1
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Tang L, Ding C, Li H, Zhou X, Yin G. A Real-World Disproportionality Analysis of Drug-Induced Immune Hemolytic Anemia in the FDA Adverse Event Reporting System. Ann Pharmacother 2024; 58:375-382. [PMID: 37522435 DOI: 10.1177/10600280231189897] [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: 08/01/2023] Open
Abstract
BACKGROUND Drug-induced immune hemolytic anemia (DIIHA) is a rare but potentially life-threatening pharmacogenic hematological adverse effect. Updating the risk of DIIHA among the currently available drugs based on spontaneously reported adverse event data is of great significance. OBJECTIVE This study aimed to identify the top 50 drugs associated with immune hemolytic anemia in adults as well as common drugs that could cause immune hemolytic anemia in children based on the United States Food and Drug Administration Adverse Event Reporting System (FAERS) database. METHODS We extracted adverse events (AE) in the FAERS database from Q1 2004 to Q3 2022 using Open vigil2.1. We use the high-level term "anaemias haemolytic immune" according to the Medical Dictionary for Regulatory Activities (MedDRA) Dictionary (version 24.0). The reported correlation between drugs and DIIHA risk was identified by reported odds ratio (ROR) and proportional reporting ratio (PRR). RESULTS There were 10500309 AEs in FAERS from 2004Q1 to 2022Q3, of which 2326 (0.02%) were DIIHA cases. The incidence of DIIHA is comparable between males and females. The most common drugs associated with DIIHA in adults and children are summarized according to the number of AE reports. The top 3 categories in terms of quantity of drugs are antineoplastic agents, immunosuppressants, and antibiotics for systemic use. The top 5 drugs in terms of ROR and PRR are alemtuzumab, daclizumab, fludarabine, busulfan, and bendamustine in adults, with entecavir, treosulfan, vinorelbine, pegademase, and alemtuzumab for children. CONCLUSIONS Our study identified the most common drugs that could induce DIIHA in adults and children, as well as the respective ROR and PRR value to discover new drug signals. This study provides references to clinicians for the management of rare DIIHA.
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Affiliation(s)
- Linlin Tang
- Department of Pharmacy, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Chuanhua Ding
- Department of Pharmacy, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Hongying Li
- Department of Pharmacy, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Xueheng Zhou
- Department of Pharmacy, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Guoqiang Yin
- Department of Pharmacy, Affiliated Hospital of Weifang Medical University, Weifang, China
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2
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Andres AM, Talayero P, Alcolea Sanchez A, Sanchez Galán A, Serradilla Rodríguez J, Bueno Jimenez A, Gonzalez Sacristan R, Stringa P, Papa Gobbi R, Lasa Lazaro M, Díaz Almirón M, Ramos Boluda E, Lopez Santamaría M, Hernández Oliveros F. Delayed introduction of sirolimus in paediatric intestinal transplant recipients: indications and long-term benefits. Transpl Int 2021; 34:1895-1907. [PMID: 34174115 DOI: 10.1111/tri.13959] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/16/2021] [Accepted: 06/16/2021] [Indexed: 12/11/2022]
Abstract
To review our experience using sirolimus in a single centre paediatric intestinal transplantation cohort. Intestinal transplant patients with more than 3 months follow-up were divided into two groups according to their immunosuppression regimen: tacrolimus, (TAC group, n = 45 grafts) or sirolimus (SRL group, n = 38 grafts), which included those partially or completely converted from tacrolimus to sirolimus. The indications to switch were tacrolimus side effects and immunological complications. Survival and complications were retrospectively analysed comparing both groups. SRL was introduced 9 months (0 months-16.9 years) after transplant. The main cause for conversion was worsening renal function (45%), followed by haemolytic anaemia (21%) and graft-versus-host-disease (16%). Both groups showed a similar overall patient/graft survival (P = 0.76/0.08) and occurrence of rejection (24%/17%, P = 0.36). Immunological complications did not recur after conversion. Renal function significantly improved in most SRL patients. After a median follow-up of 65.17 months, 28/46 survivors were on SRL, 26 with monotherapy, with good graft function. Over one-third of our patients eventually required SRL conversion that allowed to improve their kidney function and immunological events, without entailing additional complications or survival impairment. Further trials are warranted to clarify the potential improvement of the standard tacrolimus maintenance by sirolimus conversion or addition.
