAV are warranted in the pediatric heart transplant population.
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Affiliation(s)
- Kae Watanabe
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Anis Karimpour-Fard
- Department of Pharmacology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Alix Michael
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Shelley D Miyamoto
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Stephanie J Nakano
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA.
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10
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Polymorphisms in genes related to the complement system and antibody-mediated cardiac allograft rejection. J Heart Lung Transplant 2017; 37:477-485. [PMID: 28784323 DOI: 10.1016/j.healun.2017.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 07/06/2017] [Accepted: 07/11/2017] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Heart transplantation (HT) is a life-saving treatment for patients with end-stage heart failure. One of the main problems after HT is the humoral response termed antibody-mediated rejection (AMR). Complement activation plays a key role in AMR contributing to graft damage. The aim of this study was to analyze genetic variants in genes related to the complement pathways that could be associated with the development of AMR. METHODS Analysis of 51 genes related to the complement pathway was performed by next-generation sequencing in 46 HT recipients, 23 with and 23 without AMR. Statistical analysis was performed with SNPstats and R. RESULTS We identified 2 single nucleotide polymorphisms, 1 in the mannose-binding lectin 2 gene (p.Gly54Asp-MBL2) and 1 in the complement factor properdin gene (p.Asn428(p=)-CFP), that showed significant association with the absence and development of AMR, respectively. Moreover, the presence of the rare allele in p.Gly54Asp-MBL2 control patients correlated with an immunodeficiency of mannose-binding lectin (6.24 ng/ml vs 207.50 ng/ml, p < 0.01), whereas the presence of the rare allele p.Asn428(p=)-CFP in patients with AMR correlated with higher levels of properdin protein (14.65 μg/ml vs 10.77 μg/ml, p < 0.05). CONCLUSIONS AMR is a complex phenotype affected by many recipient factors. Variants in p.Gly54Asp-MBL2 and p.Asn428(p=)-CFP genes, encoding mannose-binding lectin 2 and properdin, may influence the risk of AMR.
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Green DJ, Brooks MM, Burckart GJ, Chinnock RE, Canter C, Addonizio LJ, Bernstein D, Kirklin JK, Naftel DC, Girnita DM, Zeevi A, Webber SA. The Influence of Race and Common Genetic Variations on Outcomes After Pediatric Heart Transplantation. Am J Transplant 2017; 17:1525-1539. [PMID: 27931092 DOI: 10.1111/ajt.14153] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 11/16/2016] [Accepted: 11/25/2016] [Indexed: 01/25/2023]
Abstract
Significant racial disparity remains in the incidence of unfavorable outcomes following heart transplantation. We sought to determine which pediatric posttransplantation outcomes differ by race and whether these can be explained by recipient demographic, clinical, and genetic attributes. Data were collected for 80 black and 450 nonblack pediatric recipients transplanted at 1 of 6 centers between 1993 and 2008. Genotyping was performed for 20 candidate genes. Average follow-up was 6.25 years. Unadjusted 5-year rates for death (p = 0.001), graft loss (p = 0.015), acute rejection with severe hemodynamic compromise (p = 0.001), late rejection (p = 0.005), and late rejection with hemodynamic compromise (p = 0.004) were significantly higher among blacks compared with nonblacks. Black recipients were more likely to be older at the time of transplantation (p < 0.001), suffer from cardiomyopathy (p = 0.004), and have public insurance (p < 0.001), and were less likely to undergo induction therapy (p = 0.0039). In multivariate regression models adjusting for age, sex, cardiac diagnosis, insurance status, and genetic variations, black race remained a significant risk factor for all the above outcomes. These clinical and genetic variables explained only 8-19% of the excess risk observed for black recipients. We have confirmed racial differences in survival, graft loss, and several rejection outcomes following heart transplantation in children, which could not be fully explained by differences in recipient attributes.
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Affiliation(s)
- D J Green
- Pediatric Clinical Pharmacology Staff, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - M M Brooks
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA
| | - G J Burckart
- Pediatric Clinical Pharmacology Staff, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - R E Chinnock
- Department of Pediatrics, Loma Linda University, Loma Linda, CA
| | - C Canter
- Division of Cardiology, Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO
| | - L J Addonizio
- Division of Cardiology, Department of Pediatrics, Columbia University, New York, NY
| | - D Bernstein
- Division of Cardiology, Department of Pediatrics, Stanford University, Lucile Packard Children's Hospital, Palo Alto, CA
| | - J K Kirklin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - D C Naftel
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - D M Girnita
- Department of Pathology, Thomas E Starzl Transplant Institute, University of Pittsburgh, Pittsburgh, PA
| | - A Zeevi
- Department of Pathology, Thomas E Starzl Transplant Institute, University of Pittsburgh, Pittsburgh, PA
| | - S A Webber
- Department of Pediatrics, Vanderbilt University, Nashville, TN
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12
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Daly KP, Stack M, Eisenga MF, Keane JF, Zurakowski D, Blume ED, Briscoe DM. Vascular endothelial growth factor A is associated with the subsequent development of moderate or severe cardiac allograft vasculopathy in pediatric heart transplant recipients. J Heart Lung Transplant 2016; 36:434-442. [PMID: 27865734 DOI: 10.1016/j.healun.2016.09.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 09/08/2016] [Accepted: 09/16/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is the leading cause of chronic allograft loss after pediatric heart transplantation. We hypothesized that biomarkers of endothelial injury and repair would predict CAV development in pediatric heart transplant recipients. METHODS Blood was collected from pediatric heart transplant recipients at the time of routine annual coronary angiography, and the concentrations of 13 angiogenesis-related molecules were determined. The primary end point was the presence of moderate or severe CAV by angiography during a 5-year follow-up period. RESULTS The study enrolled 48 recipients (57% male) with a median age of 15.5 years (range, 2-22 years) and median time post-transplant of 5.8 years (range, 2-15 years). Eight recipients developed moderate/severe CAV at a median follow-up of 4.7 years, of whom 3 died, 3 underwent retransplantation, 1 had a myocardial infarction, and 1 was listed for retransplantation. Clinical characteristics associated with the development of moderate/severe CAV included prednisone use at enrollment (p = 0.03) and positive recipient cytomegalovirus immunoglobulin G at the time of transplant (p = < 0.01). Multivariable Cox proportional hazards regression identified plasma vascular endothelial growth factor (VEGF)-A concentration greater than 90 pg/ml at the time of blood draw as a significant predictor of time to moderate or severe CAV (hazard ratio, 14.3; 95% confidence interval, 1.3-163). Receiver operating characteristic curve analysis demonstrated that VEGF-A shows moderate performance for association with the subsequent development of CAV (area under the curve, 0.77; 95% confidence interval, 0.61-0.92). CONCLUSIONS VEGF-A levels in pediatric heart transplant recipients are associated with clinically important CAV progression within the subsequent 5 years.
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Affiliation(s)
- Kevin P Daly
- Transplant Research Program, Department of Medicine, Boston, Massachusetts; Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Maria Stack
- Transplant Research Program, Department of Medicine, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Division of Nephrology, Department of Medicine, Boston, Massachusetts
| | - Michele F Eisenga
- Transplant Research Program, Department of Medicine, Boston, Massachusetts; Division of Nephrology, Department of Medicine, Boston, Massachusetts
| | - John F Keane
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - David Zurakowski
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Department of Anesthesia, Boston Children's Hospital, Boston, Massachusetts; Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - David M Briscoe
- Transplant Research Program, Department of Medicine, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Division of Nephrology, Department of Medicine, Boston, Massachusetts.
