1
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Vu VA, Bhayana S, Sweiss H, Castro N, Hall R, Nelson J. Impact of Cumulative 6 mg/kg Antithymocyte Globulin on Early Posttransplant Outcomes in Kidney Transplant Recipients with Delayed Graft Function. Prog Transplant 2024; 34:47-52. [PMID: 38465633 PMCID: PMC11080378 DOI: 10.1177/15269248241237816] [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] [Indexed: 03/12/2024]
Abstract
Introduction: Delayed graft function in kidney transplant is associated with an increased risk of rejection and graft loss. Use of rabbit antithymocyte globulin induction in delayed graft function has been correlated with less rejection compared to basiliximab, but optimal dosing remains unknown. Program Evaluation Aims: The purpose of this evaluation was to retrospectively assess the short-term effectiveness and tolerability of a clinical protocol that increased the net state of immunosuppression in delayed graft function kidney transplant recipients using cumulative 6 mg/kg rabbit antithymocyte globulin induction. Design: This retrospective cohort included 88 kidney transplant recipients with delayed graft function, transplanted between January 2017 and March 2021, who either received cumulative 4.5 mg/kg pre-protocol or 6 mg/kg post-protocol rabbit antithymocyte globulin. Outcomes evaluated were biopsy-proven acute rejection and incidence of graft loss, infection, and cytopenia at 6 months. Results: A significant reduction of biopsy-proven acute rejection incidence occurred post-protocol implementation (10/33, 30.3% vs 6/55, 10.9%; P = .04). Of those with rejection, significantly less post-protocol patients were classified as acute cellular rejection (9/10, 90.0% vs 2/6, 33.3%; P = .04). No death-censored graft loss was observed in either group. Rates of cytopenia and infection were similar pre- versus post-protocol implementation. Conclusion: Increasing the exposure to rabbit antithymocyte globulin and maintenance immunosuppression in delayed graft function kidney transplant recipients was tolerable and significantly reduced rejection occurrence at 6 months.
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Affiliation(s)
- Van Anh Vu
- Department of Pharmacotherapy and Pharmacy Services, University Health, San Antonio, TX, USA
- College of Pharmacy, Pharmacotherapy Division, University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education and Research Center, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- University Health Transplant Institute, San Antonio, TX, USA
| | - Suverta Bhayana
- University Health Transplant Institute, San Antonio, TX, USA
- Department of Nephrology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Helen Sweiss
- Department of Pharmacotherapy and Pharmacy Services, University Health, San Antonio, TX, USA
- College of Pharmacy, Pharmacotherapy Division, University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education and Research Center, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- University Health Transplant Institute, San Antonio, TX, USA
| | - Nohely Castro
- Pharmacy Services, Children's Health, Dallas, TX, USA
| | - Reed Hall
- Department of Pharmacotherapy and Pharmacy Services, University Health, San Antonio, TX, USA
- College of Pharmacy, Pharmacotherapy Division, University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education and Research Center, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- University Health Transplant Institute, San Antonio, TX, USA
| | - Joelle Nelson
- Department of Pharmacotherapy and Pharmacy Services, University Health, San Antonio, TX, USA
- College of Pharmacy, Pharmacotherapy Division, University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education and Research Center, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- University Health Transplant Institute, San Antonio, TX, USA
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2
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Montero N, Rodrigo E, Crespo M, Cruzado JM, Gutierrez-Dalmau A, Mazuecos A, Sancho A, Belmar L, Calatayud E, Mora P, Oliveras L, Solà E, Villanego F, Pascual J. The use of lymphocyte-depleting antibodies in specific populations of kidney transplant recipients: A systematic review and meta-analysis. Transplant Rev (Orlando) 2023; 37:100795. [PMID: 37774445 DOI: 10.1016/j.trre.2023.100795] [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: 07/27/2023] [Revised: 09/07/2023] [Accepted: 09/09/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Recommendations of the use of antibody induction treatments in kidney transplant recipients (KTR) are based on moderate quality and historical studies. This systematic review aims to reevaluate, based on actual studies, the effects of different antibody preparations when used in specific KTR subgroups. METHODS We searched MEDLINE and CENTRAL and selected randomized controlled trials (RCT) and observational studies looking at different antibody preparations used as induction in KTR. Comparisons were categorized into different KTR subgroups: standard, high risk of rejection, high risk of delayed graft function (DGF), living donor, and elderly KTR. Two authors independently assessed the risk of bias. RESULTS Thirty-seven RCT and 99 observational studies were finally included. Compared to anti-interleukin-2-receptor antibodies (IL2RA), anti-thymocyte globulin (ATG) reduced the risk of acute rejection at two years in standard KTR (RR 0.74, 95%CI 0.61-0.89) and high risk of rejection KTR (RR 0.55, 95%CI 0.43-0.72), but without decreasing the risk of graft loss. We did not find significant differences comparing ATG vs. alemtuzumab or different ATG dosages in any KTR group. CONCLUSIONS Despite many studies carried out on induction treatment in KTR, their heterogeneity and short follow-up preclude definitive conclusions to determine the optimal induction therapy. Compared with IL2RA, ATG reduced rejection in standard-risk, highly sensitized, and living donor graft recipients, but not in high DGF risk or elderly recipients. More studies are needed to demonstrate beneficial effects in other KTR subgroups and overall patient and graft survival.