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Affiliation(s)
- Ane M Andres
- Pediatric Surgery Department, La Paz University Hospital, Madrid, Spain.,Idipaz Institute, La Paz University Hospital, Madrid, Spain.,TransplantChild ERN, La Paz University Hospital, Madrid, Spain
| | - Paloma Talayero
- Immunology Department, 12 de Octubre University Hospital, Madrid, Spain
| | | | | | | | | | | | - Pablo Stringa
- Idipaz Institute, La Paz University Hospital, Madrid, Spain.,Institute for Immunological and Physiopathological Studies (IIFP-CONICET-UNLP), National University of La Plata, La plata, Buenos Aires, Argentina
| | | | - Maria Lasa Lazaro
- Immunology Department, 12 de Octubre University Hospital, Madrid, Spain
| | - Mariana Díaz Almirón
- Biostatistics Department, Idipaz Institute, La Paz University Hospital, Madrid, Spain
| | | | | | - Francisco Hernández Oliveros
- Pediatric Surgery Department, La Paz University Hospital, Madrid, Spain.,Idipaz Institute, La Paz University Hospital, Madrid, Spain.,TransplantChild ERN, La Paz University Hospital, Madrid, Spain
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3
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Wong D, Thomas W, Butler A, Sharkey L. Bortezomib for treatment-refractory autoimmune haemolytic anaemia following multivisceral transplantation. BMJ Case Rep 2021; 14:14/5/e241634. [PMID: 33980556 PMCID: PMC8118027 DOI: 10.1136/bcr-2021-241634] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 25-year-old man who received alemtuzumab as induction therapy for a multivisceral transplant experienced delayed onset of warm autoimmune haemolytic anaemia and neutropaenia. Serological testing and bone marrow biopsy excluded alternative causes. Haemolysis was refractory to standard therapies including corticosteroids, intravenous immunoglobulin and rituximab. The patient was successfully treated with bortezomib, a proteasome inhibitor, and has remained well as an outpatient without evidence of ongoing haemolysis.
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Affiliation(s)
- Darren Wong
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, UK .,Department of Gastroenterology, Austin Hospital, Heidelberg, Victoria, Australia
| | - William Thomas
- Department of Haematology, Addenbrooke's Hospital, Cambridge, UK
| | - Andrew Butler
- Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - Lisa Sharkey
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, UK
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4
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Thomas W, Foukaneli T, Cosgrove J, Massey D, Woodward J, Middleton S, Besser M, Russell N, Amin I, Butler A, Sharkey L. Transplant-associated thrombotic microangiopathy and immune haematological complications following intestine-containing organ transplantation: experience from over 100 consecutive cases. Br J Haematol 2021; 193:961-970. [PMID: 33954989 DOI: 10.1111/bjh.17430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/02/2021] [Accepted: 03/02/2021] [Indexed: 01/19/2023]
Abstract
Descriptions of passenger lymphocyte syndrome (PLS), immune cytopenias and transplant-associated thrombotic microangiopathy (TA-TMA) after intestine-containing transplants remain scarce. We describe our centre's experience of these complications from 2007 to 2019. Ninety-six patients received 103 transplants. PLS occurred in 9 (9%) patients (median 12 days post-transplant); all due to ABO antibodies. There were 31 minor ABO mismatch transplants. No patient required change in immunosuppression. Immune cytopenias (excluding PLS) occurred in six patients at an incidence of 1·7/100 patient years; three immune haemolysis, one immune thrombocytopenia, one acquired Glanzmann's and one immune neutropenia; 50% occurred with other cytopenias. All cases eventually responded to treatment, with a median of four treatments (range 1-8) and 5/6 were treated with rituximab. One patient with immune haemolysis required bortezomib. Complications were common in patients with immune cytopenias; 4/6 with infection needing intravenous antibiotics and 3/6 with venous thromboembolism. In 3/6 cases, a secondary cause for the immune cytopenia was evident. Switching from tacrolimus to ciclosporin was not necessary. There were five cases of transplant-associated thrombotic microangiopathy (TA-TMA; 1·5/100 patient years) requiring calcineurin inhibitor withdrawal; two cases associated with acute rejection. Two cases were managed with plasma exchange, one with plasma infusions and one with eculizumab. Further research in this patient group is required.
