1
|
Kanbay M, Copur S, Topçu AU, Guldan M, Ozbek L, Gaipov A, Ferro C, Cozzolino M, Cherney DZI, Tuttle KR. An update review of post-transplant diabetes mellitus: Concept, risk factors, clinical implications and management. Diabetes Obes Metab 2024; 26:2531-2545. [PMID: 38558257 DOI: 10.1111/dom.15575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/09/2024] [Accepted: 03/09/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE Kidney transplantation is the gold standard therapeutic alternative for patients with end-stage renal disease; nevertheless, it is not without potential complications leading to considerable morbidity and mortality such as post-transplant diabetes mellitus (PTDM). This narrative review aims to comprehensively evaluate PTDM in terms of its diagnostic approach, underlying pathophysiological pathways, epidemiological data, and management strategies. METHODS Articles were retrieved from electronic databases using predefined search terms. Inclusion criteria encompassed studies investigating PTDM diagnosis, pathophysiology, epidemiology, and management strategies. RESULTS PTDM emerges as a significant complication following kidney transplantation, influenced by various pathophysiological factors including peripheral insulin resistance, immunosuppressive medications, infections, and proinflammatory pathways. Despite discrepancies in prevalence estimates, PTDM poses substantial challenges to transplant. Diagnostic approaches, including traditional criteria such as fasting plasma glucose (FPG) and HbA1c, are limited in their ability to capture early PTDM manifestations. Oral glucose tolerance test (OGTT) emerges as a valuable tool, particularly in the early post-transplant period. Management strategies for PTDM remain unclear, within sufficient evidence from large-scale randomized clinical trials to guide optimal interventions. Nevertheless, glucose-lowering agents and life style modifications constitute primary modalities for managing hyperglycemia in transplant recipients. DISCUSSION The complex interplay between PTDM and the transplant process necessitates individualized diagnostic and management approaches. While early recognition and intervention are paramount, modifications to maintenance immunosuppressive regimens based solely on PTDM risk are not warranted, given the potential adverse consequences such as increased rejection risk. Further research is essential to refine management strategies and enhance outcomes for transplant recipients.
Collapse
Affiliation(s)
- Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - A Umur Topçu
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Mustafa Guldan
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Lasin Ozbek
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Abduzhappar Gaipov
- Department of Medicine, School of Medicine, Nazarbayev University, Astana, Kazakhstan
| | - Charles Ferro
- Department of Nephrology, University Hospitals Birmingham and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division, University of Milan, Milan, Italy
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Katherine R Tuttle
- Department of Medicine, Division of Nephrology, University of Washington, Seattle, Washington, USA
| |
Collapse
|
2
|
Cooper M, Wiseman AC, Doshi MD, Hall IE, Parsons RF, Pastan S, Reddy KS, Schold JD, Mohan S, Hippen BE. Understanding Delayed Graft Function to Improve Organ Utilization and Patient Outcomes: Report of a Scientific Workshop Sponsored by the National Kidney Foundation. Am J Kidney Dis 2024; 83:360-369. [PMID: 37844725 DOI: 10.1053/j.ajkd.2023.08.018] [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: 05/24/2023] [Revised: 08/22/2023] [Accepted: 08/26/2023] [Indexed: 10/18/2023]
Abstract
Delayed graft function (DGF) is a common complication after kidney transplant. Despite extensive literature on the topic, the extant definition of DGF has not been conducive to advancing the scientific understanding of the influences and mechanisms contributing to its onset, duration, resolution, or long-term prognostic implications. In 2022, the National Kidney Foundation sponsored a multidisciplinary scientific workshop to comprehensively review the current state of knowledge about the diagnosis, therapy, and management of DGF and conducted a survey of relevant stakeholders on topics of clinical and regulatory interest. In this Special Report, we propose and defend a novel taxonomy for the clinical and research definitions of DGF, address key regulatory and clinical practice issues surrounding DGF, review the current state of therapies to reduce and/or attenuate DGF, offer considerations for clinical practice related to the outpatient management of DGF, and outline a prospective research and policy agenda.
Collapse
Affiliation(s)
- Matthew Cooper
- Department of Surgery, Division of Transplantation, Medical College of Wisconsin, Milwaukee, WI.
| | | | - Mona D Doshi
- Department of Medicine, Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Isaac E Hall
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, Utah
| | | | - Stephen Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia
| | - Kunam S Reddy
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jesse D Schold
- Departments of Surgery and Epidemiology, University of Colorado Anschutz Medical College, Aurora, Colorado
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Benjamin E Hippen
- Global Medical Office, Fresenius Medical Care, Charlotte, North Carolina
| |
Collapse
|
3
|
Pham NYT, Cruz D, Madera-Marin L, Ravender R, Garcia P. Diabetic Kidney Disease in Post-Kidney Transplant Patients. J Clin Med 2024; 13:793. [PMID: 38337487 PMCID: PMC10856396 DOI: 10.3390/jcm13030793] [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: 12/12/2023] [Revised: 01/09/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
Post-transplant diabetes mellitus (PTDM) is a common occurrence in post-kidney transplantation and is associated with greater mortality, allograft failure, and increased risk of infections. The primary goal in the management of PTDM is to achieve glycemic control to minimize the risk of complications while balancing the need for immunosuppression to maintain the health of the transplanted kidney. This review summarizes the effects of maintenance immunosuppression and therapeutic options among kidney transplant recipients. Patients with PTDM are at increased risk of diabetic kidney disease development; therefore, in this review, we focus on evidence supporting the use of novel antidiabetic agents and discuss their benefits and potential side effects in detail.
Collapse
Affiliation(s)
- Ngoc-Yen T. Pham
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, NM 87106, USA
| | - Diego Cruz
- Hospital General San Juan de Dios, Guatemala City 01001, Guatemala;
| | - Luis Madera-Marin
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, NM 87106, USA
| | - Raja Ravender
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, NM 87106, USA
| | - Pablo Garcia
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, NM 87106, USA
| |
Collapse
|
4
|
Wiśnicki K, Donizy P, Hałoń A, Wawrzonkowski P, Janczak D, Krajewska M, Banasik M. Indoleamine 2,3-Dioxygenase 1 (IDO1) in Kidney Transplantation: A Guardian against Rejection. J Clin Med 2023; 12:7531. [PMID: 38137602 PMCID: PMC10743959 DOI: 10.3390/jcm12247531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/27/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
Kidney transplantation is a crucial treatment for end-stage kidney disease, with immunosuppressive drugs helping to reduce acute rejection rates. However, kidney graft longevity remains a concern. This study explores the role of indoleamine 2,3-dioxygenase 1 (IDO1) in kidney transplant immunology. IDO1 breaks down tryptophan, affecting immune cell behavior, primarily T-cells. The research focuses on both cellular and antibody-mediated immune responses, often causing graft damage. The study assessed IDO1 expression in renal transplant biopsies from patients with graft function decline, examining its connection to clinical parameters. A total of 121 biopsy samples were evaluated for IDO1 expression using immunohistochemistry. Patients were categorized as IDO1(+) positive or IDO1(-) negative based on immunoreactivity in tubular epithelium. Results showed a significant link between IDO1 expression and rejection incidence. IDO1(+) positive patients had lower rejection rates (32.9%) compared to IDO1(-) negative ones (62.2%) [p = 0.0017], with substantial differences in antibody-mediated rejection (AMR) (5.2% vs. 20%) [p = 0.0085] and T-cell mediated rejection (TCMR) (31.6% vs. 57.8%). These associations suggest that IDO1 may play a protective role in kidney transplant rejection. IDO1 modulation could offer novel therapeutic avenues to enhance graft survival. The study underscores IDO1 as a potential marker for rejection risk assessment, with its potential applications in personalized interventions and improved patient outcomes. Further research is needed to fully comprehend the mechanisms behind IDO1's immunomodulatory functions and its potential clinical translation.
Collapse
Affiliation(s)
- Krzysztof Wiśnicki
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland; (P.W.); (M.K.)
| | - Piotr Donizy
- Department of Clinical and Experimental Pathology, Wroclaw Medical University, 50-367 Wroclaw, Poland; (P.D.); (A.H.)
| | - Agnieszka Hałoń
- Department of Clinical and Experimental Pathology, Wroclaw Medical University, 50-367 Wroclaw, Poland; (P.D.); (A.H.)
| | - Patryk Wawrzonkowski
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland; (P.W.); (M.K.)
| | - Dariusz Janczak
- Department of Vascular, General and Transplantation Surgery, Wroclaw Medical University, 50-367 Wroclaw, Poland;
| | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland; (P.W.); (M.K.)
| | - Mirosław Banasik
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland; (P.W.); (M.K.)
| |
Collapse
|
5
|
Shi YQ, Xu Z, Wang L, Wang K, Xu L, Zheng H. The fluorescence and colorimetric dual-readout probe for clinical rapid detection of mycophenolic acid by the poly(ethylenimine)/silica-coated CdTe quantum dots. Anal Biochem 2023; 668:115090. [PMID: 36870552 DOI: 10.1016/j.ab.2023.115090] [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: 04/25/2022] [Revised: 02/09/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023]
Abstract
It is particularly meaningful to therapeutic drug monitoring (TDM) of mycophenolic acid (MPA) for transplant patients to maximize the drug efficacy and minimize the adverse effect. In this study, a novel fluorescence and colorimetric dual-readout probe was put forward to fast and reliable detect MPA. The blue fluorescence of MPA was largely enhanced in the presence of poly (ethylenimine) (PEI), while the red fluorescence of CdTe@SiO2 (silica-coated CdTe quantum dots) provided a reliable reference signal. Hence, combining PEI70,000 and CdTe@SiO2, a fluorescence and colorimetric dual-readout probe could be constructed. For fluorescence measurement of MPA, the linearity was obtained in the MPA concentration range of 0.5-50 μg/mL, with a limit of detection (LOD) of 33 ng/mL. For the visual detection, the fluorescent colorimetric card was established in the MPA concentration from 0.5 to 50 μg/mL corresponding to the fluorescence color from red to violet and then to blue, which could be used for semi-quantification. Furthermore, in the light of the ColorCollect APP by the smartphone, the ratio of blue and red brightness values was linear with the MPA concentration from 1 to 50 μg/mL; thus, quantification of MPA could be realized by APP with the LOD of 83 ng/mL. The developed method was successfully applied to the analysis of MPA in the plasma samples of three patients after oral administration of mycophenolate mofetil, which was the prodrug of MPA. The result was comparable to those obtained by the clinically widely-used enzyme multiplied immunoassay technique. The developed probe was fast, cost-effective and operational convenience, and possessed high potential for TDM of MPA.
Collapse
Affiliation(s)
- You Quan Shi
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Zhao Xu
- Tongji School of Pharmacy, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Le Wang
- Tongji School of Pharmacy, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Kang Wang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Li Xu
- Tongji School of Pharmacy, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Heng Zheng
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| |
Collapse
|
6
|
Sharif A. Interventions Against Posttransplantation Diabetes: A Scientific Rationale for Treatment Hierarchy Based on Literature Review. Transplantation 2022; 106:2301-2313. [PMID: 35696695 DOI: 10.1097/tp.0000000000004198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Posttransplant diabetes (PTD) is a common medical complication after solid organ transplantation. Because of adverse outcomes associated with its development and detrimental impact on long-term survival, strategies to prevent or manage PTD are critically important but remain underresearched. Treatment hierarchies of antidiabetic therapies in the general population are currently being revolutionized based on cardiovascular outcome trials, providing evidence-based rationale for optimization of medical management. However, opportunities for improving medical management of PTD are challenged by 2 important considerations: (1) translating clinical evidence data from the general population to underresearched solid organ transplant cohorts and (2) targeting treatment based on primary underlying PTD pathophysiology. In this article, the aim is to provide an overview of PTD treatment options from a new angle. Rationalized by a consideration of underlying PTD pathophysiological defects, which are heterogeneous among diverse transplant patient cohorts, a critical appraisal of the published literature and summary of current research in progress will be reviewed. The aim is to update transplant professionals regarding medical management of PTD from a new perspective tailored therapeutic intervention based on individualized characteristics. As the gap in clinical evidence between management of PTD versus type 2 diabetes widens, it is imperative for the transplant community to bridge this gap with targeted clinical trials to ensure we optimize outcomes for solid organ transplant recipients who are at risk or develop PTD. This necessary clinical research should help efforts to improve long-term outcomes for solid transplant patients from both a patient and graft survival perspective.
