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Canova TJ, Issa R, Baxter P, Thomas I, Eltahawy E, Ekwenna O. Cerebrovascular Disease Hospitalization Rates in End-Stage Kidney Disease Patients with Kidney Transplant and Peripheral Vascular Disease: Analysis Using the National Inpatient Sample (2005-2019). Healthcare (Basel) 2024; 12:454. [PMID: 38391829 PMCID: PMC10887507 DOI: 10.3390/healthcare12040454] [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: 12/20/2023] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/24/2024] Open
Abstract
Individuals with end-stage kidney disease (ESKD) face higher cerebrovascular risk. Yet, the impact of peripheral vascular disease (PVD) and kidney transplantation (KTx) on hospitalization rates for cerebral infarction and hemorrhage remains underexplored. Analyzing 2,713,194 ESKD hospitalizations (2005-2019) using the National Inpatient Sample, we investigated hospitalization rates for ischemic and hemorrhagic cerebrovascular diseases concerning ESKD, PVD, KTx, or their combinations. Patients hospitalized with cerebral infarction due to thrombosis/embolism/occlusion (CITO) or artery occlusion resulting in cerebral ischemia (AOSI) had higher rates of comorbid ESKD and PVD (4.17% and 7.29%, respectively) versus non-CITO or AOSI hospitalizations (2.34%, p < 0.001; 2.29%, p < 0.001). Conversely, patients hospitalized with nontraumatic intracranial hemorrhage (NIH) had significantly lower rates of ESKD and PVD (1.64%) compared to non-NIH hospitalizations (2.34%, p < 0.001). Furthermore, hospitalizations for CITO or AOSI exhibited higher rates of KTx and PVD (0.17%, 0.09%, respectively) compared to non-CITO or AOSI hospitalizations (0.05%, p = 0.033; 0.05%, p = 0.002). Patients hospitalized with NIH showed similar rates of KTx and PVD (0.04%) versus non-NIH hospitalizations (0.05%, p = 0.34). This nationwide analysis reveals that PVD in ESKD patients is associated with increased hospitalization rates with cerebral ischemic events and reduced NIH events. Among KTx recipients, PVD correlated with increased hospitalizations for ischemic events, without affecting NIH. This highlights management concerns for patients with KTx and PVD.
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Affiliation(s)
- Tyler John Canova
- College of Medicine and Life Sciences, The University of Toledo, Toledo, OH 43614, USA
| | - Rochell Issa
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Patrick Baxter
- Schar School of Policy and Government, George Mason University, Fairfax, VA 22030, USA
| | - Ian Thomas
- Department of Nephrology & Transplant, Mount St. John's Medical Center, St. John's, Antigua and Barbuda
| | - Ehab Eltahawy
- Department of Cardiovascular Medicine, The University of Toledo Medical Center, Toledo, OH 43614, USA
| | - Obi Ekwenna
- Department of Urology & Transplant, The University of Toledo Medical Center, Toledo, OH 43614, USA
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Elezaby A, Dexheimer R, Sallam K. Cardiovascular effects of immunosuppression agents. Front Cardiovasc Med 2022; 9:981838. [PMID: 36211586 PMCID: PMC9534182 DOI: 10.3389/fcvm.2022.981838] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/30/2022] [Indexed: 11/26/2022] Open
Abstract
Immunosuppressive medications are widely used to treat patients with neoplasms, autoimmune conditions and solid organ transplants. Key drug classes, namely calcineurin inhibitors, mammalian target of rapamycin (mTOR) inhibitors, and purine synthesis inhibitors, have direct effects on the structure and function of the heart and vascular system. In the heart, immunosuppressive agents modulate cardiac hypertrophy, mitochondrial function, and arrhythmia risk, while in vasculature, they influence vessel remodeling, circulating lipids, and blood pressure. The aim of this review is to present the preclinical and clinical literature examining the cardiovascular effects of immunosuppressive agents, with a specific focus on cyclosporine, tacrolimus, sirolimus, everolimus, mycophenolate, and azathioprine.
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Affiliation(s)
- Aly Elezaby
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Ryan Dexheimer
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States
| | - Karim Sallam
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, United States
- *Correspondence: Karim Sallam
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Spasovski G, Trajceska L, Rambabova-Bushljetik I. Pharmacotherapeutic options for the prevention of kidney transplant rejection: the evidence to date. Expert Opin Pharmacother 2022; 23:1397-1412. [PMID: 35835450 DOI: 10.1080/14656566.2022.2102418] [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: 11/04/2022]
Abstract
INTRODUCTION Although early rejection episodes are successfully controlled, the problem of unrecognized production of de novo anti HLA antibodies and associated chronic rejection still persists. AREAS COVERED In addition to the standard induction and maintenance therapy, we present a couple of new drugs as induction (Alemtuzumab), CNI free protocol (Belatacept, Sirolimus, Everolimus), maintenance treatment in transplant patients with various type of malignancies (T cell targeted immunomodulators blocking the immune checkpoints CTLA-4, PD1/PDL1) and TMA (aHUS) -eculizimab, and IL6 receptor antagonists in antibody mediated rejection (AMR). EXPERT OPINION There are couple of issues still preventing improvement in kidney transplant long-term outcomes with current and anticipated future immunosuppression: patient more susceptible to infection and CNI nephrotoxicity in kidneys obtained from elderly donors, highly sensitized patients with limited chances to get appropriate kidney and a higher risk for late AMR. A lower rate of CMV/BK virus infections has been observed in everolimus treated patients. Belatacept use has been justified only in EBV seropositive kidney transplants due to the increased risk of PTLD. Eculizumab upon recurrence of aHUS is a sole cost-effective option. A new IL-6 blocking drug (clazakizumab/tocilizumab) is promising option for prevention/treatment of AMR. Clinical experience in tailoring immunosuppression for as long as possible graft and patient survival is inevitable.