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13
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Starling RC, Stehlik J, Baran DA, Armstrong B, Stone JR, Ikle D, Morrison Y, Bridges ND, Putheti P, Strom TB, Bhasin M, Guleria I, Chandraker A, Sayegh M, Daly KP, Briscoe DM, Heeger PS. Multicenter Analysis of Immune Biomarkers and Heart Transplant Outcomes: Results of the Clinical Trials in Organ Transplantation-05 Study. Am J Transplant 2016; 16:121-36. [PMID: 26260101 PMCID: PMC4948061 DOI: 10.1111/ajt.13422] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 05/20/2015] [Accepted: 06/14/2015] [Indexed: 01/25/2023]
Abstract
Identification of biomarkers that assess posttransplant risk is needed to improve long-term outcomes following heart transplantation. The Clinical Trials in Organ Transplantation (CTOT)-05 protocol was an observational, multicenter, cohort study of 200 heart transplant recipients followed for the first posttransplant year. The primary endpoint was a composite of death, graft loss/retransplantation, biopsy-proven acute rejection (BPAR), and cardiac allograft vasculopathy (CAV) as defined by intravascular ultrasound (IVUS). We serially measured anti-HLA- and auto-antibodies, angiogenic proteins, peripheral blood allo-reactivity, and peripheral blood gene expression patterns. We correlated assay results and clinical characteristics with the composite endpoint and its components. The composite endpoint was associated with older donor allografts (p < 0.03) and with recipient anti-HLA antibody (p < 0.04). Recipient CMV-negativity (regardless of donor status) was associated with BPAR (p < 0.001), and increases in plasma vascular endothelial growth factor-C (OR 20; 95%CI:1.9-218) combined with decreases in endothelin-1 (OR 0.14; 95%CI:0.02-0.97) associated with CAV. The remaining biomarkers showed no relationships with the study endpoints. While suboptimal endpoint definitions and lower than anticipated event rates were identified as potential study limitations, the results of this multicenter study do not yet support routine use of the selected assays as noninvasive approaches to detect BPAR and/or CAV following heart transplantation.
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Affiliation(s)
| | - Josef Stehlik
- University of Utah Health Sciences Center, Salt Lake City UT
| | | | | | | | | | - Yvonne Morrison
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville MD
| | - Nancy D. Bridges
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville MD
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Wedel J, Bruneau S, Kochupurakkal N, Boneschansker L, Briscoe DM. Chronic allograft rejection: a fresh look. Curr Opin Organ Transplant 2015; 20:13-20. [PMID: 25563987 PMCID: PMC4461362 DOI: 10.1097/mot.0000000000000155] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW New developments suggest that the graft itself and molecules expressed within the graft microenvironment dictate the phenotype and evolution of chronic rejection. RECENT FINDINGS Once ischemia-reperfusion injury, cellular and humoral immune responses target the microvasculature, the associated local tissue hypoxia results in hypoxia-inducible factor 1α-dependent expression of pro-inflammatory and proangiogenic growth factors including vascular endothelial growth factor (VEGF) as a physiological response to injury. Local expression of VEGF can promote the recruitment of alloimune T cells into the graft. mTOR/Akt signaling within endothelial cells regulates cytokine- and alloantibody-induced activation and proliferation and their proinflammatory phenotype. Inhibition of mTOR and/or Akt results in an anti-inflammatory phenotype and enables the expression of coinhibitory molecules that limit local T cell reactivation and promotes immunoregulation. Semaphorin family molecules may bind to neuropilin-1 on regulatory T cell subsets to stabilize functional responses. Ligation of neuropilin-1 on Tregs also inhibits Akt-induced responses suggesting common theme for enhancing local immunoregulation and long-term graft survival. SUMMARY Events within the graft initiated by mTOR/Akt-induced signaling promote the development of chronic rejection. Semaphorin-neuropilin biology represents a novel avenue for targeting this biology and warrants further investigation.
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Affiliation(s)
- Johannes Wedel
- Transplant Research Program, Pediatric Transplant Center, Boston Children's Hospital, Boston MA
- Division of Nephrology, Department of Medicine, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Sarah Bruneau
- Transplant Research Program, Pediatric Transplant Center, Boston Children's Hospital, Boston MA
- Division of Nephrology, Department of Medicine, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Nora Kochupurakkal
- Transplant Research Program, Pediatric Transplant Center, Boston Children's Hospital, Boston MA
- Division of Nephrology, Department of Medicine, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Leo Boneschansker
- Transplant Research Program, Pediatric Transplant Center, Boston Children's Hospital, Boston MA
- Division of Nephrology, Department of Medicine, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - David M. Briscoe
- Transplant Research Program, Pediatric Transplant Center, Boston Children's Hospital, Boston MA
- Division of Nephrology, Department of Medicine, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Zuckermann A, Eisen H, See Tai S, Li H, Hahn C, Crespo-Leiro MG. Sirolimus conversion after heart transplant: risk factors for acute rejection and predictors of renal function response. Am J Transplant 2014; 14:2048-54. [PMID: 25307036 DOI: 10.1111/ajt.12833] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 03/26/2014] [Accepted: 03/27/2014] [Indexed: 01/25/2023]
Abstract
In a randomized, comparative study of cardiac transplant patients with mild-to-moderate renal insufficiency, conversion from calcineurin inhibitors (CNIs) to sirolimus improved renal function at 1 year versus continuing CNIs, with an attendant risk of biopsy-confirmed acute rejection (BCAR). Post hoc analyses were conducted to identify predictors of BCAR and GFR improvement associated with conversion. Patients with proteinuria >500 mg/day were excluded. Univariate and multivariate regression analyses tested 13 parameters for BCAR and six for GFR improvement. In 57 sirolimus-treated patients, mean daily mycophenolate mofetil (MMF) dose was lower in those with versus without BCAR (1000 vs. 1420 mg; p = 0.014). Receiver operating characteristic analysis identified MMF dose ≤1000 mg/day as the optimal cutoff to predict BCAR. Multivariate analysis confirmed low MMF dose (odds ratio: 9.94; p = 0.007) and non-white race (odds ratio: 15.3; p = 0.06) were independently associated with BCAR. GFR improvement was evaluated in intent-to-treat patients (n = 116). Significant interaction was detected between treatment effect and preexisting diabetes status (univariate p = 0.077; multivariate p = 0.022), indicating greater beneficial effect of sirolimus in those without preexisting diabetes. These findings suggest that sirolimus is more effective in improving GFR in patients without preexisting diabetes, and adequate MMF doses are needed for sirolimus conversion.
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16
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Karimi MH, Ebadi P, Pourfathollah AA. Association of cytokine/costimulatory molecule polymorphism and allograft rejection: a comparative review. Expert Rev Clin Immunol 2014; 9:1099-112. [PMID: 24168415 DOI: 10.1586/1744666x.2013.844462] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
One reason for genetic variations among human individuals is SNP which may confer diverse disease susceptibility or resistance in a population. Genetic variations in a key immunoregulatory agent can manifest various immunological responses, such as graft rejection. In fact, the outcome of organ transplantation can be impacted by several genetic causes including polymorphisms in genes encoding cytokines and costimulatory molecules in the donor or recipient. Thus, it can be helpful to contemplate the SNPs relating to these immunological determinants in order to achieve an improved transplantation therapy.
