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Jain A, Daoud D, Kees-Folts D, Freeman MA, Butt F, Abendroth CS, Shike H, Kadry Z. Steroid-free maintenance immunosuppression using alemtuzumab in pediatric kidney transplantation: Long-term longitudinal follow-up. Pediatr Transplant 2022; 26:e14173. [PMID: 34687570 DOI: 10.1111/petr.14173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 08/17/2021] [Accepted: 10/05/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND There is a scarcity of long-term data on steroid-free immunosuppression using alemtuzumab in pediatric kidney transplantation (KTx). This study examines long-term outcomes with alemtuzumab without steroid maintenance therapy in pediatric KTx. METHODS From July 2005 to June 2015, 71 pediatric KTx recipients received alemtuzumab without steroid maintenance. They were followed from 4.1 to 14.1 years post KTx. RESULTS Patient survival: One child expired with a functioning graft from post-transplant lymphoproliferative disorder (PTLD). Patient survival was 98.6%. Graft survival: Eighteen grafts were lost (16 from chronic rejection). Graft survival at 5 and 10 years was 92.3% and 61.3%, respectively. Rejection: Twenty-three (32.4%) patients were free from T-cell-mediated rejection (TCMR), 16 (22.5%) had >3 episodes. Sixteen (22.5%) were treated for antibody-mediated rejection (AMR). Infection: Twenty-three children developed Epstein-Barr virus (EBV), 5 developed cytomegalovirus (CMV), and 20 developed BK virus infection. Four (5.6%) developed PTLD. Twenty-two (31.0%) required treatment for neutropenia. Growth parameters: Mean height and weight increased by 0.56 and 0.69 SDS (standard deviation score), respectively. Body mass index increased by 5.1 kg/m2 at 10 years. Less than 40% required antihypertensive medications at all-time points. CONCLUSION Alemtuzumab, without corticosteroid maintenance, offers 98.6% patient survival at 14 years with five and 10-year graft survival of 92.3% and 61.3%, respectively. TCMR and AMR requiring treatment were 67.4% and 22.5%, respectively. CMV, EBV, and BK viremia rates were 7.0%, 32.4%, and 28.2%, respectively. Thirty-one percent were treated for neutropenia; 5.6% developed PTLD. There were improvements in growth parameters and blood pressure.
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Affiliation(s)
- Ashokkumar Jain
- Division of Transplantation, Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Deborah Daoud
- Division of Transplantation, Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Deborah Kees-Folts
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Michael A Freeman
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Fauzia Butt
- Division of Transplantation, Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Catherine S Abendroth
- Department of Pathology, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Hiroko Shike
- Department of Pathology, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Zakiyah Kadry
- Division of Transplantation, Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
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2
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Balani SS, Jensen CJ, Kouri AM, Kizilbash SJ. Induction and maintenance immunosuppression in pediatric kidney transplantation-Advances and controversies. Pediatr Transplant 2021; 25:e14077. [PMID: 34216190 DOI: 10.1111/petr.14077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/04/2021] [Accepted: 05/26/2021] [Indexed: 12/16/2022]
Abstract
Advances in immunosuppression have improved graft survival in pediatric kidney transplant recipients; however, treatment-related toxicities need to be balanced against the possibility of graft rejection. Several immunosuppressive agents are available for use in transplant recipients; however, the optimal combinations of agents remain unclear, resulting in variations in institutional protocols. Lymphocyte-depleting antibodies, specifically ATG, are the most common induction agent used for pediatric kidney transplantation in the US. Basiliximab may be used for induction in immunologically low-risk children; however, pediatric data are scarce. CNIs and antiproliferative agents (mostly Tac and mycophenolate in recent years) constitute the backbone of maintenance immunosuppression. Steroid-avoidance maintenance regimens remain controversial. Belatacept and mTOR inhibitors are used in children under specific circumstances such as non-adherence or CNI toxicity. This article reviews the indications, mechanism of action, efficacy, dosing, and side effect profiles of various immunosuppressive agents available for pediatric kidney transplantation.
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Affiliation(s)
- Shanthi S Balani
- Pediatric Nephrology, University of Minnesota, Minneapolis, MN, USA
| | - Chelsey J Jensen
- Solid Organ Transplant, University of Minnesota, Minneapolis, MN, USA
| | - Anne M Kouri
- Pediatric Nephrology, University of Minnesota, Minneapolis, MN, USA
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Liverman R, Chandran MM, Crowther B. Considerations and controversies of pharmacologic management of the pediatric kidney transplant recipient. Pharmacotherapy 2021; 41:77-102. [PMID: 33151553 DOI: 10.1002/phar.2483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/18/2020] [Accepted: 10/10/2020] [Indexed: 12/23/2022]
Abstract
Pediatric kidney transplantation has experienced considerable growth and improvement in patient and allograft outcomes over the past 20 years, in part due to advancements in immunosuppressive regimens and management. Despite this progress, care for this unique population can be challenging due to limited pediatric transplant data and trials, intricacies related to differences in children and adolescents compared with their adult counterparts, and limitations to long-term survival facing all solid organ transplant populations. Immunosuppression and infection prevention practices vary from one pediatric transplant center to another and clinical controversies exist surrounding treatment and dosing. This review aims to summarize key aspects of pharmacologic management in this population and present pertinent data that describe the influence of practice to serve as a resource for practitioners caring for this unique specialty patient population. Additionally, this review highlights select controversies that exist within pediatric kidney transplantation.