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Affiliation(s)
- Goce Spasovski
- University Department of Nephrology, Medical Faculty, University Sts Cyril and Methodius, Skopje, N. Macedonia
| | - Lada Trajceska
- University Department of Nephrology, Medical Faculty, University Sts Cyril and Methodius, Skopje, N. Macedonia
| | - Irena Rambabova-Bushljetik
- University Department of Nephrology, Medical Faculty, University Sts Cyril and Methodius, Skopje, N. Macedonia
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Aziz F, Jorgenson M, Garg N, Parajuli S, Mohamed M, Raza F, Mandelbrot D, Djamali A, Dhingra R. New Approaches to Cardiovascular Disease and Its Management in Kidney Transplant Recipients. Transplantation 2022; 106:1143-1158. [PMID: 34856598 DOI: 10.1097/tp.0000000000003990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cardiovascular events, including ischemic heart disease, heart failure, and arrhythmia, are common complications after kidney transplantation and continue to be leading causes of graft loss. Kidney transplant recipients have both traditional and transplant-specific risk factors for cardiovascular disease. In the general population, modification of cardiovascular risk factors is the best strategy to reduce cardiovascular events; however, studies evaluating the impact of risk modification strategies on cardiovascular outcomes among kidney transplant recipients are limited. Furthermore, there is only minimal guidance on appropriate cardiovascular screening and monitoring in this unique patient population. This review focuses on the limited scientific evidence that addresses cardiovascular events in kidney transplant recipients. Additionally, we focus on clinical management of specific cardiovascular entities that are more prevalent among kidney transplant recipients (ie, pulmonary hypertension, valvular diseases, diastolic dysfunction) and the use of newer evolving drug classes for treatment of heart failure within this cohort of patients. We note that there are no consensus documents describing optimal diagnostic, monitoring, or management strategies to reduce cardiovascular events after kidney transplantation; however, we outline quality initiatives and research recommendations for the assessment and management of cardiovascular-specific risk factors that could improve outcomes.
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Affiliation(s)
- Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Margaret Jorgenson
- Department of Pharmacology, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Maha Mohamed
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Farhan Raza
- Cardiovascular Division, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Didier Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Ravi Dhingra
- Cardiovascular Division, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
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Billany RE, Smith AC, Hutchinson GM, Graham-Brown MPM, Nixon DGD, Bishop NC. Feasibility and acceptability of high-intensity interval training and moderate-intensity continuous training in kidney transplant recipients: the PACE-KD study. Pilot Feasibility Stud 2022; 8:106. [PMID: 35597974 PMCID: PMC9123685 DOI: 10.1186/s40814-022-01067-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/06/2022] [Indexed: 11/29/2022] Open
Abstract
Background Kidney transplant recipients (KTRs) exhibit unique elevated inflammation, impaired immune function, and increased cardiovascular risk. Although exercise reduces cardiovascular risk, there is limited research on this population, particularly surrounding novel high-intensity interval training (HIIT). The purpose of this pilot study was to determine the feasibility and acceptability of HIIT in KTRs. Methods Twenty KTRs (male 14; eGFR 58±19 mL/min/1.73 m2; age 49±11 years) were randomised and completed one of three trials: HIIT A (4-, 2-, and 1-min intervals; 80–90% watts at V̇O2peak), HIITB (4×4 min intervals; 80–90% V̇O2peak) or MICT (~40 min; 50–60% V̇O2peak) for 24 supervised sessions on a stationary bike (approx. 3x/week over 8 weeks) and followed up for 3 months. Feasibility was assessed by recruitment, retention, and intervention acceptability and adherence. Results Twenty participants completed the intervention, and 8 of whom achieved the required intensity based on power output (HIIT A, 0/6 [0%]; HIITB, 3/8 [38%]; MICT, 5/6 [83%]). Participants completed 92% of the 24 sessions with 105 cancelled and rescheduled sessions and an average of 10 weeks to complete the intervention. Pre-intervention versus post-intervention V̇O2peak (mL/kg-1/min-1) was 24.28±4.91 versus 27.06±4.82 in HIITA, 24.65±7.67 versus 27.48±8.23 in HIIT B, and 29.33±9.04 versus 33.05±9.90 in MICT. No adverse events were reported. Conclusions This is the first study to report the feasibility of HIIT in KTRs. Although participants struggled to achieve the required intensity (power), this study highlights the potential that exercise has to reduce cardiovascular risk in KTRs. HIIT and MICT performed on a cycle, with some modification, could be considered safe and feasible in KTRs. Larger scale trials are required to assess the efficacy of HIIT in KTRs and in particular identify the most appropriate intensities, recovery periods, and session duration. Some flexibility in delivery, such as incorporating home-based sessions, may need to be considered to improve recruitment and retention. Trial registration ISRCTN, ISRCTN17122775. Registered on 30 January 2017. Supplementary Information The online version contains supplementary material available at 10.1186/s40814-022-01067-3.
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Affiliation(s)
- Roseanne E Billany
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Alice C Smith
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK.,Department of Health Sciences, University of Leicester, Leicester, UK
| | | | - Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Daniel G D Nixon
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK.,Department of Health Sciences, University of Leicester, Leicester, UK
| | - Nicolette C Bishop
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, LE11 3TU, UK.
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Sridhar VS, Ambinathan JPN, Gillard P, Mathieu C, Cherney DZI, Lytvyn Y, Singh SK. Cardiometabolic and Kidney Protection in Kidney Transplant Recipients With Diabetes: Mechanisms, Clinical Applications, and Summary of Clinical Trials. Transplantation 2022; 106:734-748. [PMID: 34381005 DOI: 10.1097/tp.0000000000003919] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Kidney transplantation is the therapy of choice for patients with end-stage renal disease. Preexisting diabetes is highly prevalent in kidney transplant recipients (KTR), and the development of posttransplant diabetes is common because of a number of transplant-specific risk factors such as the use of diabetogenic immunosuppressive medications and posttransplant weight gain. The presence of pretransplant and posttransplant diabetes in KTR significantly and variably affect the risk of graft failure, cardiovascular disease (CVD), and death. Among the many available therapies for diabetes, there are little data to determine the glucose-lowering agent(s) of choice in KTR. Furthermore, despite the high burden of graft loss and CVD among KTR with diabetes, evidence for strategies offering cardiovascular and kidney protection is lacking. Recent accumulating evidence convincingly shows glucose-independent cardiorenal protective effects in non-KTR with glucose-lowering agents, such as sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists. Therefore, our aim was to review cardiorenal protective strategies, including the evidence, mechanisms, and rationale for the use of these glucose-lowering agents in KTR with diabetes.
