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Fichtner A, Schmidt J, Süsal C, Carraro A, Oh J, Zirngibl M, König S, Guzzo I, Weber LT, Awan A, Krupka K, Schnitzler P, Hirsch HH, Tönshoff B, Höcker B. Risk of cellular or antibody-mediated rejection in pediatric kidney transplant recipients with BK polyomavirus replication-an international CERTAIN registry study. Pediatr Nephrol 2024:10.1007/s00467-024-06501-7. [PMID: 39392493 DOI: 10.1007/s00467-024-06501-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 08/09/2024] [Accepted: 08/12/2024] [Indexed: 10/12/2024]
Abstract
BACKGROUND In kidney transplant recipients (KTR), BK polyomavirus-associated nephropathy (BKPyVAN) is a major cause of graft loss. To facilitate the clearance of BKPyV-DNAemia, reduction of immunosuppression is currently the treatment of choice but may increase the risk of graft rejection. METHODS This international CERTAIN study was designed to determine the risk of alloimmune response and graft dysfunction associated with immunosuppression reduction for BKPyV treatment in 195 pediatric KTR. RESULTS BKPyV-DNAemia was associated with a more than twofold increased risk of late T cell-mediated rejection (TCMR) (HR 2.22, p = 0.024), of de novo donor-specific HLA antibodies (dnDSA) and/or antibody-mediated rejection (ABMR) (HR 2.64, p = 0.002), and of graft function deterioration (HR 2.73, p = 0.001). Additional independent risk factors for dnDSA/ABMR development were a higher HLA mismatch (HR 2.72, p = 0.006) and re-transplantation (HR 6.40, p = 0.000). Other independent predictors of graft function deterioration were TCMR (HR 3.98, p = 0.003), higher donor age (HR 1.03, p = 0.020), and re-transplantation (HR 3.56, p = 0.013). CONCLUSIONS These data indicate that reduction of immunosuppression for BKPyV-DNAemia management is associated with increased alloimmune response in pediatric KTR. Therefore, regular dnDSA screening and close monitoring of graft function in case of BKPyV-DNAemia followed by subsequent reduction of immunosuppressive therapy are recommended.
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Affiliation(s)
- Alexander Fichtner
- Heidelberg University, Medical Faculty Heidelberg, Department of Pediatrics I, University Children's Hospital, Im Neuenheimer Feld 430, Heidelberg, 69120, Germany
| | - Jeremy Schmidt
- Heidelberg University, Medical Faculty Heidelberg, Department of Pediatrics I, University Children's Hospital, Im Neuenheimer Feld 430, Heidelberg, 69120, Germany
| | - Caner Süsal
- Heidelberg University, Medical Faculty Heidelberg, Department of Transplantation Immunology, Institute of Immunology, Heidelberg, Germany
- Transplant Immunology Research Center of Excellence, Koç University, Istanbul, Turkey
| | - Andrea Carraro
- Pediatric Nephrology, Dialysis and Transplantation Unit, Department of Woman's and Child's Health, University Hospital of Padova, Via Giustiniani 3, 35128, Padua, Italy
| | - Jun Oh
- Department of Pediatric Nephrology, University Children's Hospital, Martinistr. 52, 20246, Hamburg, Germany
| | - Matthias Zirngibl
- University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany
| | - Sabine König
- Department of General Pediatrics, University Children's Hospital Münster, Waldeyerstraße 22, 48149, Münster, Germany
| | - Isabella Guzzo
- Pediatric Nephrology and Renal Transplant Unit, Bambino Gesù Children's Hospital-IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Lutz T Weber
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Faculty of Medicine, University of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Atif Awan
- Temple Street Children's University Hospital, Dublin 1, Ireland
| | - Kai Krupka
- Heidelberg University, Medical Faculty Heidelberg, Department of Pediatrics I, University Children's Hospital, Im Neuenheimer Feld 430, Heidelberg, 69120, Germany
| | - Paul Schnitzler
- Department of Infectious Diseases, Virology, Heidelberg University, Medical Faculty Heidelberg, Im Neuenheimer Feld 324, Heidelberg, 69120, Germany
| | - Hans H Hirsch
- Transplantation & Clinical Virology, Department Biomedicine, University of Basel, Petersplatz 10, 4009, Basel, Switzerland
- Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Burkhard Tönshoff
- Heidelberg University, Medical Faculty Heidelberg, Department of Pediatrics I, University Children's Hospital, Im Neuenheimer Feld 430, Heidelberg, 69120, Germany
| | - Britta Höcker
- Heidelberg University, Medical Faculty Heidelberg, Department of Pediatrics I, University Children's Hospital, Im Neuenheimer Feld 430, Heidelberg, 69120, Germany.