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Affiliation(s)
- Mohammad H Karimi
- Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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17
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Burckart GJ, Figg WD, Brooks MM, Green DJ, Troutman SM, Ferrell R, Chinnock R, Canter C, Addonizio L, Bernstein D, Kirklin JK, Naftel D, Price DK, Sissung TM, Girnita DM, Zeevi A, Webber SA. Multi-institutional Study of Outcomes After Pediatric Heart Transplantation: Candidate Gene Polymorphism Analysis of ABCC2. J Pediatr Pharmacol Ther 2014; 19:16-24. [PMID: 24782687 DOI: 10.5863/1551-6776-19.1.16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Earlier studies have indicated that the pharmacokinetics of mycophenolic acid (MPA) is influenced by polymorphisms of ABCC2, which encodes for the membrane transporter MRP2. The ABCC2 rs717620 A allele has been associated with enterohepatic recirculation of MPA, and our previous work had correlated the discontinuance of MPA with this allele in pediatric heart transplant patients. Therefore, we hypothesized that the ABCC2 rs717620 A allele would be associated with poorer outcomes including rejection with hemodynamic compromise (RHC), graft failure, and death in the pediatric heart transplant (PHTx) population receiving MPA. METHODS PHTx recipients from 6 institutions in the Pediatric Heart Transplantation Study (PHTS) from the period of 1993-2009, receiving MPA therapy, were genotyped for ABCC2 rs717620. Genotyping was accomplished by direct sequencing. Demographic and outcome data were limited to the data routinely collected as part of the PHTS and included RHC and mortality. RESULTS Two hundred ninety patients were identified who received MPA at some point post transplantation, of which 200 carried the GG genotype, 81 carried the AG genotype, and 9 carried the AA genotype. Follow-up time after transplantation was 6 years. RHC occurred in 76 patients and 18 patients died. In the 281 patients followed up more than 1 year, late RHC (>1 year post transplantation) occurred in 42 patients. While both RHC and late RHC were associated with the ABCC2 rs717620 GG genotype (hazard ratios: 1.80 and 4.57, respectively, p<0.05) in all patients, this association was not significant in PHTx patients receiving only MPA as the antiproliferative agent from the time of transplant (n=142). CONCLUSIONS ABCC2 rs717620 polymorphisms varied within racial groups. As a candidate gene assessment, the ABCC2 rs717620 AG and AA genotypes may be associated with improved, rather than poorer, RHC in PHTx patients receiving MPA therapy. ABCC2 rs717620 polymorphisms should be included in any expanded pharmacogenomic analysis of outcomes after pediatric heart transplantation.
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Affiliation(s)
- Gilbert J Burckart
- Pediatric Clinical Pharmacology Staff, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - William D Figg
- Medical Pharmacology Section, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | | | - Dionna J Green
- Pediatric Clinical Pharmacology Staff, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Sarah M Troutman
- Medical Pharmacology Section, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Robert Ferrell
- Department of Human Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Richard Chinnock
- Department of Pediatrics, Loma Linda University, Loma Linda University Children's Hospital, Loma Linda, California
| | - Charles Canter
- Department of Pediatrics, Division of Cardiology, Washington University School of Medicine, St Louis Children's Hospital, St Louis, Missouri
| | - Linda Addonizio
- Department of Pediatrics, Division of Cardiology, Columbia University, New York Presbyterian Hospital, New York, New York
| | - Daniel Bernstein
- Department of Pediatrics, Division of Cardiology, Stanford University, Lucile Packard Children's Hospital, Palo Alto, California
| | - James K Kirklin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - David Naftel
- Department of Pathology, Thomas E Starzl Transplant Institute
| | - Douglas K Price
- Medical Pharmacology Section, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Tristan M Sissung
- Medical Pharmacology Section, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Diana M Girnita
- Department of Pathology, Thomas E Starzl Transplant Institute
| | - Adriana Zeevi
- Department of Pathology, Thomas E Starzl Transplant Institute
| | - Steven A Webber
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
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18
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Meta-analysis of cytokine gene polymorphisms and outcome of heart transplantation. BIOMED RESEARCH INTERNATIONAL 2013; 2013:387184. [PMID: 24024189 PMCID: PMC3762075 DOI: 10.1155/2013/387184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 06/26/2013] [Accepted: 06/26/2013] [Indexed: 11/17/2022]
Abstract
We performed a systematic review and meta-analysis with the aim of assessing the association between cytokine gene polymorphisms and graft rejection in heart transplantation. We identified relevant studies from Medline and Embase using PubMed and Ovid search engines, respectively. Allele frequencies and allele and genotypic effects were pooled. Heterogeneity and publication bias were explored. Four to 5 studies were included in pooling of 3 gene polymorphisms. The prevalences of the minor alleles for TNF α -308, TGF β 1-c10, and TGF β 1-c25 were 0.166 (95% CI: 0.129, 0.203), 0.413 (95% CI: 0.363, 0.462), and 0.082 (95% CI: 0.054, 0.111) in the control groups, respectively. Carrying the A allele for the TNF α -308 had 18% (95% CI of OR: 0.46, 3.01) increased risk, but this was not significant for developing graft rejection than the G allele. Conversely, carrying the minor alleles for both TGF β 1-c10 and c25 had nonsignificantly lower odds of graft rejection than major alleles, with the pooled ORs of 0.87 (95% CI: 0.65, 1.18) and 0.70 (95% CI: 0.40, 1.23), respectively. There was no evidence of publication bias for all poolings. An updated meta-analysis is required when more studies are published to increase the power of detection for the association between these polymorphisms and allograft rejection.
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19
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de Denus S, Kantor PF. Pharmacogenomics and heart failure in congenital heart disease. Can J Cardiol 2013; 29:779-85. [PMID: 23790550 DOI: 10.1016/j.cjca.2013.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Revised: 04/17/2013] [Accepted: 04/17/2013] [Indexed: 01/11/2023] Open
Abstract
Congenital heart disease (CHD) constitutes a lifelong challenge in heart failure management. Current therapy is based mainly on physiologic principles extrapolated from the management of left ventricular failure in adult populations with either ischemic or nonischemic cardiomyopathy. However, there is good evidence of genomic variability in the origin and progression of CHD that suggests the need for a individualized approach to treatment. The developing science of pharmacogenomics presents an opportunity for CHD management broadly, and especially in the context of heart failure. There is growing evidence that individualizing drug therapy for these patients might be beneficial, and that prediction of response to therapy might be possible by incorporating genomic data into the treatment algorithm for individual patients.
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Affiliation(s)
- Simon de Denus
- Faculty of Pharmacy, Université de Montréal, Montreal Heart Institute, Montreal, Québec, Canada
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20
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Daly KP, Seifert ME, Chandraker A, Zurakowski D, Nohria A, Givertz MM, Karumanchi SA, Briscoe DM. VEGF-C, VEGF-A and related angiogenesis factors as biomarkers of allograft vasculopathy in cardiac transplant recipients. J Heart Lung Transplant 2013; 32:120-8. [PMID: 23260712 DOI: 10.1016/j.healun.2012.09.030] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 08/30/2012] [Accepted: 09/25/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV), the major cause of late allograft loss after cardiac transplantation, results from donor-directed cellular and humoral alloimmune responses. Graft vascular endothelial cells (EC) are primary targets of these destructive responses, suggesting that factors associated with endothelial injury and repair could serve as biomarkers of CAV. METHODS Using a protein profiler array platform, we measured the levels of 55 angiogenesis-related proteins in sera from 33 adult heart transplant recipients, including 17 with angiographically documented CAV and 16 age- and gender-matched controls without CAV. All patients were >2 years after heart transplant. RESULTS The study population was 75% male with a mean age of 62 ± 11 years. On average, patients were 12 ± 5 years after heart transplantation. We found that vascular endothelial growth factor (VEGF)-C, VEGF-A, angiopoietin-2, artemin, urokinase-type plasminogen activator and vasohibin were strongly associated with established CAV (all p < 0.01). Multivariable modeling identified VEGF-C, VEGF-A and platelet factor-4 (PF-4) as significant independent biomarkers of CAV. Furthermore, receiver-operating characteristic curve analysis demonstrated that the combination of all 3 molecules provided outstanding performance for the diagnosis of CAV (area under the curve [AUC] = 0.98; p < 0.001). CONCLUSIONS Serum levels of VEGF-C, VEGF-A and PF-4 demonstrate strong associations with established CAV and, together with related angiogenesis factors, may serve as a reliable, non-invasive diagnostic test for CAV in cardiac transplant recipients.