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Affiliation(s)
- Nuria Montero
- Nephrology Department, Hospital Universitari de Bellvitge, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Emilio Rodrigo
- Nephrology Department, Hospital Universitario Marqués de Valdecilla/IDIVAL, Santander, Spain
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Josep M Cruzado
- Nephrology Department, Hospital Universitari de Bellvitge, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Alex Gutierrez-Dalmau
- Nephrology Department, Hospital Universitario Miguel Servet, Aragon Health Research Institute, Zaragoza, Spain
| | | | - Asunción Sancho
- Nephrology Department, Hospital Universitari Dr Peset, FISABIO, Valencia, Spain
| | - Lara Belmar
- Nephrology Department, Hospital Universitario Marqués de Valdecilla/IDIVAL, Santander, Spain
| | - Emma Calatayud
- Nephrology Department, Hospital Universitari Dr Peset, FISABIO, Valencia, Spain
| | - Paula Mora
- Nephrology Department, Hospital Universitario Miguel Servet, Aragon Health Research Institute, Zaragoza, Spain
| | - Laia Oliveras
- Nephrology Department, Hospital Universitari de Bellvitge, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Eulalia Solà
- Nephrology Department, Consorci Sanitari del Garraf, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | | | - Julio Pascual
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain.
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3
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Punukollu R, Ryan M, Misra S, Budhiraja P, Ohara S, Kumm K, Guerra G, Reddy KS, Heilman R, Jadlowiec CC. Past, Current, and Future Perspectives on Transplanting Acute Kidney Injury Kidneys. Clin Pract 2023; 13:944-958. [PMID: 37623267 PMCID: PMC10453697 DOI: 10.3390/clinpract13040086] [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: 05/10/2023] [Revised: 07/24/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023] Open
Abstract
(1) Background: Acute kidney injury (AKI) kidneys have high non-utilization rates due to concerns regarding unfavorable outcomes. In this paper, we aimed to review the past, present, and future opinions on AKI kidneys. (2) Methods: A PubMed search was conducted for topics relevant to AKI kidney transplantation. (3) Results: Current short- and long-term data on AKI kidneys have demonstrated good outcomes including favorable graft function and survival. The role of procurement biopsies is controversial, but they have been shown to be beneficial in AKI kidneys by allowing clinicians to differentiate between reversible tubular injury and irreversible cortical necrosis. Machine perfusion has also been applied to AKI kidneys and has been shown to reduce delayed graft function (DGF). The incidence of DGF increases with AKI severity and its management can be challenging. Strategies employed to counteract this have included early initiation of dialysis after kidney transplantation, early targeting of adequate immunosuppression levels to minimize rejection risk, and establishment of outpatient dialysis. (4) Conclusions: Despite good outcomes, there continue to be barriers that impact AKI kidney utilization. Successful strategies have included use of procurement biopsies or machine perfusion and expectant management of DGF. With increasing experience, better use of AKI kidneys can result in additional opportunities to expand the donor pool.