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Schold JD, Tambur AR, Mohan S, Kaplan B. Calibration of Priority Points for Sensitization Status of Kidney Transplant Candidates in the United States. Clin J Am Soc Nephrol 2024; 19:767-777. [PMID: 38509037 PMCID: PMC11168827 DOI: 10.2215/cjn.0000000000000449] [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: 09/28/2023] [Accepted: 03/14/2024] [Indexed: 03/22/2024]
Abstract
Key Points There are multiple factors associated with high sensitization levels among kidney transplant candidates, which differ by candidate sex. Since the initiation of the kidney allocation system, candidates with higher sensitization have higher rates of deceased donor transplantation. Priority points assigned to candidates associated with sensitization have led to inequities in access to deceased donor transplantation. Background A primary change to the national organ allocation system in 2014 for deceased donor kidney offers was to weight candidate priority on the basis of sensitization (i.e ., calculated panel reactive antibody percentage [cPRA%]) using a sliding scale. Increased priority for sensitized patients could improve equity in access to transplantation for disadvantaged candidates. We sought to evaluate the effect of these weights using a contemporary cohort of adult US kidney transplant candidates. Methods We used the national Scientific Registry of Transplant Recipients to evaluate factors associated with sensitization using multivariable logistic models and rates of deceased donor transplantation using cumulative incidence models accounting for competing risks and multivariable Cox models. Results We examined 270,912 adult candidates placed on the waiting list between January 2016 and September 2023. Six-year cumulative incidence of deceased donor transplantation for candidates with cPRA%=80–85 and 90–95 was 48% and 53%, respectively, as compared with 37% for candidates with cPRA%=0–20. In multivariable models, candidates with high cPRA% had the highest adjusted hazards for deceased donor transplantation. There was significant effect modification such that the association of high cPRA% with adjusted rates of deceased donor transplantation varied by region of the country, sex, race and ethnicity, prior dialysis time, and blood type. Conclusions The results indicate that the weighting algorithm for highly sensitized candidates may overinflate the need for prioritization and lead to higher rates of transplantation. Findings suggest recalibration of priority weights for allocation is needed to facilitate overall equity in access to transplantation for prospective kidney transplant candidates. However, priority points should also account for subgroups of candidates who are disadvantaged for access to donor offers.
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Affiliation(s)
- Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Anat R Tambur
- Department of Surgery, Northwestern University, Chicago, Illinois
| | - Sumit Mohan
- Department of Medicine, Columbia University, New York, New York
- Department of Epidemiology, Columbia University, New York, New York
| | - Bruce Kaplan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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van den Broek DAJ, Meziyerh S, Budde K, Lefaucheur C, Cozzi E, Bertrand D, López del Moral C, Dorling A, Emonds MP, Naesens M, de Vries APJ. The Clinical Utility of Post-Transplant Monitoring of Donor-Specific Antibodies in Stable Renal Transplant Recipients: A Consensus Report With Guideline Statements for Clinical Practice. Transpl Int 2023; 36:11321. [PMID: 37560072 PMCID: PMC10408721 DOI: 10.3389/ti.2023.11321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/22/2023] [Indexed: 08/11/2023]
Abstract
Solid phase immunoassays improved the detection and determination of the antigen-specificity of donor-specific antibodies (DSA) to human leukocyte antigens (HLA). The widespread use of SPI in kidney transplantation also introduced new clinical dilemmas, such as whether patients should be monitored for DSA pre- or post-transplantation. Pretransplant screening through SPI has become standard practice and DSA are readily determined in case of suspected rejection. However, DSA monitoring in recipients with stable graft function has not been universally established as standard of care. This may be related to uncertainty regarding the clinical utility of DSA monitoring as a screening tool. This consensus report aims to appraise the clinical utility of DSA monitoring in recipients without overt signs of graft dysfunction, using the Wilson & Junger criteria for assessing the validity of a screening practice. To assess the evidence on DSA monitoring, the European Society for Organ Transplantation (ESOT) convened a dedicated workgroup, comprised of experts in transplantation nephrology and immunology, to review relevant literature. Guidelines and statements were developed during a consensus conference by Delphi methodology that took place in person in November 2022 in Prague. The findings and recommendations of the workgroup on subclinical DSA monitoring are presented in this article.
