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Gore EJ, Gard L, Niesters HGM, Van Leer Buter CC. Understanding torquetenovirus (TTV) as an immune marker. Front Med (Lausanne) 2023; 10:1168400. [PMID: 37384041 PMCID: PMC10296770 DOI: 10.3389/fmed.2023.1168400] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/02/2023] [Indexed: 06/30/2023] Open
Abstract
Torquetenovirus (TTV), a small, single stranded anellovirus, is currently being explored as a marker of immunocompetence in patients with immunological impairment and inflammatory disorders. TTV has an extremely high prevalence and is regarded as a part of the human virome, the replication of which is controlled by a functioning immune system. The viral load of TTV in plasma of individuals is thought to reflect the degree of immunosuppression. Measuring and quantifying this viral load is especially promising in organ transplantation, as many studies have shown a strong correlation between high TTV loads and increased risk of infection on one side, and low TTV loads and an increased risk of rejection on the other side. As clinical studies are underway, investigating if TTV viral load measurement is superior for gauging antirejection therapy compared to medication-levels, some aspects nevertheless have to be considered. In contrast with medication levels, TTV loads have to be interpreted bearing in mind that viruses have properties including transmission, tropism, genotypes and mutations. This narrative review describes the potential pitfalls of TTV measurement in the follow-up of solid organ transplant recipients and addresses the questions which remain to be answered.
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2
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Elalouf A. Infections after organ transplantation and immune response. Transpl Immunol 2023; 77:101798. [PMID: 36731780 DOI: 10.1016/j.trim.2023.101798] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 01/08/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023]
Abstract
Organ transplantation has provided another chance of survival for end-stage organ failure patients. Yet, transplant rejection is still a main challenging factor. Immunosuppressive drugs have been used to avoid rejection and suppress the immune response against allografts. Thus, immunosuppressants increase the risk of infection in immunocompromised organ transplant recipients. The infection risk reflects the relationship between the nature and severity of immunosuppression and infectious diseases. Furthermore, immunosuppressants show an immunological impact on the genetics of innate and adaptive immune responses. This effect usually reactivates the post-transplant infection in the donor and recipient tissues since T-cell activation has a substantial role in allograft rejection. Meanwhile, different infections have been found to activate the T-cells into CD4+ helper T-cell subset and CD8+ cytotoxic T-lymphocyte that affect the infection and the allograft. Therefore, the best management and preventive strategies of immunosuppression, antimicrobial prophylaxis, and intensive medical care are required for successful organ transplantation. This review addresses the activation of immune responses against different infections in immunocompromised individuals after organ transplantation.
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Affiliation(s)
- Amir Elalouf
- Bar-Ilan University, Department of Management, Ramat Gan 5290002, Israel.
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3
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BK DNAemia and native kidney polyomavirus nephropathy following lung transplantation. Am J Transplant 2023; 23:284-290. [PMID: 36804135 DOI: 10.1016/j.ajt.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 10/29/2022] [Accepted: 11/01/2022] [Indexed: 01/13/2023]
Abstract
BK virus DNAemia (BKPyV) and nephropathy are common after kidney transplant; however, there are limited data on BK infections in nonrenal solid organ transplant recipients. We examined the frequency, clinical and pathologic features, and kidney and lung outcomes of BKPyV and BK virus native kidney nephropathy (BKVN) in lung transplant recipients at our center. Among 878 recipients transplanted from 2003 to 2019, 56 (6%) developed BKPyV at a median of 30.1 months after transplant (range, 0.6-213) and 11 (1.3%) developed BKVN at a median of 46 months after transplant (range, 9-213). The incidence of end-stage kidney disease was significantly higher in patients with peak viral load ≥10 000 copies/mL (39% vs 8%, P < .001). All cases of BKVN were in patients with peak viral load of ≥10 000 copies/mL, and 55% of these patients developed end-stage kidney disease. Despite the reduction of immunosuppression to treat BKVN, only 1 patient developed acute rejection, and lung function was stable >1 year. BKPyV and nephropathy are more common after lung transplantation than previously reported. Routine screening for BKPyV should be considered in all lung transplant recipients.