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Affiliation(s)
- Rachana Punukollu
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Margaret Ryan
- Division of Anatomic Pathology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Suman Misra
- Division of Nephrology, Mayo Clinic, Phoenix, AZ 85054, USA
| | | | - Stephanie Ohara
- Division of Surgery, Valleywise Health Medical Center, Creighton University, Phoenix, AZ 85008, USA
| | - Kayla Kumm
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Giselle Guerra
- Division of Nephrology, Miami Transplant Institute, Miami, FL 33136, USA
| | - Kunam S. Reddy
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, USA
| | | | - Caroline C. Jadlowiec
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, USA
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4
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Delayed graft function: current status and future directions. Curr Opin Organ Transplant 2023; 28:1-7. [PMID: 36579681 DOI: 10.1097/mot.0000000000001034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW Delayed graft function is a common early posttransplant event predictive of adverse outcomes including hospital readmission, impaired long-term graft function, and decreased graft and patient survival. The purpose of this review is to summarize recent literature describing delayed graft function in hopes of better understanding and managing this condition. RECENT FINDINGS Recent research efforts have been garnered towards risk factor modification, prevention, and earlier detection of delayed graft function. In this review, we aim to summarize current innovative approaches and future directions. SUMMARY Delayed graft function portends worse graft and patient outcomes. Continued research to prevent, and detect early perturbations in allograft function, and more optimally manage this disease will hopefully improve graft function, along with graft/patient survival.
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DCD kidney transplantation in Italy: past, present, and future. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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6
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Schold JD, Nordyke RJ, Wu Z, Corvino F, Wang W, Mohan S. Clinical Events and Renal Function in the First Year Predict Long-Term Kidney Transplant Survival. KIDNEY360 2022; 3:714-727. [PMID: 35721618 PMCID: PMC9136886 DOI: 10.34067/kid.0007342021] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/20/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Estimated glomerular filtration rate (eGFR) at 1 year post transplantation has been shown to be a strong predictor of long-term graft survival. However, intercurrent events (ICEs) may affect the relationship between eGFR and failure risk. METHODS The OPTN and USRDS databases on single-organ kidney transplant recipients from 2012 to 2016 were linked. Competing risk regressions estimated adjusted subhazard ratios (SHRs) of 12-month eGFR on long-term graft failure, considering all-cause mortality as the competing risk, for deceased donor (DD) and living donor (LD) recipients. Additional predictors included recipient, donor, and transplant characteristics. ICEs examined were acute rejection, cardiovascular events, and infections. RESULTS Cohorts comprised 25,131 DD recipients and 7471 LD recipients. SHRs for graft failure increased rapidly as 12-month eGFR values decreased from the reference 60 ml/min per 1.73 m2. At an eGFR of 20 ml/min per 1.73 m2, SHRs were 13-15 for DD recipients and 12-13 for LD recipients; at an eGFR of 30 ml/min per 1.73 m2, SHRs were 5.0-5.7 and 5.0-5.5, respectively. Among first-year ICEs, acute rejection was a significant predictor of long-term graft failure in both DD (SHR=1.63, P<0.001) and LD (SHR=1.51, P=0.006) recipients; cardiovascular events were significant in DD (SHR=1.24, P<0.001), whereas non-CMV infections were significant in the LD cohort (SHR=1.32, P=0.03). Adjustment for ICEs did not significantly reduce the association of eGFR with graft failure. CONCLUSIONS Twelve-month eGFR is a strong predictor of long-term graft failure after accounting for clinical events occurring from discharge to 1 year. These findings may improve patient management and clinical evaluation of novel interventions.