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Affiliation(s)
- Dennis A. J. van den Broek
- Division of Nephrology, Department of Medicine, Leiden Transplant Center, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Soufian Meziyerh
- Division of Nephrology, Department of Medicine, Leiden Transplant Center, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Carmen Lefaucheur
- Paris Translational Research Center for Organ Transplantation, Kidney Transplant Department, Saint Louis Hospital, Université de Paris Cité, Paris, France
| | - Emanuele Cozzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Transplant Immunology Unit, Padua University Hospital, Padua, Italy
| | - Dominique Bertrand
- Department of Nephrology, Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Covadonga López del Moral
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
- Valdecilla Biomedical Research Institute (IDIVAL), Santander, Spain
| | - Anthony Dorling
- Department of Inflammation Biology, Centre for Nephrology, Urology and Transplantation, School of Immunology & Microbial Sciences, King’s College London, Guy’s Hospital, London, United Kingdom
| | - Marie-Paule Emonds
- Histocompatibility and Immunogenetics Laboratory (HILA), Belgian Red Cross-Flanders, Mechelen, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Aiko P. J. de Vries
- Division of Nephrology, Department of Medicine, Leiden Transplant Center, Leiden University Medical Center, Leiden University, Leiden, Netherlands
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4
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Seeking Standardized Definitions for HLA-incompatible Kidney Transplants: A Systematic Review. Transplantation 2023; 107:231-253. [PMID: 35915547 DOI: 10.1097/tp.0000000000004262] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is no standard definition for "HLA incompatible" transplants. For the first time, we systematically assessed how HLA incompatibility was defined in contemporary peer-reviewed publications and its prognostic implication to transplant outcomes. METHODS We combined 2 independent searches of MEDLINE, EMBASE, and the Cochrane Library from 2015 to 2019. Content-expert reviewers screened for original research on outcomes of HLA-incompatible transplants (defined as allele or molecular mismatch and solid-phase or cell-based assays). We ascertained the completeness of reporting on a predefined set of variables assessing HLA incompatibility, therapies, and outcomes. Given significant heterogeneity, we conducted narrative synthesis and assessed risk of bias in studies examining the association between death-censored graft failure and HLA incompatibility. RESULTS Of 6656 screened articles, 163 evaluated transplant outcomes by HLA incompatibility. Most articles reported on cytotoxic/flow T-cell crossmatches (n = 98). Molecular genotypes were reported for selected loci at the allele-group level. Sixteen articles reported on epitope compatibility. Pretransplant donor-specific HLA antibodies were often considered (n = 143); yet there was heterogeneity in sample handling, assay procedure, and incomplete reporting on donor-specific HLA antibodies assignment. Induction (n = 129) and maintenance immunosuppression (n = 140) were frequently mentioned but less so rejection treatment (n = 72) and desensitization (n = 70). Studies assessing death-censored graft failure risk by HLA incompatibility were vulnerable to bias in the participant, predictor, and analysis domains. CONCLUSIONS Optimization of transplant outcomes and personalized care depends on accurate HLA compatibility assessment. Reporting on a standard set of variables will help assess generalizability of research, allow knowledge synthesis, and facilitate international collaboration in clinical trials.