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Affiliation(s)
- Rochelle Liverman
- Department of Pharmacy, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Mary Moss Chandran
- Department of Pharmacy, Childeren's Hospital Colorado, Aurora, Colorado, USA
| | - Barrett Crowther
- Ambulatory Care Pharmacy Services, University of Colorado Hospital, Aurora, Colorado, USA
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4
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van der Zwan M, Baan CC, van Gelder T, Hesselink DA. Review of the Clinical Pharmacokinetics and Pharmacodynamics of Alemtuzumab and Its Use in Kidney Transplantation. Clin Pharmacokinet 2018; 57:191-207. [PMID: 28669130 PMCID: PMC5784003 DOI: 10.1007/s40262-017-0573-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Alemtuzumab is a humanized monoclonal antibody against CD52 and causes depletion of T and B lymphocytes, monocytes, and NK cells. Alemtuzumab is registered for the treatment of multiple sclerosis (MS) and is also used in chronic lymphocytic leukemia (CLL). Alemtuzumab is used off-label in kidney transplantation as induction and anti-rejection therapy. The objective of this review is to present a review of the pharmacokinetics, pharmacodynamics, and use of alemtuzumab in kidney transplantation. A systematic literature search was conducted using Ovid Medline, Embase, and Cochrane Central Register of controlled trials. No pharmacokinetic or dose-finding studies of alemtuzumab have been performed in kidney transplantation. Although such studies were conducted in patients with CLL and MS, these findings cannot be directly extrapolated to transplant recipients, because CLL patients have a much higher load of CD52-positive cells and, therefore, target-mediated clearance will differ between these two indications. Alemtuzumab used as induction therapy in kidney transplantation results in a lower incidence of acute rejection compared to basiliximab therapy and comparable results as compared with rabbit anti-thymocyte globulin (rATG). Alemtuzumab used as anti-rejection therapy results in a comparable graft survival rate compared with rATG, although infusion-related side effects appear to be less. There is a need for pharmacokinetic and dose-finding studies of alemtuzumab in kidney transplant recipients to establish the optimal balance between efficacy and toxicity. Furthermore, randomized controlled trials with sufficient follow-up are necessary to provide further evidence for the treatment of severe kidney transplant rejection.
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Affiliation(s)
- Marieke van der Zwan
- Division of Nephrology and Kidney Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Room NA523, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Carla C Baan
- Division of Nephrology and Kidney Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Room NA523, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Teun van Gelder
- Division of Nephrology and Kidney Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Room NA523, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
- Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Division of Nephrology and Kidney Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Room NA523, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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5
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McGinley M, Rossman IT. Bringing the HEET: The Argument for High-Efficacy Early Treatment for Pediatric-Onset Multiple Sclerosis. Neurotherapeutics 2017; 14:985-998. [PMID: 28895071 PMCID: PMC5722772 DOI: 10.1007/s13311-017-0568-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Pediatric-onset multiple sclerosis (POMS) is rarer than adult-onset disease, and represents a different diagnostic and treatment challenge to clinicians. We review POMS clinical and radiographic presentations, and explore important differences between POMS and adult-onset MS natural histories and long-term outcomes. Despite having more active disease, current treatment guidelines for patients with POMS endorse the off-label use of lower-efficacy disease-modifying therapies (DMTs) as first line. We review the available MS DMTs, their evidence for use in POMS, and the contrasting treatment strategies of high-efficacy early treatment and escalation therapy. We introduce a new treatment approach, the "high-efficacy early treatment", or HEET strategy, based on using directly observed, high-efficacy intravenously infused DMTs as first-line therapies. Like other proposed POMS treatment strategies, HEET will need to be prospectively studied, and all treatment decisions should be determined by an experienced neurologist, the patient, and his/her parents.
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Affiliation(s)
- Marisa McGinley
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, 9500 Euclid Avenue U10, Cleveland, OH, 44195, USA
| | - Ian T Rossman
- NeuroDevelopmental Science Center, Akron Children's Hospital, One Perkins Square, Akron, OH, 44308, USA.