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Affiliation(s)
- Kevin P Daly
- Transplantation Research Center, Division of Nephrology, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts 02115, USA
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21
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Dipchand AI, Kirk R, Mahle WT, Tresler MA, Naftel DC, Pahl E, Miyamoto SD, Blume E, Guleserian KJ, White-Williams C, Kirklin JK. Ten yr of pediatric heart transplantation: a report from the Pediatric Heart Transplant Study. Pediatr Transplant 2013; 17:99-111. [PMID: 23442098 DOI: 10.1111/petr.12038] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2012] [Indexed: 11/27/2022]
Abstract
The PHTS was founded in 1991 as a not-for-profit organization dedicated to the advancement of the science and treatment of children during listing for and following heart transplantation. Now, 21 yr later, the PHTS has contributed significantly to the field, most notably in the form of outcomes analyses and risk factor assessment, in addition to amassing the most detailed dataset on pediatric heart transplant recipients worldwide. The purpose of this report is to review the last decade of pediatric patients listed for heart transplantation (January 1, 2000-December 31, 2009) and summarize the changes, trends, outcomes, and lessons learned.
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22
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Kransdorf EP, Kobashigawa JA. Genetic and genomic approaches to the detection of heart transplant rejection. Per Med 2012; 9:693-705. [PMID: 29776273 DOI: 10.2217/pme.12.84] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Since Christiaan Barnard performed the first heart transplant in 1967, over 100,000 heart transplants have been performed worldwide. As was true then, rejection remains the major threat to the function and survival of the allograft. The development of the endomyocardial biopsy as a means to monitor for rejection has allowed heart transplantation to thrive as a therapy for patients with end-stage heart disease. The need for a noninvasive method of rejection surveillance led to the development of the first genetic test for allograft rejection, the AlloMap®. In this article, after presenting the pathological and clinical features of cardiac allograft rejection, the authors discuss the development and application of gene-expression testing for the detection of cardiac allograft rejection. We then explore emerging 'omic' approaches that will be the rejection detection methods of the future.
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Affiliation(s)
- Evan P Kransdorf
- Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
| | - Jon A Kobashigawa
- Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA.
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23
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Dormond O, Dufour M, Seto T, Bruneau S, Briscoe DM. Targeting the intragraft microenvironment and the development of chronic allograft rejection. Hum Immunol 2012; 73:1261-8. [PMID: 22863981 DOI: 10.1016/j.humimm.2012.07.334] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 06/29/2012] [Accepted: 07/25/2012] [Indexed: 01/10/2023]
Abstract
In this review, we discuss a paradigm whereby changes in the intragraft microenvironment promote or sustain the development of chronic allograft rejection. A key feature of this model involves the microvasculature including (a) endothelial cell (EC) destruction, and (b) EC proliferation, both of which result from alloimmune leukocyte- and/or alloantibody-induced responses. These changes in the microvasculature likely create abnormal blood flow patterns and thus promote local tissue hypoxia. Another feature of the chronic rejection microenvironment involves the overexpression of vascular endothelial growth factor (VEGF). VEGF stimulates EC activation and proliferation and it has potential to sustain inflammation via direct interactions with leukocytes. In this manner, VEGF may promote ongoing tissue injury. Finally, we review how these events can be targeted therapeutically using mTOR inhibitors. EC activation and proliferation as well as VEGF-VEGFR interactions require PI-3K/Akt/mTOR intracellular signaling. Thus, agents that inhibit this signaling pathway within the graft may also target the progression of chronic rejection and thus promote long-term graft survival.
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Affiliation(s)
- Olivier Dormond
- The Department of Visceral Surgery, Lausanne University Hospital, Lausanne, Switzerland
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24
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Feingold B, Brooks MM, Zeevi A, Ohmann EL, Burckart GJ, Ferrell RE, Chinnock R, Canter C, Addonizio L, Bernstein D, Kirklin JK, Naftel DC, Webber SA. Renal function and genetic polymorphisms in pediatric heart transplant recipients. J Heart Lung Transplant 2012; 31:1003-8. [PMID: 22789135 DOI: 10.1016/j.healun.2012.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 05/11/2012] [Accepted: 05/14/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Common genetic variations influence rejection, infection, drug metabolism, and side effect profiles after pediatric heart transplantation. Reports in adults suggest that genetic background may influence post-transplant renal function. In this multicenter study, we investigated the association of genetic polymorphisms (GPs) in a panel of candidate genes on renal function in 453 pediatric heart transplant recipients. METHODS We performed genotyping for functional GPs in 19 candidate genes. Renal function was determined annually after transplantation by calculation of the estimated glomerular filtration rate (eGFR). Mixed-effects and Cox proportional hazard models were used to assess recipient characteristics and the effect of GPs on longitudinal eGFR and time to eGFR < 60 mL/min/1.73m(2). RESULTS Mean age at transplantation was 6.2 ± 6.1 years. Mean follow-up was 5.1 ± 2.5 years. Older age at transplant and black race were independently associated with post-transplant renal dysfunction. Univariate analyses showed FASL (C-843T) T allele (p = 0.014) and HO-1 (A326G) G allele (p = 0.0017) were associated with decreased renal function. After adjusting for age and race, these associations were attenuated (FASL, p = 0.075; HO-1, p = 0.053). We found no associations of other GPs with post-transplant renal function, including GPs in TGFβ1, CYP3A5, ABCB1, and ACE. CONCLUSIONS In this multicenter, large, sample of pediatric heart transplant recipients, we found no strong associations between GPs in 19 candidate genes and post-transplant renal function. Our findings contradict reported associations of CYP3A5 and TGFβ1 with renal function and suggest that genotyping for these GPs will not facilitate individualized immunosuppression for the purpose of protecting renal function after pediatric heart transplantation.
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Affiliation(s)
- Brian Feingold
- Pediatric Cardiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.
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25
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Bruneau S, Woda CB, Daly KP, Boneschansker L, Jain NG, Kochupurakkal N, Contreras AG, Seto T, Briscoe DM. Key Features of the Intragraft Microenvironment that Determine Long-Term Survival Following Transplantation. Front Immunol 2012; 3:54. [PMID: 22566935 PMCID: PMC3342046 DOI: 10.3389/fimmu.2012.00054] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 03/02/2012] [Indexed: 12/17/2022] Open
Abstract
In this review, we discuss how changes in the intragraft microenvironment serve to promote or sustain the development of chronic allograft rejection. We propose two key elements within the microenvironment that contribute to the rejection process. The first is endothelial cell proliferation and angiogenesis that serve to create abnormal microvascular blood flow patterns as well as local tissue hypoxia, and precedes endothelial-to-mesenchymal transition. The second is the overexpression of local cytokines and growth factors that serve to sustain inflammation and, in turn, function to promote a leukocyte-induced angiogenesis reaction. Central to both events is overexpression of vascular endothelial growth factor (VEGF), which is both pro-inflammatory and pro-angiogenic, and thus drives progression of the chronic rejection microenvironment. In our discussion, we focus on how inflammation results in angiogenesis and how leukocyte-induced angiogenesis is pathological. We also discuss how VEGF is a master control factor that fosters the development of the chronic rejection microenvironment. Overall, this review provides insight into the intragraft microenvironment as an important paradigm for future direction in the field.