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Qeska D, Wong RBK, Famure O, Li Y, Pang H, Liang XY, Zhu MP, Husain S, Kim SJ. Incidence, risk factors, outcomes, and clinical management of BK viremia in the modern era of kidney transplantation. Transpl Infect Dis 2022; 24:e13915. [PMID: 35899972 DOI: 10.1111/tid.13915] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 06/19/2022] [Accepted: 07/04/2022] [Indexed: 12/24/2022]
Abstract
BK viremia is endemic among kidney transplant recipients (KTRs). Incidence, risk factors, outcomes, and clinical management of detectable versus high BK viremia have not been considered previously in KTR in the modern era. This observational study examined KTR transplanted between January 1, 2009 and December 31, 2016. Any BK viral load in the serum constituted detectable BK viremia and ≥103 copies/ml constituted high viremia. Among 1193 KTRs, the cumulative probability of developing detectable and high BK viremia within 2 years posttransplant were 27.8% and 19.6%, respectively. Significant risk factors for detectable BK viremia included recipient age (HR 1.02 [95% CI: 1.01, 1.03]) and donor age (HR 1.01 [95% CI: 1.00, 1.02]). Recipient age also predicted high BK viremia (HR 1.02 [95% CI: 1.01, 1.03]), whereas White race (HR 0.70 [95% CI: 0.52, 0.95]), nondepleting induction therapy (HR 0.61 [95% CI: 0.42, 0.89]), and delayed graft function (HR 0.61 [95% CI: 0.42, 0.88]) were protective. Mean estimated glomerular filtration rates were 4.28 ml/min/1.72 m2 (95% CI: 2.71, 5.84) lower with detectable BK viremia. Although low viral load was usually not acted upon at first presentation, antiproliferative dose reductions were the most common initial management. BK viremia remains a common early complication in a modern cohort of KTRs. These findings highlight the benefit of early BKV monitoring in addition to intensive clinical management. Clinical responses beyond first positive BK viremia tests, and their implications for graft outcomes, merit further investigation.
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Affiliation(s)
- Denis Qeska
- Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Rebecca Bic Kay Wong
- Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Olusegun Famure
- Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Yanhong Li
- Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Hilary Pang
- Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Xin Yun Liang
- Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Mary Parker Zhu
- Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Shahid Husain
- Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Infectious Diseases, University Health Network, Toronto, Ontario, Canada
| | - Sang Joseph Kim
- Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Division of Nephrology, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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6
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Kurašová E, Štěpán J, Krejčí K, Mrázek F, Sauer P, Janečková J, Tichý T. Current Status, Prevention and Treatment of BK Virus Nephropathy. ACTA MEDICA (HRADEC KRALOVE) 2022; 65:119-124. [PMID: 36942701 DOI: 10.14712/18059694.2023.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
All renal transplant recipients should undergo a regular screening for BK viral (BKV) viremia. Gradual reduction of immunosuppression is recommended in patients with persistent plasma BKV viremia for 3 weeks after the first detection, reflecting the presence of probable or suspected BKV-associated nephropathy. Reduction of immunosuppression is also a primary intervention in biopsy proven nephropathy associated with BKV (BKVN). Thus, allograft biopsy is not required to treat patients with BKV viremia with stabilized graft function. There is a lack of proper randomised clinical trials recommending treatment in the form of switching from tacrolimus to cyclosporin-A, from mycophenolate to mTOR inhibitors or leflunomide, or the additive use of intravenous immunoglobulins, leflunomide or cidofovir. Fluoroquinolones are not recommended for prophylaxis or therapy. There are on-going studies to evaluate the possibility of using a multi-epitope anti-BKV vaccine, administration of BKV-specific T cell immunotherapy, BKV-specific human monoclonal antibody and RNA antisense oligonucleotides. Retransplantation after allograft loss due to BKVN can be successful if BKV viremia is definitively removed, regardless of allograft nephrectomy.
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Affiliation(s)
- Ester Kurašová
- University Hospital Olomouc and Palacký University Olomouc, Faculty of Medicine and Dentistry, Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Olomouc, Czech Republic.