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6
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Kaabak MM, Babenko NN, Shapiro R, Maschan AA, Zokoev AK, Schekaturov SV, Vyunkova JN, Dymova OV. Eight-year follow-up in pediatric living donor kidney recipients receiving alemtuzumab induction. Pediatr Transplant 2017; 21. [PMID: 28600850 DOI: 10.1111/petr.12941] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2017] [Indexed: 01/27/2023]
Abstract
Recipient lymphocytes are crucial for direct and indirect pathways of allorecognition. We proposed that the administration of alemtuzumab several weeks pretransplantation could eradicate peripheral lymphatic cells and promote donor-specific acceptance. This was a single-center, retrospective review of 101 consecutive living donor kidney transplantations in pediatric patients (age 7 months-18 years), performed between September 2006 and April 2010. IS protocol included two 30 mg doses of alemtuzumab: The first was given 12-29 days prior to transplantation, and the second at the time of transplantation. Maintenance IS was based on combination of low-dose CNI and mycophenolate, with steroids tapered over the first 5 days post-transplantation. Patients were followed for 7.8±1.3 years, and protocol biopsies were taken 1 month, 1, 3, and 5 years post-transplant. The Kaplan-Meier 8-year patient and graft survival rates in the cyclosporine-treated patients were 82.0±7.3% and 71.6±7.3, and in the tacrolimus-treated patients were 97.2±5.4 and 83.8±6.0%. Biopsy-proven acute rejection developed in 35% of cyclosporine-treated patients and in 8% of tacrolimus-treated patients. Alemtuzumab pretreatment prior to LRD kidney transplantation, followed by maintenance immunosuppression with tacrolimus and MMF, is associated with reasonable long-term results in pediatric patients.
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Affiliation(s)
- Michael M Kaabak
- Organ Transplant Division, Boris Petrovsky Research Center of Surgery, Moscow, Russia
| | - Nadeen N Babenko
- Kidney Transplant Department, Boris Petrovsky Research Center of Surgery, Moscow, Russia
| | - Ron Shapiro
- Mount Sinai Hospital, Surgery, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mt. Sinai, New York, NY, USA
| | - Alexey A Maschan
- Dmitry Rogachev Federal Clinic of Pediatric Hematology, Oncology, and Immunology, Moscow, Russia
| | - Allan K Zokoev
- Kidney Transplant Department, Boris Petrovsky Research Center of Surgery, Moscow, Russia
| | | | - Julia N Vyunkova
- Kidney Transplant Department, Boris Petrovsky Research Center of Surgery, Moscow, Russia
| | - Olga V Dymova
- Laboratory Department, Boris Petrovsky Research Center of Surgery, Moscow, Russia
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7
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Guerrero-Tinoco GA, Villafañe-Bermúdez DR, Vélez-Echeverri C. Inmunosupresores y principales complicaciones en el trasplante renal pediátrico. IATREIA 2017. [DOI: 10.17533/udea.iatreia.v30n1a05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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8
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A systems-based approach to managing blood pressure in children following kidney transplantation. Pediatr Nephrol 2016; 31:1593-604. [PMID: 26482251 DOI: 10.1007/s00467-015-3192-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 08/07/2015] [Accepted: 08/11/2015] [Indexed: 02/07/2023]
Abstract
Hypertension is one of the most common and well-known complications following kidney transplantation in children. Yet, despite numerous available therapies many pediatric kidney transplant recipients continue to have poorly controlled blood pressure, suggesting that traditional approaches to blood pressure management in this population might be inadequate. Over the last two decades, the Chronic Care Model has been developed to improve chronic illness outcomes through delivery system design and clinical information systems that support patient self-management and provider decision-making. In this educational review we discuss key elements of managing blood pressure following pediatric kidney transplantation and suggest ways that they may be reliably implemented into clinical practice using principles from the Chronic Care Model.
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9
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Vélez-Echeverri C, Guerrero-Tinoco GA, Villafañe-Bermúdez DR, Nieto-Ríos JF, Serna-Higuita LM, Serna-Campuzano A, Vanegas-Ruiz JJ. Alemtuzumab in paediatric kidney transplantation, five years' experience at the Pablo Tobón Uribe Hospital in Medellín, Colombia. Nefrologia 2016; 36:709-711. [PMID: 27496824 DOI: 10.1016/j.nefro.2016.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Revised: 05/31/2016] [Accepted: 06/11/2016] [Indexed: 11/25/2022] Open
Affiliation(s)
- Catalina Vélez-Echeverri
- Universidad de Antioquia, Medellín, Antioquia, Colombia; Hospital Pablo Tobón Uribe, Medellín, Antioquia, Colombia
| | | | | | - John Fredy Nieto-Ríos
- Universidad de Antioquia, Medellín, Antioquia, Colombia; Hospital Pablo Tobón Uribe, Medellín, Antioquia, Colombia.
| | - Lina María Serna-Higuita
- Universidad de Antioquia, Medellín, Antioquia, Colombia; Hospital Pablo Tobón Uribe, Medellín, Antioquia, Colombia
| | | | - Juan José Vanegas-Ruiz
- Universidad de Antioquia, Medellín, Antioquia, Colombia; Hospital Pablo Tobón Uribe, Medellín, Antioquia, Colombia
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10
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Min SI, Han A, Choi C, Kim SY, Kang HG, Ha IS, Ha J. Immunosuppression in Pediatric Kidney Transplant Patients. KOREAN JOURNAL OF TRANSPLANTATION 2015. [DOI: 10.4285/jkstn.2015.29.1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Sang-il Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Ahram Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chanjoong Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Song Yi Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Il Soo Ha
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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11
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Abstract
The biologics used in transplantation clinical practice include several monoclonal and polyclonal antibodies aimed at specific cellular receptors. The effect of their mechanisms of action includes depleting or blocking specific cell subpopulations, complement system, or removing circulating preformed antibodies and blocking their production. They are used in induction, desensitization ABO-incompatible renal transplantation, rescue therapy of steroid-resistant acute rejection, treatment of posttransplant recurrence of primary disease such as nephrotic syndrome or atypical hemolytic-uremic syndrome, and in late humoral rejection. There are various indications for the use of biologic agents before and early or late after renal transplantation in both high- and low-risk recipients. In the latter situation, the biologics-based induction is used to further minimize immunosuppression maintenance. The targets of several biologic agents are present across a variety of cells, and manipulation of the immune system with biologics may be associated with significant risk of acute and late-onset adverse events; therefore, clinical risk-versus-benefit ratio must be carefully balanced in every case. Several trials on novel biologics are reported in adults but not in the pediatric population.