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Affiliation(s)
- Will Thomas
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Theodora Foukaneli
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,NHS Blood and Transplant, Cambridge, UK
| | - Joyce Cosgrove
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Dunecan Massey
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jeremy Woodward
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stephen Middleton
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Martin Besser
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Neil Russell
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Irum Amin
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew Butler
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Lisa Sharkey
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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5
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Knops N, Emonds MP, Herman J, Levtchenko E, Mekahli D, Pirenne J, Van Geet C, Dierickx D. Bortezomib for autoimmune hemolytic anemia after intestinal transplantation. Pediatr Transplant 2020; 24:e13700. [PMID: 32166874 DOI: 10.1111/petr.13700] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/03/2019] [Accepted: 02/24/2020] [Indexed: 01/19/2023]
Abstract
AIHA is rare in the general population and associated with a mortality of 8%. In contrast, AIHA occurs in up to 12.2% of cases after intestinal transplantation and is associated with mortality up to 50%. Treatment entails a "step-up" approach including corticosteroids, IvIg, plasmapheresis, and rituximab. However, AIHA after transplantation often is refractory to this strategy, contributing to a poor outcome. We describe a child with microvillous inclusion disease who developed AIHA 1 year after multivisceral transplantation that was refractory to standard therapy and was subsequently treated with bortezomib.We observed remission of AIHA within 1 week after the start of bortezomib. Bortezomib was associated with transient diarrhea, leucopenia, and elevated liver enzymes. Three years later, he remains in remission without important complications. Published data on bortezomib for autoimmune cytopenias outside SOT are discussed. This is the first report to support bortezomib as an important therapeutic alternative for AIHA after SOT. The occurrence and treatment of AIHA after SOT, and specifically intestinal transplantation, should be the subject of future registry studies to collect additional experience and explore the optimal therapeutic approach.
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Affiliation(s)
- Noël Knops
- Pediatrics (Pediatric Nephrology and Solid Organ Transplantation), University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration (Woman and Child), KU Leuven, Leuven, Belgium
| | - Marie-Paule Emonds
- Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium.,Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Jean Herman
- Pediatrics (Pediatric Nephrology and Solid Organ Transplantation), University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration (Woman and Child), KU Leuven, Leuven, Belgium
| | - Elena Levtchenko
- Pediatrics (Pediatric Nephrology and Solid Organ Transplantation), University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration (Woman and Child), KU Leuven, Leuven, Belgium
| | - Djalila Mekahli
- Pediatrics (Pediatric Nephrology and Solid Organ Transplantation), University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration (Woman and Child), KU Leuven, Leuven, Belgium
| | - Jacques Pirenne
- Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Chris Van Geet
- Pediatrics (Pediatric Hemato-Oncology), University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, KU Leuven, Leuven, Belgium
| | - Daan Dierickx
- Hematology, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology (Laboratorium of Experimental Hematology), KU Leuven, Leuven, Belgium
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6
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Hoshino A, Nishimura A, Naruto T, Okano T, Matsumoto K, Okamoto K, Shintaku H, Tokoro S, Okamoto H, Wada T, Takagi M, Imai K, Kanegane H, Morio T. High-throughput analysis revealed the unique immunoglobulin gene rearrangements in plasmacytoma-like post-transplant lymphoproliferative disorder. Br J Haematol 2020; 189:e164-e168. [PMID: 32191347 DOI: 10.1111/bjh.16583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Akihiro Hoshino
- Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akira Nishimura
- Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takuya Naruto
- Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tsubasa Okano
- Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuaki Matsumoto
- Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Keisuke Okamoto
- Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroshi Shintaku
- Division of Pathology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Shown Tokoro
- Department of Dermatology, Graduate School of Medicine and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroyuki Okamoto
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Taizo Wada
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Masatoshi Takagi
- Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohsuke Imai
- Department of Community Pediatrics, Perinatal and Maternal Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hirokazu Kanegane
- Department of Child Health and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomohiro Morio
- Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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7
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Jarchin L, Chu J, Januska M, Merola P, Arnon R. Autoimmune hemolytic anemia: An unusual presentation of hemophagocytic lymphohistiocytosis in a pediatric post-liver transplant patient. Pediatr Transplant 2018; 22:e13281. [PMID: 30129086 DOI: 10.1111/petr.13281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/09/2018] [Accepted: 07/24/2018] [Indexed: 01/19/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH), a rare condition characterized by immune dysfunction with uncontrolled activation of macrophages and hypersecretion of cytokines, has only been reported in a small number of pediatric patients following solid organ transplant (SOT). The diagnosis of HLH after SOT is especially difficult, as several of the diagnostic criteria, including fever, splenomegaly, and cytopenias, are nonspecific and can be seen with other post-transplant complications. Autoimmune hemolytic anemia (AIHA) has also been reported after pediatric SOT and is thought to be related to immunosuppression, specifically tacrolimus. Although HLH and AIHA have been separately described following SOT, there have been no reports of them occurring together in post-liver transplant (LT) patients. We report the first case of autoimmune hemolysis as the presenting symptom of HLH in a pediatric post-LT patient.