Collapse
Affiliation(s)
- Adnan Sharif
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| |
Collapse
|
7
|
Joachim E. Association of Pre-Transplant C-Peptide with Post-Transplant Diabetes: A New Approach to Identifying High-Risk Patients? KIDNEY360 2022; 3:1660-1661. [PMID: 36514739 PMCID: PMC9717649 DOI: 10.34067/kid.0004922022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 09/30/2022] [Indexed: 12/03/2022]
Affiliation(s)
- Emily Joachim
- Division of Nephrology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| |
Collapse
|
8
|
HAYASHI A, OKAMOTO T, NIO-KOBAYASHI J, IWAHARA N, SUZUKI R, UEDA Y, TAKAHASHI T, Yasuyuki SATO, IWANAGA T, HOTTA K. CD44 as a pathological marker for the early detection of calcineurin inhibitor-induced nephrotoxicity post kidney transplantation. Biomed Res 2022; 43:181-186. [DOI: 10.2220/biomedres.43.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Asako HAYASHI
- Department of Pediatrics, Hokkaido University Graduate School of Medicine
| | - Takayuki OKAMOTO
- Department of Pediatrics, Hokkaido University Graduate School of Medicine
| | - Junko NIO-KOBAYASHI
- Laboratory of Histology and Cytology, Hokkaido University Graduate School of Medicine
| | - Naoya IWAHARA
- Department of Renal Genitourinary Surgery, Hokkaido University Graduate School of Medicine
| | - Ryota SUZUKI
- Department of Pediatrics, Hokkaido University Graduate School of Medicine
| | - Yasuhiro UEDA
- Department of Pediatrics, Hokkaido University Graduate School of Medicine
| | | | - Yasuyuki SATO
- Department of Pediatrics, Hokkaido University Graduate School of Medicine
| | - Toshihiko IWANAGA
- Laboratory of Histology and Cytology, Hokkaido University Graduate School of Medicine
| | - Kiyohiko HOTTA
- Department of Renal Genitourinary Surgery, Hokkaido University Graduate School of Medicine
| |
Collapse
|
9
|
Naesens M, Loupy A, Hilbrands L, Oberbauer R, Bellini MI, Glotz D, Grinyó J, Heemann U, Jochmans I, Pengel L, Reinders M, Schneeberger S, Budde K. Rationale for Surrogate Endpoints and Conditional Marketing Authorization of New Therapies for Kidney Transplantation. Transpl Int 2022; 35:10137. [PMID: 35669977 PMCID: PMC9163307 DOI: 10.3389/ti.2022.10137] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 03/10/2022] [Indexed: 12/13/2022]
Abstract
Conditional marketing authorization (CMA) facilitates timely access to new drugs for illnesses with unmet clinical needs, such as late graft failure after kidney transplantation. Late graft failure remains a serious, burdensome, and life-threatening condition for recipients. This article has been developed from content prepared by members of a working group within the European Society for Organ Transplantation (ESOT) for a Broad Scientific Advice request, submitted by ESOT to the European Medicines Agency (EMA), and reviewed by the EMA in 2020. The article presents the rationale for using surrogate endpoints in clinical trials aiming at improving late graft failure rates, to enable novel kidney transplantation therapies to be considered for CMA and improve access to medicines. The paper also provides background data to illustrate the relationship between primary and surrogate endpoints. Developing surrogate endpoints and a CMA strategy could be particularly beneficial for studies where the use of primary endpoints would yield insufficient statistical power or insufficient indication of long-term benefit following transplantation.
Collapse
Affiliation(s)
- Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- *Correspondence: Maarten Naesens,
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, Hôpital Necker, Paris, France
| | - Luuk Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Rainer Oberbauer
- Department of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | | | - Denis Glotz
- Paris Translational Research Center for Organ Transplantation, Hôpital Saint Louis, Paris, France
| | | | - Uwe Heemann
- Department of Nephrology, Technical University of Munich, Munich, Germany
| | - Ina Jochmans
- Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Liset Pengel
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Marlies Reinders
- Erasmus MC Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefan Schneeberger
- Department of General, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
10
|
Graham ML, Ramachandran S, Singh A, Moore MEG, Flanagan EB, Azimzadeh A, Burlak C, Mueller KR, Martins K, Anazawa T, Balamurugan AN, Bansal-Pakala P, Murtaugh MP, O’Brien TD, Papas KK, Spizzo T, Schuurman HJ, Hancock WW, Hering BJ. Clinically available immunosuppression averts rejection but not systemic inflammation after porcine islet xenotransplant in cynomolgus macaques. Am J Transplant 2022; 22:745-760. [PMID: 34704345 PMCID: PMC9832996 DOI: 10.1111/ajt.16876] [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: 05/26/2021] [Revised: 09/30/2021] [Accepted: 10/19/2021] [Indexed: 01/25/2023]
Abstract
A safe, efficacious, and clinically applicable immunosuppressive regimen is necessary for islet xenotransplantation to become a viable treatment option for diabetes. We performed intraportal transplants of wild-type adult porcine islets in 25 streptozotocin-diabetic cynomolgus monkeys. Islet engraftment was good in 21, partial in 3, and poor in 1 recipient. Median xenograft survival was 25 days with rapamycin and CTLA4Ig immunosuppression. Adding basiliximab induction and maintenance tacrolimus to the base regimen significantly extended median graft survival to 147 days (p < .0001), with three animals maintaining insulin-free xenograft survival for 265, 282, and 288 days. We demonstrate that this regimen suppresses non-Gal anti-pig antibody responses, circulating effector memory T cell expansion, effector function, and infiltration of the graft. However, a chronic systemic inflammatory state manifested in the majority of recipients with long-term graft survival indicated by increased neutrophil to lymphocyte ratio, IL-6, MCP-1, CD40, and CRP expression. This suggests that this immunosuppression regimen fails to regulate innate immunity and resulting inflammation is significantly associated with increased incidence and severity of adverse events making this regimen unacceptable for translation. Additional studies are needed to optimize a maintenance regimen for regulating the innate inflammatory response.
Collapse
Affiliation(s)
- Melanie L. Graham
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota, Minneapolis, MN
| | | | - Amar Singh
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - Meghan E. G. Moore
- Department of Veterinary Population Medicine, University of Minnesota, St. Paul, MN
| | - E. Brian Flanagan
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - Agnes Azimzadeh
- Department of Surgery, University of Maryland, Baltimore, MD
| | - Christopher Burlak
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - Kate R. Mueller
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - Kyra Martins
- Department of Veterinary and Biomedical Sciences, University of Minnesota, St. Paul, MN
| | - Takayuki Anazawa
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota, Minneapolis, MN
| | | | - Pratima Bansal-Pakala
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - Michael P. Murtaugh
- Department of Veterinary and Biomedical Sciences, University of Minnesota, St. Paul, MN
| | - Timothy D. O’Brien
- Department of Veterinary Population Medicine, University of Minnesota, St. Paul, MN
| | - Klearchos K. Papas
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota, Minneapolis, MN
| | | | - Henk-J. Schuurman
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota, Minneapolis, MN,Spring Point Project, Minneapolis, MN
| | - Wayne W. Hancock
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA
| | - Bernhard. J. Hering
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota, Minneapolis, MN
| |
Collapse
|
11
|
Axelrod DA, Cheungpasitporn W, Bunnapradist S, Schnitzler MA, Xiao H, McAdams-DeMarco M, Caliskan Y, Bae S, Ahn JB, Segev DL, Lam NN, Hess GP, Lentine KL. Posttransplant Diabetes Mellitus and Immunosuppression Selection in Older and Obese Kidney Recipients. Kidney Med 2022; 4:100377. [PMID: 35072042 PMCID: PMC8767140 DOI: 10.1016/j.xkme.2021.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Rationale & Objective Posttransplant diabetes mellitus (DM) after kidney transplantation increases morbidity and mortality, particularly in older and obese recipients. We aimed to examine the impact of immunosuppression selection on the risk of posttransplant DM among both older and obese kidney transplant recipients. Study Design Retrospective database study. Setting & Participants Kidney-only transplant recipients aged ≥18 years from 2005 to 2016 in the United States from US Renal Data System records, which integrate Organ Procurement and Transplantation Network/United Network for Organ Sharing records with Medicare billing claims. Exposures Various immunosuppression regimens in the first 3 months after transplant. Outcomes Development of DM >3 months-to-1 year posttransplant. Analytical Approach We used multivariable Cox regression to compare the incidence of posttransplant DM by immunosuppression regimen with the reference regimen of thymoglobulin (TMG) or alemtuzumab (ALEM) with tacrolimus + mycophenolic acid + prednisone using inverse propensity weighting. Results 12.7% of kidney transplant recipients developed posttransplant DM with higher incidences in older (≥55 years vs <55 years: 16.7% vs 10.1%) and obese (body mass index [BMI] ≥ 30 kg/m2 vs BMI < 30 kg/m2: 17.1% vs 10.9%) patients. The incidence of posttransplant DM was lower with steroid avoidance [TMG/ALEM + no prednisone (8.4%) and IL2rAb + no prednisone (9.7%)] than TMG/ALEM with triple therapy (13.1%). After adjustment for donor and recipient characteristics, TMG/ALEM with steroid avoidance was beneficial for all groups [age < 55 years: adjusted HR (aHR), 0.63 (95% confidence interval [CI], 0.54-0.72); age ≥ 55 years: aHR, 0.69 (95% CI, 0.60-0.79); BMI < 30 kg/m2: aHR, 0.69 (95% CI, 0.60-0.78); BMI ≥ 30 kg/m2: aHR, 0.67 (95% CI, 0.57-0.79)]. However, IL2rAb with steroid avoidance was beneficial only for older patients (aHR, 0.76; 95% CI, 0.58-0.99) and for those with BMI < 30 kg/m2 (aHR, 0.63; 95% CI, 0.46-0.87). Limitations Retrospective study and lacked data on immunosuppression levels. Conclusions The beneficial impact of steroid avoidance using tacrolimus on posttransplant DM appears to differ by patient age and induction regimen.
Collapse
Affiliation(s)
| | | | | | - Mark A. Schnitzler
- Saint Louis University Center for Abdominal Transplantation, Saint Louis, Missouri
| | - Huiling Xiao
- Saint Louis University Center for Abdominal Transplantation, Saint Louis, Missouri
| | | | - Yasar Caliskan
- Saint Louis University Center for Abdominal Transplantation, Saint Louis, Missouri
| | - Sunjae Bae
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | - JiYoon B. Ahn
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | | | | | - Krista L. Lentine
- University of Iowa, Iowa City, Iowa
- Address for Correspondence: Krista L. Lentine, MD, PhD, Saint Louis University Center for Abdominal Transplantation, 1402 S. Grand Blvd., St. Louis, MO, 63104.
| |
Collapse
|
12
|
Vranic G, Cooper M. But Why Weight: Understanding the Implications of Obesity in Kidney Transplant. Semin Nephrol 2021; 41:380-391. [PMID: 34715967 DOI: 10.1016/j.semnephrol.2021.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Obesity is increasing in prevalence among candidates for kidney transplant. Understanding the influence of obesity on candidate evaluation, surgical risk, peritransplant management, and post-transplant outcomes is critical to ensuring equitable access to transplant for this growing population.
Collapse
Affiliation(s)
- Gayle Vranic
- MedStar Georgetown Transplant Institute, Georgetown University, Washington, DC.
| | - Matthew Cooper
- MedStar Georgetown Transplant Institute, Georgetown University, Washington, DC
| |
Collapse
|
13
|
Zeng J, Zhong Q, Feng X, Li L, Feng S, Fan Y, Song T, Huang Z, Wang X, Lin T. Conversion From Calcineurin Inhibitors to Mammalian Target of Rapamycin Inhibitors in Kidney Transplant Recipients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Front Immunol 2021; 12:663602. [PMID: 34539621 PMCID: PMC8446650 DOI: 10.3389/fimmu.2021.663602] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 08/16/2021] [Indexed: 02/05/2023] Open
Abstract
Background A systematic review and meta-analysis were performed to investigate the efficacy and safety of conversion from calcineurin inhibitors (CNIs) to mammalian target of rapamycin inhibitors (mTORi) in kidney transplant recipients (KTRs). Methods MEDLINE, EMBASE, PubMed, and Cochrane Library were searched to identify randomized controlled trials (RCTs) that compared the continuation of CNI with conversion to mTORi therapy. Results Twenty-nine RCTs (5,747 KTRs) were included in our analysis. Meta-analysis of the glomerular filtration rate (SMD 0.20; 95%CI 0.10-0.31; P<0.01) and malignancy (RR 0.74; 95%CI 0.55-0.99; P=0.04) demonstrated a significant advantage of mTORi conversion over CNI continuation. However, the risk of acute rejection (RR 1.58; 95%CI 1.22-2.04; P<0.01), infection (RR 1.55; 95%CI 1.01-1.31; P=0.04), proteinuria (RR 1.87; 95%CI 1.34-2.59; P<0.01), leukopenia (RR 1.56; 95%CI 1.27-1.91; P<0.01), acne (RR 6.43; 95%CI 3.43-12.04; P<0.01), and mouth ulcer (RR 11.70; 95%CI 6.18-22.17; P<0.01) were higher in the mTORi group. More patients in the conversion group had to discontinue study medication (RR 2.52; 95%CI 1.75-3.63; P<0.01). There was no significant difference between the two groups with regard to death, graft loss, diabetes, chronic allograft nephropathy, and interstitial fibrosis/tubular atrophy. Conclusions Posttransplant patients have a better graft function and lower incidence of malignancy after conversion from CNI to mTORi therapy. However, this conversion strategy may be prevented by the higher drug discontinuation rate due to mTORi-associated adverse events, such as more acute rejection, infection, proteinuria, leukopenia, acne, and mouth ulcer, indicating that conversion therapy may only be a treatment option in selected patients.