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Affiliation(s)
- Ryszard Grenda
- Department of Nephrology & Kidney Transplantation, The Childrens Memorial Health Institute, Warsaw, Poland,
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12
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Velez C, Zuluaga G, Ocampo C, Aristizabal A, Serna LM, Serrano Gayubo AK, Florez JA, Zuleta JJ, Vanegas Ruiz JJ. Clinical description and evolution of renal transplant pediatric patients treated with alemtuzumab. Transplant Proc 2014; 43:3350-4. [PMID: 22099794 DOI: 10.1016/j.transproceed.2011.09.101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Renal transplantation is the most effective treatment for children with end-stage renal disease. Recent work suggests that induction with alemtuzumab in the pediatric population permits the use of lower doses of maintenance immunosuppressive therapy. In addition, it has a low cost compared with other induction therapies. OBJECTIVE To conduct a clinical description of pediatric renal transplant patients comparing induction protocols to evaluate graft and patient survival, infections complications, and lymphoproliferative diseases. MATERIALS AND METHODS This descriptive and retrospective study, of evaluated pediatric renal transplant patients between 2006 and 2010. RESULTS The agents for induction therapy were: alemtuzumab (61.5%), daclizumab (19.25%), and thymoglobulin (19.25%). Graft survival was better among the alemtuzumab group (87.5%) compared with the other two induction therapies (80%). The frequency of acute rejection episodes during the first year posttransplantation as well as chronic rejection was lower among the alemtuzumab group. Cytomegalovirus infection was noted in 30% of patients with greater frequency among those induced with alemtuzumab. CONCLUSION Induction therapy with alemtuzumab was safe in a pediatric population not predisposing to a greater risk of acute or chronic rejection. Except for a greater incidence of Cytomegalovirus, there was no difference in other complications.
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Affiliation(s)
- C Velez
- Department of Pediatric Nephrology, Pablo Tobón Uribe Hospital, Medellín, Colombia
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13
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Supe-Markovina K, Melquist JJ, Connolly D, DiCarlo HN, Waltzer WC, Fine RN, Darras FS. Alemtuzumab with corticosteroid minimization for pediatric deceased donor renal transplantation: a seven-yr experience. Pediatr Transplant 2014; 18:363-8. [PMID: 24712738 DOI: 10.1111/petr.12253] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2014] [Indexed: 01/18/2023]
Abstract
Alemtuzumab is a monoclonal antibody targeting CD52 receptors on B and T lymphocytes and is an effective induction agent in pediatric renal transplantation. We report a seven-yr experience using alemtuzumab induction and steroid-free protocol in the pediatric population as safe and effective. Twenty-one pediatric deceased donor renal transplants were performed at a single academic institution. All received induction with single-dose alemtuzumab and were maintained on a steroid-free protocol using TAC and MMF immunosuppression. There were 15 males and six females in the study whose ages ranged from one to 19 yr. The average follow-up was 32 months (range from 12 to 78.2 months and median 33.7 ± 23.7 months). All patients had immediate graft function. Graft survival was 95%, and patient survival was 100%. Mean 12 and 36 months eGFR were 63.33 ± 21.01 and 59.90 ± 15.27 mL/min/1.73m(2), respectively. Three patients developed acute T-cell-mediated rejection due to non-adherence while no recipients developed cytomegalovirus infection, PTLD, or polyoma BK viral nephropathy. Steroid avoidance with single-dose alemtuzumab induction provides adequate and safe immunosuppression in pediatric deceased donor renal transplant recipients receiving TAC and low-dose MMF maintenance therapy.
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Affiliation(s)
- Katarina Supe-Markovina
- Departments of Pediatrics and Transplantation, Stony Brook Children's Hospital, Stony Brook, NY, USA
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14
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Abstract
Immunosuppressive therapy in pediatrics continues to evolve. Over the past decade, newer immunosuppressive agents have been introduced into adult and pediatric transplant patients with the goal of improving patient and allograft survival. Unfortunately, large-scale randomized clinical trials are not commonly performed in children. The purpose of this review is to discuss the newer immunosuppressive agents available for induction therapy, maintenance immunosuppression, and the treatment of rejection.