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Affiliation(s)
- Sarah Bruneau
- The Division of Nephrology, Transplantation Research Center, Children's Hospital Boston Boston, MA, USA
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26
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Feingold B, Zheng J, Law YM, Morrow WR, Hoffman TM, Schechtman KB, Dipchand AI, Canter CE. Risk factors for late renal dysfunction after pediatric heart transplantation: a multi-institutional study. Pediatr Transplant 2011; 15:699-705. [PMID: 22004544 PMCID: PMC3201752 DOI: 10.1111/j.1399-3046.2011.01564.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Renal dysfunction is a major determinant of outcome after HTx. Using a large, multi-institutional database, we sought to identify factors associated with late renal dysfunction after pediatric HTx. All patients in the PHTS database with eGFR ≥60 mL/min/1.73 m(2) at one yr post-HTx (n = 812) were analyzed by Cox regression for association with risk factors for eGFR <60 mL/min/1.73 m(2) at >1 yr after HTx. Freedom from late renal dysfunction was 71% and 57% at five and 10 yr. Multivariate risk factors for late renal dysfunction were earlier era of HTx (HR 1.84; p < 0.001), black race (HR 1.42; p = 0.048), rejection with hemodynamic compromise in the first year after HTx (HR 1.74; p = 0.038), and lowest quartile eGFR at one yr post-HTx (HR 1.83; p < 0.001). Renal function at HTx was not associated with onset of late renal dysfunction. Eleven patients (1.4%) required chronic dialysis and/or renal transplant during median follow-up of 4.1 yr (1.5-12.6). Late renal dysfunction is common after pediatric HTx, with blacks at increased risk. Decreased eGFR at one yr post-HTx, but not at HTx, predicts onset of late renal dysfunction. Future research on strategies to minimize late renal dysfunction after pediatric HTx may be of greatest benefit if focused on these subgroups.
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Affiliation(s)
- Brian Feingold
- Pediatric Cardiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA 15224, USA.
| | - Jie Zheng
- Biostatistics, Washington University, St. Louis, MO 63110
| | - Yuk M. Law
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA 98105
| | | | - Timothy M Hoffman
- Nationwide Children's Heart Center, Nationwide Children's Hospital, Columbus, OH 43205
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Daly KP, Chakravarti SB, Tresler M, Naftel DC, Blume ED, Dipchand AI, Almond CS. Sudden death after pediatric heart transplantation: analysis of data from the Pediatric Heart Transplant Study Group. J Heart Lung Transplant 2011; 30:1395-402. [PMID: 21996348 DOI: 10.1016/j.healun.2011.08.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 07/16/2011] [Accepted: 08/25/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Sudden death is a well-recognized complication of heart transplantation. Little is known about the incidence and risk factors for sudden death after transplant in children. The purpose of this study was to determine the incidence of and risk factors for sudden death. METHODS This retrospective multicenter cohort study used the Pediatric Heart Transplant Study Group (PHTS) database, an event-driven registry of children aged <18 at listing undergoing heart transplantation between 1993 and 2007. Standard Kaplan-Meier and parametric analyses were used for survival analysis. Multivariate analysis in the hazard-function domain was used to identify risk factors for sudden death after transplant. RESULTS Of 604 deaths in 2,491 children who underwent heart transplantation, 94 (16%) were classified as sudden. Freedom from sudden death was 97% at 5 years, and the hazard for sudden death remained constant over time at 0.01 deaths/year. Multivariate risk factors associated with sudden death included black race (hazard ratio [HR], 2.6; p < 0.0001), United Network of Organ Sharing (UNOS) status 2 at transplant (HR, 1.8; p = 0.008), older age (HR, 1.4/10 years of age; p = 0.03), and an increased number of rejection episodes in the first post-transplant year (HR, 1.6/episode; p = 0.03). CONCLUSION Sudden death accounts for 1 in 6 deaths after heart transplant in children. Older recipient age, recurrent rejection within the first year, black race, and UNOS status 2 at listing were associated with sudden death. Patients with 1 or more of these risk factors may benefit from primary prevention efforts.
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Affiliation(s)
- Kevin P Daly
- Department of Cardiology, Children's Hospital Boston and the Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.
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28
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VEGF gene polymorphism and response to intravitreal bevacizumab and triple therapy in age-related macular degeneration. Jpn J Ophthalmol 2011; 55:435-443. [PMID: 21744122 DOI: 10.1007/s10384-011-0061-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2010] [Accepted: 04/19/2011] [Indexed: 01/21/2023]
Abstract
PURPOSE To investigate the association between the vascular endothelial growth factor (VEGF) gene and response to either intravitreal bevacizumab (IVB) or photodynamic therapy with intravitreal triamcinolone acetonide and IVB (triple therapy) for neovascular age-related macular degeneration (AMD). METHODS The study consisted of 94 patients with neovascular AMD who underwent IVB and 79 patients with neovascular AMD who underwent triple therapy. Genotypes were determined for four selected tagging single-nucleotide polymorphism (SNP)s of the VEGF gene. RESULTS Of the four SNPs studied, one SNP (rs699946) was associated significantly with visual acuity (VA) changes 12 months after treatment-irrespective of whether they received IVB alone (P = 0.044) or triple therapy 0.010). Baseline VA was not significantly different among the three genotypes of rs699946 in either treatment group. There were no significant differences in the number of treatments, incidence of recurrence, or the period until the recurrence according to VEGF rs699946 genetic variant. CONCLUSIONS The VEGF gene SNP rs699946 was associated with response to IVB alone and to triple therapy in this study. The G allele in SNP rs699946 can thus be applied as a marker for better visual prognosis in patients with neovascular AMD who receive either IVB or triple therapy.
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29
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Gene Polymorphisms Impact the Risk of Rejection With Hemodynamic Compromise: A Multicenter Study. Transplantation 2011; 91:1326-32. [DOI: 10.1097/tp.0b013e31821c1e10] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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30
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A polymorphism linked to elevated levels of interferon-γ is associated with an increased risk of cytomegalovirus disease among Caucasian lung transplant recipients at a single center. J Heart Lung Transplant 2011; 30:523-9. [DOI: 10.1016/j.healun.2010.11.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Revised: 11/01/2010] [Accepted: 11/09/2010] [Indexed: 01/01/2023] Open
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31
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Sodsai P, Nakkuntod J, Kupatawintu P, Hirankarn N. Distribution of cytokine gene polymorphisms in Thai population. TISSUE ANTIGENS 2011; 77:593-7. [PMID: 21410656 DOI: 10.1111/j.1399-0039.2011.01647.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The distribution of 21 cytokine polymorphisms within 13 cytokine and cytokine receptor genes was analyzed in 102 healthy Thai individuals using the LIFECODES Cytokine SNP Typing kit. The TGFB codon25 marker is monomorphic in the Thai population. The IL1B+3962, IL6-174, and TNFA-238 are very rare polymorphisms, with only 0.01-0.04 minor allele frequency (MAF). The IL4-1098, IL1A-889, and IL10-1082 are found only 0.06-0.08 in Thai. Other cytokine polymorphisms (IL1B-511, IL1R pst1 1970, IL1RN mspa1 11100, IL4RA+1902, IL12B-1188, IFNG+874, TGFB codon10, TNFA-308, IL2-330, IL2+166, IL4-590, IL4-33, IL10-819, and IL10-592) in Thai have MAFs more than 0.10, ranging between 0.13 and 0.47. When comparing the allele and genotype frequencies with public single nucleotide polymorphism (SNP) database, most cytokine polymorphisms in Thai show similar distribution to Han Chinese and Japanese, but significantly different from Caucasian and African populations. Only a few markers, including IL4A+1902, TNFA-308, IL1B+3962, and IL2+166 show statistically different distribution among Thai and other Asian populations especially with the Japanese.