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Affiliation(s)
- Lauren Jarchin
- Division of Pediatric Gastroenterology, Mount Sinai Medical Center, New York City, New York
| | - Jaime Chu
- Recanati/Miller Transplantation Institute at Mount Sinai, Mount Sinai Medical Center, New York City, New York
| | - Megan Januska
- Department of Pediatrics, Mount Sinai Medical Center, New York City, New York
| | - Pamela Merola
- Division of Pediatric Hematology-Oncology, Mount Sinai Medical Center, New York City, New York
| | - Ronen Arnon
- Recanati/Miller Transplantation Institute at Mount Sinai, Mount Sinai Medical Center, New York City, New York
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8
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Rock N, Ansari M, Villard J, Ferrari-Lacraz S, Waldvogel S, McLin VA. Factors associated with immune hemolytic anemia after pediatric liver transplantation. Pediatr Transplant 2018; 22:e13230. [PMID: 29885007 DOI: 10.1111/petr.13230] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2018] [Indexed: 01/27/2023]
Abstract
Immune-mediated hemolytic anemia following SOT is a rare disorder, the risk factors for which are unknown. Our purpose was to analyze a seemingly increased incidence in our center with the aim to identify predisposing factors. This recipients single-center retrospective study reviewed the medical records of 96 pediatric LT between 2000 and 2013. IHA was defined as acute anemia with a positive direct antiglobulin test. Seven cases of immune-mediated hemolytic anemia were identified (incidence 8.5%). Three cases presented during the first 3 months following LT (early IHA), and 4 presented later (late IHA). All patients with late IHA required rituximab. Using univariate analysis, the following factors were associated with IHA onset: BA (P = .04), younger age (P = .04), and the use of IGL-1 preservation solution (P = .05). Late IHA was associated with viral infections occurring beyond 3 months following LT, younger age, and BA (P = .01). Overall, CMV infection was associated with the development of both early and late IHA: CMV-negative recipients who received an organ from a CMV-positive donor were more likely to develop IHA (P = .035), and de novo CMV infection during the first year post-LT was associated with late IHA (P = .03). IHA is a rare complication following pediatric LT, occurring more frequently in younger patients and patients with an initial diagnosis of BA. CMV-negative recipients and patients who experience a de novo CMV infection in the first year following LT seem particularly vulnerable. IGL-1 preservation solution may be associated with an increased likelihood of developing IHA, a novel finding which warrants further investigation.