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Affiliation(s)
- Vikas S Sridhar
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- The Kidney Transplant Program and the Ajmera Tranplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Jaya Prakash N Ambinathan
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- The Kidney Transplant Program and the Ajmera Tranplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Pieter Gillard
- Department of Endocrinology, University Hospitals Leuven, Catholic University Leuven, Leuven, Belgium
| | - Chantal Mathieu
- Department of Endocrinology, University Hospitals Leuven, Catholic University Leuven, Leuven, Belgium
| | - David Z I Cherney
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yuliya Lytvyn
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Sunita K Singh
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- The Kidney Transplant Program and the Ajmera Tranplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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de Pádua Borges R, Degobi NAH, Bertoluci MC. Choosing statins: a review to guide clinical practice. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 64:639-653. [PMID: 33166435 PMCID: PMC10528630 DOI: 10.20945/2359-3997000000306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 05/13/2020] [Indexed: 11/23/2022]
Abstract
Statins are among the most widely prescribed medicines in the world and have proved their value in reducing cardiovascular events and mortality. Many patients report adverse effects that lead to interruption of treatment. This review aims to individualize statin treatment, considering efficacy for reducing cardiovascular risk and safety, in the setting of specific diseases, to minimize the side effects and improve compliance. We gathered evidence that may help clinicians to choose specific statins in different clinical situations, such as the risk of new diabetes, chronic kidney disease, liver disease, human immunodeficiency virus infection, organ transplant, heart failure and elderly people. Efficacy of statins is well established in a large number of clinical conditions. Therefore, main objective is to revise statin in specific clinical settings, based on pharmacokinetics, safety, drug metabolism and interactions to provide the best choice in different clinical scenarios.
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Affiliation(s)
- Roberta de Pádua Borges
- Programa de Pós-Graduação em Endocrinologia, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil
| | - Nathália Abi Habib Degobi
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil
| | - Marcello Casaccia Bertoluci
- Programa de Pós-Graduação em Ciências Médicas, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil,
- Departamento de Medicina Interna, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil
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Rashid M, Nagaraja V, Shoaib A, Curzen N, Ludman PF, Kapadia SR, Palmer N, Elgendy IY, Kalra A, Vachharajani TJ, Anderson HV, Kwok CS, Mohamed M, Banning AP, Mamas MA. Outcomes Following Percutaneous Coronary Intervention in Renal Transplant Recipients: A Binational Collaborative Analysis. Mayo Clin Proc 2021; 96:363-376. [PMID: 33358453 DOI: 10.1016/j.mayocp.2020.04.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 04/21/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To investigate the clinical and procedural characteristics in patients with a history of renal transplant (RT) and compare the outcomes with patients without RT in 2 national cohorts of patients undergoing percutaneous coronary intervention (PCI). PATIENTS AND METHODS Data from the National Inpatient Sample (NIS) and British Cardiovascular Intervention Society (BCIS) were used to compare the clinical and procedural characteristics and outcomes of patients undergoing PCI who had RT with those who did not have RT. The primary outcome of interest was in-hospital mortality. RESULTS Of the PCI procedures performed in 2004-2014 (NIS) and 2007-2014 (BCIS), 12,529 of 6,601,526 (0.2%) and 1521 of 512,356 (0.3%), respectively, were undertaken in patients with a history of RT. Patients with RT were younger and had a higher prevalence of congestive cardiac failure, hypertension, and diabetes but similar use of drug-eluting stents, intracoronary imaging, and pressure wire studies compared with patients who did not have RT. In the adjusted analysis, patients with RT had increased odds of in-hospital mortality (NIS: odds ratio [OR], 1.90; 95% CI, 1.41-2.57; BCIS: OR, 1.60; 95% CI, 1.05-2.46) compared with patients who did not have RT but no difference in vascular or bleeding events. Meta-analysis of the 2 data sets suggested an increase in in-hospital mortality (OR, 1.79; 95% CI, 1.40-2.29) but no difference in vascular (OR, 1.24; 95% CI, 0.77-2.00) or bleeding (OR, 1.21; 95% CI, 0.86-1.68) events. CONCLUSION This large collaborative analysis of 2 national databases revealed that patients with RT undergoing PCI are younger, have more comorbidities, and have increased mortality risk compared with the general population undergoing PCI.
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Affiliation(s)
- Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Keele, UK, and Academic Department of Cardiology, Royal Stoke Hospital, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | - Vinayak Nagaraja
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Ahmad Shoaib
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Keele, UK, and Academic Department of Cardiology, Royal Stoke Hospital, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | - Nick Curzen
- Department of Cardiology, University Hospital Southampton, and University of Southampton, Southampton, UK
| | - Peter F Ludman
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Nick Palmer
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Islam Y Elgendy
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Ankur Kalra
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Tushar J Vachharajani
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - H Vernon Anderson
- Department of Internal Medicine, Division of Cardiology, McGovern Medical School, University of Texas Health Science Center, Houston
| | - Chun Shing Kwok
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Keele, UK, and Academic Department of Cardiology, Royal Stoke Hospital, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | - Mohamed Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Keele, UK, and Academic Department of Cardiology, Royal Stoke Hospital, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | - Adrian P Banning
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Keele, UK, and Academic Department of Cardiology, Royal Stoke Hospital, University Hospitals of North Midlands, Stoke-on-Trent, UK; Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA.
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Tecce MG, Othman S, Mauch JT, Nathan S, Tilahun E, Broach RB, Azoury SC, Kovach SJ. Complex oncologic resection and reconstruction of the scalp: Predictors of morbidity and mortality. Arch Craniofac Surg 2020; 21:229-236. [PMID: 32867412 PMCID: PMC7463124 DOI: 10.7181/acfs.2020.00206] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 08/18/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Oncologic resection of the scalp confers several obstacles to the reconstructive surgeon dependent upon patient-specific and wound-specific factors. We aim to describe our experiences with various reconstructive methods, and delineate risk factors for coverage failure and complications in the setting of scalp reconstruction. METHODS A retrospective chart review was conducted, examining patients who underwent resection of fungating scalp tumors with subsequent soft-tissue reconstruction from 2003 to 2019. Patient demographics, wound and oncologic characteristics, treatment modalities, and outcomes were recorded and analyzed. RESULTS A total of 189 patients were appropriate for inclusion, undergoing a range of reconstructive methods from skin grafting to free flaps. Thirty-three patients (17.5%) underwent preoperative radiation. In all, 48 patients (25.4%) suffered wound site complications, 25 (13.2%) underwent reoperation, and 47 (24.9%) suffered from mortality. Preoperative radiation therapy was an independent risk factor for wound complications (odds ratio [OR], 2.85; 95% confidence interval [CI], 1.1-7.3; p = 0.028) and reoperations (OR, 4.45; 95% CI, 1.5-13.2; p = 0.007). Similarly, the presence of an underlying titanium mesh was an independent predictor of wound complications (OR, 2.49; 95% CI, 1.1-5.6; p= 0.029) and reoperations (OR, 3.40; 95% CI, 1.2-9.7; p= 0.020). Both immunosuppressed status (OR, 2.88; 95% CI, 1.2-7.1; p= 0.021) and preoperative radiation therapy (OR, 3.34; 95% CI, 1.2-9.7; p= 0.022) were risk factors for mortality. CONCLUSION Both preoperative radiation and the presence of underlying titanium mesh are independent risk factors for wound site complications and increased reoperation rates following oncologic resection and reconstruction of the scalp. Additionally, preoperative radiation, along with an immunosuppressed state, may predict patient mortality following scalp resection and reconstruction.