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Affiliation(s)
- P Sodsai
- Medical Microbiology Interdisciplinary Program, Graduate School, Chulalongkorn University, Bangkok, Thailand
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Association of genetic polymorphisms and risk of late post-transplantation infection in pediatric heart recipients. J Heart Lung Transplant 2011; 29:1342-51. [PMID: 20869265 DOI: 10.1016/j.healun.2010.07.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Revised: 07/20/2010] [Accepted: 07/22/2010] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Late infections are common causes of morbidity and mortality after pediatric heart transplantation. In this multicenter study from 6 centers, we investigated the association between genetic polymorphisms (GPs) in immune response genes and late post-transplantation infections in 524 patients. METHODS Late infection was defined as a clinical infectious process occurring >60 days after transplantation and requiring hospitalization, intravenous antimicrobial therapy, or a life-threatening infection requiring oral therapy. All patients provided a blood sample for GP analyses of 18 GPs in cytokine, growth factor, and effector molecule genes by single specific primer-polymerase chain reaction and/or sequencing. Significant associations in univariable analyses were tested in multivariable Cox regression models. RESULTS Late infection was common, with 48.7% of patients experiencing ≥ 1 late infection, 25.2% had ≥ 1 late bacterial infection, and 30.5% had ≥ 1 late viral infection. Older age at transplantation was a protective factor for late infection, both bacterial and viral (hazard ratio [HR] 0.89-0.92 per 1-year age increase, p < 0.001). Adjusting for age, race, and transplant etiology, late bacterial infection was associated with HMOX1 A+326G AG and GG genotypes (HR, 2.41, 95% confidence interval [CI] 1.35-4.30; p = 0.003) and GZMB A-295G AA genotype (HR, 1.47; 95% CI; 1.03-2.1; p = 0.036). Late viral infection was associated with FAS A-670G GG genotype (HR, 1.42; 95% CI, 1.00-2.00; p = 0.050) in the adjusted model and with CTLA4 A+49G AA and AG genotypes (HR, 1.49; 95% CI, 1.02-2.19; p = 0.041) in univariable analysis. CONCLUSION We found an association between late bacterial infection and GP of HMOX1, which may control macrophage activation. A weaker association was also found between late viral infection and GP of CTLA4, a regulator of T-cell activation. This represents progress toward understanding the clinical and genetic risk factors of outcomes after transplantation.
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Everitt MD, Pahl E, Schechtman KB, Zheng J, Ringewald JM, L'Ecuyer T, Naftel DC, Kirklin JK, Blume ED, Bullock EA, Canter CE. Rejection with hemodynamic compromise in the current era of pediatric heart transplantation: A multi-institutional study. J Heart Lung Transplant 2011; 30:282-8. [DOI: 10.1016/j.healun.2010.08.031] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Revised: 08/03/2010] [Accepted: 08/27/2010] [Indexed: 10/18/2022] Open
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Ohmann EL, Burckart GJ, Chen Y, Pravica V, Brooks MM, Zeevi A, Webber SA. Inosine 5'-monophosphate dehydrogenase 1 haplotypes and association with mycophenolate mofetil gastrointestinal intolerance in pediatric heart transplant patients. Pediatr Transplant 2010; 14:891-5. [PMID: 20649757 PMCID: PMC2955782 DOI: 10.1111/j.1399-3046.2010.01367.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
MMF, the most commonly used adjuvant immunosuppressant in pediatric heart transplantation, has frequent GI adverse events. SNPs in inosine 5'-monophosphate dehydrogenase I (IMPDH1) may contribute to MMF GI intolerance. Phased haplotypes may have more utility than individual SNPs in candidate gene association studies for complex traits. This study defined common IMPDH1 haplotypes and investigated whether these haplotypes influence MMF GI intolerance in 59 pediatric heart recipients. Genotypes were assessed by Taqman analysis of IMPDH1 rs2288553, rs2288549, rs2278293, rs2278294, and rs2228075, and haplotypes were inferred using Arlequin 3.01 software. GI intolerance was defined as diarrhea, vomiting, nausea, or abdominal pain requiring MMF dose holding for > 48 h or MMF discontinuation. GI intolerance occurred in 21 patients (35.6%). Ten IMPDH1 haplotypes were identified in this population. In univariable analyses, one haplotype was strongly associated with MMF GI intolerance with 59.1% of carriers of this haplotype experiencing MMF GI intolerance compared to 21.6% of non-carriers (p = 0.005). In this study, we identify a common IMPDH1 haplotype associated with MMF GI intolerance in a population of pediatric heart transplant patients. This haplotype of interest did not demonstrate stronger association with MMF GI intolerance than an individual IMPDH1 SNP.
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Affiliation(s)
- Erin L Ohmann
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Gilbert J. Burckart
- Office of Clinical Pharmacology, US Food and Drug Administration, Silver Spring, MD
| | - Yan Chen
- Department of Pharmacy, University of Southern California, Los Angeles, California
| | - Vera Pravica
- Department of Pharmacy, University of Southern California, Los Angeles, California
| | - Maria M. Brooks
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Steven A. Webber
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania
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Allen JG, Weiss ES, Arnaoutakis GJ, Russell SD, Baumgartner WA, Conte JV, Shah AS. The impact of race on survival after heart transplantation: an analysis of more than 20,000 patients. Ann Thorac Surg 2010; 89:1956-63; discussion 1963-4. [PMID: 20494056 DOI: 10.1016/j.athoracsur.2010.02.093] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Revised: 02/23/2010] [Accepted: 02/26/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Evidence exists for race-linked discrepancies in survival after orthotopic heart transplantation (OHT). The United Network for Organ Sharing database provides an opportunity to examine the effect of race on outcomes in a large cohort of adult OHT patients. METHODS We retrospectively reviewed the United Network for Organ Sharing data for 20,185 adult patients receiving primary OHT (1997 through 2007). Patients were divided into groups of specific race and also stratified by donor and recipient race-matching. The impact of race on mortality was examined using multivariable Cox proportional hazard regression analysis incorporating 23 variables and interaction terms between donor and recipient race. Mortality (30 days, 90 days, 1 year, 2 years, and 5 years) and rejection in the first year were examined. Cumulative post-OHT survival was modeled using the Kaplan-Meier method. RESULTS Of 20,185 patients, 12,381 (61%) were race matched (75% of whites, n = 11,456; 17% of African Americans, n = 514; 30% of Hispanics, n = 391; 5% of Asians, n = 19). Five thousand six hundred fourteen patients (28%) died during the study. African American recipients have an 11.4% absolute decrease in 10-year survival compared with whites. After risk adjustment, African American recipients have a 46% increase in the risk of cumulative mortality (hazard ratio, 1.46; 95% confidence interval, 1.24 to 1.72; p < 0.001). Decreased survival in African American recipients was not improved with race-matched OHT, nor was there a survival advantage with race-matching in any racial subgroup. Decreased survival in African American recipients persisted after censoring deaths in the first year. CONCLUSIONS Our study represents the largest modern cohort evaluating race in adult OHT. African American recipients have significantly worse survival after OHT. Race-matching did not confer improved survival.
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Affiliation(s)
- Jeremiah G Allen
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA
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Burckart GJ, Amur S. Update on the clinical pharmacogenomics of organ transplantation. Pharmacogenomics 2010; 11:227-36. [PMID: 20136361 DOI: 10.2217/pgs.09.177] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Organ transplantation suffers from a static graft and patient survival rate, and a high incidence of serious adverse drug effects. The pharmacogenomics of organ transplantation has emerged only recently and is complementary to the immunogenetic information that has accumulated over the past decade. Gene polymorphism studies have focused on the genes that interact across the group of immunosuppressants, including ciclosporin, tacrolimus, sirolimus and corticosteroids. The polymorphisms that hold the most potential for use in a drug selection algorithm are in genes CYP3A5, ABCB1, IMPDH1 and IMPDH2, and cytokines and growth factors. Gene-expression arrays have led to gene-expression testing, such as the use of AlloMap((R)) with heart transplant patients. The expanded use of gene-expression assays, proteomics and drug selection algorithms in organ transplantation will progress slowly and may be outpaced by drug test co-development programs for new transplant drugs. In the future, clinical pharmacogenomics will be a routine part of patient care for organ transplant patients.