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Affiliation(s)
- Christina Nguyen
- Division of Pediatric Nephrology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Ron Shapiro
- Division of Transplant Surgery, UPMC Thomas E. Starzl Transplantation Institute, Pittsburgh, PA, United States
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15
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Sung J, Barry JM, Jenkins R, Rozansky D, Iragorri S, Conlin M, Al-Uzri A. Alemtuzumab induction with tacrolimus monotherapy in 25 pediatric renal transplant recipients. Pediatr Transplant 2013; 17:718-25. [PMID: 24164824 DOI: 10.1111/petr.12159] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2013] [Indexed: 12/12/2022]
Abstract
ALA induction in transplantation has been shown to reduce the need for maintenance immunosuppression. We report the outcome of 25 pediatric renal transplants between 2007 and 2010 using ALA induction followed by tacrolimus maintenance monotherapy. Patient ages were 1-19 yr (mean 14 ± 4.1 yr). Time of follow-up was 7-51 months (mean 26 ± 13 months). Tacrolimus monotherapy was maintained in 48% of patients, and glucocorticoids were avoided in 80% of recipients. Mean plasma creatinine and GFR at one yr post-transplant were 0.88 ± 0.3 mg/dL and 104.4 ± 25 mL/min/1.73m(2) , respectively. One, two, and three-yr actuarial patient and graft survival rates were 100%. The incidence of early AR (<12 months after transplantation) was 12%, while the incidence of late AR (after 12 months) was 16%. Forty-four percent of the recipients recovered normal, baseline renal function after an episode of AR, and 44% had persistent renal dysfunction (plasma creatinine 1.0-1.8 mg/dL). One graft was lost four yr after transplantation due to medication non-compliance. Four (16%) patients developed BK or CMV infection. In our experience, ALA induction with tacrolimus monotherapy resulted in excellent short- and mid-term patient and graft survival in low-immunologic risk pediatric renal transplant recipients.
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Affiliation(s)
- Jennifer Sung
- Department of Urology, Oregon Health and Science University, Portland, OR, USA
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16
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Steroid withdrawal in renal transplantation. Pediatr Nephrol 2013; 28:2107-12. [PMID: 23288351 DOI: 10.1007/s00467-012-2391-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 12/05/2012] [Accepted: 12/05/2012] [Indexed: 10/27/2022]
Abstract
Over the last decade, steroid minimization became one of the major goals in pediatric renal transplantation. Different protocols have been used by individual centers and multicenter study groups, including early and late steroid withdrawal or even complete avoidance. The timing of steroid withdrawal determines if antibodies are used, as avoidance and early withdrawal require antibody induction, while late withdrawal typically does not. A monoclonal antibody was used in most protocols during an early steroid withdrawal together with tacrolimus and mycophenolate mofetil in low immunological risk patients. Polyclonal induction was reported as effective in high-risk patients. Cyclosporine A and mycophenolate mofetil were used in late steroid withdrawal with no induction. All described protocols were effective in terms of preventing acute rejection and preserving renal graft function. There was no superiority of any specific protocol in terms of clinical benefits of steroid withdrawal. Pre-puberty determined growth benefit while other clinical advantages, including better control of glycemia, lipids, and blood pressure, were age independent. It is not clear whether the steroid withdrawal increases the risk of recurrence of primary glomerular diseases post-transplant, however it cannot be excluded. There is no evidence to date for a higher risk of anti-HLA production in steroid-free children after renal transplantation. Key summary points--Current strategies to minimize the steroid-related adverse effects in pediatric renal graft recipients include steroid withdrawal, early or late after transplantation, or complete steroid avoidance--Early steroid withdrawal or avoidance is generally used following the induction therapy with mono- or polyclonal antibodies, while in late steroid withdrawal induction therapy was generally not used- Elimination of steroids (early or late) does not increase the risk of acute rejection and does not deteriorate long-term renal graft function- Early steroid withdrawal is possible in patients at high immunological risk using a combination of polyclonal antibody induction, tacrolimus, and mycophenolate mofetil- All protocols of steroid minimization showed relevant clinical benefits, however the growth-related benefit was limited to pre-pubertal patients in all but one of the studies- Adverse events of steroid withdrawal occurred in a higher incidence of post-transplant bone marrow suppression Key research points - There is no clear evidence of the impact of steroid withdrawal on the risk of recurrence of primary glomerulonephritis after renal transplantation in children, therefore further evaluation of this important issue should be performed in prospective trials- There is limited pediatric data on the risk of anti-HLA/donor-specific antibody production in steroid-free patients after renal transplantation. It is not clear whether the selection of the type of induction antibody (lymphocyte depleting versus short, two-dose administration of anti-IL2R inhibitor) is important in this term. The production of anti-HLA antibodies should then be monitored on a regular basis and analyzed in prospective trials.