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Affiliation(s)
- Michael G Tecce
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Sammy Othman
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jaclyn T Mauch
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Shelby Nathan
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Estifanos Tilahun
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Saïd C Azoury
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Yadav V, Jha SC, Gajurel RM, Poudel CM, Sahi R, Sharma M, Adhikari S. <p>Spectrum of Coronary Angiographic Findings in Potential Renal Transplant Recipients in a Tertiary Care Center of Nepal</p>. TRANSPLANT RESEARCH AND RISK MANAGEMENT 2020. [DOI: 10.2147/trrm.s261084] [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] Open
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Devine PA, Cardwell C, Maxwell AP. Association of soluble ST2 with all-cause and cardiovascular mortality in renal transplant recipients: a single-centre cohort study. BMC Nephrol 2020; 21:22. [PMID: 31992225 PMCID: PMC6986045 DOI: 10.1186/s12882-020-1690-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 01/14/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Soluble ST2 is a novel biomarker of myocardial fibrosis with an established role in prognostication of patients with heart failure. Its role in cardiovascular risk prediction for renal transplant recipients has not been investigated despite promising results for ST2 in other populations with renal disease. METHODS In this prospective cohort study, 367 renal transplant recipients were followed up for a median of 16.2 years to investigate the association of soluble ST2 concentration with all-cause mortality. Cardiovascular mortality and major adverse cardiovascular events were secondary outcomes. Cox regression models were used to calculate hazard ratios and 95% confidence intervals for ST2 before and after adjustments. ST2 concentration was analysed both as a continuous variable and following categorisation according to the recommended cut-point of 35 ng/ml. RESULTS A twofold higher ST2 concentration was associated with a 36% increased risk of all-cause mortality after adjustment for conventional cardiovascular risk factors and high-sensitivity C-reactive protein (adjusted hazard ratio 1.36; 95% confidence interval 1.06-1.75; p = 0.016). Associations with ST2 concentration were similar for cardiovascular events (adjusted hazard ratio 1.31; 95% confidence interval 1.00-1.73; p = 0.054), but were stronger for cardiovascular mortality (adjusted hazard ratio 1.61; 95% confidence interval 1.07-2.41; p = 0.022). Addition of ST2 to risk prediction models for mortality and cardiovascular events failed to improve their predictive accuracy. CONCLUSIONS ST2 is associated with, but does not improve prediction of, adverse outcomes in renal transplant recipients.
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Affiliation(s)
- Paul A Devine
- Regional Nephrology and Transplant Unit, Belfast City Hospital, Belfast, UK.
- Centre for Public Health, Queen's University Belfast, Belfast, UK.
| | | | - Alexander P Maxwell
- Regional Nephrology and Transplant Unit, Belfast City Hospital, Belfast, UK
- Centre for Public Health, Queen's University Belfast, Belfast, UK
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12
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Li L, Zhao H, Chen B, Fan Z, Li N, Yue J, Ye Q. FXR activation alleviates tacrolimus-induced post-transplant diabetes mellitus by regulating renal gluconeogenesis and glucose uptake. J Transl Med 2019; 17:418. [PMID: 31836014 PMCID: PMC6909577 DOI: 10.1186/s12967-019-02170-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 12/05/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Tacrolimus (FK506)-induced diabetes mellitus is one of the most important factors of post-transplant diabetes mellitus (PTDM). However, the detailed mechanisms underlying PTDM are still unclear. Farnesoid X receptor (FXR) regulates glycolipid metabolism. The objective of this study was to explore whether FXR is involved in the development of tacrolimus-induced diabetes mellitus. METHODS After C57BL/6J mice were treated with tacrolimus (FK506) for 3 months, the fasting blood glucose levels, body weights, renal morphological alterations, and mRNA expression levels of phosphoenolpyruvate carboxykinase (PEPCK) and glucose transporter 2 (GLUT2) among the control group, the FK506 group and the FK506 + GW4064 (a FXR agonist) group (n = 7) were measured. The intracellular location of peroxisome proliferator activated receptor γ coactivator-1α (PGC1α) and forkhead box O1 (FOXO1) was detected by immunofluorescence. Human renal cortex proximal tubule epithelial cells (HK-2) were treated with 15 μM FK506 or 4 μM FXR agonist (GW4064) for 24, 48 and 72 h, and the expression levels of FXR, gluconeogenesis and glucose uptake, representing the enzymes PEPCK and GLUT2, were detected with real-time PCR and western blot analyses. Finally, the mRNA levels of PEPCK and GLUT2 in HK-2 cells were measured after FXR was upregulated. RESULTS FK506 significantly inhibited the mRNA and protein levels of FXR at 48 h and 72 h in HK-2 cells (P < 0.05). Meanwhile, FK506 promoted gluconeogenesis and inhibited glucose uptake in HK-2 cells (P < 0.05). However, overexpression of FXR in transfected HK-2 cell lines significantly inhibited gluconeogenesis and promoted glucose uptake (P < 0.05). The FXR agonist GW4064 significantly decreased the fasting blood glucose in mice challenged with FK506 for 3 months (P < 0.05), inhibited gluconeogenesis (P < 0.05) and significantly promoted glucose uptake (P < 0.05). Immunofluorescence staining and western blot analyses further revealed that FXR activation may affect the translocation of PGC1α and FOXO1 from the nucleus to the cytoplasm. CONCLUSIONS FXR activation may mitigate tacrolimus-induced diabetes mellitus by regulating gluconeogenesis as well as glucose uptake of renal cortex proximal tubule epithelial cells in a PGC1α/FOXO1-dependent manner, which may be a potential therapeutic strategy for the prevention and treatment of PTDM.