Collapse
Affiliation(s)
- Jun Zeng
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Qiang Zhong
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaobing Feng
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Linde Li
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Shijian Feng
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yu Fan
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Turun Song
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Zhongli Huang
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xianding Wang
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Tao Lin
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
14
|
Chowdhury TA, Wahba M, Mallik R, Peracha J, Patel D, De P, Fogarty D, Frankel A, Karalliedde J, Mark PB, Montero RM, Pokrajac A, Zac-Varghese S, Bain SC, Dasgupta I, Banerjee D, Winocour P, Sharif A. Association of British Clinical Diabetologists and Renal Association guidelines on the detection and management of diabetes post solid organ transplantation. Diabet Med 2021; 38:e14523. [PMID: 33434362 DOI: 10.1111/dme.14523] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 11/24/2020] [Accepted: 01/09/2021] [Indexed: 01/06/2023]
Abstract
Post-transplant diabetes mellitus (PTDM) is common after solid organ transplantation (SOT) and associated with increased morbidity and mortality for allograft recipients. Despite the significant burden of disease, there is a paucity of literature with regards to detection, prevention and management. Evidence from the general population with diabetes may not be translatable to the unique context of SOT. In light of emerging clinical evidence and novel anti-diabetic agents, there is an urgent need for updated guidance and recommendations in this high-risk cohort. The Association of British Clinical Diabetologists (ABCD) and Renal Association (RA) Diabetic Kidney Disease Clinical Speciality Group has undertaken a systematic review and critical appraisal of the available evidence. Areas of focus are; (1) epidemiology, (2) pathogenesis, (3) detection, (4) management, (5) modification of immunosuppression, (6) prevention, and (7) PTDM in the non-renal setting. Evidence-graded recommendations are provided for the detection, management and prevention of PTDM, with suggested areas for future research and potential audit standards. The guidelines are endorsed by Diabetes UK, the British Transplantation Society and the Royal College of Physicians of London. The full guidelines are available freely online for the diabetes, renal and transplantation community using the link below. The aim of this review article is to introduce an abridged version of this new clinical guideline ( https://abcd.care/sites/abcd.care/files/site_uploads/Resources/Position-Papers/ABCD-RA%20PTDM%20v14.pdf).
Collapse
Affiliation(s)
| | | | | | | | - Dipesh Patel
- Diabetes & Endocrinology, Royal Free NHS foundation Trust, UCL, London, UK
| | | | | | | | - Janaka Karalliedde
- Guy's and St Thomas NHS Foundation Trust and King's College London, London, UK
| | | | | | - Ana Pokrajac
- West Hertfordshire Hospitals NHS Trust, Watford, UK
| | | | | | - Indranil Dasgupta
- Heartlands Hospital, Birmingham, UK
- Warwick Medical School, Warwick, UK
| | - Debasish Banerjee
- Renal and Transplant Unit, St George's University Hospitals NHS Foundation Trust and MCSRI, St George's University of London, London, UK
| | | | | |
Collapse
|
15
|
Chevallier E, Jouve T, Rostaing L, Malvezzi P, Noble J. pre-existing diabetes and PTDM in kidney transplant recipients: how to handle immunosuppression. Expert Rev Clin Pharmacol 2020; 14:55-66. [PMID: 33196346 DOI: 10.1080/17512433.2021.1851596] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Preexisting diabetes (PD) and post-transplant diabetes mellitus (PTDM) are common and severe comorbidities posttransplantation. The immunosuppressive regimens are modifiable risk factors. AREAS COVERED We reviewed Pubmed and Cochrane database and we summarize the mechanisms and impacts of available immunosuppressive treatments on the risk of PD and PTDM. We also assess the possible management of these drugs to improve glycemic parameters while considering risks inherent in transplantation. EXPERT OPINION PD i) increases the risk of sepsis, ii) is an independent risk factor for infection-related mortality, and iii) increases acute rejection risk. Regarding PTDM development i) immunosuppressive strategies without corticosteroids significantly reduce the risk but the price may be a higher incidence of rejection; ii) minimization or rapid withdrawal of steroids are two valuable approaches; iii) the diabetogenic role of calcineurin inhibitors(CNIs) is also well-described and is more important for tacrolimus than for cyclosporine. Reducing tacrolimus-exposure may improve glycemic parameters but also has a higher risk of rejection. PTDM risk is higher in patients that receive sirolimus compared to mycophenolate mofetil. Finally, conversion from CNIs to belatacept may offer the best benefits to PTDM-recipients in terms of glycemic parameters, graft and patient-outcomes.
Collapse
Affiliation(s)
- Eloi Chevallier
- Service De Néphrologie, Hémodialyse, Aphérèses Et Transplantation Rénale, CHU Grenoble-Alpes , Grenoble, France
| | - Thomas Jouve
- Service De Néphrologie, Hémodialyse, Aphérèses Et Transplantation Rénale, CHU Grenoble-Alpes , Grenoble, France.,Université Grenoble Alpes , Grenoble, France
| | - Lionel Rostaing
- Service De Néphrologie, Hémodialyse, Aphérèses Et Transplantation Rénale, CHU Grenoble-Alpes , Grenoble, France.,Université Grenoble Alpes , Grenoble, France
| | - Paolo Malvezzi
- Service De Néphrologie, Hémodialyse, Aphérèses Et Transplantation Rénale, CHU Grenoble-Alpes , Grenoble, France
| | - Johan Noble
- Service De Néphrologie, Hémodialyse, Aphérèses Et Transplantation Rénale, CHU Grenoble-Alpes , Grenoble, France
| |
Collapse
|
16
|
Wang S, Wang Y, Qiu K, Zhu J, Wu Y. RCAN1 in cardiovascular diseases: molecular mechanisms and a potential therapeutic target. Mol Med 2020; 26:118. [PMID: 33267791 PMCID: PMC7709393 DOI: 10.1186/s10020-020-00249-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 11/26/2020] [Indexed: 02/07/2023] Open
Abstract
Cardiovascular diseases (CVDs) are the leading cause of mortality worldwide. Considerable efforts are needed to elucidate the underlying mechanisms for the prevention and treatment of CVDs. Regulator of calcineurin 1 (RCAN1) is involved in both development/maintenance of the cardiovascular system and the pathogenesis of CVDs. RCAN1 reduction protects against atherosclerosis by reducing the uptake of oxidized low-density lipoproteins, whereas RCAN1 has a protective effect on myocardial ischemia/reperfusion injury, myocardial hypertrophy and intramural hematoma/aortic rupture mainly mediated by maintaining mitochondrial function and inhibiting calcineurin and Rho kinase activity, respectively. In this review, the regulation and the function of RCAN1 are summarized. Moreover, the dysregulation of RCAN1 in CVDs is reviewed. In addition, the beneficial role of RCAN1 reduction in atherosclerosis and the protective role of RCAN1 in myocardial ischemia/reperfusion injury, myocardial hypertrophy and intramural hematoma /aortic rupture are discussed, as well as underlying mechanisms. Furthermore, the therapeutic potential and challenges of targeting RCAN1 for CVDs treatment are also discussed.
Collapse
Affiliation(s)
- Shuai Wang
- Shandong Collaborative Innovation Center for Diagnosis, Treatment and Behavioral Interventions of Mental Disorders, Institute of Mental Health, Jining Medical University, Jianshe South Road No. 45, Rencheng District, Jining, 272013, Shandong, China.,Shandong Key Laboratory of Behavioral Medicine, School of Mental Health, Jining Medical University, Jianshe South Road No. 45, Rencheng District, Jining, 272013, Shandong, China
| | - Yuqing Wang
- Shandong Collaborative Innovation Center for Diagnosis, Treatment and Behavioral Interventions of Mental Disorders, Institute of Mental Health, Jining Medical University, Jianshe South Road No. 45, Rencheng District, Jining, 272013, Shandong, China.,Shandong Key Laboratory of Behavioral Medicine, School of Mental Health, Jining Medical University, Jianshe South Road No. 45, Rencheng District, Jining, 272013, Shandong, China.,Cheeloo College of Medicine, Shandong University, Wenhua West Road No. 44, Lixia District, JinanShandong, 250012, China
| | - Kaixin Qiu
- Shandong Collaborative Innovation Center for Diagnosis, Treatment and Behavioral Interventions of Mental Disorders, Institute of Mental Health, Jining Medical University, Jianshe South Road No. 45, Rencheng District, Jining, 272013, Shandong, China.,Shandong Key Laboratory of Behavioral Medicine, School of Mental Health, Jining Medical University, Jianshe South Road No. 45, Rencheng District, Jining, 272013, Shandong, China.,Cheeloo College of Medicine, Shandong University, Wenhua West Road No. 44, Lixia District, JinanShandong, 250012, China
| | - Jin Zhu
- Shandong Collaborative Innovation Center for Diagnosis, Treatment and Behavioral Interventions of Mental Disorders, Institute of Mental Health, Jining Medical University, Jianshe South Road No. 45, Rencheng District, Jining, 272013, Shandong, China.,Shandong Key Laboratory of Behavioral Medicine, School of Mental Health, Jining Medical University, Jianshe South Road No. 45, Rencheng District, Jining, 272013, Shandong, China
| | - Yili Wu
- Shandong Collaborative Innovation Center for Diagnosis, Treatment and Behavioral Interventions of Mental Disorders, Institute of Mental Health, Jining Medical University, Jianshe South Road No. 45, Rencheng District, Jining, 272013, Shandong, China. .,Shandong Key Laboratory of Behavioral Medicine, School of Mental Health, Jining Medical University, Jianshe South Road No. 45, Rencheng District, Jining, 272013, Shandong, China.
| |
Collapse
|
17
|
Hecking M, Sharif A, Eller K, Jenssen T. Management of post-transplant diabetes: immunosuppression, early prevention, and novel antidiabetics. Transpl Int 2020; 34:27-48. [PMID: 33135259 PMCID: PMC7839745 DOI: 10.1111/tri.13783] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/20/2020] [Accepted: 10/29/2020] [Indexed: 12/12/2022]
Abstract
Post‐transplant diabetes mellitus (PTDM) shows a relationship with risk factors including obesity and tacrolimus‐based immunosuppression, which decreases pancreatic insulin secretion. Several of the sodium–glucose‐linked transporter 2 inhibitors (SGLT2is) and glucagon‐like peptide 1 receptor agonists (GLP1‐RAs) dramatically improve outcomes of individuals with type 2 diabetes with and without chronic kidney disease, which is, as heart failure and atherosclerotic cardiovascular disease, differentially affected by both drug classes (presumably). Here, we discuss SGLT2is and GLP1‐RAs in context with other PTDM management strategies, including modification of immunosuppression, active lifestyle intervention, and early postoperative insulin administration. We also review recent studies with SGLT2is in PTDM, reporting their safety and antihyperglycemic efficacy, which is moderate to low, depending on kidney function. Finally, we reference retrospective case reports with GLP1‐RAs that have not brought forth major concerns, likely indicating that GLP1‐RAs are ideal for PTDM patients suffering from obesity. Although our article encompasses PTDM after solid organ transplantation in general, data from kidney transplant recipients constitute the largest proportion. The PTDM research community still requires data that treating and preventing PTDM will improve clinical conditions beyond hyperglycemia. We therefore suggest that it is time to collaborate, in testing novel antidiabetics among patients of all transplant disciplines.
Collapse
Affiliation(s)
- Manfred Hecking
- Department of Internal Medicine III, Clinical Division of Nephrology & Dialysis, Medical University of Vienna, Vienna, Austria
| | - Adnan Sharif
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Kathrin Eller
- Clinical Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Trond Jenssen
- Department of Organ Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| |
Collapse
|
18
|
Téblick A, Philipse E, Vleut R, Massart A, Couttenye MM, Bracke B, Hartman V, Chapelle T, Roeyen G, Ysebaert DK, Abramowicz D, Hellemans R. "Does Perioperative Patient Perfusion Obviate the Need for Kidney Machine Perfusion?" A Retrospective Analysis of Patients Receiving a Kidney From "Donation After Circulatory Death" Donors. Transplant Proc 2020; 52:2923-2929. [PMID: 32591137 DOI: 10.1016/j.transproceed.2020.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 05/12/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Delayed graft function (DGF) remains a clinically relevant problem in the post-transplant period, especially in patients with a renal graft from a "donation after cardiac death" (DCD) donor. Controversy exists around the optimal perioperative fluid therapy in such patients. These patients may benefit from a perioperative saline loading fluid protocol, which may reduce the risk of DGF. METHODS We compared 2 cohorts of patients who underwent a renal transplantation with a graft from a DCD donor. From January 2003 until December 2012, patients (N = 46) were hemodynamically managed at the discretion of the care-giving physician, without a preoperative fluid administration protocol (first study period). From January 2015 until March 2019 (N = 26), patients received saline loading before, during, and after kidney transplantation according to a well-defined saline loading fluid protocol (second study period). The relationship between the use of this perioperative fluid protocol and DGF was analyzed using univariable and multivariable logistic regression models. RESULTS DGF occurred in 11 of 46 (24%) patients in the first study period and in 1 of 26 (4%) in the second study period (P < .05). In a multivariable model, correcting for cold ischemia time and Kidney Donor Risk Index, the use of a saline loading fluid protocol in the perioperative phase was nearly significantly associated with a decrease in DGF (P = .07). CONCLUSION In our DCD transplant population, DGF rates were low. Our data further strongly suggest that implementation of a perioperative saline loading fluid protocol was independently associated with a lower risk of DGF.