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Affiliation(s)
- Christina Nguyen
- Department of Pediatric Nephrology, Children's Hospital of Pittsburgh; Pittsburgh; PA; USA
| | - Ron Shapiro
- Department of Surgery; Thomas E. Starzl Transplantation Institute; University of Pittsburgh; Pittsburgh; PA; USA
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18
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Abstract
OBJECTIVE To minimize maintenance immunosuppression in upper-extremity transplantation to favor the risk-benefit balance of this procedure. BACKGROUND Despite favorable outcomes, broad clinical application of reconstructive transplantation is limited by the risks and side effects of multidrug immunosuppression. We present our experience with upper-extremity transplantation under a novel, donor bone marrow (BM) cell-based treatment protocol ("Pittsburgh protocol"). METHODS Between March 2009 and September 2010, 5 patients received a bilateral hand (n = 2), a bilateral hand/forearm (n = 1), or a unilateral (n = 2) hand transplant. Patients were treated with alemtuzumab and methylprednisolone for induction, followed by tacrolimus monotherapy. On day 14, patients received an infusion of donor BM cells isolated from 9 vertebral bodies. Comprehensive follow-up included functional evaluation, imaging, and immunomonitoring. RESULTS All patients are maintained on tacrolimus monotherapy with trough levels ranging between 4 and 12 ng/mL. Skin rejections were infrequent and reversible. Patients demonstrated sustained improvements in motor function and sensory return correlating with time after transplantation and level of amputation. Side effects included transient increase in serum creatinine, hyperglycemia managed with oral hypoglycemics, minor wound infection, and hyperuricemia but no infections. Immunomonitoring revealed transient moderate levels of donor-specific antibodies, adequate immunocompetence, and no peripheral blood chimerism. Imaging demonstrated patent vessels with only mild luminal narrowing/occlusion in 1 case. Protocol skin biopsies showed absent or minimal perivascular cellular infiltrates. CONCLUSIONS Our data suggest that this BM cell-based treatment protocol is safe, is well tolerated, and allows upper-extremity transplantation using low-dose tacrolimus monotherapy.
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Kaabak MM, Babenko NN, Samsonov DV, Sandrikov VA, Maschan AA, Zokoev AK. Alemtuzumab induction in pediatric kidney transplantation. Pediatr Transplant 2013; 17:168-78. [PMID: 23442101 PMCID: PMC3644867 DOI: 10.1111/petr.12048] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2012] [Indexed: 12/14/2022]
Abstract
Recipient parenchymal lymphatic cells are crucial for direct and indirect pathways of allorecognition. We proposed that alemtuzumab, being infused several weeks pretransplant could eradicate peripheral lymphatic cells and promote donor-specific tolerance. We present here a single center, retrospective review of 101 consecutive living-donor kidney transplantations to pediatric patients aged from seven month to 18 yr, performed between September 2006 and April 2010. Immunosupression protocol included two 30 mg doses of alemtuzumab: first given 12-29 d prior to transplantation and second at the time of transplantation. Maintenance immunosupression was based on combination of low dose and wide range CNI and mycophenolate. Patients were followed for 3.8 ± 1.4 yr and protocol biopsies were taken one month, one, and three yr post transplant. The Kaplan-Meier graft and patient survival was 96% and 97% for one yr, 89% and 93% for three yr. Biopsy proven acute rejection developed in 26% patients at one yr and in 35% at two yr, no rejections occurred beyond two yr. We conclude that alemtuzumab pretreatment prior to living related donor kidney transplantation allows to reach satisfactory middle-term results in pediatric patients with wide range and low CNI concentrations.
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Affiliation(s)
- Michael M Kaabak
- Organ Transplant Division, Russian Scientific Center of Surgery, Moscow, Russia.
| | - Nadezda N Babenko
- Kidney Transplant Department, Russian Scientific Center of SurgeryMoscow, Russia
| | | | - Valery A Sandrikov
- Diagnostic Division, Russian Scientific Center for SurgeryMoscow, Russia
| | - Alexey A Maschan
- Federal Clinical Research Center for Pediatric Hematology, Oncology and ImmunologyMoscow, Russia
| | - Alan K Zokoev
- Kidney Transplant Department, Russian Scientific Center of SurgeryMoscow, Russia
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Upadhyay K, Midgley L, Moudgil A. Safety and efficacy of alemtuzumab in the treatment of late acute renal allograft rejection. Pediatr Transplant 2012; 16:286-93. [PMID: 22118373 DOI: 10.1111/j.1399-3046.2011.01615.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Safety and efficacy of alemtuzumab in the treatment of AR in children after renal transplantation is unknown. Five episodes of refractory late AR in three children (three episodes in patient 1 and a single episode in patients 2 and 3 occurring after 7-23 months of transplantation) were treated with one dose of alemtuzumab as a rescue therapy. Four episodes (Banff IA-IB) in patients 1 and 2 reversed fully or partially with alemtuzumab, whereas patient 3 with Banff IB-IIA AR failed to respond. Patient 1 had recurrent AR 5, 13, and 15 months later; first two episodes responded to retreatment with alemtuzumab, and the last episode was not treated causing allograft failure. Patient 2 had steroid-responsive AR after two months and had a functioning allograft 25 months later. A transient reduction in all lymphocyte subsets except natural killer cells occurred in all patients. Patient 3 (treated with steroids, Thymoglobulin(R) , intravenous immunoglobulin, and rituximab prior to alemtuzumab) suffered many bacterial infections during one-yr period after therapy. However, symptomatic viral infections were not observed in any of the children. Treatment with alemtuzumab may prolong allograft survival in multidrug-resistant AR but may not prevent recurrent AR in non-adherent children.