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Affiliation(s)
- Ling Li
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, 430071, Hubei, People's Republic of China
| | - Huijia Zhao
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, 430071, Hubei, People's Republic of China
| | - Binyao Chen
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, 430071, Hubei, People's Republic of China
| | - Zhipeng Fan
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, 430071, Hubei, People's Republic of China
| | - Ning Li
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiovascular Research Institute, Hubei Key Laboratory of Cardiology, Wuhan University, Jiefang Road 238, Wuhan, 430060, People's Republic of China.
| | - Jiang Yue
- Department of Pharmacology, Basic Medical School of Wuhan University, Wuhan, 430071, People's Republic of China.
| | - Qifa Ye
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, 430071, Hubei, People's Republic of China. .,The 3rd Xiangya Hospital of Central South University, Research Center of National Health Ministry on Transplantation Medicine Engineering and Technology, Changsha, 410013, People's Republic of China.
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13
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Devine PA, Courtney AE, Maxwell AP. Cardiovascular risk in renal transplant recipients. J Nephrol 2019; 32:389-399. [PMID: 30406606 PMCID: PMC6482292 DOI: 10.1007/s40620-018-0549-4] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 10/30/2018] [Indexed: 02/07/2023]
Abstract
Successful kidney transplantation offers patients with end-stage renal disease the greatest likelihood of survival. However, cardiovascular disease poses a major threat to both graft and patient survival in this cohort. Transplant recipients are unique in their accumulation of a wide range of traditional and non-traditional cardiovascular risk factors. Hypertension, diabetes, dyslipidaemia and obesity are highly prevalent in patients with end-stage renal disease. These risk factors persist following transplantation and are often exacerbated by the drugs used for immunosuppression in organ transplantation. Additional transplant-specific factors such as poor graft function and proteinuria are also associated with increased cardiovascular risk. However, these transplant-related factors remain unaccounted for in current cardiovascular risk prediction models, making it challenging to identify transplant recipients with highest risk. With few interventional trials in this area specific to transplant recipients, strategies to reduce cardiovascular risk are largely extrapolated from other populations. Aggressive management of traditional cardiovascular risk factors remains the cornerstone of prevention, though there is also a potential role for selecting immunosuppression regimens to minimise additional cardiovascular injury.
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Affiliation(s)
- Paul A Devine
- Regional Nephrology and Transplant Unit, Belfast City Hospital Northern Ireland, Belfast, BT9 7AB, UK.
- Centre for Public Health, Queen's University Belfast, Belfast, UK.
| | - Aisling E Courtney
- Regional Nephrology and Transplant Unit, Belfast City Hospital Northern Ireland, Belfast, BT9 7AB, UK
| | - Alexander P Maxwell
- Regional Nephrology and Transplant Unit, Belfast City Hospital Northern Ireland, Belfast, BT9 7AB, UK
- Centre for Public Health, Queen's University Belfast, Belfast, UK
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14
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Abstract
Renal transplantation is the preferred treatment for patients with end-stage kidney disease. However, despite successful kidney transplantation, cardiovascular disease (CVD) remains one of the major causes of patient death and hence graft loss. The antecedents of this increased risk reside within the development of end-stage kidney disease and dialysis. Risk factors for the development of CVD include diabetes, hypertension, and dyslipidemia. Other transplant-specific factors include the presence of a patent arteriovenous fistula and immunosuppressive therapy. Efforts to modify these factors should be strongly encouraged to improve long-term outcomes of transplant patients and reduce death from CVD in this at-risk patient population.
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Affiliation(s)
- Nitesh N Rao
- Renal Unit, Lyell McEwin Hospital, Elizabeth Vale, South Australia
| | - P Toby Coates
- Renal Unit, Lyell McEwin Hospital, Elizabeth Vale, South Australia; Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia.
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15
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Campagne O, Mager DE, Brazeau D, Venuto RC, Tornatore KM. The impact of tacrolimus exposure on extrarenal adverse effects in adult renal transplant recipients. Br J Clin Pharmacol 2019; 85:516-529. [PMID: 30414331 DOI: 10.1111/bcp.13811] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 10/12/2018] [Accepted: 10/24/2018] [Indexed: 12/28/2022] Open
Abstract
AIMS Tacrolimus has been associated with notable extrarenal adverse effects (AEs), which are unpredictable and impact patient morbidity. The association between model-predicted tacrolimus exposure metrics and standardized extrarenal AEs in stable renal transplant recipients was investigated and a limited sampling strategy (LSS) was developed to predict steady-state tacrolimus area under the curve over a 12-h dosing period (AUCss,0-12h ). METHODS All recipients receiving tacrolimus and mycophenolic acid ≥6 months completed a 12-h cross-sectional observational pharmacokinetic-pharmacodynamic study. Patients were evaluated for the presence of individual and composite gastrointestinal, neurological, and aesthetic AEs during the study visit. The associations between AEs and tacrolimus exposure metrics generated from a published population pharmacokinetic model were investigated using a logistic regression analysis in NONMEM 7.3. An LSS was determined using a Bayesian estimation method with the same patients. RESULTS Dose-normalized tacrolimus AUCss,0-12h and apparent clearance were independently associated with diarrhoea, dyspepsia, insomnia and neurological AE ratio. Dose-normalized tacrolimus maximum concentration was significantly correlated with skin changes and acne. No AE associations were found with trough concentrations. Using limited sampling at 0, 2h; 0, 1, 4h; and 0, 1, 2, 4h provided a precise and unbiased prediction of tacrolimus AUC (root mean squared prediction error < 10%), which was not well characterized using trough concentrations only (root mean squared prediction error >15%). CONCLUSIONS Several AEs (i.e. diarrhoea, dyspepsia, insomnia and neurological AE ratio) were associated with tacrolimus dose normalized AUCss,0-12h and clearance. Skin changes and acne were associated with dose-normalized maximum concentrations. To facilitate clinical implementation, a LSS was developed to predict AUCss,0-12h values using sparse patient data to efficiently assess projected immunosuppressive exposure and potentially minimize AE manifestations.
