1
|
Elamin S, Ibrahim SS, Mudawi H, Ali SEAM, Abdel-Satir A, Foad AFA. High malignancy rate in the absence of viral prophylaxis after kidney transplantation in Sudan. J Nephrol 2024; 37:1653-1659. [PMID: 38847938 DOI: 10.1007/s40620-024-01978-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 04/26/2024] [Indexed: 10/15/2024]
Abstract
BACKGROUND Kidney transplantation in Sudan is funded by the government. Cytomegalovirus prophylaxis is provided for patients who receive biological induction or have recipient-negative donor-positive cytomegalovirus serology. Doctor Selma Center for Kidney Diseases joined the national kidney transplant program in May 2019. Since then, we observed the frequent occurrence of cancer in patients who received modest immunosuppression without viral prophylaxis. METHODS We retrospectively divided kidney transplant recipients between 2019 and 2021 into two groups according to cytomegalovirus prophylaxis and compared tumor occurrence rates. RESULTS The first group included 77 patients who did not receive biological induction or cytomegalovirus prophylaxis. The second group included 92 patients who received valganciclovir for 3-6 months. There was no other antiviral treatment except entecavir for chronic hepatitis B virus infection in eight patients. Five patients in the first group developed malignancy. The first patient presented eight months post-transplant with Kaposi sarcoma of the stomach and responded to treatment with sirolimus. The second patient presented nine months post-transplant with cutaneous Kaposi sarcoma and also responded to sirolimus. Two patients presented two and four months post-transplant with aggressive non-cutaneous Kaposi sarcoma that involved the gastrointestinal tract and lymphatic system and died soon afterwards. The fifth patient presented three years post-transplant with non-Hodgkin lymphoma of the duodenum and is currently receiving chemotherapy. Malignancy rate (6.5% vs 0.0%, P = 0.02) and Kaposi sarcoma rate (5.2% vs 0.0%, P = 0.04) were significantly higher in the first group. CONCLUSION In Sudan, omitting valganciclovir prophylaxis after kidney transplantation was associated with a high rate of virus-induced malignancy.
Collapse
Affiliation(s)
- Sarra Elamin
- Doctor Selma Center for Kidney Diseases, University of Khartoum, Khartoum, Sudan.
| | - Selma S Ibrahim
- Doctor Selma Center for Kidney Diseases, University of Khartoum, Khartoum, Sudan
| | - Hatim Mudawi
- Gastroenterology Unit, Soba University Hospital, University of Khartoum, Khartoum, Sudan
| | - Sara E A Mohamed Ali
- Gastroenterology Unit, Soba University Hospital, University of Khartoum, Khartoum, Sudan
| | | | - Ayman F A Foad
- Histopathology Department, National University, Khartoum, Sudan
| |
Collapse
|
2
|
Maggiore U. Twenty Years, and More to Come: Learning What Makes Some Transplants Ultra-Long Survivors. Transpl Int 2022; 35:11036. [PMID: 36545155 PMCID: PMC9760690 DOI: 10.3389/ti.2022.11036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022]
|
3
|
Reimann AV, Nilsson J, Wuethrich RP, Mueller TF, Schachtner T. Entering the Third Decade After Kidney Transplantation: Excellent Graft Function Refers to Superior Graft but Not Patient Survival. Transpl Int 2022; 35:10675. [PMID: 36388427 PMCID: PMC9659610 DOI: 10.3389/ti.2022.10675] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 10/18/2022] [Indexed: 04/19/2024]
Abstract
Kidney transplant recipients (KTRs) with ultralong-term survival represent a growing, yet insufficiently studied patient cohort. In this single-center retrospective study, we analyzed 248 ultralong-term survivors (≥20 years). KTRs were classified into those with superior graft function (defined as eGFR ≥45 ml/min + proteinuria ≤300 mg/day + eGFR-slope ≤ 2 ml/min/1.73 m2/year) and inferior graft function regarding the risk of CKD progression. 20 years post-transplant, median eGFR was 54 ml/min (11-114), proteinuria 200 mg/24 h (0-7,620), eGFR decline 0.45 ml/min/1.73 m2/year (11.7 6.5) and DSA had been detected in 19.7% of KTRs. We identified 96 KTRs (38.7%) with superior (group 1) and 152 KTRs (61.3%) with inferior graft function (group 2). Donation after cardiac death, female sex, glomerulonephritis as primary disease, and early TCMR were independently associated with inferior graft function. Graft survival was significantly better in group 1 compared to group 2 (LogRank, p < 0.001). Besides group affiliation (HR 20.515, p = 0.003), multivariable analysis identified DSA development (HR 3.081, p = 0.023) and donor age (HR 1.032, p = 0.024) as independent factors. Interestingly, there was no significant difference in patient survival (LogRank, p = 0.350). In ultralong-term survivors, excellent graft function refers to superior graft survival but does not extend ultimate patient survival. DSA-formation should be taken seriously even in the ultralong-term.
Collapse
Affiliation(s)
- Anna Vera Reimann
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Jakob Nilsson
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
| | | | - Thomas F. Mueller
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Schachtner
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
4
|
Guillén-Gómez I, Blanco-García M, Aránega-Gavilán S, Crespo-Montero R. Alteraciones neoplásicas en el paciente trasplantado renal. Una revisión sistemática. ENFERMERÍA NEFROLÓGICA 2022. [DOI: 10.37551/52254-28842022021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introducción: El trasplante renal se ha destacado como la mejor terapia renal sustitutiva para la enfermedad renal crónica terminal, aunque conlleva una serie de riesgos entre los que el cáncer se destaca cada vez más, por lo que parece importante determinar el impacto que tiene en esta población.Objetivo: Conocer y sintetizar la evidencia científica acerca de la incidencia de neoplasias en pacientes trasplantados renales, así como las variables relacionadas con las mismas.Metodología: Se realizó una revisión sistemática en la que se incluyeron 14 artículos procedentes de las bases de Pubmed, Scopus, Scielo, WOS y Google Académico. Como términos MeSH se utilizaron: neoplasias (neoplasms), trasplante de riñón (kidney transplantation), incidencia (incidence), riesgo (risk), factores de riesgo (risk factors). Se incluyeron artículos originales en inglés y español, en población trasplantada adulta.Resultados: Se incluyeron 14 artículos de diseño observacional. De la revisión emergieron como principales variables: incidencia general, datos demográficos y tratamientos previos, otras características asociadas, tumores más frecuentes y medidas preventivas.Conclusiones: La incidencia de neoplasias en el paciente trasplantado es alta, sobre todo en la edad avanzada y pacientes con tratamiento inmunosupresor con ciclosporina y azatioprina siendo este último, junto al trasplante procedente de cadáver, los principales factores de riesgo encontrados. Los cánceres de piel no melanoma son los más prevalentes y como medidas de prevención se destaca llevar a cabo un cribado rutinario, fomento de una vida saludable, y promoción y potenciación de la vacunación de la hepatitis B.