| | - Jakub Štěpán
- University Hospital Olomouc and Palacký University Olomouc, Faculty of Medicine and Dentistry, Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Olomouc, Czech Republic
| | - Karel Krejčí
- University Hospital Olomouc and Palacký University Olomouc, Faculty of Medicine and Dentistry, Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Olomouc, Czech Republic
| | - František Mrázek
- University Hospital Olomouc and Palacký University Olomouc, Faculty of Medicine and Dentistry, Department of Immunology, Olomouc, Czech Republic
| | - Pavel Sauer
- University Hospital Olomouc and Palacký University Olomouc, Faculty of Medicine and Dentistry, Department of Microbiology, Olomouc, Czech Republic
| | - Jana Janečková
- University Hospital Olomouc and Palacký University Olomouc, Faculty of Medicine and Dentistry, Department of Surgery II, Olomouc, Czech Republic
| | - Tomáš Tichý
- University Hospital Olomouc and Palacký University Olomouc, Faculty of Medicine and Dentistry, Department of Clinical and Molecular Pathology, Olomouc, Czech Republic
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7
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Charnaya O, Jones J, Philogene MC, Chiang PY, Segev DL, Massie AB, Garonzik-Wang J. Eplet mismatches associated with de novo donor-specific HLA antibody in pediatric kidney transplant recipients. Pediatr Nephrol 2021; 36:3971-3979. [PMID: 34100108 PMCID: PMC8602732 DOI: 10.1007/s00467-021-05078-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/22/2021] [Accepted: 03/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Optimizing amino acid (eplet) histocompatibility at first transplant decreases the risk of de novo donor-specific antibody (dnDSA) development and may improve long-term graft survival in pediatric kidney transplant recipients (KTR). We performed a retrospective analysis of pediatric KTR and their respective donors to identify eplets most commonly associated with dnDSA formation. METHODS Eplet mismatch analysis was performed in a cohort of 125 pediatric KTR-donor pairs (2006-2018). We determined the prevalence of each eplet mismatch and quantified the percentage of exposed patients who developed dnDSA for each mismatched eplet. RESULTS Recipient median age was 14 (IQR 8-17) years with a racial distribution of 42% Black, 48% Caucasian, and 5.6% Middle-Eastern. Median eplet load varied significantly by recipient race, Black 82 (IQR 58-98), White 60 (IQR 44-81) and Other 66 (IQR 61-76), p = 0.002. Forty-four percent of patients developed dnDSA after median 37.1 months. Compared to dnDSA- patients, dnDSA+ patients had higher median eplet load, 64 (IQR 46-83) vs. 77 (IQR 56-98), p = 0.012. The most common target of dnDSA were eplets expressed in HLA-A*11 and A2 in Class I, and HLA-DQ6 and DQA5 in Class II. The most commonly mismatched eplets were not the most likely to result in dnDSA formation. CONCLUSIONS In a racially diverse population, only a subset of eplets was linked to antibody formation. Eplet load alone is not a sufficient surrogate for eplet immunogenicity. These findings illustrate the need to optimize precision in donor selection and allocation to improve long-term graft outcomes. Graphical Abstract A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Olga Charnaya
- Department of Pediatrics, Johns Hopkins University School of Medicine, 200 N Wolfe St, Baltimore, MD, 21287, USA.
| | - June Jones
- Department of Immunogenetics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Po-Yu Chiang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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8
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Race and sex based disparities in sepsis. Heart Lung 2021; 52:37-41. [PMID: 34837726 DOI: 10.1016/j.hrtlng.2021.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 11/04/2021] [Accepted: 11/07/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Studies of sepsis evaluating sex- and race-related disparities in treatment and outcome have been limited by using administrative databases, which may not adequately capture sepsis diagnosis, used limited number and types of races, or not included both sex and race in the analyses. OBJECTIVE To determine if patients of different races and sexes with sepsis have different mortality, receipt of mechanical ventilation or renal replacement therapy, or time to antibiotics? METHODS We retrospectively analyzed clinical data from 34,999 patients with sepsis, defined by Sepsis-3 criteria, using logistic regression and linear regression. RESULTS After adjustments for confounders, Asian females had the lowest adjusted 90-day mortality (OR=0.656, 95% CI=0.385-1.118, p<0.001 compared to White males). Similarly, compared to White males, African-American males had a lower adjusted mortality (OR=0.790, 95% CI=0.648-0.963, p = 0.019), while Asian males (OR=1.185, 95% CI=0. 828-1.696, p = 0.354) and both African-American (OR=0.972, 95% CI=0.800-1.182, p = 0.779) and Caucasian (OR=1.054, 95% CI=0.960-1.158, p = 0.270) females had similar mortality. Both male and female patients with Other/unknown race had higher mortality (OR=1.776, 95% CI=1.395-2.261, p<0.001 and OR=1.658, 95% CI=1.359-2.021, p<0.001), respectively. In the secondary analyses for new-onset mechanical ventilation and new-onset renal replacement therapy post-sepsis, we found no association between any of the race-sex groups and receipt of these therapies. CONCLUSION We found that Asian females had the lowest adjusted 90-day mortality for patients with sepsis. Understanding the reasons for disparities in outcome after sepsis may improve care and outcomes in diverse populations.