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Woywodt A, Dhanda R, van Dellen D, So B, Bright-Thomas RJ. Kidney and combined kidney and pancreas transplantation may be under-utilized in cystic fibrosis. FRONTIERS IN TRANSPLANTATION 2022; 1:992985. [PMID: 38994374 PMCID: PMC11235247 DOI: 10.3389/frtra.2022.992985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/05/2022] [Indexed: 07/13/2024]
Abstract
Cystic fibrosis (CF) is a multisystem disorder and represents the most common inherited condition leading to death in Western countries. Previous reports of chronic kidney disease (CKD) in CF focus on cases post lung, or other solid organ, transplantation but CKD in CF patients pre transplantation is increasingly recognized as a challenging complication of CF. CKD can evolve as a sequel to acute kidney injury for example after prolonged treatment with aminoglycoside antibiotics during episodes of infection. Nephrolithiasis, diabetic nephropathy and a variety of glomerular lesions, such as amyloidosis and Immunoglobulin A nephropathy are also seen. Muscle depletion is common in CF, hence creatinine-based estimates of kidney function may underestimate the degree of renal impairment and lead to delayed diagnosis and management. Improved treatment options for CF patients have resulted in a sustained increase in life expectancy with increasing numbers of CF patients with CKD approaching end-stage renal failure prior to consideration of lung transplantation. We believe that kidney or combined kidney-pancreas transplantation are under-utilized in this population. We provide a brief primer on the landscape of CF and CKD and discuss transplant options. Suitable patients with CF and advanced CKD should be formally assessed for kidney or kidney-pancreas transplantation.
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Affiliation(s)
- Alexander Woywodt
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Preston, United Kingdom
| | - Raman Dhanda
- Manchester Centre for Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - David van Dellen
- Manchester Centre for Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Beng So
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Preston, United Kingdom
| | - Rowland J Bright-Thomas
- Manchester Adult Cystic Fibrosis Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
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5
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Agrawal A, Ison MG, Danziger-Isakov L. Long-Term Infectious Complications of Kidney Transplantation. Clin J Am Soc Nephrol 2022; 17:286-295. [PMID: 33879502 PMCID: PMC8823942 DOI: 10.2215/cjn.15971020] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Infections remain a common complication of solid-organ transplantation. Most infections in the first month after transplant are typically health care-associated infections, whereas late infections, beyond 6-12 months, are community-acquired infections. Opportunistic infections most frequently present in the first 12 months post-transplant and can be modulated on prior exposures and use of prophylaxis. In this review, we summarize the current epidemiology of postkidney transplant infections with a focus on key viral (BK polyomavirus, cytomegalovirus, Epstein-Barr virus, and norovirus), bacterial (urinary tract infections and Clostridioides difficile colitis), and fungal infections. Current guidelines for safe living post-transplant are also summarized. Literature supporting prophylaxis and vaccination is also provided.
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Affiliation(s)
- Akansha Agrawal
- Division of Nephrology, Northwestern University Feinberg School of Medicine, Chicago, Illinois,Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael G. Ison
- Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois,Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lara Danziger-Isakov
- Division of Pediatric Infectious Diseases, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
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6
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Myint TM, Chong CHY, Wyld M, Nankivell B, Kable K, Wong G. Polyoma BK Virus in Kidney Transplant Recipients: Screening, Monitoring, and Management. Transplantation 2022; 106:e76-e89. [PMID: 33908382 DOI: 10.1097/tp.0000000000003801] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Polyomavirus BK virus (BKPyV) infection is an important complication of kidney transplantation and allograft failure. The prevalence of viremia is 10%-15%, compared with BK-associated nephropathy (BKPyVAN) at 3%-5%. Given that there are no effective antiviral prophylaxis or treatment strategies for BKPyVAN, active screening to detect BKPyV viremia is recommended, particularly during the early posttransplant period. Immunosuppression reduction to allow viral clearance may avoid progression to severe and irreversible allograft damage. The frequency and duration of screening are highly variable between transplant centers because the evidence is reliant largely on observational data. While the primary treatment goals center on achieving viral clearance through immunosuppression reduction, prevention of subsequent acute rejection, premature graft loss, and return to dialysis remain as major challenges. Treatment strategies for BKPyV infection should be individualized to the recipient's underlying immunological risk and severity of the allograft infection. Efficacy data for adjuvant therapies including intravenous immunoglobulin and cidofovir are sparse. Future well-powered and high-quality randomized controlled trials are needed to inform evidence-based clinical practice for the management of BKPy infection.