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Affiliation(s)
- Jesse D. Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Zheng Wu
- Genesis Research, Hoboken, New Jersey
| | - Frank Corvino
- Genesis Research, Hoboken, New Jersey
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | | | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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7
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Chukwu CA, Spiers HV, Middleton R, Kalra PA, Asderakis A, Rao A, Augustine T. Alemtuzumab in renal transplantation. Reviews of literature and usage in the United Kingdom. Transplant Rev (Orlando) 2022; 36:100686. [DOI: 10.1016/j.trre.2022.100686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 11/24/2022]
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8
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Halpern SE, Moris D, Shaw BI, Krischak MK, Olaso DG, Kesseli SJ, Ravindra K, McElroy LM, Barbas AS. The Systemic Immune-Inflammation Index Predicts Clinical Outcomes in Kidney Transplant Recipients. In Vivo 2021; 34:3349-3360. [PMID: 33144442 DOI: 10.21873/invivo.12173] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/08/2020] [Accepted: 09/14/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Outcomes after kidney transplantation (KTx) remain limited by delayed graft function (DGF) and acute rejection. Non-invasive biomarkers may help identify patients at increased risk for these events. We examined the association between the systemic immune-inflammation index (SII), a novel inflammatory biomarker, and outcomes after KTx and evaluated its ability to predict post-transplant prognosis. PATIENTS AND METHODS Adult patients who underwent primary KTx at our institution between 2016-2019 were included. SII was calculated from pre-transplant complete blood counts as the ratio of the neutrophil count to the lymphocyte count multiplied by the platelet count. The cutoff between high and low SII was determined by maximizing the area under the curve. Multivariable logistic and Cox regression were used to identify factors associated with DGF and patient, rejection-free, and graft survival respectively. RESULTS Overall, 378 KTx recipients were included; 224 (59.3%) had high SII. On unadjusted analysis, high SII was associated with reduced odds of DGF, and improved patient and rejection-free survival. After adjustment, high SII was independently associated with improved patient survival alone. Multivariable models incorporating SII performed well for the prediction of DGF (c-statistic=0.755) and patient survival (c-statistic=0.786), though rejection-free survival was more difficult to predict (c-statistic=0.635). CONCLUSION SII demonstrated limited utility as an independent predictor of outcomes after KTx. However, in combination with other clinically relevant parameters, SII is a useful predictor of post-KTx prognosis. Validation of this novel inflammatory biomarker in a multi-institutional study is needed to further elucidate its practical applications in transplantation.
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Affiliation(s)
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, U.S.A.
| | - Brian I Shaw
- Department of Surgery, Duke University Medical Center, Durham, NC, U.S.A
| | | | - Danae G Olaso
- School of Medicine, Duke University, Durham, NC, U.S.A
| | - Samuel J Kesseli
- Department of Surgery, Duke University Medical Center, Durham, NC, U.S.A
| | - Kadiyala Ravindra
- Department of Surgery, Duke University Medical Center, Durham, NC, U.S.A
| | - Lisa M McElroy
- Department of Surgery, Duke University Medical Center, Durham, NC, U.S.A
| | - Andrew S Barbas
- Department of Surgery, Duke University Medical Center, Durham, NC, U.S.A
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9
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Bath NM, Leverson G, Al-Adra D, D’Alessandro A, Mezrich J, Foley DP. Microsteatosis in Livers From Donation After Circulatory Death Donors Is Associated With Inferior Outcomes Following Liver Transplantation. Liver Transpl 2020; 26:1127-1137. [PMID: 32453905 PMCID: PMC8860344 DOI: 10.1002/lt.25803] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/20/2020] [Accepted: 04/05/2020] [Indexed: 12/20/2022]
Abstract
The acceptable threshold remains unknown for the percentage of macrosteatosis (MaS) and microsteatosis (MiS) to yield optimal outcomes after donation after circulatory death (DCD) liver transplantation (LT). The purpose of this analysis was to determine the impact of donor liver MaS and MiS on DCD LT outcomes. Using the Organ Procurement and Transplantation Network database, we analyzed pretransplant biopsy results from adult, solitary, DCD livers transplanted between January 1, 2006, and December 31, 2017. Kaplan-Meier analysis was used to assess graft and patient survival based on MaS and MiS severity. MiS was divided into the groups MiS ≤10% and >10%. MaS was divided into the groups MaS ≤15% and >15%. Of 7757 recovered DCD livers, 11.4% (n = 885) were biopsied and transplanted. Patients who received DCD livers with MaS >15% had significantly worse patient survival (P < 0.04), and those with MiS >10% demonstrated inferior graft and patient survival (P < 0.02). In multivariate analyses including known risk factors, both MaS >15% and MiS >10% were associated with increased risk of graft failure and patient mortality (P < 0.03). Recipient and donor age >60 years were also associated with increased risk of graft failure and patient death. This analysis demonstrates that MaS >15% and MiS >10% are additional risk factors for graft loss and patient mortality in DCD LT.