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Affiliation(s)
- Olivia Campagne
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA.,Faculty of Pharmacy, Universités Paris Descartes-Paris Diderot, Paris, France
| | - Donald E Mager
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Daniel Brazeau
- Department of Pharmaceutical Sciences, College of Pharmacy, University of New England, Portland, ME, USA
| | - Rocco C Venuto
- Erie County Medical Center, Division of Nephrology; Department of Medicine: Nephrology Division; School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Kathleen M Tornatore
- Erie County Medical Center, Division of Nephrology; Department of Medicine: Nephrology Division; School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.,Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, Immunosuppressive Pharmacology Research Program, University at Buffalo, Buffalo, NY, USA
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16
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De Lucena DD, Rangel ÉB. Glucocorticoids use in kidney transplant setting. Expert Opin Drug Metab Toxicol 2018; 14:1023-1041. [DOI: 10.1080/17425255.2018.1530214] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Débora Dias De Lucena
- Department of Medicine, Division of Nephrology, Federal University of São Paulo/Hospital do Rim e Hipertensão, São Paulo, Brazil
| | - Érika Bevilaqua Rangel
- Department of Medicine, Division of Nephrology, Federal University of São Paulo/Hospital do Rim e Hipertensão, São Paulo, Brazil
- Instituto Israelita de Ensino e Pesquisa, Hospital Israelita Albert Einstein, São Paulo, Brazil
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17
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Findlay MD, Dawson J, MacIsaac R, Jardine AG, MacLeod MJ, Metcalfe W, Traynor JP, Mark PB. Inequality in Care and Differences in Outcome Following Stroke in People With ESRD. Kidney Int Rep 2018; 3:1064-1076. [PMID: 30197973 PMCID: PMC6127409 DOI: 10.1016/j.ekir.2018.04.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 04/18/2018] [Accepted: 04/23/2018] [Indexed: 11/27/2022] Open
Abstract
Introduction Stroke rate and mortality are greater in individuals with end-stage renal disease (ESRD) than in those without ESRD. We examined discrepancies in stroke care in ESRD patients and their influence on mortality. Methods This is a national record linkage cohort study of hospitalized stroke individuals from 2005 to 2013. Presentation, measures of care quality (admission to stroke unit, swallow assessment, antithrombotics, or thrombolysis use), and outcomes were compared in those with and without ESRD after propensity score matching (PSM). We examined the effect of being admitted to a stroke unit on survival using Kaplan-Meier and Cox survival analyses. Results A total of 8757 individuals with ESRD and 61,367 individuals with stroke were identified. ESRD patients (n =486) experienced stroke over 34,551.9 patient-years of follow-up; incidence rates were 25.3 (dialysis) and 4.5 (kidney transplant)/1000 patient-years. After PSM, dialysis patients were less likely to be functionally independent (61.4% vs. 77.7%; P < 0.0001) before stroke, less frequently admitted to stroke units (64.6% vs. 79.6%; P < 0.001), or to receive aspirin (75.3% vs. 83.2%; P = 0.01) than non-ESRD stroke patients. There were no significant differences in management of kidney transplantation patients. Stroke with ESRD was associated with a higher death rate during admission (dialysis 22.9% vs.14.4%, P = 0.002; transplantation: 19.6% vs. 9.3%; P = 0.034). Managing ESRD patients in a stroke unit was associated with a lower risk of death at follow-up (hazard ratio: 0.68; 95% confidence interval: 0.55-0.84). Conclusion Stroke incidence is high in ESRD. Individuals on dialysis are functionally more dependent before stroke and less frequently receive optimal stroke care. After a stroke, death is more likely in ESRD patients. Acute stroke unit care may be associated with lower mortality.
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Affiliation(s)
- Mark D Findlay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Rachael MacIsaac
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Alan G Jardine
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Mary Joan MacLeod
- Institute of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Wendy Metcalfe
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jamie P Traynor
- The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
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18
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Maestro de la Calle G, Fernández-Ruiz M, López-Medrano F, Polanco N, González E, San Juan R, Ruiz-Merlo T, Origüen J, Paz-Artal E, Andrés A, Aguado JM. Post-transplant hypocomplementemia: A novel marker of cardiovascular risk in kidney transplant recipients? Atherosclerosis 2018; 269:204-210. [PMID: 29407595 DOI: 10.1016/j.atherosclerosis.2018.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 12/22/2017] [Accepted: 01/12/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND AIMS Cardiovascular disease (CVD) is a leading cause of mortality after kidney transplantation (KT). The potential role of the complement system in the pathogenesis of post-transplant CVD remains unexplored. METHODS Serum complement (C3 and C4) levels were measured at baseline and post-transplant months 1 and 6 in 447 kT recipients. The study outcome was post-transplant atherothrombotic event (PAE), a composite of acute coronary syndrome, critical peripheral arterial disease, stroke and/or transient ischemic attack. RESULTS After a median follow-up of 4.2 years, 48 PAEs occurred in 43 patients (cumulative incidence: 9.6%; incidence rate: 2.6 events per 100 transplant-years). No differences were found in C3 and C4 levels at baseline or month 1 between patients with or without PAE. However, C3 levels at month 6 were significantly lower in patients developing PAE beyond that point (i.e., late PAE) (96.9 ± 22.3 vs. 109.6 ± 24.0 mg/dL; p = 0.013). The presence of C3 hypocomplementemia at month 6 was associated with a lower PAE-free survival (p = 0.002). After adjusting for conventional CVD risk factors and acute graft rejection, C3 hypocomplementemia at month 6 remained as an independent risk factor for late PAE in all the exploratory models (minimum hazard ratio: 3.24; p = 0.011). With respect to a model exclusively based on clinical variables, the inclusion of C3 levels at month 6 improved predictive capacity (areas under ROC curves: 0.788 and 0.812, respectively). CONCLUSIONS Post-transplant monitoring of serum C3 levels might be useful to identify KT recipients at increased risk of CVD.
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Affiliation(s)
- Guillermo Maestro de la Calle
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain.