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Affiliation(s)
- Thida Maung Myint
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Newcastle Transplant Unit, John Hunter Hospital, Newcastle, NSW, Australia
| | - Chanel H Y Chong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Melanie Wyld
- Department of Renal Medicine, Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Brian Nankivell
- Department of Renal Medicine, Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Kathy Kable
- Department of Renal Medicine, Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Department of Renal Medicine, Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
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7
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Albasha W, Vahdani G, Ashoka A, Bracamonte E, Yau AA. Native BK virus nephropathy in lung transplant: a case report and literature review. Clin Kidney J 2021; 15:808-811. [PMID: 35371460 PMCID: PMC8967672 DOI: 10.1093/ckj/sfab251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Indexed: 11/14/2022] Open
Abstract
Classically described in renal allografts, BK virus nephropathy is increasingly recognized in native kidneys of other non-renal solid organ transplants. We discuss a 68-year-old woman with a history of bilateral lung transplant referred for worsening renal function, confirmed to have BK virus nephropathy by biopsy with a serum BK virus polymerase chain reaction of over 59 million copies/mL. She was managed with a reduction in immunosuppression and intravenous cidofovir with no improvement in her clinical parameters. The seven prior reported cases of polyoma virus nephropathy in lung transplant recipients are reviewed, and the challenges of screening and management are discussed.
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Affiliation(s)
- Waseem Albasha
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, University of Arizona College of Medicine, USA
| | - Golnaz Vahdani
- Division of Nephrology, Department of Medicine, The Ohio State University, USA
| | - Ankita Ashoka
- Department of Medicine, University of Arizona College of Medicine, USA
| | - Erika Bracamonte
- Department of Pathology, University of Arizona College of Medicine, USA
| | - Amy A Yau
- Division of Nephrology, Department of Medicine, The Ohio State University, USA
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Munker D, Veit T, Schönermarck U, Arnold P, Leuschner G, Barton J, Mümmler C, Briegel I, Mumm JN, Zoller M, Kauke T, Sisic A, Ghiani A, Walter J, Milger K, Mueller S, Michel S, Munker S, Keppler O, Fischereder M, Meiser B, Behr J, Kneidinger N, Neurohr C. Polyomavirus exerts detrimental effects on renal function in patients after lung transplantation. J Clin Virol 2021; 145:105029. [PMID: 34798365 DOI: 10.1016/j.jcv.2021.105029] [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: 07/28/2021] [Revised: 11/03/2021] [Accepted: 11/10/2021] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Chronic kidney disease (CKD) is associated with significant morbidity and mortality after lung transplantation (LTX). Calcineurin inhibitor (CNI) nephrotoxicity is the leading cause of CKD. After kidney transplantation, polyomavirus-associated nephropathy (PyVAN) is a well-recognized problem. This study aims to evaluate the role of polyomavirus in patients after LTX. METHODS From January 2017 to January 2020, all lung transplant recipients who performed follow-up visits in our center were included in the study and retrospectively assessed. We measured renal function (creatinine levels before and after transplantation), JCPyV, and BKPyV load by polymerase chain reaction (PCR) in serum and urine samples after transplantation. RESULTS In total, 104 consecutive patients (59 males, 56.7%) with a mean age of 49.6 ± 11.1 years were identified. JCPyV was found in urine of 36 patients (34.6%) and serum of 3 patients (2.9%). BKPyV was found in urine of 40 patients (38.5%) and serum of 4 patients (3.8%), respectively. Urine evidence for JCPyV (p < 0.001, coefficient: +21.44) and BKPyV (p < 0.001, coefficient: +29.65) correlated highly with further kidney function decline. CONCLUSION Kidney function deterioration is associated with JCPyV and BKPyV viruria in patients after LTX. This might indicate a role of PyVAN in lung transplant recipients.