Collapse
Affiliation(s)
- Arno Téblick
- Department of Nephrology, Antwerp University Hospital, Edegem, Belgium.
| | - Ester Philipse
- Department of Nephrology, Antwerp University Hospital, Edegem, Belgium
| | - Rowena Vleut
- Department of Nephrology, Antwerp University Hospital, Edegem, Belgium
| | - Annick Massart
- Department of Nephrology, Antwerp University Hospital, Edegem, Belgium
| | - Marie M Couttenye
- Department of Nephrology, Antwerp University Hospital, Edegem, Belgium
| | - Bart Bracke
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Vera Hartman
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Thiery Chapelle
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Geert Roeyen
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Dirk K Ysebaert
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Daniel Abramowicz
- Department of Nephrology, Antwerp University Hospital, Edegem, Belgium
| | - Rachel Hellemans
- Department of Nephrology, Antwerp University Hospital, Edegem, Belgium
| |
Collapse
|
19
|
Conversion From Calcineurin Inhibitors to Belatacept in HLA-sensitized Kidney Transplant Recipients With Low-level Donor-specific Antibodies. Transplantation 2020; 103:2150-2156. [PMID: 30720681 DOI: 10.1097/tp.0000000000002592] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Belatacept could be the treatment of choice in renal-transplant recipients with renal dysfunction attributed to calcineurin inhibitor (CNI) nephrotoxicity. Few studies have described its use in patients with donor-specific antibody (DSA). METHODS We retrospectively evaluated conversion from CNIs to belatacept in 29 human leukocyte antigen-immunized renal-transplant recipients. Data about acute rejection, DSA, and renal function were collected. These patients were compared with 42 nonimmunized patients treated with belatacept. RESULTS Patients were converted from CNIs to belatacept a median of 444 days (interquartile range, 85-1200) after transplantation and were followed up after belatacept conversion, for a median of 308 days (interquartile range, 125-511). At conversion, 16 patients had DSA. Nineteen DSA were observed in these 16 patients, of which 11/19 were <1000 mean fluorescence intensity (MFI), 7/19 were between 1000 and 3000 MFI, and one was >3000 MFI. At last follow-up, preexisting DSA had decreased or stabilized. Seven patients still had DSA with a mean MFI of 1298 ± 930 at the last follow-up. No patient developed a de novo DSA in the DSA-positive group. In the nonimmunized group, one patient developed de novo DSA (A24-MFI 970; biopsy for cause did not show biopsy-proven acute rejection or microinflammation score). After belatacept conversion, one antibody-mediated rejection was diagnosed. The mean estimated glomerular filtration rate improved from 31.7 ± 14.2 mL/min/1.73 m to 40.7 ± 12.3 mL/min/1.73 m (P < 0.0001) at 12 months after conversion. We did not find any significant difference between groups in terms of renal function, proteinuria, or biopsy-proven acute rejection. CONCLUSIONS We report on a safe conversion to belatacept in human leukocyte antigen-immunized patients with low DSA levels.
Collapse
|
20
|
Abstract
Solid organ transplantation (SOT) is an established therapeutic option for chronic disease resulting from end-stage organ dysfunction. Long-term use of immunosuppression is associated with post-transplantation diabetes mellitus (PTDM), placing patients at increased risk of infections, cardiovascular disease and mortality. The incidence rates for PTDM have varied from 10 to 40% between different studies. Diagnostic criteria have evolved over the years, as a greater understating of PTDM has been reached. There are differences in pathophysiology and clinical course of type 2 diabetes and PTDM. Hence, managing this condition can be a challenge for a diabetes physician, as there are several factors to consider when tailoring therapy for post-transplant patients to achieve better glycaemic as well as long-term transplant outcomes. This article is a detailed review of PTDM, examining the pathogenesis, diagnostic criteria and management in light of the current evidence. The therapeutic options are discussed in the context of their safety and potential drug-drug interactions with immunosuppressive agents.
Collapse
Affiliation(s)
| | - Kathryn Biddle
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Shazli Azmi
- Manchester University NHS Foundation Trust, Manchester, UK
| |
Collapse
|
21
|
Miano TA, Flesch JD, Feng R, Forker CM, Brown M, Oyster M, Kalman L, Rushefski M, Cantu E, Porteus M, Yang W, Localio AR, Diamond JM, Christie JD, Shashaty MGS. Early Tacrolimus Concentrations After Lung Transplant Are Predicted by Combined Clinical and Genetic Factors and Associated With Acute Kidney Injury. Clin Pharmacol Ther 2020; 107:462-470. [PMID: 31513279 PMCID: PMC6980920 DOI: 10.1002/cpt.1629] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/25/2019] [Indexed: 12/13/2022]
Abstract
Tacrolimus exhibits unpredictable pharmacokinetics (PKs) after lung transplant, partly explained by cytochrome P450 (CYP)-enzyme polymorphisms. However, whether exposure variability during the immediate postoperative period affects outcomes is unknown, and pharmacogenetic dosing may be limited by residual PK variability. We estimated adjusted associations between early postoperative tacrolimus concentrations and acute kidney injury (AKI) and acute cellular rejection (ACR), and identified clinical and pharmacogenetic factors that explain postoperative tacrolimus concentration variability in 484 lung transplant patients. Increasing tacrolimus concentration was associated with higher AKI risk (hazard ratio (HR) 1.54; 95% confidence interval (CI) 1.20-1.96 per 5-mg/dL); and increasing AKI severity (odds ratio 1.29; 95% CI 1.04-1.60 per 5-mg/dL), but not ACR (HR 1.02; 95% CI 0.73-1.42). A model with clinical and pharmacogenetic factors explained 42% of concentration variance compared with 19% for pharmacogenetic factors only. Early tacrolimus exposure was independently associated with AKI after lung transplantation, but not ACR. Clinical factors accounted for substantial residual tacrolimus concentration variability not explained by CYP-enzyme polymorphisms.
Collapse
Affiliation(s)
- Todd A. Miano
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania
| | - Judd D. Flesch
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania
| | - Rui Feng
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania
| | - Caitlin M. Forker
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania
| | - Melanie Brown
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania
| | - Michelle Oyster
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania
| | - Laurel Kalman
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania
| | - Melanie Rushefski
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania
| | - Edward Cantu
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania
| | - Mary Porteus
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania
| | - Wei Yang
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania
| | - A. Russel Localio
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania
| | - Joshua M. Diamond
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania
| | - Jason D. Christie
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania
| | - Michael G. S. Shashaty
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania
| |
Collapse
|
22
|
The Causes of Kidney Allograft Failure: More Than Alloimmunity. A Viewpoint Article. Transplantation 2020; 104:e46-e56. [DOI: 10.1097/tp.0000000000003012] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
23
|
Cucchiari D, Ríos J, Molina-Andujar A, Montagud-Marrahi E, Revuelta I, Ventura-Aguiar P, Piñeiro GJ, De Sousa-Amorim E, Esforzado N, Cofán F, Torregrosa JV, Ugalde-Altamirano J, Ricart MJ, Rovira J, Torres F, Solè M, Campistol JM, Diekmann F, Oppenheimer F. Combination of calcineurin and mTOR inhibitors in kidney transplantation: a propensity score analysis based on current clinical practice. J Nephrol 2019; 33:601-610. [PMID: 31853792 DOI: 10.1007/s40620-019-00675-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 11/18/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The TRANSFORM study demonstrated that an immunosuppression based on a combination of calcineurin inhibitors and de-novo mTOR inhibitors (mTORi) is safe and effective in kidney transplant recipients. However, data that validate this approach in clinical practice are currently missing. MATERIALS AND METHODS Analysis of 401 kidney transplant recipients transplanted from June 2013 to December 2016. All patients received tacrolimus with prednisone in combination with either mycophenolate (n = 186) or mTORi (either everolimus or sirolimus, n = 215). A propensity score to receive mTORi was calculated based on the inverse probability of treatment weighting (IPTW) from the following parameters: age and sex of donor and recipient, BMI, previous transplants, diabetes, cPRA, dialysis before transplantation, dialysis vintage, type of donor, ABO-incompatibility, HLA-mismatches, induction and ischemia time. Median follow-up was 2.6 [1.9; 3.7] years. RESULTS Cox-regression analysis suggests good results for mTORi versus MPA in terms of 1-year biopsy-proven acute rejection (BPAR, P = 0.063), 1-year graft loss (P = 0.025) and patient survival (P < 0.001). Results observed for BPAR and graft failure were largely attributed to those patients that would have been excluded by the TRANSFORM because of some exclusion criteria (52.9% of the population, P = 0.003 for 1-year BPAR and P = 0.040 for graft loss). In patients who met selection criteria for TRANSFORM, no effect of treatment for BPAR or graft failure was observed, while the beneficial effect on overall survival persisted. CONCLUSIONS In a real-life setting, a protocol based on de-novo mTORi with tacrolimus and prednisone could be employed as a standard immunosuppressive regimen and was associated with good outcomes.
Collapse
Affiliation(s)
- David Cucchiari
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain.
| | - José Ríos
- Medical Statistics Core Facility, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alicia Molina-Andujar
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain
| | | | - Ignacio Revuelta
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain
- Laboratori Experimental de Nefrologia I Trasplantament (LENIT), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Pedro Ventura-Aguiar
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain
| | - Gastón J Piñeiro
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain
| | - Erika De Sousa-Amorim
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain
| | - Nuria Esforzado
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain
| | - Frederic Cofán
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain
| | | | | | - Maria José Ricart
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain
| | - Jordi Rovira
- Laboratori Experimental de Nefrologia I Trasplantament (LENIT), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Ferran Torres
- Medical Statistics Core Facility, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manel Solè
- Pathology Unit, Hospital Clínic, Barcelona, Spain
| | - Josep M Campistol
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain
| | - Fritz Diekmann
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain.
- Laboratori Experimental de Nefrologia I Trasplantament (LENIT), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
- Red de Investigación Renal (REDINREN), Madrid, Spain.
| | - Frederic Oppenheimer
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain
| |
Collapse
|
24
|
Everolimus and Long-term Clinical Outcomes in Kidney Transplant Recipients: A Registry-based 10-year Follow-up of 5 Randomized Trials. Transplantation 2019; 103:1705-1713. [DOI: 10.1097/tp.0000000000002499] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
|
25
|
Leibler C, Thiolat A, Elsner RA, El Karoui K, Samson C, Grimbert P. Costimulatory blockade molecules and B-cell-mediated immune response: current knowledge and perspectives. Kidney Int 2019; 95:774-786. [PMID: 30711200 DOI: 10.1016/j.kint.2018.10.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/17/2018] [Accepted: 10/18/2018] [Indexed: 12/12/2022]
Abstract
There is an urgent need for therapeutic agents that target humoral alloimmunity in solid organ transplantation. This includes sensitized patients with preformed donor-specific human leukocyte antigen antibodies and patients who develop de novo donor-specific antibodies, both of which are associated with acute and chronic antibody-mediated rejection and allograft loss. In the last decade, both experimental and clinical studies highlighted the major impact of costimulation molecules in the control of immune responses both in the field of transplantation and autoimmune disease. Although these molecules have been initially developed to control the early steps of T-cell activation, recent evidence also supports their influence at several steps of the humoral response. In this review, we aim to provide an overview of the current knowledge of the effects of costimulatory blockade agents on humoral responses in both autoimmune and allogeneic contexts. We first present the effects of costimulatory molecules on the different steps of alloantibody production. We then summarize mechanisms and clinical results observed using cytotoxic T lymphocyte antigen-4 (CTLA4)-Ig molecules both in transplantation and autoimmunity. Finally, we present the potential interest and implications of other costimulatory family members as therapeutic targets, with emphasis on combinatorial approaches, for the optimal control of the alloantigen-specific humoral response.
Collapse
Affiliation(s)
- Claire Leibler
- Service de Néphrologie et Transplantation, Pôle Cancérologie-Immunité-Transplantation-Infectiologie, Paris-Est Creteil, France; Institut National de la Santé et de la Recherch Médicale, U955, Equipe 21 and Université Paris-Est, Créteil, France; Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Allan Thiolat
- Institut National de la Santé et de la Recherch Médicale, U955, Equipe 21 and Université Paris-Est, Créteil, France
| | - Rebecca A Elsner
- Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Khalil El Karoui
- Service de Néphrologie et Transplantation, Pôle Cancérologie-Immunité-Transplantation-Infectiologie, Paris-Est Creteil, France; Institut National de la Santé et de la Recherch Médicale, U955, Equipe 21 and Université Paris-Est, Créteil, France
| | - Chloe Samson
- Institut National de la Santé et de la Recherch Médicale, U955, Equipe 21 and Université Paris-Est, Créteil, France
| | - Philippe Grimbert
- Service de Néphrologie et Transplantation, Pôle Cancérologie-Immunité-Transplantation-Infectiologie, Paris-Est Creteil, France; Institut National de la Santé et de la Recherch Médicale, U955, Equipe 21 and Université Paris-Est, Créteil, France.
| |
Collapse
|
26
|
Lemaitre F, Lorcy N, Tron C, Golbin L, Petitcollin A, Verdier MC, Vigneau C, Bellissant E. Tacrolimus overexposure in kidney transplant recipients during the first post-operative week: caution is required in older patients. Fundam Clin Pharmacol 2018; 33:347-354. [PMID: 30431672 DOI: 10.1111/fcp.12432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/22/2018] [Accepted: 11/12/2018] [Indexed: 11/28/2022]
Abstract
In liver transplantation, tacrolimus trough concentrations (Cmin) above 20 ng/mL during the first days led to worse outcome at 1 year but data in the kidney transplant (KT) era are scarce. The aim of this study was to evaluate the impact of tacrolimus overexposure during the first week post-transplantation on the kidney function (KF) of KT recipients. In this retrospective study, 105 KT recipients were attributed to overexposure group (OG) or normal group according to their Cmin during the first week of treatment. KF was evaluated by comparing the rate of delayed graft function (DGF) and by collecting plasma creatinine from day 1, 2, 3, 4, 5, 6, 7, 14, 21, 28 and at 1 year. Risk factors for developing DGF were also investigated using a multivariate model. DGF was more frequent in OG (43% of patients; P = 0.027) which has higher plasma creatinine on day 7, 14, and 21. OG patients were older with more extended criteria donor's grafts. In the multivariate analysis, only cold ischemia time (CIT) remained associated with DGF (OR = 1.003), while TAC overexposure did not reach significance (P = 0.06; OR = 3.9). In this study, we confirmed the predominant role of CIT as a risk factor for the onset of DGF in kidney transplantation. 43% of KT recipients were overexposed with more DGF, especially older patients.