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Affiliation(s)
- Natalie M. Bath
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Glen Leverson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - David Al-Adra
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Anthony D’Alessandro
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Joshua Mezrich
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - David P. Foley
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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10
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Cha SW, Shin IS, Kim DG, Kim SH, Lee JY, Kim JS, Yang JW, Han BG, Choi SO. Effectiveness of serum beta-2 microglobulin as a tool for evaluating donor kidney status for transplantation. Sci Rep 2020; 10:8109. [PMID: 32415140 PMCID: PMC7229179 DOI: 10.1038/s41598-020-65134-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 04/26/2020] [Indexed: 11/09/2022] Open
Abstract
Kidney transplantations using expanded criteria donors (ECD) are being increasingly adopted, but no consensus tools are available to evaluate donor kidney status. Beta-2 microglobulin (B2MG) is a marker of kidney function, and herein, we evaluate the usefulness of assessing B2MG to evaluate donor kidney status. Fifty-seven kidney transplantations were performed from March 2017 to April 2019. Medical records were retrospectively reviewed, and relationships between clinical and laboratory variables and transplant outcomes were investigated. Thirty-eight patients received a standard criteria donor kidney and 19 patients an ECD kidney. Ten patients experienced delayed graft function (DGF), but no patient experienced primary nonfunction. Of the parameters studied, only donor renal replacement therapy (RRT) [odds ratio (OR) 24.162; p = 0.018] and donor serum B2MG (OR 22.685; p = 0.022) significantly predicted DGF. The presence of either of these two risk factors can better reflect the condition of the donor than previous classification. However, on their last follow-up creatinine and estimated glomerular filtration rate values in those with or without these risk factors were not significantly different. For an ECD with a B2MG level of <7.18 and no history of RRT, kidney transplantation can be undertaken without considering the possibility of kidney discard.
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Affiliation(s)
- Sung Whan Cha
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, South Korea
| | - In Sik Shin
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, South Korea
| | - Deok Gie Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, South Korea
| | - Sung Hoon Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, South Korea.
| | - Jun Young Lee
- Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, South Korea
| | - Jae Seok Kim
- Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, South Korea
| | - Jae Won Yang
- Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, South Korea
| | - Byoung-Geun Han
- Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, South Korea
| | - Seung Ok Choi
- Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, South Korea
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11
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Turki AT, Klisanin V, Bayraktar E, Kordelas L, Trenschel R, Ottinger H, Steckel NK, Tsachakis-Mück N, Leserer S, Ditschkowski M, Liebregts T, Koldehoff M, Fleischhauer K, Beelen DW. Optimizing anti-T-lymphocyte globulin dosing to improve long-term outcome after unrelated hematopoietic cell transplantation for hematologic malignancies. Am J Transplant 2020; 20:677-688. [PMID: 31597002 DOI: 10.1111/ajt.15642] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/06/2019] [Accepted: 09/25/2019] [Indexed: 01/25/2023]
Abstract
Prophylaxis of graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (HCT) remains challenging. Because prospective randomized trials of in-vivo T cell depletion using anti-T-lymphocyte globulin (ATLG) in addition to a calcineurin inhibitor and methotrexate (MTX) led to conflicting outcome results, we evaluated the impact of ATLG on clinical outcome, lymphocyte- and immune reconstitution survival models. In total, 1500 consecutive patients with hematologic malignancies received matched unrelated donor (MUD) HCT with cyclosporin and MTX (N = 723, 48%) or with additional ATLG (N = 777, 52%). In the ATLG cohort, grades III-IV acute (12% vs 23%) and extensive chronic GVHD (18% vs 34%) incidences were significantly reduced (P < .0001). Nonrelapse mortality (27% vs 45%) and relapse (30% vs 22%) differed also significantly. Event-free and overall survival estimates at 10 years were 44% and 51% with ATLG and 33% and 35% without ATLG (P < .002 and <.0001). A dose-dependent ATLG effect on lymphocyte- and neutrophil reconstitution was observed. At ATLG exposure, lymphocyte counts and survival associated through a logarithmically increasing function. In this survival model, the lymphocyte count optimum range at exposure was between 0.4 and 1.45/nL (P = .001). This study supports additional ATLG immune prophylaxis and is the first study to associate optimal lymphocyte counts with survival after MUD-HCT.