Collapse
|
5
|
Anderson B, Qasim M, Evison F, Gallier S, Townend JN, Ferro CJ, Sharif A. A population cohort analysis of English transplant centers indicates major adverse cardiovascular events after kidney transplantation. Kidney Int 2022; 102:876-884. [PMID: 35716956 DOI: 10.1016/j.kint.2022.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 04/27/2022] [Accepted: 05/09/2022] [Indexed: 11/16/2022]
Abstract
Major adverse cardiovascular event (MACE) rates immediately after kidney transplantation remain uncertain due to heterogeneous reporting in the literature. To clarify this, we retrospectively studied every eligible kidney transplant procedure performed in England between April 1, 2002 and March 31. 2018 with follow-up through August 31, 2019. The primary outcome of interest was MACE broadly defined as any hospital admission with myocardial infarction, stroke, unstable angina, heart failure, any coronary revascularisation procedure and/or any cardiovascular death. Among 30,325 kidney transplant recipients, MACE occurred in 781 within the first year after transplantation (2.6% of all kidney transplant procedures). Of these 781 events, 201 occurred during the index admission for kidney transplantation surgery representing 25.7% of all first-year MACE and 0.7% of all kidney transplant procedures. Kidney transplant recipients who suffered a non-fatal MACE within the first year had significantly decreased 1-, 3-, 5- and 10-year patient survival of 80.5%, 70.2%, 59.5% and 38.6% respectively, compared to 97.4%, 94.4%, 90.7% and 78.4% for kidney transplant recipients not developing MACE.. In an adjusted Cox proportional hazard model, non-fatal MACE within the first-year post-transplant was associated with significant long-term mortality risk (hazard ratio 2.59; 95% confidence interval 2.34-2.88). Kidney transplant recipients experiencing MACE during the index admission compared to subsequent admissions were differentiated by age, sex and previous cardiac history but had similar patient survival. These rates are significantly lower than those reported in North America. Thus, our data confirms MACE is not a benign post-transplant event and has a strong association with long-term mortality risk.
Collapse
Affiliation(s)
- Benjamin Anderson
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Muhammad Qasim
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Felicity Evison
- Department of Health Informatics, Queen Elizabeth Hospital, Birmingham, UK
| | - Suzy Gallier
- Department of Health Informatics, Queen Elizabeth Hospital, Birmingham, UK
| | - Jonathan N Townend
- Department of Cardiology, University Hospitals Birmingham, UK; Institute of Cardiovascular Sciences, University of Birmingham, UK
| | - Charles J Ferro
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK; Institute of Cardiovascular Sciences, University of Birmingham, UK
| | - Adnan Sharif
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, UK.
| |
Collapse
|
6
|
Fuhrmann JD, Valkova K, von Moos S, Wüthrich RP, Müller TF, Schachtner T. Cancer among kidney transplant recipients >20 years after transplantation: post-transplant lymphoproliferative disorder remains the most common cancer type in the ultra long-term. Clin Kidney J 2022; 15:1152-1159. [PMID: 35664271 PMCID: PMC9155242 DOI: 10.1093/ckj/sfac013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Indexed: 11/23/2022] Open
Abstract
Background Cancer risk is increased by 2- to 4-fold in kidney transplant recipients (KTRs) compared with the general population. Little attention, however, has been given to KTRs with ultra long-term survival >20 years. Methods We studied 293 of 1241 KTRs (23.6%), transplanted between 1981 and 1999, who showed kidney allograft survival >20 years. These long-term survivors were analysed for cancer development, cancer type, cancer-associated risk factors and patient and allograft outcomes. Results By 10, 20 and 30 years post-transplantation, these long-term KTRs showed a cancer rate of 4.4%, 14.6% and 33.2%, and a non-melanoma skin cancer (NMSC) rate of 10.3%, 33.5% and 76.8%, respectively. By recipients' ages of 40, 60 and 80 years, KTRs showed a cancer rate of 3.4%, 14.5% 55.2%, and a NMSC rate of 1.7%, 31.6% and 85.2%, respectively. By 30 years post-transplantation, post-transplant lymphoproliferative disorder (PTLD) showed the highest incidence of 8.5%, followed by renal cell carcinoma (RCC) with 5.1%. Risk factors associated with the development of cancer were only recipient age (P = 0.016). Smoking history was associated with the risk of lung cancer (P = 0.018). Risk factors related to the development of NMSC included recipient age (P = 0.001) and thiazide diuretics (P = 0.001). Cancer increased the risk of death by 2.4-fold (P = 0.002), and PTLD increased the risk of kidney allograft loss by 6.5-fold (P = 0.001). No differences were observed concerning the development of donor-specific antibodies (P > 0.05). Conclusions In long-term KTRs, cancer is a leading cause of death. PTLD remains the most common cancer type followed by RCC. These results emphasize the need for focused long-term cancer surveillance protocols.
Collapse
Affiliation(s)
- Julia D Fuhrmann
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Kristyna Valkova
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Seraina von Moos
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Rudolf P Wüthrich
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas F Müller
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Schachtner
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
7
|
Vonbrunn E, Angeloni M, Büttner-Herold M, Müller-Deile J, Heller K, Bleich E, Söllner S, Amann K, Ferrazzi F, Daniel C. Can Gene Expression Analysis in Zero-Time Biopsies Predict Kidney Transplant Rejection? Front Med (Lausanne) 2022; 9:793744. [PMID: 35433772 PMCID: PMC9005644 DOI: 10.3389/fmed.2022.793744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
Zero-time biopsies are taken to determine the quality of the donor organ at the time of transplantation. Histological analyses alone have so far not been able to identify parameters that allow the prediction of subsequent rejection episodes or graft survival. This study investigated whether gene expression analyses of zero-time biopsies might support this prediction. Using a well-characterized cohort of 26 zero-time biopsies from renal transplant patients that include 4 living donor (LD) and 22 deceased donor (DD) biopsies that later developed no rejection (Ctrl, n = 7), delayed graft function (DGF, n = 4), cellular (T-cell mediated rejection; TCMR, n = 8), or antibody-mediated rejection (ABMR, n = 7), we analyzed gene expression profiles for different types of subsequent renal transplant complication. To this end, RNA was isolated from formalin-fixed, paraffin-embedded (FFPE) sections and gene expression profiles were quantified. Results were correlated with transplant data and B-cell, and plasma cell infiltration was assessed by immunofluorescence microscopy. Both principal component analysis and clustering analysis of gene expression data revealed marked separation between LDs and DDs. Differential expression analysis identified 185 significant differentially expressed genes (adjusted p < 0.05). The expression of 68% of these genes significantly correlated with cold ischemia time (CIT). Furthermore, immunoglobulins were differentially expressed in zero-time biopsies from transplants later developing rejection (TCMR + ABMR) compared to non-rejected (Ctrl + DGF) transplants. In addition, immunoglobulin expression did not correlate with CIT but was increased in transplants with previous acute renal failure (ARF). In conclusion, gene expression profiles in zero-time biopsies derived from LDs are markedly different from those of DDs. Pre-transplant ARF increased immunoglobulin expression, which might be involved in triggering later rejection events. However, these findings must be confirmed in larger cohorts and the role of early immunoglobulin upregulation in zero-biopsies needs further clarification.