Collapse
Affiliation(s)
- Florian Lemaitre
- Department of Clinical and Biological Pharmacology, Pharmacovigilance, Pharmacoepidemiology and Drug Information Center, Rennes University Hospital, 2, rue Henri Le Guilloux, 35000, Rennes, France.,Faculty of Medicine, Laboratory of Experimental and Clinical Pharmacology, Rennes 1 University, 2 avenue du Professeur Léon Bernard, 35000, Rennes, France.,Inserm, CIC-P 1414 Clinical Investigation Center, 2, rue Henri Le Guilloux, 35000, Rennes, France
| | - Nolwen Lorcy
- Division of Nephrology, Rennes University Hospital, 2, rue Henri Le Guilloux, 35000, Rennes, France
| | - Camille Tron
- Department of Clinical and Biological Pharmacology, Pharmacovigilance, Pharmacoepidemiology and Drug Information Center, Rennes University Hospital, 2, rue Henri Le Guilloux, 35000, Rennes, France.,Faculty of Medicine, Laboratory of Experimental and Clinical Pharmacology, Rennes 1 University, 2 avenue du Professeur Léon Bernard, 35000, Rennes, France.,Inserm, CIC-P 1414 Clinical Investigation Center, 2, rue Henri Le Guilloux, 35000, Rennes, France
| | - Léonard Golbin
- Division of Nephrology, Rennes University Hospital, 2, rue Henri Le Guilloux, 35000, Rennes, France
| | - Antoine Petitcollin
- Department of Clinical and Biological Pharmacology, Pharmacovigilance, Pharmacoepidemiology and Drug Information Center, Rennes University Hospital, 2, rue Henri Le Guilloux, 35000, Rennes, France.,Faculty of Medicine, Laboratory of Experimental and Clinical Pharmacology, Rennes 1 University, 2 avenue du Professeur Léon Bernard, 35000, Rennes, France.,Inserm, CIC-P 1414 Clinical Investigation Center, 2, rue Henri Le Guilloux, 35000, Rennes, France
| | - Marie-Clémence Verdier
- Department of Clinical and Biological Pharmacology, Pharmacovigilance, Pharmacoepidemiology and Drug Information Center, Rennes University Hospital, 2, rue Henri Le Guilloux, 35000, Rennes, France.,Faculty of Medicine, Laboratory of Experimental and Clinical Pharmacology, Rennes 1 University, 2 avenue du Professeur Léon Bernard, 35000, Rennes, France.,Inserm, CIC-P 1414 Clinical Investigation Center, 2, rue Henri Le Guilloux, 35000, Rennes, France
| | - Cécile Vigneau
- Division of Nephrology, Rennes University Hospital, 2, rue Henri Le Guilloux, 35000, Rennes, France.,Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR 1085, 9 avenue du Professeur Léon Bernard, 35000, Rennes, France
| | - Eric Bellissant
- Department of Clinical and Biological Pharmacology, Pharmacovigilance, Pharmacoepidemiology and Drug Information Center, Rennes University Hospital, 2, rue Henri Le Guilloux, 35000, Rennes, France.,Faculty of Medicine, Laboratory of Experimental and Clinical Pharmacology, Rennes 1 University, 2 avenue du Professeur Léon Bernard, 35000, Rennes, France.,Inserm, CIC-P 1414 Clinical Investigation Center, 2, rue Henri Le Guilloux, 35000, Rennes, France
| |
Collapse
|
27
|
Sommerer C, Witzke O, Lehner F, Arns W, Reinke P, Eisenberger U, Vogt B, Heller K, Jacobi J, Guba M, Stahl R, Hauser IA, Kliem V, Wüthrich RP, Mühlfeld A, Suwelack B, Duerr M, Paulus EM, Zeier M, Porstner M, Budde K. Onset and progression of diabetes in kidney transplant patients receiving everolimus or cyclosporine therapy: an analysis of two randomized, multicenter trials. BMC Nephrol 2018; 19:237. [PMID: 30231851 PMCID: PMC6146542 DOI: 10.1186/s12882-018-1031-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 08/31/2018] [Indexed: 01/03/2023] Open
Abstract
Background Conversion from calcineurin inhibitor (CNI) therapy to a mammalian target of rapamycin (mTOR) inhibitor following kidney transplantation may help to preserve graft function. Data are sparse, however, concerning the impact of conversion on posttransplant diabetes mellitus (PTDM) or the progression of pre-existing diabetes. Methods PTDM and other diabetes-related parameters were assessed post hoc in two large open-label multicenter trials. Kidney transplant recipients were randomized (i) at month 4.5 to switch to everolimus or remain on a standard cyclosporine (CsA)-based regimen (ZEUS, n = 300), or (ii) at month 3 to switch to everolimus, remain on standard CNI therapy or convert to everolimus with reduced-exposure CsA (HERAKLES, n = 497). Results There were no significant differences in the incidence of PTDM between treatment groups (log rank p = 0.97 [ZEUS], p = 0.90 [HERAKLES]). The mean change in random blood glucose from randomization to month 12 was also similar between treatment groups in both trials for patients with or without PTDM, and with or without pre-existing diabetes. The change in eGFR from randomization to month 12 showed a benefit for everolimus versus comparator groups in all subpopulations, but only reached significance in larger subgroups (no PTDM or no pre-existing diabetes). Conclusions Within the restrictions of this post hoc analysis, including non-standardized diagnostic criteria and limited glycemia laboratory parameters, these data do not indicate any difference in the incidence or severity of PTDM with early conversion from a CsA-based regimen to everolimus, or in the progression of pre-existing diabetes. Trial registration clinicaltrials.gov, NCT00154310 (registered September 2005) and NCT00514514 (registered August 2007); EudraCT (2006-007021-32 and 2004-004346-40). Electronic supplementary material The online version of this article (10.1186/s12882-018-1031-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Claudia Sommerer
- Department of Nephrology, University of Heidelberg, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany.
| | - Oliver Witzke
- Department of Infectious Diseases, University Duisburg-Essen, Essen, Germany
| | - Frank Lehner
- Department of General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Wolfgang Arns
- Department of Nephrology and Transplantation, Cologne Merheim Medical Center, Cologne, Germany
| | - Petra Reinke
- Department of Nephrology and Intensive Care, Charité Campus Virchow, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ute Eisenberger
- Department of Nephrology and Hypertension, University of Bern, Inselspital, Bern, Switzerland
| | - Bruno Vogt
- Department of Nephrology and Hypertension, University of Bern, Inselspital, Bern, Switzerland
| | - Katharina Heller
- Department of Nephrology and Hypertension, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Johannes Jacobi
- Department of Nephrology and Hypertension, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Markus Guba
- Department of General-, Visceral- and Transplantation Surgery, Munich University Hospital, Campus Grosshadern, Munich, Germany
| | - Rolf Stahl
- Division of Nephrology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ingeborg A Hauser
- Med. Klinik III, Department of Nephrology, UKF, Goethe University, Frankfurt, Germany
| | - Volker Kliem
- Department of Internal Medicine and Nephrology, Kidney Transplant Center, Nephrological Center of Lower Saxony, Klinikum Hann, Münden, Germany
| | | | - Anja Mühlfeld
- Division of Nephrology and Immunology, University Hospital RWTH Aachen, Aachen, Germany
| | - Barbara Suwelack
- Department of Internal Medicine - Transplant Nephrology, University Hospital of Münster, Münster, Germany
| | - Michael Duerr
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Martin Zeier
- Department of Nephrology, University of Heidelberg, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany
| | | | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | |
Collapse
|
28
|
Girerd S, Schikowski J, Girerd N, Duarte K, Busby H, Gambier N, Ladrière M, Kessler M, Frimat L, Aarnink A. Impact of reduced exposure to calcineurin inhibitors on the development of de novo DSA: a cohort of non-immunized first kidney graft recipients between 2007 and 2014. BMC Nephrol 2018; 19:232. [PMID: 30219043 PMCID: PMC6139146 DOI: 10.1186/s12882-018-1014-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 08/24/2018] [Indexed: 12/15/2022] Open
Abstract
Background In low-immunological risk kidney transplant recipients (KTRs), reduced exposure to calcineurin inhibitor (CNI) appears particularly attractive for avoiding adverse events, but may increase the risk of developing de novo Donor Specific Antibodies (dnDSA). Methods CNI exposure was retrospectively analyzed in 247 non-HLA immunized first KTRs by taking into account trough levels (C0) collected during follow-up. Reduced exposure to CNI was defined as follows: C0 less than the lower limit of the international targets for ≥50% of follow-up. Results During a mean follow-up of 5.0 ± 2.0 years, 39 patients (15.8%) developed dnDSA (MFI ≥1000). Patients with DSA were significantly younger (46.6 ± 13.8 vs. 51.7 ± 14.0 years, p = 0.039), received more frequently poorly-matched grafts (59% with 6–8 A-B-DR-DQ HLA mismatches vs. 34.6%, p = 0.016) and had more frequently a reduced exposure to CNI (92.3% vs. 62.0%, p = 0.0002). Reduced exposure to CNI was associated with an increased risk of dnDSA (multivariable HR = 9.77, p = 0.002). Reduced exposure to CNI had no effect on patient survival, graft loss from any cause including death, or post-transplant cancer. Conclusions Even in a low-immunological risk population, reduced exposure to CNI is associated with increased risk of dnDSA. Benefits and risks of under-immunosuppression must be carefully evaluated before deciding on CNI minimization.
Collapse
Affiliation(s)
- S Girerd
- Service de Néphrologie et Transplantation rénale, CHRU Nancy Brabois, Vandoeuvre-les-, Nancy, France. .,INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France.
| | - J Schikowski
- Service de Néphrologie et Transplantation rénale, CHRU Nancy Brabois, Vandoeuvre-les-, Nancy, France
| | - N Girerd
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - K Duarte
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - H Busby
- Service d'Anatomie pathologique, CHRU Nancy Brabois, Vandœuvre-lès-Nancy, France
| | - N Gambier
- Service de Pharmacologie-Toxicologie, CHRU Nancy Brabois, Vandœuvre-lès-Nancy, France
| | - M Ladrière
- Service de Néphrologie et Transplantation rénale, CHRU Nancy Brabois, Vandoeuvre-les-, Nancy, France
| | - M Kessler
- Service de Néphrologie et Transplantation rénale, CHRU Nancy Brabois, Vandoeuvre-les-, Nancy, France
| | - L Frimat
- Service de Néphrologie et Transplantation rénale, CHRU Nancy Brabois, Vandoeuvre-les-, Nancy, France
| | - A Aarnink
- Laboratoire d'Histocompatibilité, CHRU Nancy Brabois, Vandœuvre-lès-Nancy, France
| |
Collapse
|
29
|
Uchida J, Iwai T, Nakatani T. Introduction of everolimus in kidney transplant recipients at a late posttransplant stage. World J Transplant 2018; 8:150-155. [PMID: 30211023 PMCID: PMC6134274 DOI: 10.5500/wjt.v8.i5.150] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 06/23/2018] [Accepted: 06/28/2018] [Indexed: 02/05/2023] Open
Abstract
This minireview focuses on the current knowledge about the introduction of everolimus (EVL), a mammalian target of rapamycin inhibitor, with calcineurin inhibitor (CNI) elimination or minimization in kidney transplant recipients at a late posttransplant stage. Within, we have summarized two major clinical trials, ASCERTAIN and APOLLO, and seven other retrospective or nonrandomized studies. In the open-label multicenter ASCERTAIN study, the estimated glomerular filtration rate (eGFR) at 24 mo after conversion was not significantly different between three groups-EVL with CNI elimination, CNI minimization and continued CNI unchanged-at a mean of 5.4 years after transplantation. However, recipients with baseline creatinine clearance higher than 50 mL/min had a greater increase in measured GFR after CNI elimination. In the open-label multicenter APOLLO study, adjusted eGFR within the on-treatment population was significantly higher in the EVL continuation group than in the CNI continuation group at 12 mo after conversion at a mean of 7 years posttransplantation. Other studies on recipients without adverse events and already having satisfactory renal function showed favorable graft function by EVL late-induction with CNI elimination or reduction. These studies showed that chronic allograft nephropathy, CNI nephrotoxicity, CNI arteriolopathy, cancer and viral infection (especially cytomegalovirus infection) may be good indications for late conversion to EVL.
Collapse
Affiliation(s)
- Junji Uchida
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Tomoaki Iwai
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Tatsuya Nakatani
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| |
Collapse
|
30
|
Conte C, Secchi A. Post-transplantation diabetes in kidney transplant recipients: an update on management and prevention. Acta Diabetol 2018; 55:763-779. [PMID: 29619563 DOI: 10.1007/s00592-018-1137-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 03/26/2018] [Indexed: 12/14/2022]
Abstract
Post-transplantation diabetes mellitus (PTDM) may severely impact both short- and long-term outcomes of kidney transplant recipients in terms of graft and patient survival. However, PTDM often goes undiagnosed is underestimated or poorly managed. A diagnosis of PTDM should be delayed until the patient is on stable maintenance doses of immunosuppressive drugs, with stable kidney graft function and in the absence of acute infections. Risk factors for PTDM should be assessed during the pre-transplant evaluation period, in order to reduce the likelihood of developing diabetes. The oral glucose tolerance test is considered as the gold standard for diagnosing PTDM, whereas HbA1c is not reliable during the first months after transplantation. Glycaemic targets should be individualised, and comorbidities such as dyslipidaemia and hypertension should be treated with drugs that have the least possible impact on glucose metabolism, at doses that do not interact with immunosuppressants. While insulin is the preferred agent for treating inpatient hyperglycaemia in the immediate post-transplantation period, little evidence is available to guide therapeutic choices in the management of PTDM. Metformin and incretins may offer some advantage over other glucose-lowering agents, particularly with respect to risk of hypoglycaemia and weight gain. Tailoring immunosuppressive regimens may be of help, although maintenance of good kidney function should be prioritised over prevention/treatment of PTDM. The aim of this narrative review is to provide an overview of the available evidence on management and prevention of PTDM, with a focus on the available therapeutic options.