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Affiliation(s)
- Amin T Turki
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany.,Institute for Experimental Cellular Therapy, University Hospital Essen, Essen, Germany
| | - Vesna Klisanin
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | - Evren Bayraktar
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany.,Chair of Applied Mathematics and Numerics, TU Dortmund University, Dortmund, Germany
| | - Lambros Kordelas
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | - Rudolf Trenschel
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | - Hellmut Ottinger
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | - Nina K Steckel
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | - Nikolaos Tsachakis-Mück
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | - Saskia Leserer
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | - Markus Ditschkowski
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | - Tobias Liebregts
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | - Michael Koldehoff
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | | | - Dietrich W Beelen
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
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12
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Bae S, Garonzik Wang JM, Massie AB, Jackson KR, McAdams-DeMarco MA, Brennan DC, Lentine KL, Coresh J, Segev DL. Early Steroid Withdrawal in Deceased-Donor Kidney Transplant Recipients with Delayed Graft Function. J Am Soc Nephrol 2019; 31:175-185. [PMID: 31852720 DOI: 10.1681/asn.2019040416] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 09/10/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Early steroid withdrawal (ESW) is associated with acceptable outcomes in kidney transplant (KT) recipients. Recipients with delayed graft function (DGF), however, often have a suboptimal allograft milieu, which may alter the risk/benefit equation for ESW. This may contribute to varying practices across transplant centers. METHODS Using the Scientific Registry of Transplant Recipients, we studied 110,019 adult deceased-donor KT recipients between 2005 and 2017. We characterized the association of DGF with the use of ESW versus continued steroid maintenance across KT centers, and quantified the association of ESW with acute rejection, graft failure, and mortality using multivariable logistic and Cox regression with DGF-ESW interaction terms. RESULTS Overall 29.2% of KT recipients underwent ESW. Recipients with DGF had lower odds of ESW (aOR=0.600.670.75). The strength of this association varied across 261 KT centers, with center-specific aOR of <0.5 at 31 (11.9%) and >1.0 at 22 (8.4%) centers. ESW was associated with benefits and harms among recipients with immediate graft function (IGF), but only with harms among recipients with DGF. ESW was associated with increased acute rejection (aOR=1.091.161.23), slightly increased graft failure (aHR=1.011.061.12), but decreased mortality (aHR=0.860.890.93) among recipients with IGF. Among recipients with DGF, ESW was associated with a similar increase in rejection (aOR=1.12; 95% CI, 1.02 to 1.23), a more pronounced increase in graft failure (aHR=1.16; 95% CI, 1.08 to 1.26), and no improvement in mortality (aHR=1.00; 95% CI, 0.94 to 1.07). DGF-ESW interaction was statistically significant for graft failure (P=0.04) and mortality (P=0.003), but not for rejection (P=0.6). CONCLUSIONS KT centers in the United States use ESW inconsistently in recipients with DGF. Our findings suggest ESW may lead to worse KT outcomes in recipients with DGF.