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Affiliation(s)
- Kiran Upadhyay
- Department of Nephrology, Children's National Medical Center, Washington, DC 20010, USA.
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21
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Coelho T, Tredger M, Dhawan A. Current status of immunosuppressive agents for solid organ transplantation in children. Pediatr Transplant 2012; 16:106-22. [PMID: 22360399 DOI: 10.1111/j.1399-3046.2012.01644.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Immunosuppression after organ transplantation is complex and ever evolving. Over the past two decades, newer immunosuppressive agents have been introduced with an aim to provide better patient and graft survival. Improved therapeutic strategies have been developed offering the option to use combinations of drugs with non-overlapping toxicities. There are, however, only a few clinical studies with robust data to rationalize the use of these agents in children. This review will discuss the newer immunosuppressive agents used for solid organ transplant, their current status in post-transplant management and prevention of allograft rejection.
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Affiliation(s)
- Tracy Coelho
- Paediatric Liver GI and Nutrition Centre, King's College Hospital, King's College London School of Medicine, London, UK
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Abstract
PURPOSE OF REVIEW The recent surge in the use of steroid-avoidance protocols for pediatric renal transplant recipients has been fueled by the numerous adverse side effects of steroids and development of alternatives for successful immunosuppression. Steroid-avoidance protocols were first attempted in the adult population, and with positive outcomes, pediatrics soon followed. As more pediatric patients are placed on steroid-avoidance protocols, we must begin answering several important questions such as patient and graft outcome, safety profiles of various steroid-avoidance induction protocols, viral complications and incidence of transplant lymphoproliferative disease (PTLD), metabolic benefits, and the affect of steroid minimization on growth. RECENT FINDINGS Initial results from steroid-avoidance protocols show these protocols are safe and effective with improved graft survival, metabolic profiles, and linear growth without an increase in viremia or PTLD. SUMMARY Although initial results are promising, there is still a lack of long-term data from large, prospective randomized trials, and there is not enough data to determine the optimal steroid-avoidance protocol for pediatric renal transplant recipients.
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Abstract
PURPOSE OF REVIEW To outline the rationale of powerful depleting induction therapy with alemtuzumab and minimal maintenance immunosuppression after organ transplantation. RECENT FINDINGS The original observations in principle have been confirmed by many independent centres. SUMMARY Follow-up of the 'prope tolerance' protocol has confirmed a low incidence of rejection, infection and post transplant lymphoproliferative disorder (PTLD). Especially, encouraging results were obtained in African-Americans. There were few side effects and the regimen was well tolerated by patients. Treg cells were observed in the circulation, which could be an important factor in the mechanisms of graft acceptance using a prope tolerance regimen. There was a considerable reduction in the costs of the transplantation procedure. It is suggested that this minimalisation of maintenance immunosuppression is the best therapy currently available that we can offer to our patients.
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De Serres SA, Mfarrej BG, Magee CN, Benitez F, Ashoor I, Sayegh MH, Harmon WE, Najafian N. Immune profile of pediatric renal transplant recipients following alemtuzumab induction. J Am Soc Nephrol 2011; 23:174-82. [PMID: 22052056 DOI: 10.1681/asn.2011040360] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The incidence of developing circulating anti-human leukocyte antigen antibodies and the kinetics of T cell depletion and recovery among pediatric renal transplant recipients who receive alemtuzumab induction therapy are unknown. In a collaborative endeavor to minimize maintenance immunosuppression in pediatric renal transplant recipients, we enrolled 35 participants from four centers and treated them with alemtuzumab induction therapy and a steroid-free, calcineurin-inhibitor-withdrawal maintenance regimen. At 3 months after transplant, there was greater depletion of CD4(+) than CD8(+) T cells within the total, naive, memory, and effector memory subsets, although depletion of the central memory subset was similar for CD4(+) and CD8(+) cells. Although CD8(+) T cells recovered faster than CD4(+) subsets overall, they failed to return to pretransplant levels by 24 months after transplant. There was no evidence for greater recovery of either CD4(+) or CD8(+) memory cells than naïve cells. Alemtuzumab relatively spared CD4(+)CD25(+)FoxP3(+) regulatory T cells, resulting in a rise in their numbers relative to total CD4(+) cells and a ratio that remained at least at pretransplant levels throughout the study period. Seven participants (20%) developed anti-human leukocyte antigen antibodies without adversely affecting allograft function or histology on 2-year biopsies. Long-term follow-up is underway to assess the potential benefits of this regimen in children.