Collapse
Affiliation(s)
- Caterina Conte
- I.R.C.C.S. Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy.
| | - Antonio Secchi
- I.R.C.C.S. Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Via Olgettina 58, 20132, Milan, Italy
| |
Collapse
|
31
|
Liu Y, Liu H, Shen Y, Chen Y, Cheng Y. Delayed Initiation of Tacrolimus Is Safe and Effective in Renal Transplant Recipients With Delayed and Slow Graft Function. Transplant Proc 2018; 50:2368-2370. [PMID: 30316359 DOI: 10.1016/j.transproceed.2018.03.101] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 02/25/2018] [Accepted: 03/06/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Tacrolimus is widely used in renal transplantation to help prevent acute and chronic rejection, but the nephrotoxicity of tacrolimus may compromise renal function. This study investigates the safety and efficacy in delayed initiation of tacrolimus after antilymphocyte induction therapy in kidney transplant recipients. METHODS This retrospective cohort analysis involved data from 68 kidney transplant recipients receiving standard induction therapy (basiliximab [Simulect] or thymoglobulin) combined with tacrolimus. The patients were divided into 2 groups according to whether the start time of tacrolimus therapy was before or after 24 hours posttransplantation. Acute rejection, common complications of immunosuppression, and graft survival were compared. RESULTS The mean (SD) timing of tacrolimus administered in the Delayed group was 4 (1.9) days after transplantation. The Delayed group patients had a higher percentage of slow graft function and delayed graft function than the No-delay group. Compared with the No-delay group, delayed initiation of tacrolimus did not increase risk of biopsy-proven acute rejection, infection, posttransplant diabetes mellitus, graft survival, and patient survival. CONCLUSIONS Our study confirmed delayed initiation of tacrolimus after antilymphocyte induction therapy is safe and effective in renal transplant recipients with slow or delayed graft function.
Collapse
Affiliation(s)
- Y Liu
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - H Liu
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Y Shen
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Y Chen
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Y Cheng
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| |
Collapse
|
32
|
Song JL, Li M, Yan LN, Yang JY, Yang J, Jiang L. Higher tacrolimus blood concentration is related to increased risk of post-transplantation diabetes mellitus after living donor liver transplantation. Int J Surg 2018; 51:17-23. [PMID: 29360611 DOI: 10.1016/j.ijsu.2017.12.037] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 09/03/2017] [Accepted: 12/04/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND/AIMS To investigate the association between tacrolimus (TAC) blood concentration and the risk of post-transplantation diabetes mellitus (PTDM) development after living donor liver transplantation (LDLT). METHODS This study reviewed the clinical data of 158 adult LDLT recipients. A cut-off of mean trough concentration of TAC (cTAC) value at the sixth month postoperatively was identified using a receptor operating characteristic curve. Other clinical complications rates were compared between different cTAC groups. RESULTS Thirty-four (21.5%) recipients developed PTDM during follow-up period. Recipients with PTDM suffered lower 1-, 5- and 10-year overall survival rates (85.2%, 64.9%, and 55.6% vs 92.4%, 81.4%, and 79.1%, p < 0.05) and allograft survival rates (87.9%, 76.9%, and 65.9% vs 94.1%, 88.5%, and 86.0%, p < 0.05) than those without PTDM. The best cut-off value of mean cTAC was 5.9 ng/mL. Recipients with higher cTAC (>5.9 ng/mL) were more likely to develop hyperlipidemia (39.6% vs 21.9%, p < 0.05), cardio-cerebral events (7.5% vs1.0%, p < 0.05), and infections (37.7% vs19.0%, p < 0.05) than recipients exposed to low cTAC (≤5.9 ng/mL). However, the two groups showed no difference in the incidence of acute and chronic rejection. CONCLUSION Higher mean cTAC at the sixth month postoperatively is related to increased risk of PTDM in LDLT recipients.
Collapse
Affiliation(s)
- Jiu-Lin Song
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Ming Li
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Lu-Nan Yan
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jia-Yin Yang
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jian Yang
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Li Jiang
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China.
| |
Collapse
|
33
|
|
34
|
Rao N, Rathi M, Sharma A, Ramachandran R, Kumar V, Kohli HS, Gupta KL, Sakhuja V. Pretransplant HbA1c and Glucose Metabolism Parameters in Predicting Posttransplant Diabetes Mellitus and Their Course in the First 6 Months After Living-Donor Renal Transplant. EXP CLIN TRANSPLANT 2017; 16:446-454. [PMID: 29251576 DOI: 10.6002/ect.2017.0020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Posttransplant diabetes mellitus is a common and serious metabolic complication after renal transplant. Patients with uremia are known to have abnormal glucose metabolism characterized by insulin resistance and defects in insulin secretion, which are ameliorated to some extent with renal replacement therapy and more so with renal transplant. However, the diabetogenicity of calcineurin inhibitors compounds this state of dysglycemia and promotes the development of diabetes in some patients. It is not clear whether pretransplant dysglycemia is a risk factor for posttransplant diabetes mellitus and, if so, which between insulin resistance and pancreatic β-cell dysfunction is a major determinant in predicting posttransplant diabetes mellitus. Here, we examined the roles of the pretransplant oral glucose tolerance test, glycated hemoglobin (HbA1c) levels, and homeostatic model assessment-derived insulin resistance and beta-cell function in the prediction of posttransplant diabetes mellitus and the course of these indexes posttransplant. Our aim was to examine the correlations between these factors and their changes posttransplant with the development of posttransplant diabetes mellitus. MATERIALS AND METHODS Pretransplant fasting blood was drawn from patients for plasma glucose, insulin, C-peptide, and HbA1c levels, which was followed by a 2-hour oral glucose tolerance test. After transplant, patients were followed for 6 months to detect posttransplant diabetes mellitus. Serum insulin, C-peptide, and glycated hemoglobin levels were reexamined in patients with posttransplant diabetes mellitus at 1 and 6 months. RESULTS Twenty-one patients (29%) developed posttransplant diabetes mellitus. Pretransplant HbA1c was associated with development of posttransplant diabetes mellitus (odds ratio 27.04) on logistic regression. Homeostatic model assessment-derived insulin resistance improved significantly at 6 months posttransplant, whereas beta-cell function remained lower than pretransplant levels in patients with posttransplant diabetes mellitus. CONCLUSIONS Pretransplant HbA1c may be used as a predictive marker for posttransplant diabetes mellitus. Insulin resistance but not beta-cell function improves in patients with posttransplant diabetes mellitus at 6 months posttransplant.
Collapse
Affiliation(s)
- Namrata Rao
- From the Department of Nephrology, Postgraduate Institute of Medical Education & Research, Chandigarh, India 160012
| | | | | | | | | | | | | | | |
Collapse
|
35
|
Triñanes J, Rodriguez-Rodriguez AE, Brito-Casillas Y, Wagner A, De Vries APJ, Cuesto G, Acebes A, Salido E, Torres A, Porrini E. Deciphering Tacrolimus-Induced Toxicity in Pancreatic β Cells. Am J Transplant 2017; 17:2829-2840. [PMID: 28432716 DOI: 10.1111/ajt.14323] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 04/14/2017] [Accepted: 04/14/2017] [Indexed: 01/25/2023]
Abstract
β Cell transcription factors such as forkhead box protein O1 (FoxO1), v-maf musculoaponeurotic fibrosarcoma oncogene homolog A (MafA), pancreatic and duodenal homeobox 1, and neuronal differentiation 1, are dysfunctional in type 2 diabetes mellitus (T2DM). Posttransplant diabetes mellitus resembles T2DM and reflects interaction between pretransplant insulin resistance and immunosuppressants, mainly calcineurin inhibitors (CNIs). We evaluated the effect of tacrolimus (TAC), cyclosporine A (CsA), and metabolic stressors (glucose plus palmitate) on insulinoma β cells in vitro and in pancreata of obese and lean Zucker rats. Cells were cultured for 5 days with 100 μM palmitate and 22 mM glucose; CsA (250 ng/mL) or TAC (15 ng/mL) were added in the last 48 h. Glucose plus palmitate increased nuclear FoxO1 and decreased nuclear MafA. TAC in addition to glucose plus palmitate magnified these changes in nuclear factors, whereas CsA did not. In addition to glucose plus palmitate, both drugs reduced insulin content, and TAC also affected insulin secretion. TAC withdrawal or conversion to CsA restored these changes. Similar results were observed in pancreata of obese animals on CNIs. TAC and CsA, in addition to glucose plus palmitate, induced comparable inhibition of calcineurin and nuclear factor of activated T cells (NFAT); therefore, TAC potentiates glucolipotoxicity in β cells, possibly by sharing common pathways of β cell dysfunction. TAC-induced β cell dysfunction is potentially reversible. Inhibition of the calcineurin-NFAT pathway may contribute to the diabetogenic effect of CNIs but does not explain the stronger effect of TAC compared with CsA.
Collapse
Affiliation(s)
- J Triñanes
- Centre for Biomedical Research of the Canary Islands (CIBICAN), University of La Laguna, La Laguna, Tenerife, Spain.,Division of Nephrology and Leiden Transplant Center, Leiden University Medical Center and Leiden University, Leiden, the Netherlands
| | | | - Y Brito-Casillas
- Unit of Endocrinology and Nutrition, Complejo Hospitalario Universitario Insular Materno-Infantil de Gran Canaria, Instituto Universitario de Investigaciones Biomédicas y Sanitarias, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - A Wagner
- Unit of Endocrinology and Nutrition, Complejo Hospitalario Universitario Insular Materno-Infantil de Gran Canaria, Instituto Universitario de Investigaciones Biomédicas y Sanitarias, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - A P J De Vries
- Division of Nephrology and Leiden Transplant Center, Leiden University Medical Center and Leiden University, Leiden, the Netherlands
| | - G Cuesto
- Centre for Biomedical Research of the Canary Islands (CIBICAN), University of La Laguna, La Laguna, Tenerife, Spain
| | - A Acebes
- Centre for Biomedical Research of the Canary Islands (CIBICAN), University of La Laguna, La Laguna, Tenerife, Spain
| | - E Salido
- Centre for Biomedical Research of the Canary Islands (CIBICAN), University of La Laguna, La Laguna, Tenerife, Spain.,Pathology Department, Hospital Universitario de Canarias, La Laguna, Tenerife, Spain.,Centre for Biomedical Research on Rare Diseases (CIBERER), La Laguna, Tenerife, Spain
| | - A Torres
- Centre for Biomedical Research of the Canary Islands (CIBICAN), University of La Laguna, La Laguna, Tenerife, Spain.,Research Unit of the University Hospital of the Canary Islands, La Laguna, Tenerife, Spain.,Nephrology Department, Hospital Universitario de Canarias, La Laguna, Tenerife, Spain
| | - E Porrini
- Centre for Biomedical Research of the Canary Islands (CIBICAN), University of La Laguna, La Laguna, Tenerife, Spain
| |
Collapse
|
36
|
de Graav GN, Baan CC, Clahsen-van Groningen MC, Kraaijeveld R, Dieterich M, Verschoor W, von der Thusen JH, Roelen DL, Cadogan M, van de Wetering J, van Rosmalen J, Weimar W, Hesselink DA. A Randomized Controlled Clinical Trial Comparing Belatacept With Tacrolimus After De Novo Kidney Transplantation. Transplantation 2017; 101:2571-2581. [PMID: 28403127 DOI: 10.1097/tp.0000000000001755] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Belatacept, an inhibitor of the CD28-CD80/86 costimulatory pathway, allows for calcineurin-inhibitor free immunosuppressive therapy in kidney transplantation but is associated with a higher acute rejection risk than ciclosporin. Thus far, no biomarker for belatacept-resistant rejection has been validated. In this randomized-controlled trial, acute rejection rate was compared between belatacept- and tacrolimus-treated patients and immunological biomarkers for acute rejection were investigated. METHODS Forty kidney transplant recipients were 1:1 randomized to belatacept or tacrolimus combined with basiliximab, mycophenolate mofetil, and prednisolone. The 1-year incidence of biopsy-proven acute rejection was monitored. Potential biomarkers, namely, CD8CD28, CD4CD57PD1, and CD8CD28 end-stage terminally differentiated memory T cells were measured pretransplantation and posttransplantation and correlated to rejection. Pharmacodynamic monitoring of belatacept was performed by measuring free CD86 on monocytes. RESULTS The rejection incidence was higher in belatacept-treated than tacrolimus-treated patients: 55% versus 10% (P = 0.006). All 3 graft losses, due to rejection, occurred in the belatacept group. Although 4 of 5 belatacept-treated patients with greater than 35 cells CD8CD28 end-stage terminally differentiated memory T cells/μL rejected, median pretransplant values of the biomarkers did not differ between belatacept-treated rejectors and nonrejectors. In univariable Cox regressions, the studied cell subsets were not associated with rejection-risk. CD86 molecules on circulating monocytes in belatacept-treated patients were saturated at all timepoints. CONCLUSIONS Belatacept-based immunosuppressive therapy resulted in higher and more severe acute rejection compared with tacrolimus-based therapy. This trial did not identify cellular biomarkers predictive of rejection. In addition, the CD28-CD80/86 costimulatory pathway appeared to be sufficiently blocked by belatacept and did not predict rejection.