Collapse
Affiliation(s)
- Eva Vonbrunn
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg and University Hospital, Erlangen, Germany
| | - Miriam Angeloni
- Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg and University Hospital, Erlangen, Germany
| | - Maike Büttner-Herold
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg and University Hospital, Erlangen, Germany
| | - Janina Müller-Deile
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nuremberg and University Hospital, Erlangen, Germany
| | - Katharina Heller
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nuremberg and University Hospital, Erlangen, Germany
| | - Erik Bleich
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg and University Hospital, Erlangen, Germany
| | - Stefan Söllner
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg and University Hospital, Erlangen, Germany
| | - Kerstin Amann
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg and University Hospital, Erlangen, Germany
| | - Fulvia Ferrazzi
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg and University Hospital, Erlangen, Germany.,Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg and University Hospital, Erlangen, Germany
| | - Christoph Daniel
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg and University Hospital, Erlangen, Germany
| |
Collapse
|
8
|
Kim B, Kang M, Kim Y, Lee HS, Kim B, Lee JJ, Park Y, Lee KA. De Novo Cancer Incidence after Kidney Transplantation in South Korea from 2002 to 2017. J Clin Med 2021; 10:jcm10163530. [PMID: 34441826 PMCID: PMC8396914 DOI: 10.3390/jcm10163530] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/05/2021] [Accepted: 08/10/2021] [Indexed: 12/26/2022] Open
Abstract
Advances in patient care and immunosuppressive drugs have improved graft survival, resulting in an increase in kidney transplantation (KT); however, persistent immunosuppression is thought to cause late occurrence of cancer. This population-based study consisted of a total of 14,842 patients whose data from the years 2002 to 2017 were collected from the National Health Information Database in South Korea. Malignancies occurred in 7.6% of the total KT patients. Prostate and thyroid cancers were the most common in males and females, respectively. From the age-adjusted incidence analysis, Kaposi’s sarcoma showed the highest standardized incidence ratio in both male and female patients. According to the linear regression model, cancer incidence in KT recipients under immunosuppressive conditions increased by approximately 0.1% each month. Patients’ age over 39 and the use of prednisolone as an initial steroid regimen were associated with increased risk of cancer development after KT. Our regression and proportional hazards models will help clinicians to predict the approximate cancer incidence risk when monitoring KT recipients. Based on the largest available national database, screening or monitoring methods for cancer detection and prevention can be established for KT patients by considering the factors involved in cancer development.
Collapse
Affiliation(s)
- Boyeon Kim
- Department of Laboratory Medicine, National Health Insurance Service Ilsan Hospital, Goyang-si 10444, Korea; (B.K.); (B.K.)
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (Y.K.); (K.-A.L.)
| | - Minjin Kang
- Research Institute, National Health Insurance Service Ilsan Hospital, Goyang 10444, Korea;
| | - Yoonjung Kim
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (Y.K.); (K.-A.L.)
| | - Hyung Soon Lee
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang 10444, Korea;
| | - Banseok Kim
- Department of Laboratory Medicine, National Health Insurance Service Ilsan Hospital, Goyang-si 10444, Korea; (B.K.); (B.K.)
| | - Jung Jun Lee
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea
- Correspondence: (J.J.L.); (Y.P.); Tel.: +82-2-2019-3533 (Y.P.)
| | - Yongjung Park
- Department of Laboratory Medicine, National Health Insurance Service Ilsan Hospital, Goyang-si 10444, Korea; (B.K.); (B.K.)
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (Y.K.); (K.-A.L.)
- Correspondence: (J.J.L.); (Y.P.); Tel.: +82-2-2019-3533 (Y.P.)
| | - Kyung-A Lee
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (Y.K.); (K.-A.L.)
| |
Collapse
|
9
|
Chowdhury TA, Wahba M, Mallik R, Peracha J, Patel D, De P, Fogarty D, Frankel A, Karalliedde J, Mark PB, Montero RM, Pokrajac A, Zac-Varghese S, Bain SC, Dasgupta I, Banerjee D, Winocour P, Sharif A. Association of British Clinical Diabetologists and Renal Association guidelines on the detection and management of diabetes post solid organ transplantation. Diabet Med 2021; 38:e14523. [PMID: 33434362 DOI: 10.1111/dme.14523] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 11/24/2020] [Accepted: 01/09/2021] [Indexed: 01/06/2023]
Abstract
Post-transplant diabetes mellitus (PTDM) is common after solid organ transplantation (SOT) and associated with increased morbidity and mortality for allograft recipients. Despite the significant burden of disease, there is a paucity of literature with regards to detection, prevention and management. Evidence from the general population with diabetes may not be translatable to the unique context of SOT. In light of emerging clinical evidence and novel anti-diabetic agents, there is an urgent need for updated guidance and recommendations in this high-risk cohort. The Association of British Clinical Diabetologists (ABCD) and Renal Association (RA) Diabetic Kidney Disease Clinical Speciality Group has undertaken a systematic review and critical appraisal of the available evidence. Areas of focus are; (1) epidemiology, (2) pathogenesis, (3) detection, (4) management, (5) modification of immunosuppression, (6) prevention, and (7) PTDM in the non-renal setting. Evidence-graded recommendations are provided for the detection, management and prevention of PTDM, with suggested areas for future research and potential audit standards. The guidelines are endorsed by Diabetes UK, the British Transplantation Society and the Royal College of Physicians of London. The full guidelines are available freely online for the diabetes, renal and transplantation community using the link below. The aim of this review article is to introduce an abridged version of this new clinical guideline ( https://abcd.care/sites/abcd.care/files/site_uploads/Resources/Position-Papers/ABCD-RA%20PTDM%20v14.pdf).
Collapse
Affiliation(s)
| | | | | | | | - Dipesh Patel
- Diabetes & Endocrinology, Royal Free NHS foundation Trust, UCL, London, UK
| | | | | | | | - Janaka Karalliedde
- Guy's and St Thomas NHS Foundation Trust and King's College London, London, UK
| | | | | | - Ana Pokrajac
- West Hertfordshire Hospitals NHS Trust, Watford, UK
| | | | | | - Indranil Dasgupta
- Heartlands Hospital, Birmingham, UK
- Warwick Medical School, Warwick, UK
| | - Debasish Banerjee
- Renal and Transplant Unit, St George's University Hospitals NHS Foundation Trust and MCSRI, St George's University of London, London, UK
| | | | | |
Collapse
|
10
|
Buxeda A, Redondo-Pachón D, Pérez-Sáez MJ, Crespo M, Pascual J. Sex differences in cancer risk and outcomes after kidney transplantation. Transplant Rev (Orlando) 2021; 35:100625. [PMID: 34020178 DOI: 10.1016/j.trre.2021.100625] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 02/06/2023]
Abstract
Kidney transplant recipients (KTRs) experience a two- to four-fold increased risk of developing and dying from cancer compared with the general population. High cancer risk results from the interaction of both modifiable and non-modifiable factors. This mapping review explores the impact of sex disparity on cancer's increased incidence and mortality after kidney transplantation (KT). In terms of age, population-based studies indicate that younger recipients of both sexes experience a higher risk of cancer, but this is more pronounced in young women. On the contrary, older men are more likely to be diagnosed with cancer, although their increased risk is not statistically significant compared with the general population. Regarding cancer type, studies show an increased risk of Kaposi sarcoma, gynecologic and lung cancer in women, and bladder and kidney cancer in men. Immune-related cancers such as pos-transplant lymphoproliferative disorders and melanoma are increased in both sexes. Mortality also shows differences between sexes. Although cancer is the second cause of death in both male and female KTRs, studies show higher overall mortality in men and elderly recipients. However, the relative risk of cancer mortality compared with the general population is higher at a younger age, with disparate results regarding sex. Female KTRs appear to die at a younger age than males when compared with the general population. Differences in cancer rates by sex after renal transplantation need further studies. A better understanding of sex-specific differences in cancer epidemiology after KT could help nephrologists to better address pre-transplant counseling, to establish early surveillance programs, and to plan modifiable risk factors such as immunosuppression.