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Affiliation(s)
- Gilbert J Burckart
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, 10903 New Hampshire Avenue, Building 51, Room 3184, Silver Spring, MD 20993, USA.
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Cardiovascular disease in kidney transplant recipients: the prognostic value of inflammatory cytokine genotypes. Transplantation 2010; 89:1001-8. [PMID: 20061995 DOI: 10.1097/tp.0b013e3181ce243f] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cardiovascular disease (CVD) represents the main cause of morbidity and mortality after renal transplantation. In view of the modern paradigm of atherosclerosis as an inflammatory disease, this study investigated the impact of inflammatory cytokine polymorphisms on posttransplant CVD. METHODS The association between cytokine polymorphisms and CVD was assessed in a case-control study to identify the differences in genotype distributions between kidney allografts with or without posttransplant CVD. To validate our results in two independent groups, we divided a cohort of 798 renal transplant recipients according to geographic area: an evaluation cohort of 478 patients from Emilia-Romagna and a validation cohort of 320 patients from the rest of Italy. Tumor necrosis factor (TNF)-alpha, transforming growth factor-beta1, interleukin (IL)-10, IL-6, interferon-gamma, and IL-8 polymorphisms were analyzed, and thereafter, the cytokine production genotype was assigned. RESULTS In the evaluation cohort, the patients in the CVD and no-CVD groups differed significantly in TNF-alpha and IL-10 genotype frequencies. Using multivariate analyses to test the association with CVD, the TNF-alpha high-producer genotype was associated with a significantly increased cardiovascular risk (odds ratio [OR]=4.41, 95% confidence interval (CI)=2.53-7.67). Conversely, the IL-10 high-producer genotype resulted protective against CVD (OR=0.07, 95% CI=0.02-0.29). These findings were confirmed in the validation cohort where the carriers of the TNF-alpha high-producer genotype proved to be at 2.45-fold increased cardiovascular risk (OR=2.45, 95% CI=1.29-4.63), whereas the IL-10 high-producer genotype was associated with a 0.08-fold reduced risk (OR=0.08, 95% CI=0.02-0.36). CONCLUSIONS This work suggests a prognostic value of TNF-alpha and IL-10 genotypes, which might represent cardiovascular risk markers in renal transplant.
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Gossett JG, Canter CE, Zheng J, Schechtman K, Blume ED, Rodgers S, Naftel DC, Kirklin JK, Scheel J, Fricker FJ, Kantor P, Pahl E. Decline in rejection in the first year after pediatric cardiac transplantation: a multi-institutional study. J Heart Lung Transplant 2010; 29:625-32. [PMID: 20207171 DOI: 10.1016/j.healun.2009.12.009] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Revised: 11/25/2009] [Accepted: 12/07/2009] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Rejection is a major cause of morbidity and mortality after pediatric heart transplantation (HTx). Survival after pediatric HTx has improved over time, but whether there has been an era-related improvement in the occurrence of allograft rejection is unknown. METHODS The Pediatric Heart Transplant Study (PHTS) database was queried for patients who underwent HTx from January 1993 to December 2005 to determine the incidence of rejection and identify factors associated with the first episode of rejection in the first year after HTx. RESULTS Data were reviewed in 1,852 patients from 36 centers. The incidence of rejection declined over 13 years at a rate of -2.58 +/- 0.41 (p < 0.001) from approximately 60% to 40% (p < 0.001). The mean number of episodes of rejection also significantly fell at a rate of -0.05 +/- 0.01 per patient/year from 1.19 to 0.66 (p < 0.001). The incidence of rejection with hemodynamic compromise and death from rejection did not change. Multivariate analysis for the risk of a first rejection episode demonstrated decreased risk of rejection with later year of HTx (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.85-0.91; p < 0.001) and use of mechanical support (OR, 0.65; 95% CI, 0.42-0.99; p = 0.046). Increased risk of rejection was associated with positive donor-specific crossmatch (OR, 1.85; 95% CI, 1.18-2.88; p = 0.007) and older recipient age (OR, 1.05; 95% CI, 1.02-1.07; p < 0.001). CONCLUSIONS Although the overall incidence and prevalence of rejection has substantially decreased over time in pediatric HTx recipients in the first year after HTx, the rate of rejection with hemodynamic compromise or death from rejection remains unchanged.
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Affiliation(s)
- Jeffrey G Gossett
- Department of Pediatrics, Children's Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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Genetic polymorphisms influence mycophenolate mofetil-related adverse events in pediatric heart transplant patients. J Heart Lung Transplant 2010; 29:509-16. [PMID: 20061166 DOI: 10.1016/j.healun.2009.11.602] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Revised: 11/18/2009] [Accepted: 11/20/2009] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Mycophenolate mofetil (MMF) is an effective and commonly used immunosuppressant but has frequent adverse events. Genetic polymorphisms may contribute to variability in MMF efficacy and related complications. In this study we explore the distribution frequencies of common single nucleotide polymorphisms (SNPs) of IMPDH1, IMPDH2 and ABCC2 and investigate whether these SNPs influence MMF adverse events in 59 pediatric heart recipients. METHODS Genotypes were assessed by TaqMan analysis of: ABCC2 rs717620; IMPDH2 rs11706052; and IMPDH1 rs2288553, rs2288549, rs2278293, rs2278294 and rs2228075. Gastrointestinal (GI) intolerance was defined as diarrhea, vomiting, nausea or abdominal pain requiring dose-holding for >48 hours or MMF discontinuation. Bone marrow toxicity was evaluated using Common Terminology Criteria for Adverse Events Version 3 (CTCAE). RESULTS GI intolerance occurred in 21 patients, and 21 had bone marrow toxicity. The ABCC2 rs717620 A variant was significantly associated with GI intolerance leading to drug discontinuation (p < 0.001); the IMPDH1 rs2278294 A variant and rs2228075 A variant were also associated with greater GI intolerance (p = 0.029 and p = 0.002, respectively). The IMPDH2 rs11706052 G variant was associated with more frequent neutropenia requiring dose-holding (p = 0.046). CONCLUSIONS In this small sample of pediatric heart transplant patients receiving MMF, ABCC2, IMPDH1 and IMPDH2 SNPs were associated with MMF GI intolerance and bone marrow toxicity. Thus, genetic polymorphisms may directly influence MMF adverse events.