Collapse
Affiliation(s)
- Gretchen N de Graav
- 1 Division of Nephrology and Kidney Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands. 2 Department of Pathology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands. 3 Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands. 4 Department of Biostatistics, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Karpe KM, Talaulikar GS, Walters GD. Calcineurin inhibitor withdrawal or tapering for kidney transplant recipients. Cochrane Database Syst Rev 2017; 7:CD006750. [PMID: 28730648 PMCID: PMC6483545 DOI: 10.1002/14651858.cd006750.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Calcineurin inhibitors (CNI) can reduce acute transplant rejection and immediate graft loss but are associated with significant adverse effects such as hypertension and nephrotoxicity which may contribute to chronic rejection. CNI toxicity has led to numerous studies investigating CNI withdrawal and tapering strategies. Despite this, uncertainty remains about minimisation or withdrawal of CNI. OBJECTIVES This review aimed to look at the benefits and harms of CNI tapering or withdrawal in terms of graft function and loss, incidence of acute rejection episodes, treatment-related side effects (hypertension, hyperlipidaemia) and death. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register to 11 October 2016 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings; and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) where drug regimens containing CNI were compared to alternative drug regimens (CNI withdrawal, tapering or low dose) in the post-transplant period were included, without age or dosage restriction. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for eligibility, risk of bias, and extracted data. Results were expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS We included 83 studies that involved 16,156 participants. Most were open-label studies; less than 30% of studies reported randomisation method and allocation concealment. Studies were analysed as intent-to-treat in 60% and all pre-specified outcomes were reported in 54 studies. The attrition and reporting bias were unclear in the remainder of the studies as factors used to judge bias were reported inconsistently. We also noted that 50% (47 studies) of studies were funded by the pharmaceutical industry.We classified studies into four groups: CNI withdrawal or avoidance with or without substitution with mammalian target of rapamycin inhibitors (mTOR-I); and low dose CNI with or without mTOR-I. The withdrawal groups were further stratified as avoidance and withdrawal subgroups for major outcomes.CNI withdrawal may lead to rejection (RR 2.54, 95% CI 1.56 to 4.12; moderate certainty evidence), may make little or no difference to death (RR 1.09, 95% CI 0.96 to 1.24; moderate certainty), and probably slightly reduces graft loss (RR 0.85, 95% CI 0.74 to 0.98; low quality evidence). Hypertension was probably reduced in the CNI withdrawal group (RR 0.82, 95% CI 0.71 to 0.95; low certainty), while CNI withdrawal may make little or no difference to malignancy (RR 1.10, 95% CI 0.93 to 1.30; low certainty), and probably makes little or no difference to cytomegalovirus (CMV) (RR 0.87, 95% CI 0.52 to 1.45; low certainty)CNI avoidance may result in increased acute rejection (RR 2.16, 95% CI 0.85 to 5.49; low certainty) but little or no difference in graft loss (RR 0.96, 95% CI 0.79 to 1.16; low certainty). Late CNI withdrawal increased acute rejection (RR 3.21, 95% CI 1.59 to 6.48; moderate certainty) but probably reduced graft loss (RR 0.84, 95% CI 0.72 to 0.97, low certainty).Results were similar when CNI avoidance or withdrawal was combined with the introduction of mTOR-I; acute rejection was probably increased (RR 1.43; 95% CI 1.15 to 1.78; moderate certainty) and there was probably little or no difference in death (RR 0.96; 95% CI 0.69 to 1.36, moderate certainty). mTOR-I substitution may make little or no difference to graft loss (RR 0.94, 95% CI 0.75 to 1.19; low certainty), probably makes little of no difference to hypertension (RR 0.86, 95% CI 0.64 to 1.15; moderate), and probably reduced the risk of cytomegalovirus (CMV) (RR 0.60, 95% CI 0.44 to 0.82; moderate certainty) and malignancy (RR 0.69, 95% CI 0.47 to 1.00; low certainty). Lymphoceles were increased with mTOR-I substitution (RR 1.45, 95% CI 0.95 to 2.21; low certainty).Low dose CNI combined with mTOR-I probably increased glomerular filtration rate (GFR) (MD 6.24 mL/min, 95% CI 3.28 to 9.119; moderate certainty), reduced graft loss (RR 0.75, 95% CI 0.55 to 1.02; moderate certainty), and made little or no difference to acute rejection (RR 1.13 ; 95% CI 0.91 to 1.40; moderate certainty). Hypertension was decreased (RR 0.98, 95% CI 0.80 to 1.20; low certainty) as was CMV (RR 0.41, 95% CI 0.16 to 1.06; low certainty). Low dose CNI plus mTOR-I makes probably makes little of no difference to malignancy (RR 1.22, 95% CI 0.42 to 3.53; low certainty) and may make little of no difference to death (RR 1.16, 95% CI 0.71 to 1.90; moderate certainty). AUTHORS' CONCLUSIONS CNI avoidance increased acute rejection and CNI withdrawal increases acute rejection but reduced graft loss at least over the short-term. Low dose CNI with induction regimens reduced acute rejection and graft loss with no major adverse events, also in the short-term. The use of mTOR-I reduced CMV infections but increased the risk of acute rejection. These conclusions must be tempered by the lack of long-term data in most of the studies, particularly with regards to chronic antibody-mediated rejection, and the suboptimal methodological quality of the included studies.
Collapse
Affiliation(s)
- Krishna M Karpe
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
| | - Girish S Talaulikar
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
| | - Giles D Walters
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
| | | |
Collapse
|
38
|
Abstract
Malignancy is the second most common single cause of death observed in organ transplant recipients. The excess cancer risk is related to intensity and duration of immunosuppressive therapy and inversely to recipient age. Immunodeficiency and (chronic/oncogenic) viral infections together constitute a major risk. Nonmelanoma skin cancer, Kaposi sarcoma, and posttransplant lymphoproliferative disease have standardized incidence ratios exceeding 10- or 50-fold. The mammalian target of rapamycin (mTOR) inhibitors, sirolimus and everolimus, are increasingly used after organ transplantation with potential advantages in virus-associated posttransplant malignancies as well as anti-cancer properties. Despite a seemingly clear mechanism of action and solid rationale for their use in cancer therapy, mTORis have met only modest success rates in clinical trials with advanced malignancies except for specific tumors, such as Kaposi sarcoma and mantle cell lymphoma. Because mTORis are primarily cytostatic, not cytotoxic, the observed clinical efficacy is a reflection of disease stabilization rather than tumor regression. Nonmelanoma skin cancers, in particular cutaneous squamous cell carcinoma, have the highest standardized incidence ratios in transplant recipients. Recent meta-analyses and randomized trials on secondary prevention of squamous cell carcinoma observed a reduction in cumulative tumor load, suggesting most benefit to be gained by early conversion to an mTOR inhibitor-based maintenance regime. There is ongoing debate on the mechanisms involved including withdrawal of the carcinogenic effects of calcineurin inhibitors and/or their impact on chronic (oncogenic) viral infections. At present, there is, however, insufficient evidence for the primary use of mTORis as protective agents against most other cancer types.
Collapse
|
39
|
Santulli G, Nakashima R, Yuan Q, Marks AR. Intracellular calcium release channels: an update. J Physiol 2017; 595:3041-3051. [PMID: 28303572 PMCID: PMC5430224 DOI: 10.1113/jp272781] [Citation(s) in RCA: 156] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 02/20/2017] [Indexed: 12/19/2022] Open
Abstract
Ryanodine receptors (RyRs) and inositol 1,4,5-trisphosphate receptors (IP3 Rs) are calcium (Ca2+ ) release channels on the endo/sarcoplasmic reticulum (ER/SR). Here we summarize the latest advances in the field, describing the recently discovered mechanistic roles of intracellular Ca2+ release channels in the regulation of mitochondrial fitness and endothelial function, providing novel therapeutic options for the treatment of heart failure, hypertension, and diabetes mellitus.
Collapse
Affiliation(s)
- Gaetano Santulli
- The Wu Center for Molecular CardiologyColumbia UniversityNew YorkNYUSA
- Department of Physiology and Cellular BiophysicsCollege of Physicians and SurgeonsColumbia University Medical CenterNew YorkNYUSA
| | - Ryutaro Nakashima
- The Wu Center for Molecular CardiologyColumbia UniversityNew YorkNYUSA
- Department of Physiology and Cellular BiophysicsCollege of Physicians and SurgeonsColumbia University Medical CenterNew YorkNYUSA
| | - Qi Yuan
- The Wu Center for Molecular CardiologyColumbia UniversityNew YorkNYUSA
- Department of Physiology and Cellular BiophysicsCollege of Physicians and SurgeonsColumbia University Medical CenterNew YorkNYUSA
| | - Andrew R. Marks
- The Wu Center for Molecular CardiologyColumbia UniversityNew YorkNYUSA
- Department of Physiology and Cellular BiophysicsCollege of Physicians and SurgeonsColumbia University Medical CenterNew YorkNYUSA
- Department of MedicineColumbia UniversityNew YorkNYUSA
| |
Collapse
|
40
|
Practical Recommendations for Long-term Management of Modifiable Risks in Kidney and Liver Transplant Recipients: A Guidance Report and Clinical Checklist by the Consensus on Managing Modifiable Risk in Transplantation (COMMIT) Group. Transplantation 2017; 101:S1-S56. [PMID: 28328734 DOI: 10.1097/tp.0000000000001651] [Citation(s) in RCA: 181] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Short-term patient and graft outcomes continue to improve after kidney and liver transplantation, with 1-year survival rates over 80%; however, improving longer-term outcomes remains a challenge. Improving the function of grafts and health of recipients would not only enhance quality and length of life, but would also reduce the need for retransplantation, and thus increase the number of organs available for transplant. The clinical transplant community needs to identify and manage those patient modifiable factors, to decrease the risk of graft failure, and improve longer-term outcomes.COMMIT was formed in 2015 and is composed of 20 leading kidney and liver transplant specialists from 9 countries across Europe. The group's remit is to provide expert guidance for the long-term management of kidney and liver transplant patients, with the aim of improving outcomes by minimizing modifiable risks associated with poor graft and patient survival posttransplant.The objective of this supplement is to provide specific, practical recommendations, through the discussion of current evidence and best practice, for the management of modifiable risks in those kidney and liver transplant patients who have survived the first postoperative year. In addition, the provision of a checklist increases the clinical utility and accessibility of these recommendations, by offering a systematic and efficient way to implement screening and monitoring of modifiable risks in the clinical setting.
Collapse
|
41
|
Bemelman FJ, de Fijter JW, Kers J, Meyer C, Peters-Sengers H, de Maar EF, van der Pant KAMI, de Vries APJ, Sanders JS, Zwinderman A, Idu MM, Berger S, Reinders MEJ, Krikke C, Bajema IM, van Dijk MC, Ten Berge IJM, Ringers J, Lardy J, Roelen D, Moes DJ, Florquin S, Homan van der Heide JJ. Early Conversion to Prednisolone/Everolimus as an Alternative Weaning Regimen Associates With Beneficial Renal Transplant Histology and Function: The Randomized-Controlled MECANO Trial. Am J Transplant 2017; 17:1020-1030. [PMID: 27639190 DOI: 10.1111/ajt.14048] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 08/20/2016] [Accepted: 09/07/2016] [Indexed: 01/25/2023]
Abstract
In renal transplantation, use of calcineurin inhibitors (CNIs) is associated with nephrotoxicity and immunosuppression with malignancies and infections. This trial aimed to minimize CNI exposure and total immunosuppression while maintaining efficacy. We performed a randomized controlled, open-label multicenter trial with early cyclosporine A (CsA) elimination. Patients started with basiliximab, prednisolone (P), mycophenolate sodium (MPS), and CsA. At 6 months, immunosuppression was tapered to P/CsA, P/MPS, or P/everolimus (EVL). Primary outcomes were renal fibrosis and inflammation. Secondary outcomes were estimated glomerular filtration rate (eGFR) and incidence of rejection at 24 months. The P/MPS arm was prematurely halted. The trial continued with P/CsA (N = 89) and P/EVL (N = 96). Interstitial fibrosis and inflammation were significantly decreased and the eGFR was significantly higher in the P/EVL arm. Cumulative rejection rates were 13% (P/EVL) and 19% (P/CsA), (p = 0.08). A post hoc analysis of HLA and donor-specific antibodies at 1 year after transplantation revealed no differences. An individualized immunosuppressive strategy of early CNI elimination to dual therapy with everolimus was associated with decreased allograft fibrosis, preserved allograft function, and good efficacy, but also with more serious adverse events and discontinuation. This can be a valuable alternative regimen in patients suffering from CNI toxicity.