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Natalia Polanco
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Esther González
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Rafael San Juan
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Tamara Ruiz-Merlo
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Julia Origüen
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Estela Paz-Artal
- Department of Immunology, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Amado Andrés
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
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19
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Impact of low-dose steroids on HbA1c levels and development of pre-diabetes and NODAT in non-diabetic renal transplant recipients on long-term follow-up. Int Urol Nephrol 2017; 50:771-777. [DOI: 10.1007/s11255-017-1754-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 11/20/2017] [Indexed: 12/26/2022]
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20
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Bishop NC, Billany R, Smith AC. Participant acceptability of exercise in kidney disease (PACE-KD): a feasibility study protocol in renal transplant recipients. BMJ Open 2017; 7:e017494. [PMID: 28947458 PMCID: PMC5623462 DOI: 10.1136/bmjopen-2017-017494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Cardiovascular disease (CVD) is a major cause of mortality in renal transplant recipients (RTRs). General population risk scores for CVD underestimate the risk in patients with chronic kidney disease (CKD) suggesting additional non-traditional factors. Renal transplant recipients also exhibit elevated inflammation and impaired immune function. Exercise has a positive impact on these factors in patients with CKD but there is a lack of rigorous research in RTRs, particularly surrounding the feasibility and acceptability of high-intensity interval training (HIIT) versus moderate-intensity continuous training (MICT) in this population. This study aims to explore the feasibility of three different supervised aerobic exercise programmes in RTRs to guide the design of future large-scale efficacy studies. METHODS AND ANALYSIS Renal transplant recipients will be randomised to HIIT A (16 min interval training with 4, 2 and 1 min intervals at 80%-90% of peak oxygen uptake (VO2 peak)), HIIT B (4×4 min interval training at 80%-90% VO2peak) or MICT (~40 min cycling at 50%-60% VO2peak) where they will undertake 24 supervised sessions (approximately thrice weekly over 8 weeks). Assessment visits will be at baseline, midtraining, immediate post-training and 3 months post-training. The study will evaluate the feasibility of recruitment, randomisation, retention, assessment procedures and the implementation of the interventions. A further qualitative sub-study QPACE-KD (Qualitative Participant Acceptability of Exercise in Kidney Disease) will explore patient experiences and perspectives through semistructured interviews and focus groups. ETHICS AND DISSEMINATION All required ethical and regulatory approvals have been obtained. Findings will be disseminated through conference presentations, public platforms and academic publications. TRIAL REGISTRATION NUMBER Prospectively registered; ISRCTN17122775.
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Affiliation(s)
- Nicolette C Bishop
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Roseanne Billany
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Alice C Smith
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
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21
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Abstract
Solid organ transplantation is the criterion standard treatment for many with end-organ failure and can offer a new independence from the burden of disease. However solid organ transplant recipients (SOTRs) remain at high risk of cardiovascular (CV) disease, and poor quality of life and physical functioning. Increasing physical activity and exercise can improve the health of the general population; however, the effects on those with a transplant remain unclear. Intensive exercise and sporting activity has the potential to be beneficial, although there remain concerns particularly around the effects on immune function and the CV system. This review summarizes what is known about the effects of exercise on determinants of health in SOTRs and then collates the available literature investigating the consequences of intensive exercise and sport on the health of SOTR. There is a paucity of high-quality research, with most evidence being case studies or anecdotal; this is understandable given the relatively few numbers of SOTRs who are performing sport and exercise at a high level. However, if suitable evidence-based guidelines are to be formed and SOTRs are to be given reassurances that their activity levels are not detrimental to their transplanted organ and overall health, then more high-quality studies are required.
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Yates W, McCluskey P, Wakefield D. Long-term immunosuppressive therapy for inflammatory eye disease – the link between systemic treatment, cardiovascular risk and disease? EXPERT REVIEW OF OPHTHALMOLOGY 2017. [DOI: 10.1080/17469899.2017.1349610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- William Yates
- Department of Ophthalmology, Sydney Eye Hospital, Sydney, Australia
- School of Medical Sciences, University of New South Wales, Kensington, Australia
| | - Peter McCluskey
- Department of Ophthalmology, Sydney Eye Hospital, Sydney, Australia
- Save Sight Institute, University of Sydney, Sydney, Australia
| | - Denis Wakefield
- School of Medical Sciences, University of New South Wales, Kensington, Australia
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23
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High-risk cutaneous malignancies and immunosuppression: Challenges for the reconstructive surgeon in the renal transplant population. J Plast Reconstr Aesthet Surg 2017; 70:922-930. [PMID: 28457679 DOI: 10.1016/j.bjps.2017.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 03/08/2017] [Accepted: 03/11/2017] [Indexed: 02/02/2023]
Abstract
Renal transplantation is the most frequently performed transplant procedure. Immunosuppressive therapies have dramatically increased survival rates in transplant recipients but are associated with an increased risk of skin cancers. Recent changes in immunosuppressive strategies have been adopted with the aim of reducing this challenging adverse effect. Despite these new strategies, cutaneous malignancies tend to be numerous, aggressive and associated with a higher risk of local and distant dissemination than in the non-transplant population. This represents a significant workload for transplant physicians, dermatologists, and head and neck and plastic surgeons. This review highlights key concepts in the pathogenesis of skin cancer in transplant patients, the impact current and evolving immunosuppressive strategies and regimens will have on the epidemiology, and the management of cutaneous malignancies in renal transplant patients, with particular focus on the implications for the plastic surgery community.
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24
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Affiliation(s)
- A Sinclair
- Aspreva Pharmaceuticals Corporation, Victoria, Canada
| | - R Baildon
- Aspreva Pharmaceuticals Corporation, Victoria, Canada
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25
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Van Leuven SI, Kastelein JJP, Hayden MR, Stroes ES. Mycophenolate mofetil as an immunomodulatory silver bullet in atherogenesis? Lupus 2016. [DOI: 10.1177/0961203306071670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Atherosclerotic vascular disease is a chronic disorder of the vasculature with a substantial impact on society. Although the availability of statins has represented an unparalleled improvement in the treatment of patients with such cardiovascular disease, even more effective measures are required to reverse this disorder with a continuously growing incidence. The classification of atherosclerosis as an inflammatory disorder has prompted the hypothesis that immunomodulation could comprise a novel anti-atherosclerotic strategy. Mycophenolate mofetil (MMF) has various anti-atherogenic effects on major components of the atherosclerotic plaque such as T-lymphocytes, monocytes/macrophages and the endothelium. MMF can inhibit leukocyte recruitment to the subendothelium and the subsequent reduced activation of leukocytes will translate into attenuation of subendothelial crosstalk between T-cells and macrophages. This cascade of events will interrupt the self-perpetuating pro-inflammatory environment within the arterial wall, the hallmark of atherosclerotic vascular disease.
