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Rabbit Antithymocyte Globulin Induction in Heart Transplant Recipients at High Risk for Rejection. Ochsner J 2021; 21:133-138. [PMID: 34239371 PMCID: PMC8238107 DOI: 10.31486/toj.20.0024] [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] [Indexed: 11/25/2022] Open
Abstract
Background: Induction with lymphocyte-depleting antibodies may improve allograft outcomes in heart transplant recipients who are at high immunologic risk for rejection. Methods: We conducted a single-center retrospective cohort study that compared outcomes between adult patients receiving rabbit antithymocyte globulin (rATG) induction vs no induction from 2011 through 2017. Key exclusion criteria were patients who did not receive tacrolimus and mycophenolate and patients who did not meet high immunologic risk criteria. Results: A total of 50 patients were included in the analysis. At 1 year, the composite primary outcome of ≥2R rejection as defined by the International Society for Heart and Lung Transplantation, any treated rejection, development of cardiac allograft vasculopathy, or graft loss was not different between groups (P=0.474). Serious infections were also similar between groups (P=0.963). In accordance with institutional guidelines, prednisone exposure was decreased in the rATG induction group at 1 month (24.04 mg ± 13.74 vs 35.18 mg ± 16.95; P=0.014). Conclusion: These results suggest that while rATG induction does not improve heart allograft outcomes, it may enable reducing early corticosteroid exposure in patients at high immunologic risk.
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Nozohoor S, Stehlik J, Lund LH, Ansari D, Andersson B, Nilsson J. Induction immunosuppression strategies and long‐term outcomes after heart transplantation. Clin Transplant 2020; 34:e13871. [DOI: 10.1111/ctr.13871] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 03/27/2020] [Accepted: 03/30/2020] [Indexed: 01/06/2023]
Affiliation(s)
- Shahab Nozohoor
- Department of Clinical Sciences Lund, Cardiothoracic Surgery Lund University and Skane University Hospital Lund Sweden
| | - Josef Stehlik
- Department of Cardiovascular Medicine University of Utah School of Medicine Salt Lake City Utah USA
- The ISHLT Transplant Registry Dallas TX USA
| | - Lars H. Lund
- Unit of Cardiology Department of Medicine Karolinska Institutet and Heart and Vascular Theme Karolinska University Hospital Stockholm Sweden
| | - David Ansari
- Department of Clinical Sciences Lund, Cardiothoracic Surgery Lund University and Skane University Hospital Lund Sweden
| | - Bodil Andersson
- Department of Clinical Sciences in Lund, Surgery Lund University and Skane University Hospital Lund Sweden
| | - Johan Nilsson
- Department of Clinical Sciences Lund, Cardiothoracic Surgery Lund University and Skane University Hospital Lund Sweden
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Blanchard-Rohner G, Enriquez N, Lemaître B, Cadau G, Combescure C, Giostra E, Hadaya K, Meyer P, Gasche-Soccal PM, Berney T, van Delden C, Siegrist CA. Usefulness of a systematic approach at listing for vaccine prevention in solid organ transplant candidates. Am J Transplant 2019; 19:512-521. [PMID: 30144276 DOI: 10.1111/ajt.15097] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 08/15/2018] [Accepted: 08/16/2018] [Indexed: 01/25/2023]
Abstract
Solid organ transplant (SOT) candidates may not be immune against potentially vaccine-preventable diseases because of insufficient immunizations and/or limited vaccine responses. We evaluated the impact on vaccine immunity at transplant of a systematic vaccinology workup at listing that included (1) pneumococcal with and without influenza immunization, (2) serology-based vaccine recommendations against measles, varicella, hepatitis B virus, hepatitis A virus, and tetanus, and (3) the documentation of vaccines and serology tests in a national electronic immunization registry (www.myvaccines.ch). Among 219 SOT candidates assessed between January 2014 and November 2015, 54 patients were transplanted during the study. Between listing and transplant, catch-up immunizations increased the patients' immunity from 70% to 87% (hepatitis A virus, P = .008), from 22% to 41% (hepatitis B virus, P = .008), from 77% to 91% (tetanus, P = .03), and from 78% to 98% (Streptococcus pneumoniae, P = .002). Their immunity at transplant was significantly higher against S. pneumoniae (P = .006) and slightly higher against hepatitis A virus (P = .07), but not against hepatitis B virus, than that of 65 SOT recipients transplanted in 2013. This demonstrates the value of a systematic multimodal serology-based approach of immunizations of SOT candidates at listing and the need for optimized strategies to increase their hepatitis B virus vaccine responses.