Collapse
Affiliation(s)
- Anna Buxeda
- Department of Nephrology, Hospital del Mar, Barcelona, Spain.
| | | | | | - Marta Crespo
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| |
Collapse
|
11
|
Incidence of malignancy and related mortality after kidney transplantation: a nationwide, population-based cohort study in Korea. Sci Rep 2020; 10:21398. [PMID: 33293655 PMCID: PMC7722878 DOI: 10.1038/s41598-020-78283-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 11/05/2020] [Indexed: 01/01/2023] Open
Abstract
Post-transplant malignancy (PTM) is a leading cause of premature mortality among kidney transplantation recipients. However, population-based cohort studies that cover incidence, mortality, and risk factors for PTM are rarely reported, especially in East Asia. We designed a retrospective cohort study using a national population-based database. A total of 9915 kidney recipients between 2003 and 2016 were included. During this period, 598 cases (6.0%) of de novo PTM occurred. The most common PTM was thyroid cancer (14.2%), followed by colorectal (11.2%), kidney (10.7%), and stomach cancers (8.9%). The standardised incidence ratio for all-site cancer was 3.9. The risks of Kaposi sarcoma (192.9) and kidney cancer (21.1) were more than 10 times those of the general population. Cancer-related deaths were 89 (14.9%) with liver cancer being the highest (14.6%), followed by lung cancer (13.5%), non-Hodgkin lymphoma (NHL) (12.4%), stomach cancer (9.0%), and colorectal cancer (7.9%). The standardised mortality ratio (SMR) was slightly elevated (1.4). A notable increase in SMR was observed for lymphoma (9.3 for Hodgkin lymphoma and 5.5 for NHL). Older age and graft failure were significantly related to PTM. These findings reflecting geographical variation have implications for the development of strategies for fatal cancers to prevent premature deaths from PTM.
Collapse
|
12
|
Braun WE, Herlitz L, Li J, Schold J, Poggio E, Stephany B, Fatica R, Nally J, Brown K, Fairchild R, Baldwin W, Goldfarb D, Kiser W, Augustine J, Avery R, Tomford JW, Nakamoto S. Continuous function of 80 primary renal allografts for 30-47 years with maintenance prednisone and azathioprine/mycophenolate mofetil therapy: A clinical mosaic of long-term successes. Clin Transplant 2020; 35:e14131. [PMID: 33112428 DOI: 10.1111/ctr.14131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/09/2020] [Accepted: 10/14/2020] [Indexed: 11/30/2022]
Abstract
Eighty primary renal allograft recipients, 61 living-related and 19 deceased donor, transplanted from 1963 through 1984 had continuous graft function for 30-47 years. They were treated with three different early immunosuppression programs (1963-1970: thymectomy, splenectomy, high oral prednisone; 1971-1979: divided-dose intravenous methylprednisolone; and 1980-1984: antilymphocyte globulin) each with maintenance prednisone and azathioprine, and no calcineurin inhibitor. Long-term treatment often included the anti-platelet medication, dipyridamole. Although both recipient and donor ages were young (27.2 ± 9.5 and 33.1 ± 12.0 years, respectively), six recipients with a parent donor had >40-year success. At 35 years, death-censored graft survival was 85.3% and death with a functioning graft 84.2%; overall graft survival was 69.5% (Kaplan-Meier estimate). Biopsy-documented early acute cellular and highly probable antibody-mediated rejections were reversed with divided-dose intravenous methylprednisolone. Complications are detailed in an integrated timeline. Hypogammaglobulinemia identified after 20 years doubled the infection rate. An association between a monoclonal gammopathy of undetermined significance and non-plasma-cell malignancies was identified. Twenty-seven azathioprine-treated patients tested after 37 years had extremely low levels of T1/T2 B lymphocytes representing a "low immunosuppression state of allograft acceptance (LISAA)". The lifetime achievements of these patients following a single renal allograft and low-dose maintenance immunosuppression are remarkable. Their success evolved as a clinical mosaic.
Collapse
Affiliation(s)
- William E Braun
- Department of Nephrology & Hypertension, Cleveland Clinic, Cleveland, OH, USA
| | - Leal Herlitz
- Department of Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - Jianbo Li
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Jesse Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Emilio Poggio
- Department of Nephrology & Hypertension, Cleveland Clinic, Cleveland, OH, USA
| | - Brian Stephany
- Department of Nephrology & Hypertension, Cleveland Clinic, Cleveland, OH, USA
| | - Richard Fatica
- Department of Nephrology & Hypertension, Cleveland Clinic, Cleveland, OH, USA
| | - Joseph Nally
- Department of Nephrology & Hypertension, Cleveland Clinic, Cleveland, OH, USA
| | - Kathleen Brown
- Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH, USA
| | - Robert Fairchild
- Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH, USA
| | - William Baldwin
- Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH, USA
| | - David Goldfarb
- Department of Urology, Cleveland Clinic, Cleveland, OH, USA
| | - William Kiser
- Department of Urology, Cleveland Clinic, Cleveland, OH, USA
| | - Joshua Augustine
- Department of Nephrology & Hypertension, Cleveland Clinic, Cleveland, OH, USA
| | - Robin Avery
- Division of Infectious Disease (Transplant/Oncology), Johns Hopkins, Baltimore, MD, USA
| | - J Walton Tomford
- Department of Infectious Disease, Cleveland Clinic, Cleveland, OH, USA
| | - Satoru Nakamoto
- Department of Nephrology & Hypertension, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
13
|
Bekbolsynov D, Mierzejewska B, Borucka J, Liwski RS, Greenshields AL, Breidenbach J, Gehring B, Leonard-Murali S, Khuder SA, Rees M, Green RC, Stepkowski SM. Low Hydrophobic Mismatch Scores Calculated for HLA-A/B/DR/DQ Loci Improve Kidney Allograft Survival. Front Immunol 2020; 11:580752. [PMID: 33193383 PMCID: PMC7659444 DOI: 10.3389/fimmu.2020.580752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/02/2020] [Indexed: 12/17/2022] Open
Abstract
We evaluated the impact of human leukocyte antigen (HLA) disparity (immunogenicity; IM) on long-term kidney allograft survival. The IM was quantified based on physicochemical properties of the polymorphic linear donor/recipient HLA amino acids (the Cambridge algorithm) as a hydrophobic, electrostatic, amino acid mismatch scores (HMS\AMS\EMS) or eplet mismatch (EpMM) load. High-resolution HLA-A/B/DRB1/DQB1 types were imputed to calculate HMS for primary/re-transplant recipients of deceased donor transplants. The multiple Cox regression showed the association of HMS with graft survival and other confounders. The HMS integer 0–10 scale showed the most survival benefit between HMS 0 and 3. The Kaplan–Meier analysis showed that: the HMS=0 group had 18.1-year median graft survival, a 5-year benefit over HMS>0 group; HMS ≤ 3.0 had 16.7-year graft survival, a 3.8-year better than HMS>3.0 group; and, HMS ≤ 7.8 had 14.3-year grafts survival, a 1.8-year improvement over HMS>7.8 group. Stratification based on EMS, AMS or EpMM produced similar results. Additionally, the importance of HLA-DR with/without -DQ IM for graft survival was shown. In our simulation of 1,000 random donor/recipient pairs, 75% with HMS>3.0 were re-matched into HMS ≤ 3.0 and the remaining 25% into HMS≥7.8: after re-matching, the 13.5 years graft survival would increase to 16.3 years. This approach matches donors to recipients with low/medium IM donors thus preventing transplants with high IM donors.