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Molnar MZ, Azhar A, Tsujita M, Talwar M, Balaraman V, Bhalla A, Podila PSB, Kothadia J, Agbim UA, Maliakkal B, Satapathy SK, Kovesdy CP, Nair S, Eason JD. Transplantation of Kidneys From Hepatitis C Virus-Infected Donors to Hepatitis C Virus-Negative Recipients: One-Year Kidney Allograft Outcomes. Am J Kidney Dis 2020; 77:739-747.e1. [PMID: 33333148 DOI: 10.1053/j.ajkd.2020.10.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/21/2020] [Indexed: 01/26/2023]
Abstract
RATIONALE & OBJECTIVE Transplant centers in the United States are increasingly willing to transplant kidneys from hepatitis C virus (HCV)-infected (HCV+) donors into HCV- recipients. We studied the association between donor HCV infection status and kidney allograft function and posttransplantation allograft biopsy findings. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS We examined 65 HCV- recipients who received a kidney from a HCV+ donor and 59 HCV- recipients who received a kidney from a HCV- donor during 2018 at a single transplant center. EXPOSURE Predictor(s) of donor infection with HCV. OUTCOMES Kidney allograft function and allograft biopsy findings during the first year following transplantation. ANALYTICAL APPROACH We compared estimated glomerular filtration rate (eGFR), findings on for-cause and surveillance protocol biopsies, development of de novo donor-specific antibodies (DSAs), and patient and allograft outcomes during the first year following transplantation between recipients of HCV+ and HCV- kidneys. We used linear regression to estimate the independent association between allograft function and HCV viremic status of the kidney donor. RESULTS The mean age of recipients was 52 ± 11 (SD) years, 43% were female, 19% and 80% of recipients were White and Black, respectively. Baseline characteristics were similar between the HCV+ and HCV- groups. There were no statistically significant differences between the HCV+ and HCV- groups in delayed graft function rates (12% vs 8%, respectively); eGFRs at 3, 6, 9, and 12 months post-transplantation; proportions of patients with cellular rejection (6% vs 7%, respectively); and proportions with antibody-mediated rejection (7% vs 10%, respectively) or de novo DSAs (31% vs 20%, respectively). HCV viremic status was not associated with eGFR at 3, 6, 9, or 12 months. LIMITATIONS Generalizability from a single-center study and small sample size was limited. CONCLUSIONS Recipients of kidneys from donors infected with HCV had similar kidney allograft function and probability of rejection in the first year after transplantation compared to those who received kidneys from donors without HCV infection.
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Affiliation(s)
- Miklos Z Molnar
- Division of Nephrology & Hypertension, Department of Medicine, University of Utah, Salt Lake City, UT.