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Wong BW, Rahmani M, Luo Z, Yanagawa B, Wong D, Luo H, McManus BM. Vascular endothelial growth factor increases human cardiac microvascular endothelial cell permeability to low-density lipoproteins. J Heart Lung Transplant 2010; 28:950-7. [PMID: 19716049 DOI: 10.1016/j.healun.2009.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Revised: 05/03/2009] [Accepted: 05/03/2009] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Endothelial cell hyperpermeability is a proposed mechanism of increased lipid insudation into the vessel walls of allografts. Vascular endothelial growth factor (VEGF) is a potent inducer of vascular permeability and its expression is upregulated in human heart allografts. The goal of these experiments was to investigate the effects of VEGF on low-density lipoprotein (LDL) permeability through confluent monolayers of human cardiac microvascular endothelial cells (HCMEC) in vitro. METHODS VEGF mRNA and protein expression was characterized in coronary arteries from cardiac allograft vasculopathy patients as compared with healthy controls using in situ hybridization and immunohistochemical staining of sub-adjacent sections. HCMEC were grown to confluence and treated with VEGF-A(121) or VEGF-A(165). Permeability of LDL in confluent endothelial monolayers was measured using fluorometry. Transendothelial electrical resistance (TER) measurements were used to indirectly measure the tight junctional status. Immunocytochemical staining was performed to visualize changes in CD31 and zonula occludens-1. RESULTS We observed significant increases in VEGF expression within the superficial and deep intima and media of coronaries from allografts, as compared with controls. In vitro treatment with VEGF-A(121) and VEGF-A(165) significantly increased LDL passage through endothelial monolayers. We further showed that VEGF-A(121) and VEGF-A(165) caused significant decreases in TER at 2 to 4 hours post-treatment. Also, VEGF induced disruption of tight junctions, resulting in an increase in the intercellular gap formation. CONCLUSIONS These results demonstrate that VEGF increases low-density lipoprotein permeability through endothelial monolayers, and this effect is correlated with VEGF-induced disruption of endothelial tight junctions resulting in the formation of intercellular gaps.
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Affiliation(s)
- Brian W Wong
- James Hogg iCAPTURE Centre for Cardiovascular and Pulmonary Research, Providence Heart + Lung Institute, St. Paul's Hospital, Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Lammers AE, Roberts P, Brown KL, Fenton M, Rees P, Sebire NJ, Burch M. Acute rejection after paediatric heart transplantation: far less common and less severe. Transpl Int 2010; 23:38-46. [DOI: 10.1111/j.1432-2277.2009.00941.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Socioeconomic Status and Pediatric Heart Transplantation—Does it Matter? J Heart Lung Transplant 2009; 28:1252-3. [DOI: 10.1016/j.healun.2009.05.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2009] [Revised: 05/24/2009] [Accepted: 05/24/2009] [Indexed: 11/21/2022] Open
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Zangwill SD, Naftel D, L'Ecuyer T, Rosenthal D, Robinson B, Kirklin JK, Stendahl G, Dipchand AI. Outcomes of Children With Restrictive Cardiomyopathy Listed for Heart Transplant: A Multi-institutional Study. J Heart Lung Transplant 2009; 28:1335-40. [DOI: 10.1016/j.healun.2009.06.028] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Revised: 06/06/2009] [Accepted: 06/27/2009] [Indexed: 11/29/2022] Open
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Dipchand AI, Naftel DC, Feingold B, Spicer R, Yung D, Kaufman B, Kirklin JK, Allain-Rooney T, Hsu D. Outcomes of Children With Cardiomyopathy Listed for Transplant: A Multi-institutional Study. J Heart Lung Transplant 2009; 28:1312-21. [DOI: 10.1016/j.healun.2009.05.019] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Accepted: 05/10/2009] [Indexed: 10/20/2022] Open
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Daniel V, Opelz G. Clinical Relevance of Immune Monitoring in Solid Organ Transplantation. Int Rev Immunol 2009; 28:155-84. [DOI: 10.1080/08830180902929404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
BACKGROUND Granzyme B has been associated with allograft rejection in solid organ transplantation. Single nucleotide polymorphisms (SNPs) in the granzyme B gene might impact its expression. The aims of this study were (1) to establish the frequency of two granzyme B SNPs (A-295G; Q-55R) in pediatric heart transplant (PHTx) recipients and (2) to determine their phenotypic expression in healthy individuals. METHODS Three hundred ninety-six PHTx patients (245 white non-Hispanic, 49 black non-Hispanic, 82 Hispanics, and 20 others) and 52 healthy controls were screened for Q-55R and A-295G. For the control samples, we assessed the frequency of granzyme B positive cells by ELISPOT assay after mitogen stimulation. RESULTS Among the PHTx recipients, 57% percent of the population carried the Q/Q genotype, whereas 6% were R/R homozygotes. Seven of 49 (14%) black non-Hispanics were R/R homozygotes, whereas 13 of 245 (5%) of white non-Hispanics and 5 of 82 (6%) Hispanics carried the R/R genotype (P=0.02). The A allele frequency of granzyme B A-295G (49.6%) was similar to that of the G allele (50.4%). However, 80% of Black non-Hispanics were A allele carriers compared with 68% of White non-Hispanics (P<0.0001). After mitogen stimulation, the frequency of granzyme B positive cells was higher in the Q/Q homozygotes compared with R/R carriers (P=0.006), whereas a similar frequency of granzyme B positive cells was noticed among the genotypes of A-295G SNP. CONCLUSIONS These data indicate that 55 Q/Q genotype is associated with increased in vitro expression of granzyme B.
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Uber PA, Ross HJ, Zuckermann AO, Sweet SC, Corris PA, McNeil K, Mehra MR. Generic Drug Immunosuppression in Thoracic Transplantation: An ISHLT Educational Advisory. J Heart Lung Transplant 2009; 28:655-60. [DOI: 10.1016/j.healun.2009.05.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Revised: 05/01/2009] [Accepted: 05/01/2009] [Indexed: 10/20/2022] Open
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Girnita DM, Webber SA, Zeevi A. Clinical impact of cytokine and growth factor genetic polymorphisms in thoracic organ transplantation. Clin Lab Med 2009; 28:423-40, vi. [PMID: 19028261 DOI: 10.1016/j.cll.2008.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Demographic and clinical risk factors may only partially predict short- and long-term outcomes after thoracic transplantation. The interindividual variability seen in rejection profiles could be related to the recipient's or donor's genetic background. Rejection, either acute or chronic, elicits an alloimmune response that involves a complex network of cytokines, growth factors, adhesion molecules, and other molecules, which may modulate the immune response toward rejection or, conversely, mediate graft acceptance. Herein, the authors discuss the current evidence regarding the importance of genetic polymorphisms as independent predictors of allograft outcome. They believe that pretransplant genotype profiling of patients, in combination with other relevant clinical information, might be useful to predict the risk for posttransplant adverse events and also to facilitate the implementation of individualized immunosuppression.
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Affiliation(s)
- Diana M Girnita
- Department of Pathology, Thomas E. Starzl Transplant Institute, 200 Lothrop Street, BST, W1558, Pittsburgh, PA 15217, USA
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Morrow WR. Outcomes following heart transplantation in children. PROGRESS IN PEDIATRIC CARDIOLOGY 2009. [DOI: 10.1016/j.ppedcard.2008.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Girnita DM, Burckart G, Zeevi A. Effect of cytokine and pharmacogenomic genetic polymorphisms in transplantation. Curr Opin Immunol 2008; 20:614-25. [PMID: 18706500 PMCID: PMC2739872 DOI: 10.1016/j.coi.2008.08.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Revised: 08/01/2008] [Accepted: 08/04/2008] [Indexed: 12/13/2022]
Abstract
Consolidating the information that we have on pharmacogenetics and on cytokine genetics to produce patient-oriented individualized drug regimens is an important challenge in transplantation medicine. Using a multi-variant approach based on genetic profile and other relevant clinical factors a score system may be developed to predict the severity of rejection, infection, or other complications associated with transplantation. The ultimate goal of these studies is to improve patient outcome through individualized drug regimens.
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Affiliation(s)
- Diana M Girnita
- Department of Pathology, Thomas E Starzl Transplant Institute, University of Pittsburgh, Pittsburgh, PA 15213
| | - Gilbert Burckart
- Office of Clinical Pharmacology, Office of Translational Science, U.S. Food and Drug Administration, Silver Spring, MD 20993
| | - Adriana Zeevi
- Department of Pathology, Thomas E Starzl Transplant Institute, University of Pittsburgh, Pittsburgh, PA 15213
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