Collapse
Affiliation(s)
- Dulat Bekbolsynov
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH, United States
| | - Beata Mierzejewska
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH, United States
| | | | - Robert S Liwski
- Department of Pathology, Dalhousie University, Halifax, NS, Canada
| | | | - Joshua Breidenbach
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH, United States
| | - Bradley Gehring
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH, United States
| | | | - Sadik A Khuder
- Department of Medicine and Public Health, University of Toledo, Toledo, OH, United States
| | - Michael Rees
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH, United States.,Department of Urology, University of Toledo College of Medicine, Toledo, OH, United States.,The Alliance for Paired Donation, Maumee, OH, United States
| | - Robert C Green
- Department of Computer Science, Bowling Green State University, Bowling Green, OH, United States
| | - Stanislaw M Stepkowski
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH, United States
| |
Collapse
|
14
|
Bellini MI, Courtney AE, McCaughan JA. Living Donor Kidney Transplantation Improves Graft and Recipient Survival in Patients with Multiple Kidney Transplants. J Clin Med 2020; 9:jcm9072118. [PMID: 32635614 PMCID: PMC7408952 DOI: 10.3390/jcm9072118] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/01/2020] [Accepted: 07/02/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Failed kidney transplant recipients benefit from a new graft as the general incident dialysis population, although additional challenges in the management of these patients are often limiting the long-term outcomes. Previously failed grafts, a long history of comorbidities, side effects of long-term immunosuppression and previous surgical interventions are common characteristics in the repeated kidney transplantation population, leading to significant complex immunological and technical aspects and often compromising the short- and long-term results. Although recipients’ factors are acknowledged to represent one of the main determinants for graft and patient survival, there is increasing interest in expanding the donor’s pool safely, particularly for high-risk candidates. The role of living kidney donation in this peculiar context of repeated kidney transplantation has not been assessed thoroughly. The aim of the present study is to analyse the effects of a high-quality graft, such as the one retrieved from living kidney donors, in the repeated kidney transplant population context. Methods: Retrospective analysis of the outcomes of the repeated kidney transplant population at our institution from 1968 to 2019. Data were extracted from a prospectively maintained database and stratified according to the number of transplants: 1st, 2nd or 3rd+. The main outcomes were graft and patient survivals, recorded from time of transplant to graft failure (return to dialysis) and censored at patient death with a functioning graft. Duration of renal replacement therapy was expressed as cumulative time per month. A multivariate analysis considering death-censored graft survival, decade of transplantation, recipient age, donor age, living donor, transplant number, ischaemic time, time on renal replacement therapy prior to transplant and HLA mismatch at HLA-A, -B and -DR was conducted. In the multivariate analysis of recipient survival, diabetic nephropathy as primary renal disease was also included. Results: A total of 2395 kidney transplant recipients were analysed: 2062 (83.8%) with the 1st kidney transplant, 279 (11.3%) with the 2nd graft, 46 (2.2%) with the 3rd+. Mean age of 1st kidney transplant recipients was 43.6 ± 16.3 years, versus 39.9 ± 14.4 for 2nd and 41.4 ± 11.5 for 3rd+ (p < 0.001). Aside from being younger, repeated kidney transplant patients were also more often males (p = 0.006), with a longer time spent on renal replacement therapy (p < 0.0001) and a higher degree of sensitisation, expressed as calculated reaction frequency (p < 0.001). There was also an association between multiple kidney transplants and better HLA match at transplantation (p < 0.0001). A difference in death-censored graft survival by number of transplants was seen, with a median graft survival of 328 months for recipients of the 1st transplant, 209 months for the 2nd and 150 months for the 3rd+ (p = 0.038). The same difference was seen in deceased donor kidneys (p = 0.048), but not in grafts from living donors (p = 0.2). Patient survival was comparable between the three groups (p = 0.59). Conclusions: In the attempt to expand the organ donor pool, particular attention should be reserved to high complex recipients, such as the repeated kidney transplant population. In this peculiar context, the quality of the donor has been shown to represent a main determinant for graft survival—in fact, kidney retrieved from living donors provide comparable outcomes to those from single-graft recipients.
Collapse
|
15
|
Chang EH, Tan HJ, Nielsen M. Management of small renal masses in patients with chronic kidney disease: Perspectives from a nephrologist. Urol Oncol 2019; 38:533-536. [PMID: 31889616 DOI: 10.1016/j.urolonc.2019.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 11/04/2019] [Accepted: 11/08/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Emily H Chang
- Division of Nephrology, UNC Kidney Center, Chapel Hill, NC.
| | - Hung-Jui Tan
- Department of Urology, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Matthew Nielsen
- Department of Urology, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| |
Collapse
|
16
|
Park B, Yoon J, Choi D, Kim HJ, Jung YK, Kwon OJ, Lee KG. De novo cancer incidence after kidney and liver transplantation: Results from a nationwide population based data. Sci Rep 2019; 9:17202. [PMID: 31748582 PMCID: PMC6868238 DOI: 10.1038/s41598-019-53163-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 10/16/2019] [Indexed: 12/20/2022] Open
Abstract
The cancer risk among solid organ transplantation recipients in East-Asia has been insufficiently studied. This study estimated de novo cancer incidence in kidney and liver recipients 2008-2015, compared with the general population in Korea using nationwide data. This is a retrospective cohort study using nationwide health insurance claims data. The study population was comprised of cancer-free 10,085 kidney recipients and 3,822 liver recipients. Standardized incidence ratio (SIR) of cancer using indirect standardization was calculated. Compared with the general population, the cancer risk increased by 3.19-fold in male and 2.56-fold in female kidney recipients. By cancer type, a notably increased SIR was observed for Kaposi sarcoma, renal cancer, skin cancer, and non-Hodgkin's lymphoma in male and for bladder cancer, renal cancer, and non-Hodgkin's lymphoma in female kidney recipients. In liver recipients, the SIR of all cancers was 3.43 in males and 2.30 in females. In male liver recipients, the SIRs for Kaposi sarcoma, non-Hodgkin's lymphoma, myeloid leukemia, and skin cancer and in female recipients those for non-Hodgkin's lymphoma and liver cancer were prominent. A greatly higher SIRs for overall cancer and non-Hodgkin's lymphoma in kidney and liver recipients aged 0-19 were observed, compared with recipients in other age group. The incidence of de novo cancer in kidney and liver recipients was higher than the general population and common types were different. Strategies of cancer prevention and screening after kidney and liver transplantation should be developed in response to the incidence of common types of de novo cancers.
Collapse
Affiliation(s)
- Boyoung Park
- Department of Medicine, College of Medicine, Hanyang University, Seoul, South Korea
| | - Junghyun Yoon
- Graduate School of Public Health, Hanyang University, Seoul, South Korea
| | - Dongho Choi
- Department of Surgery, College of Medicine, Hanyang University, Seoul, South Korea. .,Hanyang ICT fusion medical research center, Seoul, South Korea.