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Affiliation(s)
- Nathalie Rock
- Swiss Center for Liver Disease in Children, University Hospitals Geneva, Geneva, Switzerland
| | - Marc Ansari
- Pediatric Hematology and Oncology Unit, University Hospitals Geneva, Geneva, Switzerland
| | - Jean Villard
- Transplant Immunology Unit, Division of Immunology and Allergy, University Hospitals Geneva, Geneva, Switzerland
| | - Sylvie Ferrari-Lacraz
- Transplant Immunology Unit, Division of Immunology and Allergy, University Hospitals Geneva, Geneva, Switzerland
| | - Sophie Waldvogel
- Immunology and Hematology Laboratory, University Hospitals Geneva, Geneva, Switzerland
| | - Valérie Anne McLin
- Swiss Center for Liver Disease in Children, University Hospitals Geneva, Geneva, Switzerland
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9
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Second-line therapy in paediatric warm autoimmune haemolytic anaemia. Guidelines from the Associazione Italiana Onco-Ematologia Pediatrica (AIEOP). BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018; 16:352-357. [PMID: 29757134 DOI: 10.2450/2018.0024-18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 03/27/2018] [Indexed: 02/08/2023]
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10
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Kanellopoulou T. Autoimmune hemolytic anemia in solid organ transplantation-The role of immunosuppression. Clin Transplant 2017. [PMID: 28621877 DOI: 10.1111/ctr.13031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Hemolysis after solid organ transplantation can be caused by both immune and non-immune-mediated mechanisms, and the evaluation must take into account issues distinctive to the post-transplant period. Autoimmune hemolytic anemia usually occurs within the first year and has been attributed to immunosuppressive treatment, infections, or underlying post-transplant lymphoproliferative disorder. Review of the literature revealed 59 cases with autoimmune hemolytic anemia mostly in children after liver transplantation. Almost all of the patients at the time of diagnosis received immunosuppression with tacrolimus, and first-line treatment with steroids and/or intravenous immunoglobulin was ineffective for complete remission. Rituximab was used as second-line treatment especially in patients with underlying lymphoproliferative disorders whereas sirolimus showed encouraging results.
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Affiliation(s)
- Theoni Kanellopoulou
- Department of Clinical Hematology, Blood Bank and Hemostasis, Onassis Cardiac Surgery Centre, Kallithea, Greece
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11
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Hill QA, Stamps R, Massey E, Grainger JD, Provan D, Hill A. Guidelines on the management of drug-induced immune and secondary autoimmune, haemolytic anaemia. Br J Haematol 2017; 177:208-220. [PMID: 28369704 DOI: 10.1111/bjh.14654] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Quentin A Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | | | | | - John D Grainger
- Royal Manchester Children's Hospital, University of Manchester, Manchester, UK
| | - Drew Provan
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Anita Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
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12
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Abstract
PURPOSE OF REVIEW Intestine has become a transplantable organ due to the improvement in immunosuppressive drugs. The early referral to a reference unit is crucial in prognosis. There are still some pending issues like chronic rejection, the knowledge of the role of DSA development or early noninvasive detection of acute rejection. RECENT FINDINGS The appearance of tacrolimus and mTOR, and the use of induction therapy have marked a turning point with better graft and patient survival rates. The inclusion of the liver in the graft seems to have a protective effect. Surveillance of opportunistic infections has also contributed to improved results. Infection, post-transplant lymphoproliferative disease, rejection and GVHD have still a major role in survival; however, antibody-mediated rejection has gained increased attention. SUMMARY Parenteral nutrition remains the main therapeutic resource in the management of intestinal failure, but intestinal transplant is a therapeutic option when this therapy has failed. Finding the balanced immunosuppression that minimizes risk of rejection while preventing occurrence of complications like post-transplant lymphoproliferative disease or GVHD is an ongoing challenge. The current survival rates of intestinal transplantation are similar to other solid organ transplant.