| | - Ambreen Azhar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN; Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Makoto Tsujita
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN; Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Manish Talwar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN; Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Vasanthi Balaraman
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN; Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Anshul Bhalla
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN; Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Pradeep S B Podila
- Faith and Health Division, Methodist Le Bonheur Healthcare, Memphis, TN; Division of Health Systems Management and Policy, School of Public Health, The University of Memphis, Memphis, TN
| | - Jiten Kothadia
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN; Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Uchenna A Agbim
- Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Benedict Maliakkal
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN; Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Sanjaya K Satapathy
- Department of Medicine, Sandra Atlas Bass Center for Liver Diseases and Transplantation, Zucker School of Medicine at Hofstra University, Northshore University Hospital/Northwell Health, Manhasset, NY
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN; Nephrology Section, Memphis Veterans' Affairs Medical Center, Memphis, TN
| | - Satheesh Nair
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN; Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - James D Eason
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN; Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
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10
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Burek Kamenaric M, Ivkovic V, Kovacevic Vojtusek I, Zunec R. The Role of HLA and KIR Immunogenetics in BK Virus Infection after Kidney Transplantation. Viruses 2020; 12:v12121417. [PMID: 33317205 PMCID: PMC7763146 DOI: 10.3390/v12121417] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 12/13/2022] Open
Abstract
BK virus (BKV) is a polyomavirus with high seroprevalence in the general population with an unremarkable clinical presentation in healthy people, but a potential for causing serious complications in immunosuppressed transplanted patients. Reactivation or primary infection in kidney allograft recipients may lead to allograft dysfunction and subsequent loss. Currently, there is no widely accepted specific treatment for BKV infection and reduction of immunosuppressive therapy is the mainstay therapy. Given this and the sequential appearance of viruria-viremia-nephropathy, screening and early detection are of utmost importance. There are numerous risk factors associated with BKV infection including genetic factors, among them human leukocyte antigens (HLA) and killer cell immunoglobulin-like receptors (KIR) alleles have been shown to be the strongest so far. Identification of patients at risk for BKV infection would be useful in prevention or early action to reduce morbidity and progression to frank nephropathy. Assessment of risk involving HLA ligands and KIR genotyping of recipients in the pre-transplant or early post-transplant period might be useful in clinical practice. This review summarizes current knowledge of the association between HLA, KIR and BKV infection and potential future directions of research, which might lead to optimal utilization of these genetic markers.
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Affiliation(s)
- Marija Burek Kamenaric
- Tissue Typing Center, Clinical Department of Transfusion Medicine and Transplantation Biology, University Hospital Center Zagreb, 10 000 Zagreb, Croatia;
| | - Vanja Ivkovic
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb, 10 000 Zagreb, Croatia; (V.I.); (I.K.V.)
- Department of Public Health, Faculty of Health Studies, University of Rijeka, 51 000 Rijeka, Croatia
| | - Ivana Kovacevic Vojtusek
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb, 10 000 Zagreb, Croatia; (V.I.); (I.K.V.)
| | - Renata Zunec
- Tissue Typing Center, Clinical Department of Transfusion Medicine and Transplantation Biology, University Hospital Center Zagreb, 10 000 Zagreb, Croatia;
- Correspondence:
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11
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Safety and Efficacy of a Steroid Avoidance Immunosuppression Regimen in Renal Transplant Patients With De Novo or Preformed Donor-Specific Antibodies: A Single-Center Study. Transplant Proc 2020; 53:950-961. [PMID: 33293041 DOI: 10.1016/j.transproceed.2020.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/18/2020] [Accepted: 10/20/2020] [Indexed: 11/23/2022]
Abstract
Although interest in the role of donor-specific antibodies (DSAs) in kidney transplant rejection, graft survival, and histopathological outcomes is increasing, their impact on steroid avoidance or minimization in renal transplant populations is poorly understood. Primary outcomes of graft survival, rejection, and histopathological findings were assessed in 188 patients who received transplants between 2012 and 2015 at the Scripps Center for Organ Transplantation, which follows a steroid avoidance protocol. Analyses were performed using data from the United Network for Organ Sharing. Cohorts included kidney transplant recipients with de novo DSAs (dnDSAs; n = 27), preformed DSAs (pfDSAs; n = 15), and no DSAs (nDSAs; n = 146). Median time to dnDSA development (classes I and II) was shorter (102 days) than in previous studies. Rejection of any type was associated with DSAs to class I HLA (P < .05) and class II HLA (P < .01) but not with graft loss. Although mean fluorescence intensity (MFI) independently showed no association with rejection, an MFI >5000 showed a trend toward more antibody-mediated rejection (P < .06), though graft loss was not independently associated. Banff chronic allograft nephropathy scores and a modified chronic injury score were increased in the dnDSA cohort at 6 months, but not at 2 years (P < .001 and P < .08, respectively). Our data suggest that dnDSAs and pfDSAs impact short-term rejection rates but do not negatively impact graft survival or histopathological outcomes at 2 years. Periodic protocol post-transplant DSA monitoring may preemptively identify patients who develop dnDSAs who are at a higher risk for rejection.