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Affiliation(s)
- Sacha A De Serres
- Brigham and Women's Hospital, Transplantation Research Center, 221 Longwood Ave, 3rd Floor, Boston, MA 02115, USA
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Sinha R, Tse Y, Marks SD. Conversion to monotherapy maintenance immunosuppression in pediatric renal transplant recipients: a single center experience. Pediatr Transplant 2011; 15:119-20. [PMID: 21155956 DOI: 10.1111/j.1399-3046.2010.01427.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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26
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Grenda R, Webb NJA. Steroid minimization in pediatric renal transplantation: Early withdrawal or avoidance? Pediatr Transplant 2010; 14:961-7. [PMID: 20874824 DOI: 10.1111/j.1399-3046.2010.01403.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Clinically important adverse events associated with the use of corticosteroids post-transplantation include hypertension, dyslipidemia, impaired glucose metabolism (including diabetes mellitus), growth retardation, bone fractures, and cosmetic problems. Over recent years, a number of studies have investigated the effect of minimizing exposure to corticosteroids in post-transplant immunosuppression protocols in both adults and children. In pediatric patients, several different approaches have been evaluated, including late steroid withdrawal, early steroid withdrawal, and complete steroid avoidance with or without poly- or monoclonal antibody induction and a variety of maintenance immunosuppressants. This manuscript reviews the key studies and documents the specific clinical benefits associated with steroid minimization. The development of PTLD and bone marrow suppression has been a major safety concern in some of these studies. These studies and other adverse effects are discussed.
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Affiliation(s)
- Ryszard Grenda
- Department of Nephrology, Kidney Transplantation and Hypertension, The Children's Memorial Health Institute, Warsaw, Poland.
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Urschel S, Altamirano-Diaz LA, West LJ. Immunosuppression armamentarium in 2010: mechanistic and clinical considerations. Pediatr Clin North Am 2010; 57:433-57, table of contents. [PMID: 20371046 DOI: 10.1016/j.pcl.2010.01.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Effective immunosuppression is the key to successful organ transplantation, with success being defined as minimal rejection risk with concomitant minimal drug toxicities. Despite the general recognition of this fact, a paucity of appropriate clinical trials in children has contributed to lack of standardization of clinical management regimens, resulting in an extensive diversity of favored approaches. Nonetheless, although consensus has not been reached on the ideal approach to immunosuppression in pediatric transplantation, new drug therapies have contributed to a continuing improvement in graft and patient survival. Future clinical research must focus on diminishing the extensive burden of toxicities of these therapeutic agents in children.
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Affiliation(s)
- Simon Urschel
- Cardiac Transplant Research, University of Alberta, Alberta Diabetes Institute, Edmonton, AB T6G 2E1, Canada
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Abstract
PURPOSE OF REVIEW Transplantation is the preferred method of treatment for end-stage renal disease in children. The rate of pediatric kidney transplantation has been steadily rising over the past decade. The use of increasingly potent immunosuppressive drugs has lessened the risk for acute rejection substantially and improved short-term outcomes; however, the long-term outcomes have remained inadequate. RECENT FINDINGS The follow-up of pediatric cohorts and the encouraging results from data registries prompt us to revisit our practices in transplantation so as to devise additional strategies to improve long-term outcomes. SUMMARY This review presents a comprehensive discussion of the major issues in pediatric renal transplantation, the newer immunosuppression approaches to limit toxicities of therapies in children and some critical issues that remain to be addressed, specific to the care of the transplanted child. The ultimate goal of designing optimum conditions for equating graft survival to patient survival still remains a major goal for pediatric organ transplantation.
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Alemtuzumab versus interleukin-2 receptor antibodies induction in living donor kidney transplantation. Transplantation 2010; 88:904-10. [PMID: 19935462 DOI: 10.1097/tp.0b013e3181b724a5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Alemtuzumab use has been increasing in kidney transplantation. We aimed to compare posttransplantation outcomes between alemtuzumab and interleukin-2 receptor antibodies (IL-2RA) in living donor kidney transplant recipients in the United States. METHODS Organ Procurement Transplant Network/United Network of Organ Sharing data, as of August 2007, were used to identify all living donor kidney transplants performed in adults in the United States from 2003 to 2006 where induction therapy with alemtuzumab or IL-2RA (daclizumab or basiliximab) was used. Primary outcomes included incidence of acute rejection, graft survival, and patient survival. RESULTS One thousand nine hundred thirteen recipients received alemtuzumab and 7011 received IL-2RA. There were few significant differences in baseline characteristics. The incidence of acute rejection at discharge was lower in the alemtuzumab group, when compared with that in the IL-2RA group (0.8% vs. 4.4%, respectively, P<0.001), but it was similar by 1 year posttransplant (9.8% vs. 11%, respectively). After adjusting for confounding factors, those in alemtuzumab group had a higher adjusted relative risk of graft loss (hazard ratios 1.23, 95% CI 1.03-1.48) in 4 years. Patient survival was comparable between the study groups. A higher rate of acute rejection and graft failure was seen in the recipients who used triple regimen (calcineurin-mycophenolate-steroid) in association with alemtuzumab. CONCLUSION The incidence of acute rejection at discharge was lower with alemtuzumab but was comparable with IL-2RA up to 1 year posttransplant. There was no difference in patient survival, but the risk of graft loss among patients who received alemtuzumab was higher compared with those who received IL-2RA induction.
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30
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Prope tolerance: is it the end or the means? Transplantation 2009; 87:1750-1. [PMID: 19502973 DOI: 10.1097/tp.0b013e3181a64304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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