| | - Han Joon Kim
- Department of Surgery, College of Medicine, Hanyang University, Seoul, South Korea
| | - Yun Kyung Jung
- Department of Surgery, College of Medicine, Hanyang University, Seoul, South Korea.,Hanyang ICT fusion medical research center, Seoul, South Korea
| | - Oh Jung Kwon
- Department of Surgery, College of Medicine, Hanyang University, Seoul, South Korea
| | - Kyeong Geun Lee
- Department of Surgery, College of Medicine, Hanyang University, Seoul, South Korea
| |
Collapse
|
17
|
Buxeda A, Redondo-Pachón D, Pérez-Sáez MJ, Bartolomé Á, Mir M, Pascual-Dapena A, Sans A, Duran X, Crespo M, Pascual J. Gender differences in cancer risk after kidney transplantation. Oncotarget 2019; 10:3114-3128. [PMID: 31139324 PMCID: PMC6517099 DOI: 10.18632/oncotarget.26859] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/23/2019] [Indexed: 02/06/2023] Open
Abstract
Kidney transplant (KT) recipients are at greater risk of developing some cancers than the general population. Moreover, cancer is the only cause of death that is currently increasing after kidney transplantation. We analyzed incidence, risk factors and characteristics of post-transplant malignancies (solid organ tumors and lymphoproliferative disorders) at our center in 925 KT recipients (1979-2014). Sex differences were particularly assessed. One hundred and eight patients (11.7%) developed solid organ tumors (76.9%) or lymphoma (23.1%). Twenty-one percent of patients who reached 20 years after KT developed cancer, with a median post-KT time to diagnosis of 7.4 years. Most common solid organs affected were lung (30.1%), prostate (10.8%), bladder (9.6%), and native kidney (7.2%). When analyzing standardized incidence ratios (SIR) by gender compared to the general population, relative risk was increased in women (SIR = 1.81; 95%CI, 1.28-2.45) but not significantly increased in men (SIR = 1.22; 0.95-2.52). Regarding specific types, gynecological (SIR = 11.6; 4.2-22.7) and lung (SIR = 10.0; 4.3-18.2) in women, and bladder (SIR = 16.3; 5.9-32.1) in men were the most affected locations. Thymoglobulin, a polyclonal antibody that has been used as an immunosuppressive agent in kidney transplantation over the last decades, was a significant risk factor for developing cancer in adjusted regression analysis [IRR = 1.62, 1.02-2.57; p = 0.041], and was associated with lower patient survival. Compared with the general population, the incidence of post-KT non-skin cancer is almost two-fold higher in women but not significantly higher in men. Lung is the most common solid organ affected. Thymoglobulin induction therapy is associated with a greater risk.
Collapse
Affiliation(s)
- Anna Buxeda
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | | | | | - Álvaro Bartolomé
- Department of Medicine, University Autonoma Barcelona, Barcelona, Spain
- Department of Experimental and Health Sciences, University Pompeu-Fabra, Barcelona, Spain
| | - Marisa Mir
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Ana Pascual-Dapena
- Department of Medicine, University Autonoma Barcelona, Barcelona, Spain
- Department of Experimental and Health Sciences, University Pompeu-Fabra, Barcelona, Spain
| | - Anna Sans
- Department of Medicine, University Autonoma Barcelona, Barcelona, Spain
- Department of Experimental and Health Sciences, University Pompeu-Fabra, Barcelona, Spain
| | - Xavier Duran
- Methodology and Biostatistics Support Unit, Institute Hospital del Mar for Medical Research (IMIM), Barcelona, Spain
| | - Marta Crespo
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
- Department of Medicine, University Autonoma Barcelona, Barcelona, Spain
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
- Department of Medicine, University Autonoma Barcelona, Barcelona, Spain
| |
Collapse
|
18
|
Moroni G, Binda V, Quaglini S, Sacchi L, Raffiotta F, Cosa F, Montagnino G, Favi E, Messa P, Ponticelli C. Causes of late transplant failure in cyclosporine-treated kidney allograft recipients. Clin Exp Nephrol 2019; 23:1076-1086. [PMID: 31016431 DOI: 10.1007/s10157-019-01740-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 04/10/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND There is little information about very long-term outcomes of kidney allograft recipients exposed to calcineurin inhibitors. METHODS In this single-centre retrospective study with 20-year follow-up, we analyzed data from 644 patients who underwent primary renal transplantation between 1983 and 1993. Participants were treated with a cyclosporine-based immunosuppressive scheme and had allograft function at 1 year. RESULTS After 20 years, 15.2% patients died, 39.7% experienced allograft loss, 26.8% were alive with a functioning transplant, and 18.2% were lost to follow-up. Cardiovascular disease (30.8%), malignancy (26.6%) and infection (17.0%) were the main causes of death. Age, new-onset proteinuria > 1 g/day, major acute cardiovascular event (MACE), and malignancy were independent predictors of mortality at time-dependent multivariate analysis. Chronic rejection (63.3%), recurrent glomerulonephritis (14.0%), and nonspecific interstitial fibrosis/tubular atrophy (13.2%) were the leading cause of allograft loss. Basal disease, hepatitis C, difference between 1 year and nadir serum creatinine, new-onset proteinuria > 1 g/day, and MACE were independent predictors of transplant failure. Among patients with 20-year allograft function, we recorded the following complications: hypertension (85%), malignancy (13%), diabetes (9%), and cardiovascular disease (9%). Median serum creatinine and proteinuria were 1.4 mg/dL and 0.6 g/day, respectively. CONCLUSIONS Prolonged use of cyclosporine may expose to several dose-related adverse events and may contribute to the development of allograft dysfunction but it does not necessarily cause relentless, progressive transplant failure if patients are carefully and consistently monitored during the follow-up.
Collapse
Affiliation(s)
- Gabriella Moroni
- Nephrology and Dialysis, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valentina Binda
- Nephrology and Dialysis, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvana Quaglini
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Lucia Sacchi
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Francesca Raffiotta
- Nephrology and Dialysis, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Cosa
- Nephrology and Dialysis, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Montagnino
- Nephrology and Dialysis, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Evaldo Favi
- Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via della Commenda 15, 20122, Milan, Italy.
| | - Piergiorgio Messa
- Nephrology and Dialysis, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Claudio Ponticelli
- Renal Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
19
|
Establishing a Core Outcome Measure for Graft Health: A Standardized Outcomes in Nephrology-Kidney Transplantation (SONG-Tx) Consensus Workshop Report. Transplantation 2019; 102:1358-1366. [PMID: 29470347 DOI: 10.1097/tp.0000000000002125] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Graft loss, a critically important outcome for transplant recipients, is variably defined and measured, and incompletely reported in trials. We convened a consensus workshop on establishing a core outcome measure for graft loss for all trials in kidney transplantation. METHODS Twenty-five kidney transplant recipients/caregivers and 33 health professionals from 8 countries participated. Transcripts were analyzed thematically. RESULTS Five themes were identified. "Graft loss as a continuum" conceptualizes graft loss as a process, but requiring an endpoint defined as a discrete event. In "defining an event with precision and accuracy," loss of graft function requiring chronic dialysis (minimum, 90 days) provided an objective and practical definition; retransplant would capture preemptive transplantation; relisting was readily measured but would overestimate graft loss; and allograft nephrectomy was redundant in being preceded by dialysis. However, the thresholds for renal replacement therapy varied. Conservative management was regarded as too ambiguous and complex to use routinely. "Distinguishing death-censored graft loss" would ensure clarity and meaningfulness in interpreting results. "Consistent reporting for decision making" by specifying time points and metrics (ie time to event) was suggested. "Ease of ascertainment and data collection" of the outcome from registries could support use of registry data to efficiently extend follow-up of trial participants. CONCLUSIONS A practical and meaningful core outcome measure for graft loss may be defined as chronic dialysis or retransplant, and distinguished from loss due to death. Consistent reporting of graft loss using standardized metrics and time points may improve the contribution of trials to decision making in kidney transplantation.