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13
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Park JA, Lee HH, Kwon HS, Baik CR, Song SA, Lee JN. Sirolimus for Refractory Autoimmune Hemolytic Anemia after Allogeneic Hematopoietic Stem Cell Transplantation: A Case Report and Literature Review of the Treatment of Post-Transplant Autoimmune Hemolytic Anemia. Transfus Med Rev 2016; 30:6-14. [DOI: 10.1016/j.tmrv.2015.09.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/18/2015] [Accepted: 09/18/2015] [Indexed: 12/18/2022]
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14
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ElAnsary M, Hanna MOF, Saadi G, ElShazly M, Fadel FI, Ahmed HA, Aziz AM, ElSharnouby A, Kandeel MMT. Passenger lymphocyte syndrome in ABO and Rhesus D minor mismatched liver and kidney transplantation: A prospective analysis. Hum Immunol 2015; 76:447-52. [PMID: 25842056 DOI: 10.1016/j.humimm.2015.03.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 02/04/2015] [Accepted: 03/11/2015] [Indexed: 11/19/2022]
Abstract
The increasing demand for solid organs has necessitated the use of ABO and Rhesus (Rh) D minor mismatched transplants. The passenger lymphocyte syndrome (PLS) occurs when donor lymphocytes produce antibodies that react with host red blood cell (RBC) antigens and result in hemolysis. Our aim was to evaluate prospectively the role of PLS in post transplant anemia and hemolysis in ABO and RhD minor mismatched recipients of liver and kidney grafts and to study the association of PLS with donor lymphocyte microchimerism. We examined 11 liver and 10 kidney recipients at Day +15 for anemia, markers of hemolysis, direct antiglobulin test and eluates, and serum RBC antibodies. Microchimerism was determined in peripheral blood lymphocytes by genotyping of simple sequence length polymorphisms encoding short tandem repeats. Immune hemolytic anemia and anti-recipient RBC antibodies were observed in 2 out of 11 liver (18.2%) and 2 out of 10 kidney (20%) transplants. RBC antibody specificity reflected the donor to recipient transplant, with anti-blood group B antibodies identified in 2 cases of O to B and 1 case of A to AB transplants while anti-D antibodies were detected in 1 case of RhD-negative to RhD-positive transplant. Donor microchimerism was found in only 1 patient. In conclusion, passenger lymphocyte mediated hemolysis is frequent in minor mismatched liver and kidney transplantation. Recognizing PLS as a potential cause of post transplant anemia may allow for early diagnosis and management to decrease the morbidity and mortality in some patients.
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Affiliation(s)
- Mervat ElAnsary
- Department of Clinical Pathology, Cairo University, Cairo, Egypt
| | | | - Gamal Saadi
- Department of Internal Medicine and Nephrology, Cairo University, Cairo, Egypt
| | | | - Fatina I Fadel
- Department of Pediatric Nephrology, Cairo University, Cairo, Egypt
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15
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Koepsell SA, Grant W, Landmark JD. Autoantibodies to red blood cell antigens occur frequently with hemolysis among pediatric small bowel transplant recipients: clinical implications and management. Pediatr Transplant 2015; 19:62-7. [PMID: 25400072 DOI: 10.1111/petr.12391] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2014] [Indexed: 11/27/2022]
Abstract
Reports have linked pediatric solid organ transplant recipients with the development of hemolytic autoimmune antibodies, especially in the setting of the immunosuppressant tacrolimus. This study aims to identify whether these observations also occurred at an institution that frequently performs pediatric multivisceral transplants and to characterize the treatment and outcome. Chart review was performed on all patients with RBC autoantibodies. Laboratory and clinical data were used to identify hemolysis. For transplant recipients with RBC autoantibodies, the type of transplant and outcome of the AIHA were profiled. One hundred twenty-eight patients were identified with RBC autoantibodies, of which 22 patients were solid organ transplant recipients, including 18 SB graft recipients. Sixteen of the 18 had evidence of hemolysis. The incidence rate of AIHA in this population is estimated to be 10%, resulting in significant cost. Treatment included immunosuppressant modulation, steroids, IVIG, and plasma exchange, with 12 of the 16 patients responding. RBC autoantibodies occur in up to 10% in pediatric SB transplant recipients, with high cost of obtaining compatible blood. Neither tacrolimus nor receipts of a donor spleen were associated with the development of AIHA. Treatment using steroids and IVIG appears to be effective.
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Affiliation(s)
- Scott A Koepsell
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA
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Schoettler M, Elisofon SA, Kim HB, Blume ED, Rodig N, Boyer D, Neufeld EJ, Grace RF. Treatment and outcomes of immune cytopenias following solid organ transplant in children. Pediatr Blood Cancer 2015; 62:214-218. [PMID: 25308853 PMCID: PMC4394012 DOI: 10.1002/pbc.25215] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 07/10/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Immune cytopenias are a recognized life-threatening complication following pediatric solid organ transplants (SOT), but treatment responses and overall outcome are not well described. The aim of this study was to evaluate the demographic characteristics, response to treatments, and outcomes of a cohort of patients who developed immune cytopenias following SOT. PROCEDURE In this single center retrospective review, patients with immune cytopenias after SOT were identified by electronic medical record (EMR) search and transplant databases from 1995-2012. RESULTS Of 764 SOT patients, 19 (2.4%) developed immune cytopenias. Incidence varied widely by transplant type from 1.2% (renal) to 23.5% (multivisceral). Autoimmune hemolytic anemia (AIHA) was the most common immune cytopenia. Overall median time from transplant to immune cytopenia was 8 m and varied by transplant type from 3 m (liver) to 74 m (heart). Standard therapies for immune cytopenias were often used and ineffective. The most effective therapy for the immune cytopenia was changing immunosuppression from tacrolimus to another agent. Three of 19 patients died; none directly attributed to the immune cytopenia. CONCLUSIONS Immune cytopenias are not rare after SOT, and patients usually do not respond well to traditional first line therapies. Provided that the risk of organ rejection is otherwise manageable, temporary cessation of tacrolimus could be more widely explored in this challenging clinical context. Pediatr Blood Cancer 2015;62:214-218. © 2014 Wiley Periodicals, Inc.