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12
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Jucaud V, Shaked A, DesMarais M, Sayre P, Feng S, Levitsky J, Everly MJ. Prevalence and Impact of De Novo Donor-Specific Antibodies During a Multicenter Immunosuppression Withdrawal Trial in Adult Liver Transplant Recipients. Hepatology 2019; 69:1273-1286. [PMID: 30229989 DOI: 10.1002/hep.30281] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/09/2018] [Indexed: 01/07/2023]
Abstract
The development of human leukocyte antigen (HLA) donor-specific antibody/antibodies (DSA) is not well described in liver transplant (LT) patients undergoing immunosuppression (IS) withdrawal protocols despite the allograft risk associated with de novo DSA (dnDSA). We analyzed the development of dnDSA in 69 LT patients who received calcineurin inhibitor monotherapy and were enrolled in the ITN030ST study. Of these 69 patients, 40 stable patients were randomized to IS maintenance (n = 9) or IS minimization (n = 31). Nine of the 31 IS minimization patients achieved complete withdrawal and were free of IS. Among patients who achieved stable IS monotherapy 1 year after transplantation, the prevalence of dnDSA was 18.8%. Acute rejections and the biopsy-proven findings disqualifying patients from IS withdrawal attempt were factors associated with dnDSA development (P = 0.011 and P = 0.041, respectively). Among randomized patients, dnDSA prevalence was 51.7% after IS minimization and 66.7% in IS-free patients. dnDSA prevalence in patients on IS maintenance was 44.4%. dnDSA development during IS minimization was a risk factor for acute rejection (P = 0.015). The majority of dnDSA were against HLA-DQ antigens (78.7%). Conclusion. During the first year following transplantation, acute rejections increase the risk of developing dnDSA, so dnDSA positivity should be considered for IS withdrawal eligibility; during IS minimization, dnDSA development was associated with acute rejection, which prevented further IS withdrawal attempts.
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Affiliation(s)
| | | | | | - Peter Sayre
- Immune Tolerance Network, San Francisco, CA.,University of California San Francisco, San Francisco, CA
| | - Sandy Feng
- University of California San Francisco, San Francisco, CA
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13
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Krejci K, Tichy T, Bednarikova J, Zamboch K, Zadrazil J. BK virus-induced renal allograft nephropathy. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2018; 162:165-177. [DOI: 10.5507/bp.2018.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 04/11/2018] [Indexed: 12/11/2022] Open
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Associations between Interleukin-31 Gene Polymorphisms and Dilated Cardiomyopathy in a Chinese Population. DISEASE MARKERS 2017; 2017:4191365. [PMID: 28572699 PMCID: PMC5442432 DOI: 10.1155/2017/4191365] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 03/04/2017] [Accepted: 03/28/2017] [Indexed: 02/05/2023]
Abstract
To explore the role of Interkeulin-31 (IL-31) in dilated cardiomyopathy (DCM), in our study, two SNPs of IL-31, rs4758680 (C/A) and rs7977932 (C/G), were analyzed in 331 DCM patients and 493 controls in a Chinese Han population. The frequencies of C allele and CC genotype of rs4758680 were significantly increased in DCM patients (P = 0.005, P = 0.001, resp.). Compared to CC genotype of rs4758680, the A carriers (CA/AA genotypes) were the protect factors in DCM susceptibility while the frequencies of CA/AA genotypes were decreased in the dominant model for DCM group (P < 0.001, OR = 0.56, 95%CI = 0.39–0.79). Moreover, IL-31 mRNA expression level of white blood cells was increased in DCM patients (0.072 (0.044–0.144) versus 0.036 (0.020–0.052), P < 0.001). In survival analysis of 159 DCM patients, Kaplan-Meier curve revealed the correlation between CC homozygote of rs4758680 and worse prognosis for DCM group (P = 0.005). Compared to CC genotype, the CA/AA genotypes were the independent factors in both univariate (HR = 0.530, 95%CI = 0.337–0.834, P = 0.006) and multivariate analyses after age, gender, left ventricular end-diastolic diameter, and left ventricular ejection fraction adjusted (HR = 0.548, 95%CI = 0.345–0.869, P = 0.011). Thus, we concluded that IL-31 gene polymorphisms were tightly associated with DCM susceptibility and contributed to worse prognosis in DCM patients.
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