Collapse
|
20
|
Rolak S, Di Bartolomeo S, Jorgenson MR, Saddler CM, Singh T, Astor BC, Parajuli S. Outcomes of Norovirus diarrheal infections and
Clostridioides difficile
infections in kidney transplant recipients: A single‐center retrospective study. Transpl Infect Dis 2019; 21:e13053. [PMID: 30689283 DOI: 10.1111/tid.13053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 01/02/2019] [Accepted: 01/20/2019] [Indexed: 01/25/2023]
Affiliation(s)
- Stacey Rolak
- Division of Nephrology, Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Sarah Di Bartolomeo
- Division of Nephrology, Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | | | - Christopher M. Saddler
- Division of Infection Disease, Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Tripti Singh
- Division of Nephrology, Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Brad C. Astor
- Division of Nephrology, Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
- Department of Population Health Sciences University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| |
Collapse
|
21
|
Parajuli S, Mandelbrot DA, Aziz F, Garg N, Muth B, Mohamed M, Armbrust MJ, Astor BC, Djamali A. Characteristics and Outcomes of Kidney Transplant Recipients with a Functioning Graft for More than 25 Years. KIDNEY DISEASES 2018; 4:255-261. [PMID: 30574502 DOI: 10.1159/000491575] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/27/2018] [Indexed: 01/01/2023]
Abstract
Background Information regarding the clinical characteristics and outcomes of kidney transplant recipients (KTRs) with > 25 years of graft survival is limited. Methods In this single-center observational study, we characterized KTRs transplanted between 1973 and 1992 with active follow-up as of July 31, 2017. Results We identified 112 patients with > 25 years of allograft function. The mean posttransplantation follow-up was 29.8 ± 4.0 years. Glomerulonephritis was the most common cause of end-stage renal disease (ESRD) (52%). The majority received live donor transplants (66%), including 25 patients (22%) with human leukocyte antigen-matched kidneys. The incidence of biopsy-confirmed acute rejection was 21%, ranging from 0 to 26 years post transplantation. Donor-specific antibodies (DSA) were checked in 80% of patients at a mean of 28.4 ± 0.11 years post transplantation. Of these, only 15% were positive. The incidence of malignancy was 44%, with nonmelanoma skin cancers being most common. The incidence of infectious complications was 77%, mostly represented by urinary tract infections. At the time of last follow-up, 63% were on a calcineurin inhibitor (CNI)-free regimen, mean serum creatinine was 1.4 ± 0.6 mg/dL, and the prevalence of hypertension and dyslipidemia was 89 and 88%, respectively. Conclusion The majority of patients with a long-term functioning graft had glomerulonephritis as cause of ESRD, had received a live donor kidney, were on a CNI-free regimen, and had a low incidence of DSA and opportunistic infections. These characteristics define a unique group of patients requiring specific posttransplantation monitoring and management.
Collapse
Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Didier A Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Brenda Muth
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Maha Mohamed
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Michael J Armbrust
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Brad C Astor
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,Division of Transplant Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| |
Collapse
|
22
|
Cohen J, Owei L, Sawinski D, Porrett P. Inferior long-term allograft and patient outcomes among recipients of offspring living donor kidneys. Am J Transplant 2018; 18:1699-1709. [PMID: 29266831 PMCID: PMC6013327 DOI: 10.1111/ajt.14631] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 12/07/2017] [Accepted: 12/12/2017] [Indexed: 01/25/2023]
Abstract
While offspring-to-parent living donor kidney transplantations may represent an ideal donor-recipient combination to optimize long-term transplantation outcomes, the sex-specific long-term success of these transplantations remains unclear. We hypothesize that allograft and recipient survivals in offspring-to-parent living donor kidney transplantation differ between men and women due to donor-specific alloimmunization during pregnancy. We retrospectively analyzed long-term allograft and patient survival among men and women who received an offspring living donor kidney compared with those who received other haplotype-matched living donor kidneys. Based on multivariable Cox proportional hazards modeling of Organ Procurement and Transplantation Network data from 2001 to 2015, we found that both men and women who received offspring living donor kidneys had significantly increased mortality compared with recipients who received nonoffspring living donor kidneys. While male recipients of any living donor kidney had greater risk of mortality and allograft failure than female recipients, there was no significant difference in all-cause allograft failure or mortality in male versus female recipients of offspring living donor kidney transplantations. Our analysis demonstrated no significant interaction between recipient sex and donor offspring status. We conclude that nonoffspring living donors should be considered whenever feasible for both men and women with multiple donor options.
Collapse
Affiliation(s)
- J.B. Cohen
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - L. Owei
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - D.L. Sawinski
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - P.M. Porrett
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Division of Transplant Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
23
|
Severova-Andreevska G, Grcevska L, Petrushevska G, Cakalaroski K, Sikole A, Stojceva–Taneva O, Danilovska I, Ivanovski N. The Spectrum of Histopathological Changes in the Renal Allograft - a 12 Months Protocol Biopsy Study. Open Access Maced J Med Sci 2018; 6:606-612. [PMID: 29731924 PMCID: PMC5927487 DOI: 10.3889/oamjms.2018.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 03/16/2017] [Accepted: 03/17/2018] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Renal transplantation became a routine and successful medical treatment for Chronic Kidney Disease in the last 30 years all over the world. Introduction of Luminex based Single Antigen Beads (SAB) and recent BANFF consensus of histopathological phenotypes of different forms of rejection enables more precise diagnosis and changes the therapeutic approach. The graft biopsies, protocol or cause, indicated, remain a golden diagnostic tool for clinical follow up of kidney transplant recipients (KTR). AIM The study aimed to analyse the histopathological changes in renal grafts 12 months after the surgery in KTR with satisfactory kidney function. MATERIAL AND METHODS A 12-month protocol biopsy study was performed in a cohort of 50 Kidney transplant recipients (42 from living and 8 from deceased donors). Usual work-up for suitable donors and recipients, standard surgical procedure, basic principles of peri and postoperative care and follow up were done in all KTR. Sequential quadruple immunosuppression including induction with Anti-thymocyte globulin (ATG) or Interleukin-2R antagonist (IL-2R), and triple drug maintenance therapy with Calcineurin Inhibitors (CNI), Mycophenolate Mofetil (MMF) and Steroids were prescribed to all pts. Different forms of Glomerulonephritis (16), Hypertension (10), End Stage Renal Disease (13), Hereditary Nephropathies (6), Diabetes (3) and Vesicoureteral Reflux (2) were the underlying diseases. All biopsies were performed under ultrasound guidance. The 16 gauge needles with automated "gun" were used to take 2 cores of tissue. The samples were stained with HE, PAS, Trichrome Masson and Silver and reviewed by the same pathologist. A revised and uploaded BANFF 2013 classification in 6 categories (Cat) was used. RESULTS Out of 48 biopsies, 15 (31%) were considered as normal, 4 (8%), Borderline (BL-Cat 3), 5 (10%) as Interstitial Fibrosis/Tubular Atrophy (IF/TA-Cat 5), 5 (10%) were classified as non-immunological (Cat 6), 2 as a pure antibody-mediated rejection (ABMR-Cat 2) and T-cell Mediated Rejection (TCMR-Cat 4). The remaining 17 samples were classified as a "mixed" rejection: 7 (41%) ABMR + IF/TA, 5 (29%) ABMR + BL + IF/TA, 2 (11%) BL + IF/TA, 1 (5%) ABMR + BL, 1 (5%) ABMR + TCMR and 1 (5%) TCMR + IF/TA. The mean serum creatinine at the time of the biopsy was 126.7 ± 23.4 µmol/L, while GFR-MDRD 63.4 ± 20.7 ml/min, which means that the majority of the findings were subclinical. Among the non-immunological histological findings (Cat 6), 3 cases belonged to CNI toxicity, 1 to BK nephropathy and 1 to recurrence of the primary disease. CONCLUSION Our 12-month protocol biopsy study revealed the presence of different forms of mixed subclinical rejection. Use of recent BANFF classification and scoring system enables more precise diagnosis and subsequently different approach to the further treatment of the KTR. More correlative long-term studies including Anti HLA antibodies and Endothelial Cell Activation- Associated Transcripts (ENDAT) are needed.