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Affiliation(s)
- Sunjae Bae
- Departments of Epidemiology and.,Departments of Surgery and.,Biostatistics, Johns Hopkins School of Public Health, Baltimore, Maryland
| | | | - Allan B Massie
- Departments of Epidemiology and.,Departments of Surgery and
| | | | | | - Daniel C Brennan
- Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University, St. Louis, Missouri
| | - Josef Coresh
- Departments of Epidemiology and.,Biostatistics, Johns Hopkins School of Public Health, Baltimore, Maryland.,Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Dorry L Segev
- Departments of Epidemiology and .,Departments of Surgery and
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Favi E, James A, Puliatti C, Whatling P, Ferraresso M, Rui C, Cacciola R. Utility and safety of early allograft biopsy in adult deceased donor kidney transplant recipients. Clin Exp Nephrol 2019; 24:356-368. [PMID: 31768863 DOI: 10.1007/s10157-019-01821-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 11/12/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Delayed graft function (DGF) is considered a risk factor for rejection after kidney transplantation (KTx). Clinical guidelines recommend weekly allograft biopsy until DGF resolves. However, who may benefit the most from such an aggressive policy and when histology should be evaluated remain debated. METHODS We analyzed 223 biopsies in 145 deceased donor KTx treated with basiliximab or anti-thymocyte globulin (rATG) and calcineurin inhibitor-based maintenance. The aim of the study was to assess the utility and safety of biopsies performed within 28 days of transplant. Relationships between transplant characteristics, indication, timing, and biopsy-related outcomes were evaluated. RESULTS Main indication for biopsy was DGF (87.8%) followed by lack of improvement in graft function (9.2%), and worsening graft function (3.1%). Acute tubular necrosis was the leading diagnosis (89.8%) whereas rejection was detected in 8.2% specimens. Rejection was more frequent in patients biopsied due to worsening graft function or lack of improvement in graft function than DGF (66.7% vs. 3.5%; P = 0.0075 and 33.3% vs. 3.5%; P = 0.0104, respectively) and in biopsies performed between day 15 and 28 than from day 0 to 14 (31.2% vs. 3.7%; P = 0.0002). Complication rate was 4.1%. Management was affected by the information gained with histology in 12.2% cases (7% considering DGF). CONCLUSIONS In low-immunological risk recipients treated with induction and calcineurin inhibitors maintenance, protocol biopsies obtained within 2 weeks of surgery to rule out rejection during DGF do not necessarily offer a favourable balance between risks and benefits. In these patients, a tailored approach may minimize complications thus optimizing results.
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Affiliation(s)
- Evaldo Favi
- Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza n. 35, 20122, Milan, Italy.
| | - Ajith James
- Nephrology, Royal London Hospital, Barts Health NHS Trust, Whitechapel Rd, London, E1 1BB, UK
| | - Carmelo Puliatti
- Organ Transplantation, Parma University Hospital, Via A. Gramsci 14, 43126, Parma, Italy
| | - Phil Whatling
- Nephrology, Royal London Hospital, Barts Health NHS Trust, Whitechapel Rd, London, E1 1BB, UK
| | - Mariano Ferraresso
- Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza n. 35, 20122, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Chiara Rui
- Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza n. 35, 20122, Milan, Italy
| | - Roberto Cacciola
- HPB and Transplant Unit, Department of Surgery, Tor Vergata University, Viale Oxford 81, 00133, Rome, Italy
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14
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Blazel JW, Turk JA, Muth BL, Parajuli S. Blessing and a curse of outpatient management of delayed graft function. World J Transplant 2019; 9:58-61. [PMID: 31523628 PMCID: PMC6715577 DOI: 10.5500/wjt.v9.i4.58] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 07/13/2019] [Accepted: 08/07/2019] [Indexed: 02/05/2023] Open
Abstract
Delayed graft function (DGF) is a common complication occurring most often after deceased donor kidney transplant with several donor characteristics as well as immunologic factors that lead to its development post-transplant. These patients require dialysis and close kidney function monitoring until sufficient allograft function is achieved. This has resulted in limited options for DGF management, either prolonged hospitalization until graft function improves to the point where dialysis is no longer needed or discharge back to their home dialysis unit with periodic follow up in the transplant clinic. DGF is associated with a higher risk for acute rejection, premature graft failure, and 30-d readmission; therefore, these patients need close monitoring, immunosuppression management, and prompt allograft biopsy if prolonged DGF is observed. This may not occur if these patients are discharged back to their home dialysis unit. To address this issue, the University of Wisconsin-Madison created a clinic in 2011 specialized in outpatient DGF management. This clinic was able to successfully reduce hospital length of stay without an increase in 30-d readmission, graft loss, and patient death.
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Affiliation(s)
- Justin W Blazel
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, United States
| | - Jennifer A Turk
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, United States
| | - Brenda L Muth
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, United States
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, United States
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