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Affiliation(s)
- Geraldine Blanchard-Rohner
- Department of Pediatrics and Pathology-Immunology, Center for Vaccinology and Neonatal Immunology, Medical Faculty and University Hospitals of Geneva, Geneva, Switzerland.,Department of Pediatrics, Children's Hospital of Geneva, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Natalia Enriquez
- Department of Pediatrics and Pathology-Immunology, Center for Vaccinology and Neonatal Immunology, Medical Faculty and University Hospitals of Geneva, Geneva, Switzerland.,Transplant Infectious Diseases Unit, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Barbara Lemaître
- Laboratory of Vaccinology, University Hospitals of Geneva, Geneva, Switzerland
| | - Gianna Cadau
- Laboratory of Vaccinology, University Hospitals of Geneva, Geneva, Switzerland
| | - Christophe Combescure
- Clinical Research Center, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Emiliano Giostra
- Departments of Gastroenterology and Hepatology, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Karine Hadaya
- Division of Nephrology, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Philippe Meyer
- Division of Cardiology, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Paola M Gasche-Soccal
- Division of Pneumology, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Thierry Berney
- Division of Transplantation, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Christian van Delden
- Transplant Infectious Diseases Unit, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Claire-Anne Siegrist
- Department of Pediatrics and Pathology-Immunology, Center for Vaccinology and Neonatal Immunology, Medical Faculty and University Hospitals of Geneva, Geneva, Switzerland.,Department of Pediatrics, Children's Hospital of Geneva, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
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Abstract
Immunosuppressive therapy is arguably the most important component of medical care after lung transplantation. The goal of immunosuppression is to prevent acute and chronic rejection while maximizing patient survival and long-term allograft function. However, the benefits of immunosuppressive therapy must be balanced against the side effects and major toxicities of these medications. Immunosuppressive agents can be classified as induction agents, maintenance therapies, treatments for acute rejection and chronic rejection and antibody directed therapies. Although induction therapy remains an area of controversy in lung transplantation, it is still used in the majority of transplant centers. On the other hand, maintenance immunosuppression is less contentious; but, unfortunately, since the creation of three-drug combination therapy, including a glucocorticoid, calcineurin inhibitor and anti-metabolite, there have been relatively modest improvements in chronic maintenance immunosuppressive regimens. The presence of HLA antibodies in transplant candidates and development of de novo antibodies after transplantation remain a major therapeutic challenge before and after lung transplantation. In this chapter we review the medications used for induction and maintenance immunosuppression along with their efficacy and side effect profiles. We also review strategies and evidence for HLA desensitization prior to lung transplantation and management of de novo antibody formation after transplant. Finally, we review immune tolerance and the future of lung transplantation to limit the toxicities of conventional immunosuppressive therapy.
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Affiliation(s)
- Luke J Benvenuto
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Michaela R Anderson
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Selim M Arcasoy
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
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Ariyamuthu VK, Amin AA, Drazner MH, Araj F, Mammen PPA, Ayvaci M, Mete M, Ozay F, Ghanta M, Mohan S, Mohan P, Tanriover B. Induction regimen and survival in simultaneous heart-kidney transplant recipients. J Heart Lung Transplant 2017; 37:587-595. [PMID: 29198930 DOI: 10.1016/j.healun.2017.11.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/03/2017] [Accepted: 11/13/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Induction therapy in simultaneous heart-kidney transplantation (SHKT) is not well studied in the setting of contemporary maintenance immunosuppression consisting of tacrolimus (TAC), mycophenolic acid (MPA), and prednisone (PRED). METHODS We analyzed the Organ Procurement and Transplant Network registry from January 1, 2000, to March 3, 2015, for recipients of SHKT (N = 623) maintained on TAC/MPA/PRED at hospital discharge. The study cohort was further stratified into 3 groups by induction choice: induction (n = 232), rabbit anti-thymoglobulin (r-ATG; n = 204), and interleukin-2 receptor-α (n = 187) antagonists. Survival rates were estimated using the Kaplan-Meier estimator. Multivariable inverse probability weighted Cox proportional hazard regression models were used to assess hazard ratios associated with post-transplant mortality as the primary outcome. The study cohort was censored on March 4, 2016, to allow at least 1-year of follow-up. RESULTS During the study period, the number of SHKTs increased nearly 5-fold. The Kaplan-Meier survival curve showed superior outcomes with r-ATG compared with no induction or interleukin-2 receptor-α induction. Compared with the no-induction group, an inverse probability weighted Cox proportional hazard model showed no independent association of induction therapy with the primary outcome. In sub-group analysis, r-ATG appeared to lower mortality in sensitized patients with panel reactive antibody of 10% or higher (hazard ratio, 0.19; 95% confidence interval, 0.05-0.71). CONCLUSION r-ATG may provide a survival benefit in SHKT, especially in sensitized patients maintained on TAC/MPA/PRED at hospital discharge.
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Affiliation(s)
| | - Alpesh A Amin
- Division of, Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mark H Drazner
- Division of, Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Faris Araj
- Division of, Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Pradeep P A Mammen
- Division of, Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mehmet Ayvaci
- Information Systems, School of Management, University of Texas at Dallas, Dallas, Texas
| | - Mutlu Mete
- Department of Computer Science, Texas A&M University-Commerce, Commerce, Texas
| | - Fatih Ozay
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mythili Ghanta
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sumit Mohan
- Division of Nephrology, Columbia University Medical Center, New York, New York
| | - Prince Mohan
- Division of Nephrology, Geisinger Medical Center, Danville, Pennnsylvania
| | - Bekir Tanriover
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
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