Collapse
Affiliation(s)
- Galina Severova-Andreevska
- University Clinic of Nephrology, Medical Faculty, University St Cyril and Methodius of Skopje, Skopje, Republic of Macedonia
| | - Ladislava Grcevska
- University Clinic of Nephrology, Medical Faculty, University St Cyril and Methodius of Skopje, Skopje, Republic of Macedonia
| | - Gordana Petrushevska
- Institute for Pathology, Medical Faculty, University St Cyril and Methodius of Skopje, Skopje, Republic of Macedonia
| | - Koco Cakalaroski
- Medical Faculty, University St Cyril and Methodius of Skopje, Skopje, Republic of Macedonia
| | - Aleksandar Sikole
- University Clinic of Nephrology, Medical Faculty, University St Cyril and Methodius of Skopje, Skopje, Republic of Macedonia
| | - Olivera Stojceva–Taneva
- University Clinic of Nephrology, Medical Faculty, University St Cyril and Methodius of Skopje, Skopje, Republic of Macedonia
| | - Ilina Danilovska
- University Clinic of Nephrology, Medical Faculty, University St Cyril and Methodius of Skopje, Skopje, Republic of Macedonia
| | - Ninoslav Ivanovski
- Medical Faculty, University St Cyril and Methodius of Skopje, Skopje, Republic of Macedonia
| |
Collapse
|
24
|
Risk Factors for De Novo Malignancies in Women After Kidney Transplantation: A Multicenter Transversal Study. Int J Gynecol Cancer 2017; 26:967-70. [PMID: 27206219 DOI: 10.1097/igc.0000000000000710] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Transplantation results in a 5-time elevated risk for a variety of malignancies (Kaposi sarcoma, skin, liver, lung, gastrointestinal cancer). A patient's risk for malignancies could be of particular interest for the follow-up programs of patients and risk adaption after kidney transplantation. The aim of this study was to identify independent risk factors for de novo malignancies in women after renal transplantation. METHODS AND MATERIALS This is a multicenter transversal study, conducted at the Medical University of Vienna and Hospital Rudolfstiftung, Vienna, Austria. We included female kidney graft recipients who were transplanted between 1980 and 2012 and followed-up at our institutions (N = 280). Clinical data of patients were extracted from hospital charts and electronic patient files. Patients were interviewed using a standardized questionnaire regarding their medical history, history of transplantation, and malignant diseases. Detailed information about present and past immunosuppressive regimens, rejection episodes and therapies, renal graft function, and information about primary disease was obtained. Diagnostic work-up and/or surgical exploration was performed if any presence of malignancy was suspected during routine follow-up. Histological specimens were obtained from all patients. MAIN OUTCOME MEASURES the presence of de novo malignancy after kidney transplantation. RESULTS Two hundred sixty-two women were included for statistical analysis. Median (interquartile range) follow-up period after transplantation was 101.1 (27.3-190.7) months. Thirty-two patients (12.2%) developed a malignancy: dermatologic malignancies (5.7%), breast cancer (3.4%), cervical cancer (0.8%), lung cancer (0.4%), gastrointestinal malignancies (1.5%), vulvar cancer (0.4%), and unclassified malignancies (1.9%). Median (interquartile range) time to malignancy after transplantation was 185.9 (92.0-257.6) months. Cumulative cancer rates were 4.9% (1 year), 14.4% (3 years), 16.4% (5 years), and 21.8% (10 years). Second transplantations were identified as independent risk factor for development of malignancy after transplantation. CONCLUSIONS Long-term risk of developing a malignancy after kidney transplantation is high, which might justify a follow-up of more than 10 years.
Collapse
|
25
|
McCaughan JA, Courtney AE. Successful kidney transplantation in highly sensitized, ultra-long-term dialysis patients. Transpl Int 2017; 30:844-846. [PMID: 28419581 DOI: 10.1111/tri.12970] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jennifer A McCaughan
- Department of Nephrology and Transplantation, Belfast City Hospital, Belfast, UK
| | - Aisling E Courtney
- Department of Nephrology and Transplantation, Belfast City Hospital, Belfast, UK
| |
Collapse
|
26
|
Pettenati C, Jannot AS, Hurel S, Verkarre V, Kreis H, Housset M, Legendre C, Méjean A, Timsit MO. Prostate cancer characteristics and outcome in renal transplant recipients: results from a contemporary single center study. Clin Transplant 2016; 30:964-71. [DOI: 10.1111/ctr.12773] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2016] [Indexed: 12/20/2022]
Affiliation(s)
- Caroline Pettenati
- Department of Urology and Transplant Surgery; Hôpital européen Georges-Pompidou, AP-HP; Paris France
- Université Paris Descartes; Paris France
| | - Anne-Sophie Jannot
- Université Paris Descartes; Paris France
- Department of Statistics, Computing and Public Health; Hôpital européen Georges-Pompidou, AP-HP; Paris France
| | - Sophie Hurel
- Department of Urology and Transplant Surgery; Hôpital européen Georges-Pompidou, AP-HP; Paris France
- Université Paris Descartes; Paris France
| | - Virginie Verkarre
- Université Paris Descartes; Paris France
- Department of Pathology; Hôpital Necker, AP-HP; Paris France
| | - Henri Kreis
- Université Paris Descartes; Paris France
- Department of Nephrology and Transplantation; Hôpital Necker, AP-HP; Paris France
| | - Martin Housset
- Université Paris Descartes; Paris France
- Department of Onco-Radiotherapy; Hôpital européen Georges-Pompidou, AP-HP; Paris France
| | - Christophe Legendre
- Université Paris Descartes; Paris France
- Department of Nephrology and Transplantation; Hôpital Necker, AP-HP; Paris France
| | - Arnaud Méjean
- Department of Urology and Transplant Surgery; Hôpital européen Georges-Pompidou, AP-HP; Paris France
- Université Paris Descartes; Paris France
| | - Marc-Olivier Timsit
- Department of Urology and Transplant Surgery; Hôpital européen Georges-Pompidou, AP-HP; Paris France
- Université Paris Descartes; Paris France
| |
Collapse
|
27
|
Doycheva I, Amer S, Watt KD. De Novo Malignancies After Transplantation: Risk and Surveillance Strategies. Med Clin North Am 2016; 100:551-67. [PMID: 27095645 DOI: 10.1016/j.mcna.2016.01.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
De novo malignancies are one of the leading causes of late mortality after liver and kidney transplantation. Nonmelanoma skin cancer is the most common malignancy, followed by posttransplant lymphoproliferative disorder and solid organ tumors. Immunosuppression is a key factor for cancer development, although many other transplant-related and traditional risk factors also play a role. In this review, the authors summarize risk factors and outcomes of frequently encountered de novo malignancies after liver and kidney transplantation to stratify recipients at highest risk. Future efforts in prospectively validated, cost-effective surveillance strategies that improve survival of these complex patients are greatly needed.
Collapse
Affiliation(s)
- Iliana Doycheva
- Division of Gastroenterology and Hepatology, Medical University-Sofia, 1 G. Sofiisky Boulevard, Sofia 1431, Bulgaria
| | - Syed Amer
- Division of Internal Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic and Foundation, CH-10, 200 First Street Southwest, Rochester, MN 55905, USA.
| |
Collapse
|