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Affiliation(s)
- Michelle Schoettler
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, MA
| | - Scott A Elisofon
- The Division of Gastroenterology, Boston Children's Hospital, Boston, MA
| | - Heung Bae Kim
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | | | - Nancy Rodig
- Division of Nephrology, Boston Children's Hospital, Boston, MA
| | - Debra Boyer
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA
| | - Ellis J Neufeld
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, MA
| | - Rachael F Grace
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, MA
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Alemtuzumab plus cyclosporine treatment of the autoimmune hemolytic anemia in an adult bowel transplant. Case Rep Transplant 2014; 2014:262953. [PMID: 25177510 PMCID: PMC4142660 DOI: 10.1155/2014/262953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 07/29/2014] [Indexed: 11/17/2022] Open
Abstract
An adult male underwent a bowel transplant for tufting enteropathy, receiving alemtuzumab, tacrolimus, and steroids as immunosuppressants. Five years later, he developed an autoimmune hemolytic anemia (AIHA), anti-IgG positive, with reduced reticulocyte count, leukopenia, and thrombocytopenia with antiplatelet antibodies. After an unsuccessful initial treatment with high dose steroids, reduction in tacrolimus dose, and intravenous immunoglobulin (IVIG), a bone marrow biopsy revealed absence of erythroid maturation with precursor hyperplasia. The patient was switched to sirolimus and received four doses of rituximab plus two courses of plasmapheresis, which decreased his transfusion requirements. After a febrile episode one month later, the AIHA relapsed with corresponding decreases in platelet and leukocyte count: cyclosporine A (CsA) was started with a second course of rituximab and IVIG without response, even though repeat bone marrow biopsy did not reveal morphology correlated to an acquired pure red cell aplasia (APRCA). Considering the similarity in his clinical and laboratory findings to APRCA, alemtuzumab was added (three doses over a week) with CsA followed by steroids. The patient was eventually discharged transfusion-independent, with increasing hemoglobin (Hb) levels and normal platelet and leukocyte count. One year later he is still disease-free with functioning graft.
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Hernandez F, Andres AM, Encinas JL, Domínguez E, Gamez M, Murcia FJ, Leal N, Martinez L, Molina M, Ramos E, Sarria J, Martinez-Ojinaga E, Prieto G, Frauca E, Lopez-Santamaria M. Preservation of the native spleen in multivisceral transplantation. Pediatr Transplant 2013; 17:556-60. [PMID: 23890077 DOI: 10.1111/petr.12124] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2013] [Indexed: 11/29/2022]
Abstract
The native spleen is usually removed in patients undergoing MTV. The consequential asplenic state is associated with a high risk of sepsis, especially in immunosuppressed children. In contrast, the inclusion of an allogeneic spleen in multivisceral grafts has been associated with a high incidence of GVHD. We propose an alternative technique for patients undergoing MTV, consisting of the preservation of the native spleen. This approach avoids the additional risk of infection that characterizes the asplenic state without the detrimental side effects of the allogeneic spleen.
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Affiliation(s)
- F Hernandez
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain.