Collapse
Affiliation(s)
- F J Bemelman
- Renal Transplant Unit, Amsterdam, the Netherlands
| | - J W de Fijter
- Renal Transplant Unit, Department of Nephrology, Leiden University Medical Centre, Leiden, the Netherlands
| | - J Kers
- Department of Pathology, Academic Medical Centre, Amsterdam, the Netherlands
| | - C Meyer
- University of Amsterdam, Amsterdam, the Netherlands
| | | | - E F de Maar
- Department of Nephrology, Groningen University Hospital, Groningen, the Netherlands
| | | | - A P J de Vries
- Renal Transplant Unit, Department of Nephrology, Leiden University Medical Centre, Leiden, the Netherlands
| | - J-S Sanders
- Department of Nephrology, Groningen University Hospital, Groningen, the Netherlands
| | - A Zwinderman
- Department of Epidemiology and Biostatistics, Academic Medical Centre, Amsterdam, the Netherlands
| | - M M Idu
- Department of Surgery, Academic Medical Centre, Amsterdam, the Netherlands
| | - S Berger
- Department of Nephrology, Groningen University Hospital, Groningen, the Netherlands
| | - M E J Reinders
- Renal Transplant Unit, Department of Nephrology, Leiden University Medical Centre, Leiden, the Netherlands
| | - C Krikke
- Department of Surgery, Groningen University Hospital, Groningen, the Netherlands
| | - I M Bajema
- Department of Pathology, Leiden University Medical Centre, Leiden, the Netherlands
| | - M C van Dijk
- Department of Pathology, Groningen University Hospital, Groningen, the Netherlands
| | | | - J Ringers
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - J Lardy
- Sanquin Diagnostic Services, Amsterdam, the Netherlands
| | - D Roelen
- Department of Immunogenetics and Transplantation Immunology, Leiden University Medical Centre, Leiden, the Netherlands
| | - D-J Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Leiden, the Netherlands
| | - S Florquin
- Department of Pathology, Academic Medical Centre, Amsterdam, the Netherlands
| | | |
Collapse
|
42
|
Williams KR, Colangelo CM, Hou L, Chung L, Belcher JM, Abbott T, Hall IE, Zhao H, Cantley LG, Parikh CR. Use of a Targeted Urine Proteome Assay (TUPA) to identify protein biomarkers of delayed recovery after kidney transplant. Proteomics Clin Appl 2017; 11. [PMID: 28261998 DOI: 10.1002/prca.201600132] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 01/17/2017] [Accepted: 03/01/2017] [Indexed: 11/07/2022]
Abstract
PURPOSE Development of delayed graft function (DGF) following kidney transplant is associated with poor outcomes. An ability to rapidly identify patients with DGF versus those with immediate graft function (IGF) may facilitate the treatment of DGF and the research needed to improve prognosis. The purpose of this study was to use a Targeted Urine Proteome Assay to identify protein biomarkers of delayed recovery from kidney transplant. EXPERIMENTAL DESIGN Potential biomarkers were identified using the Targeted Urine Proteome (MRM) Assay to interrogate the relative DGF/IGF levels of expression of 167 proteins in urine taken 12-18 h after kidney implantation from 21 DGF, 15 SGF (slow graft function), and 16 IGF patients. An iterative Random Forest analysis approach evaluated the relative importance of each biomarker, which was then used to identify an optimum biomarker panel that provided the maximum sensitivity and specificity with the least number of biomarkers. CONCLUSIONS AND CLINICAL RELEVANCE Four proteins were identified that together distinguished DGF with a sensitivity of 77.4%, specificity of 82.6%, and AUC of 0.891. This panel represents an important step toward identifying DGF at an early stage so that more effective treatments can be developed to improve long-term graft outcomes.
Collapse
Affiliation(s)
- Kenneth R Williams
- W.M. Keck Foundation Biotechnology Laboratory, Yale University School of Medicine, New Haven, USA
- Molecular Biophysics and Biochemistry, Yale University School of Medicine, New Haven, USA
| | | | - Lin Hou
- Center for Statistical Science, Tsinghua University, Beijing, China
| | - Lisa Chung
- W.M. Keck Foundation Biotechnology Laboratory, Yale University School of Medicine, New Haven, USA
| | - Justin M Belcher
- Internal Medicine, Yale University School of Medicine, New Haven, USA
| | - Thomas Abbott
- W.M. Keck Foundation Biotechnology Laboratory, Yale University School of Medicine, New Haven, USA
| | - Isaac E Hall
- Division of Nephrology, Hypertension & Renal Transplantation, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, USA
| | - Hongyu Zhao
- Epidemiology & Public Health, Yale University School of Medicine, New Haven, USA
| | - Lloyd G Cantley
- Internal Medicine, Yale University School of Medicine, New Haven, USA
| | - Chirag R Parikh
- Internal Medicine, Yale University School of Medicine, New Haven, USA
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, USA
| |
Collapse
|
43
|
Riella LV, Djamali A, Pascual J. Chronic allograft injury: Mechanisms and potential treatment targets. Transplant Rev (Orlando) 2017; 31:1-9. [DOI: 10.1016/j.trre.2016.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 10/05/2016] [Indexed: 01/05/2023]
|
44
|
Tabibzadeh N, Glowacki F, Frimat M, Elsermans V, Provôt F, Lionet A, Gnemmi V, Hertig A, Noël C, Hazzan M. Long-term outcome after early cyclosporine withdrawal in kidney transplantation: ten years after. Clin Transplant 2016; 30:1480-1487. [DOI: 10.1111/ctr.12843] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Nahid Tabibzadeh
- CHU Lille - Service de Néphrologie - F-59000 Lille France
- Université de Lille - UMR 995, F-59000 Lille France
| | - François Glowacki
- CHU Lille - Service de Néphrologie - F-59000 Lille France
- Université de Lille - UMR 995, F-59000 Lille France
| | - Marie Frimat
- CHU Lille - Service de Néphrologie - F-59000 Lille France
- Université de Lille - UMR 995, F-59000 Lille France
| | - Vincent Elsermans
- Université de Lille - UMR 995, F-59000 Lille France
- CHU Lille - Laboratoire d'Immunologie - F-59000 Lille France
| | | | - Arnaud Lionet
- CHU Lille - Service de Néphrologie - F-59000 Lille France
| | - Viviane Gnemmi
- Université de Lille - UMR 995, F-59000 Lille France
- CHU Lille - Laboratoire d'Anatomopathologie - F-59000 Lille France
| | - Alexandre Hertig
- Urgences Néphrologiques et Transplantation Rénale; Hôpital Tenon, APHP; Paris France
- UPMC Sorbonne Université Paris 06, UMR S 1155, F-75020; Paris France
| | - Christian Noël
- CHU Lille - Service de Néphrologie - F-59000 Lille France
- Université de Lille - UMR 995, F-59000 Lille France
| | - Marc Hazzan
- CHU Lille - Service de Néphrologie - F-59000 Lille France
- Université de Lille - UMR 995, F-59000 Lille France
| |
Collapse
|
45
|
Chand S, Atkinson D, Collins C, Briggs D, Ball S, Sharif A, Skordilis K, Vydianath B, Neil D, Borrows R. The Spectrum of Renal Allograft Failure. PLoS One 2016; 11:e0162278. [PMID: 27649571 PMCID: PMC5029903 DOI: 10.1371/journal.pone.0162278] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 08/21/2016] [Indexed: 01/15/2023] Open
Abstract
Background Causes of “true” late kidney allograft failure remain unclear as study selection bias and limited follow-up risk incomplete representation of the spectrum. Methods We evaluated all unselected graft failures from 2008–2014 (n = 171; 0–36 years post-transplantation) by contemporary classification of indication biopsies “proximate” to failure, DSA assessment, clinical and biochemical data. Results The spectrum of graft failure changed markedly depending on the timing of allograft failure. Failures within the first year were most commonly attributed to technical failure, acute rejection (with T-cell mediated rejection [TCMR] dominating antibody-mediated rejection [ABMR]). Failures beyond a year were increasingly dominated by ABMR and ‘interstitial fibrosis with tubular atrophy’ without rejection, infection or recurrent disease (“IFTA”). Cases of IFTA associated with inflammation in non-scarred areas (compared with no inflammation or inflammation solely within scarred regions) were more commonly associated with episodes of prior rejection, late rejection and nonadherence, pointing to an alloimmune aetiology. Nonadherence and late rejection were common in ABMR and TCMR, particularly Acute Active ABMR. Acute Active ABMR and nonadherence were associated with younger age, faster functional decline, and less hyalinosis on biopsy. Chronic and Chronic Active ABMR were more commonly associated with Class II DSA. C1q-binding DSA, detected in 33% of ABMR episodes, were associated with shorter time to graft failure. Most non-biopsied patients were DSA-negative (16/21; 76.1%). Finally, twelve losses to recurrent disease were seen (16%). Conclusion This data from an unselected population identifies IFTA alongside ABMR as a very important cause of true late graft failure, with nonadherence-associated TCMR as a phenomenon in some patients. It highlights clinical and immunological characteristics of ABMR subgroups, and should inform clinical practice and individualised patient care.
Collapse
Affiliation(s)
- Sourabh Chand
- Department of Nephrology and Kidney Transplantation, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Centre for Translational Inflammation Research, University of Birmingham, Birmingham, United Kingdom
- Renal Department, Royal Shrewsbury Hospital, Shropshire, United Kingdom
- * E-mail:
| | - David Atkinson
- Histocompatibility and Immunogenetics Laboratory, NHSBT Birmingham Centre, Vincent Drive, Edgbaston, Birmingham, United Kingdom
| | - Clare Collins
- Histocompatibility and Immunogenetics Laboratory, NHSBT Birmingham Centre, Vincent Drive, Edgbaston, Birmingham, United Kingdom
| | - David Briggs
- Histocompatibility and Immunogenetics Laboratory, NHSBT Birmingham Centre, Vincent Drive, Edgbaston, Birmingham, United Kingdom
| | - Simon Ball
- Department of Nephrology and Kidney Transplantation, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Centre for Translational Inflammation Research, University of Birmingham, Birmingham, United Kingdom
| | - Adnan Sharif
- Department of Nephrology and Kidney Transplantation, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Centre for Translational Inflammation Research, University of Birmingham, Birmingham, United Kingdom
| | - Kassiani Skordilis
- Department of Renal Histopathology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Bindu Vydianath
- Department of Renal Histopathology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Desley Neil
- Department of Renal Histopathology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Richard Borrows
- Department of Nephrology and Kidney Transplantation, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Centre for Translational Inflammation Research, University of Birmingham, Birmingham, United Kingdom
| |
Collapse
|
46
|
Nashan B, Abbud-Filho M, Citterio F. Prediction, prevention, and management of delayed graft function: where are we now? Clin Transplant 2016; 30:1198-1208. [PMID: 27543840 DOI: 10.1111/ctr.12832] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2016] [Indexed: 12/28/2022]
Abstract
Delayed graft function (DGF) remains a major barrier to improved outcomes after kidney transplantation. High-risk transplant recipients can be identified, but no definitive prediction model exists. Novel biomarkers to predict DGF in the first hours post-transplant, such as neutrophil gelatinase-associated lipocalin (NGAL), are under investigation. Donor management to minimize the profound physiological consequences of brain death is highly complex. A hormonal resuscitation package to manage the catecholamine "storm" that follows brain death is recommended. Donor pretreatment with dopamine prior to procurement lowers the rate of DGF. Hypothermic machine perfusion may offer a significant reduction in the rate of DGF vs simple cold storage, but costs need to be evaluated. Surgically, reducing warm ischemia time may be advantageous. Research into recipient preconditioning options has so far not generated clinically helpful interventions. Diagnostic criteria for DGF vary, but requirement for dialysis and/or persistent high serum creatinine is likely to remain key to diagnosis until current work on early biomarkers has progressed further. Management centers on close monitoring of graft (non)function and physiological parameters. With so many unanswered questions, substantial reductions in the toll of DGF in the near future seem unlikely but concentrated research on many levels offers long-term promise.
Collapse
Affiliation(s)
- Björn Nashan
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Mario Abbud-Filho
- Department of Nephrology, Medical School FAMERP, Director Organ Transplantation Center Foundation FUNFARME, São José do Rio Preto, SP, Brazil
| | - Franco Citterio
- Department of Surgery, Renal Transplantation, Catholic University, Rome, Italy
| |
Collapse
|
47
|
Størset E, Åsberg A, Hartmann A, Reisaeter AV, Holdaas H, Skauby M, Bergan S, Midtvedt K. Low-target tacrolimus in de novo standard risk renal transplant recipients: A single-centre experience. Nephrology (Carlton) 2016; 21:821-7. [DOI: 10.1111/nep.12738] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 01/20/2016] [Accepted: 02/01/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Elisabet Størset
- Department of Transplant Medicine; Oslo University Hospital Rikshospitalet; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Anders Åsberg
- Department of Transplant Medicine; Oslo University Hospital Rikshospitalet; Oslo Norway
- School of Pharmacy; University of Oslo; Oslo Norway
| | - Anders Hartmann
- Department of Transplant Medicine; Oslo University Hospital Rikshospitalet; Oslo Norway
| | - Anna V. Reisaeter
- Department of Transplant Medicine; Oslo University Hospital Rikshospitalet; Oslo Norway
| | - Hallvard Holdaas
- Department of Transplant Medicine; Oslo University Hospital Rikshospitalet; Oslo Norway
| | - Morten Skauby
- Department of Transplant Medicine; Oslo University Hospital Rikshospitalet; Oslo Norway
| | - Stein Bergan
- School of Pharmacy; University of Oslo; Oslo Norway
- Department of Pharmacology; Oslo University Hospital; Oslo Norway
| | - Karsten Midtvedt
- Department of Transplant Medicine; Oslo University Hospital Rikshospitalet; Oslo Norway
| |
Collapse
|
48
|
|
49
|
|
50
|
Calcineurin Inhibitor Nephrotoxicity in the Era of Antibody-Mediated Rejection. Transplantation 2016; 100:1599-600. [DOI: 10.1097/tp.0000000000001244] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|