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Affiliation(s)
- Dieter Munker
- Department of Medicine V, University hospital, LMU Munich; Comprehensive Pneumology Center (CPC-M); Member of the German Center for Lung Research (DZL), Munich, Germany.
| | - Tobias Veit
- Department of Medicine V, University hospital, LMU Munich; Comprehensive Pneumology Center (CPC-M); Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Ulf Schönermarck
- Department of Medicine IV, University hospital, LMU Munich, Germany
| | - Paola Arnold
- Department of Medicine V, University hospital, LMU Munich; Comprehensive Pneumology Center (CPC-M); Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Gabriela Leuschner
- Department of Medicine V, University hospital, LMU Munich; Comprehensive Pneumology Center (CPC-M); Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Jürgen Barton
- Department of Medicine V, University hospital, LMU Munich; Comprehensive Pneumology Center (CPC-M); Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Carlo Mümmler
- Department of Medicine V, University hospital, LMU Munich; Comprehensive Pneumology Center (CPC-M); Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Ignaz Briegel
- Department of Medicine V, University hospital, LMU Munich; Comprehensive Pneumology Center (CPC-M); Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Jan-Niclas Mumm
- Department of Urology, University hospital, LMU Munich, Germany
| | - Michael Zoller
- Department of Anesthesiology, University hospital, LMU Munich, Germany
| | - Teresa Kauke
- Department of Thoracic Surgery, University hospital, LMU Munich, Germany
| | - Alma Sisic
- Transplant Center, University hospital, LMU Munich, Germany
| | - Alessandro Ghiani
- Department of Pneumology and Respiratory Medicine, Schillerhoehe Clinic (affiliated to Rober-Bosch-Hospital GmbG, Stuttgart), Solitudestr. 18, 70839, Gerlingen, Germany
| | - Julia Walter
- Department of Medicine V, University hospital, LMU Munich; Comprehensive Pneumology Center (CPC-M); Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Katrin Milger
- Department of Medicine V, University hospital, LMU Munich; Comprehensive Pneumology Center (CPC-M); Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Susanna Mueller
- Department of Pathology, University hospital, LMU Munich, Germany
| | - Sebastian Michel
- Department of Thoracic Surgery, University hospital, LMU Munich, Germany; Transplant Center, University hospital, LMU Munich, Germany
| | - Stefan Munker
- Department of Internal Medicine II, University hospital, LMU Munich, Germany
| | - Oliver Keppler
- Department of Internal Medicine II, University hospital, LMU Munich, Germany
| | | | - Bruno Meiser
- Transplant Center, University hospital, LMU Munich, Germany
| | - Jürgen Behr
- Department of Medicine V, University hospital, LMU Munich; Comprehensive Pneumology Center (CPC-M); Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Nikolaus Kneidinger
- Department of Medicine V, University hospital, LMU Munich; Comprehensive Pneumology Center (CPC-M); Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Claus Neurohr
- Department of Virology, University hospital, LMU Munich, Germany; Department of Pneumology and Respiratory Medicine, Schillerhoehe Clinic (affiliated to Rober-Bosch-Hospital GmbG, Stuttgart), Solitudestr. 18, 70839, Gerlingen, Germany
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9
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Dashti-Khavidaki S, Saidi R, Lu H. Current status of glucocorticoid usage in solid organ transplantation. World J Transplant 2021; 11:443-465. [PMID: 34868896 PMCID: PMC8603633 DOI: 10.5500/wjt.v11.i11.443] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/16/2021] [Accepted: 11/03/2021] [Indexed: 02/06/2023] Open
Abstract
Glucocorticoids (GCs) have been the mainstay of immunosuppressive therapy in solid organ transplantation (SOT) for decades, due to their potent effects on innate immunity and tissue protective effects. However, some SOT centers are reluctant to administer GCs long-term because of the various related side effects. This review summarizes the advantages and disadvantages of GCs in SOT. PubMed and Scopus databases were searched from 2011 to April 2021 using search syntaxes covering “transplantation” and “glucocorticoids”. GCs are used in transplant recipients, transplant donors, and organ perfusate solution to improve transplant outcomes. In SOT recipients, GCs are administered as induction and maintenance immunosuppressive therapy. GCs are also the cornerstone to treat acute antibody- and T-cell-mediated rejections. Addition of GCs to organ perfusate solution and pretreatment of transplant donors with GCs are recommended by some guidelines and protocols, to reduce ischemia-reperfusion injury peri-transplant. GCs with low bioavailability and high potency for GC receptors, such as budesonide, nanoparticle-mediated targeted delivery of GCs to specific organs, and combination use of dexamethasone with inducers of immune-regulatory cells, are new methods of GC application in SOT patients to reduce side effects or induce immune-tolerance instead of immunosuppression. Various side effects involving different non-targeted organs/tissues, such as bone, cardiovascular, neuromuscular, skin and gastrointestinal tract, have been noted for GCs. There are also potential drug-drug interactions for GCs in SOT patients.