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20
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Acquazzino MA, Fischer RT, Langnas A, Coulter DW. Refractory autoimmune hemolytic anemia after intestinal transplant responding to conversion from a calcineurin to mTOR inhibitor. Pediatr Transplant 2013; 17:466-71. [PMID: 23730873 DOI: 10.1111/petr.12101] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2013] [Indexed: 11/28/2022]
Abstract
AIHA is a rare and serious complication of solid organ transplantation. Herein, we report four cases of warm or mixed AIHA in pediatric patients following combined liver, small bowel and pancreas transplant. The hemolysis was refractory to multiple treatment modalities including steroids, rituximab, IVIG, plasmapheresis, cytoxan, discontinuation of prophylactic penicillin, and a change in immunosuppression from tacrolimus to cyclosporine. All patients had resolution or marked improvement of hemolysis after discontinuation of maintenance of CNI and initiation of sirolimus immunosuppression. One patient developed nephrotic syndrome but responded to a change in immunosuppression to everolimus. Three of the four patients continue on immunosuppression with sirolimus or everolimus without further hemolysis, evidence of rejection or medication side effects. Based on our experience and review of similar cases in the literature, we have proposed a treatment algorithm for AIHA in the pediatric intestinal transplant patient population that recommends an early change in immunosuppressive regimen from CNIs to sirolimus therapy.
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Affiliation(s)
- Melissa A Acquazzino
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE 68198-2168, USA
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21
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Immunological complications beyond rejection after intestinal transplantation. Curr Opin Organ Transplant 2012; 17:268-72. [DOI: 10.1097/mot.0b013e32835337b2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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22
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Bogie AL, Guthrie C. High-Technology Gastroenterology Disorders in Children. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2012. [DOI: 10.1016/j.cpem.2012.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Li M, Goldfinger D, Yuan S. Autoimmune hemolytic anemia in pediatric liver or combined liver and small bowel transplant patients: a case series and review of the literature. Transfusion 2011; 52:48-54. [DOI: 10.1111/j.1537-2995.2011.03254.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nayyar NS, McGhee W, Martin D, Sindhi R, Soltys K, Bond G, Mazariegos GV. Intestinal transplantation in children: a review of immunotherapy regimens. Paediatr Drugs 2011; 13:149-59. [PMID: 21500869 PMCID: PMC7101554 DOI: 10.2165/11588530-000000000-00000] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
This review summarizes the outcomes and known adverse effects of current immunosuppression strategies in use in pediatric intestinal transplantation. Intestinal transplantation has evolved from an experimental therapy to a highly successful treatment for children with intestinal failure who have complications with total parenteral nutrition. Because of continued success with intestinal transplantation over the past decade, the focus of clinicians and researchers is shifting from short-term patient survival to optimizing long-term outcomes. Current 5-year patient and graft survival rates after intestinal transplantation are 58% and 40%, respectively, in the US; single centers have reported nearly 80% patient and 60% graft survival rates at 5 years. The immunosuppression strategy in intestinal transplantation includes a tacrolimus-based regimen, usually in conjunction with an antibody induction therapy such as rabbit-antithymocyte globulin, interleukin-2 receptor antagonists, or alemtuzumab. The use of these immunosuppressive regimens, along with improved medical and surgical care, has contributed significantly toward improved outcomes. Optimization of post-transplant immunosuppression strategies to reduce adverse effects while minimizing acute and chronic graft rejection is a strong clinical and research focus.
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Affiliation(s)
- Navdeep S. Nayyar
- Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh of UPMC, One Children’s Hospital Drive, 4401 Penn Avenue, Faculty Pavilion, Floor 6, Pittsburgh, Pennsylvania 15224 USA
| | - William McGhee
- Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania USA ,Department of Pharmacy, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania USA
| | - Dolly Martin
- Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania USA
| | - Rakesh Sindhi
- Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh of UPMC, One Children’s Hospital Drive, 4401 Penn Avenue, Faculty Pavilion, Floor 6, Pittsburgh, Pennsylvania 15224 USA ,Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania USA
| | - Kyle Soltys
- Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh of UPMC, One Children’s Hospital Drive, 4401 Penn Avenue, Faculty Pavilion, Floor 6, Pittsburgh, Pennsylvania 15224 USA ,Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania USA
| | - Geoffrey Bond
- Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh of UPMC, One Children’s Hospital Drive, 4401 Penn Avenue, Faculty Pavilion, Floor 6, Pittsburgh, Pennsylvania 15224 USA ,Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania USA
| | - George V. Mazariegos
- Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh of UPMC, One Children’s Hospital Drive, 4401 Penn Avenue, Faculty Pavilion, Floor 6, Pittsburgh, Pennsylvania 15224 USA ,Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania USA
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