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Affiliation(s)
- Simin Dashti-Khavidaki
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran 14155, Iran
| | - Reza Saidi
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Hong Lu
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
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10
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Mejia C, Yadav A. Kidney Disease After Nonkidney Solid Organ Transplant. Adv Chronic Kidney Dis 2021; 28:577-586. [PMID: 35367026 DOI: 10.1053/j.ackd.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 11/11/2022]
Abstract
Nonkidney solid organ transplants (NKSOTs) are increasing in the United States with improving long-term allograft and patient survival. CKD is prevalent in patients with NKSOT and is associated with increased morbidity and mortality especially in those who progress to end-stage kidney disease. Calcineurin inhibitor nephrotoxicity is a main contributor to CKD after NKSOT, but other factors in the pretransplant, peritransplant, and post-transplant period can predispose to progressive kidney dysfunction. The management of CKD after NKSOT generally follows society guidelines for native kidney disease. Kidney-protective and calcineurin inhibitor-sparing immunosuppression has been explored in this population and warrants a discussion with transplant teams. Kidney transplantation in NKSOT recipients remains the kidney replacement therapy of choice for suitable candidates, as it provides a survival benefit over remaining on dialysis.
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11
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Mallavarapu RK, Sanoff SL, Howell DN, Roberts JK. BK virus nephropathy in non-renal solid organ transplant recipients: Are we looking hard enough? Clin Transplant 2021; 35:e14265. [PMID: 33615555 DOI: 10.1111/ctr.14265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/06/2021] [Accepted: 02/11/2021] [Indexed: 01/02/2023]
Abstract
We retrospectively examined the clinical characteristics, pathological features, and outcomes of BK viremia and nephropathy in a population of non-renal solid organ transplant patients (NRSOT) referred for outpatient nephrology consultation over a period of 5 years. In the entire cohort of liver, heart, and lung transplant recipients referred to this clinic, 14% percent were found to have BK viremia with a median peak serum BK viral load of 35 500 copies/ml (range 250 to 21 100 000 copies/ml). BK viremia resolved in six of the seventeen patients (35%). Four out of five patients biopsied showed BK virus (BKV) nephropathy. Eleven out of seventeen patients with BK viremia developed advanced (stage 4 or 5) chronic kidney disease. Four patients developed rejection of their solid organ transplant within the first year post detection of BK viremia after immunosuppression reduction. We conclude that a multi-center study is required to evaluate whether implementation of a systematic BK screening program would be effective in early detection and management of this problem in the NRSOT population.
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Affiliation(s)
- Ravi K Mallavarapu
- Division of Transplant Nephrology, Augusta University-Medical College of Georgia, Augusta, GA, USA
| | - Scott L Sanoff
- Division of Nephrology, Duke University School of Medicine, Durham, NC, USA
| | - David N Howell
- Department of Pathology, Duke University School of Medicine, Durham, NC, USA
| | - John K Roberts
- Division of Nephrology, Duke University School of Medicine, Durham, NC, USA
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