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Affiliation(s)
- SI Van Leuven
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - JJP Kastelein
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - MR Hayden
- Centre for Molecular Medicine and Therapeutics, B.C. Children's and Women's Hospital, Department of Medical Genetics, University of British Columbia, Vancouver, Canada
| | - ES Stroes
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
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Summaria F, Giannico MB, Talarico GP, Patrizi R. Percutaneous coronary interventions and antiplatelet therapy in renal transplant recipients. Ther Adv Cardiovasc Dis 2016; 10:86-97. [PMID: 26680559 PMCID: PMC5933627 DOI: 10.1177/1753944715622120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Cardiovascular disease is the leading cause of mortality and morbidity following renal transplantation (RT), accounting for 40-50% of all deaths. After renal transplantation, an adverse cardiovascular event occurs in nearly 40% of patients; given the dialysis vintage and the average wait time, the likelihood of receiving coronary revascularization is very high. There is a significant gap in the literature in terms of the outcomes of prophylactic coronary revascularization in renal transplantation candidates. Current guidelines on myocardial revascularization stipulate that renal transplant patients with significant coronary artery disease (CAD) should not be excluded from the potential benefit of revascularization. Compared with percutaneous coronary intervention (PCI), however, coronary artery bypass grafting is associated with higher early and 30-day mortality. About one-third of renal transplant patients with CAD have to be treated invasively and so PCI is currently the most popular mode of revascularization in these fragile and compromised patients. A newer generation drug-eluting stent (DES) should be preferred over a bare metal stent (BMS) because of its lower risk of restenosis and improved safety concerns (stent thrombosis) compared with first generation DES and BMS. Among DES, despite no significant differences being reported in terms of efficacy, the newer everolimus and zotarolimus eluting stents should be preferred given the possibility of discontinuing, if necessary, dual antiplatelet therapy before 12 months. Since there is a lack of randomized controlled trials, the current guidelines are inadequate to provide a specifically tailored antiplatelet therapeutic approach for renal transplant patients. At present, clopidogrel is the most used agent, confirming its central role in the therapeutic management of renal transplant patients undergoing PCI. While progress in malignancy-related mortality seems a more distant target, a slow but steady reduction in cardiovascular deaths, improving pharmacological and interventional therapy, is nowadays an achievable medium-term target in renal transplant patients.
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Affiliation(s)
- Francesco Summaria
- Cath-Lab/Department of Cardiology-Policlinico Casilino, Via Casilina, 1049, Rome 00199, Italy
| | | | | | - Roberto Patrizi
- Cath-Lab/Department of Cardiology-Policlinico Casilino, Rome, Italy
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Neale J, Smith AC. Cardiovascular risk factors following renal transplant. World J Transplant 2015; 5:183-95. [PMID: 26722646 PMCID: PMC4689929 DOI: 10.5500/wjt.v5.i4.183] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 08/19/2015] [Accepted: 09/25/2015] [Indexed: 02/05/2023] Open
Abstract
Kidney transplantation is the gold-standard treatment for many patients with end-stage renal disease. Renal transplant recipients (RTRs) remain at an increased risk of fatal and non-fatal cardiovascular (CV) events compared to the general population, although rates are lower than those patients on maintenance haemodialysis. Death with a functioning graft is most commonly due to cardiovascular disease (CVD) and therefore this remains an important therapeutic target to prevent graft failure. Conventional CV risk factors such as diabetes, hypertension and renal dysfunction remain a major influence on CVD in RTRs. However it is now recognised that the morbidity and mortality from CVD are not entirely accounted for by these traditional risk-factors. Immunosuppression medications exert a deleterious effect on many of these well-recognised contributors to CVD and are known to exacerbate the probability of developing diabetes, graft dysfunction and hypertension which can all lead on to CVD. Non-traditional CV risk factors such as inflammation and anaemia have been strongly linked to increased CV events in RTRs and should be considered alongside those which are classified as conventional. This review summarises what is known about risk-factors for CVD in RTRs and how, through identification of those which are modifiable, outcomes can be improved. The overall CV risk in RTRs is likely to be multifactorial and a complex interaction between the multiple traditional and non-traditional factors; further studies are required to determine how these may be modified to enhance survival and quality of life in this unique population.
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Wong N, Tee PS, Kee TYS, Tan JWC. Current practices in coronary artery disease evaluation of renal transplant candidates prior to renal transplantation. PROCEEDINGS OF SINGAPORE HEALTHCARE 2015. [DOI: 10.1177/2010105815611803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Cardiovascular disease is the leading cause of morbidity and mortality in renal transplant recipients and candidates awaiting transplant. Pre-transplant coronary artery disease evaluation can aid in determining transplant candidacy, identifying patients who may benefit from pre-operative cardiac intervention, and implementing measures to reduce perioperative and post-transplant cardiovascular events. However, the choice of investigations and approach in evaluation has yet to be well defined. This article aims to review the evidence for the use of non-invasive investigations and coronary angiography in prognostication, as well as the evidence for revascularization in reducing future cardiac events. The article will also summarize international recommendations and describe the local practice in coronary artery disease evaluation prior to transplant.
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Affiliation(s)
- Ningyan Wong
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Ping Sing Tee
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Terence Yi-Shern Kee
- Department of Renal Medicine, Singapore General Hospital, Singapore
- Duke-NUS Graduate Medical School, Singapore
| | - Jack Wei Chieh Tan
- Department of Cardiology, National Heart Centre Singapore, Singapore
- Duke-NUS Graduate Medical School, Singapore
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Pimentel AL, Bauer AC, Camargo JL. Renal posttransplantation diabetes mellitus: An overview. Clin Chim Acta 2015; 450:327-32. [DOI: 10.1016/j.cca.2015.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 09/05/2015] [Accepted: 09/10/2015] [Indexed: 12/25/2022]
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Venuto RC, Meaney CJ, Chang S, Leca N, Consiglio JD, Wilding GE, Brazeau D, Gundroo A, Nainani N, Morse SE, Cooper LM, Tornatore KM. Association of Extrarenal Adverse Effects of Posttransplant Immunosuppression With Sex and ABCB1 Haplotypes. Medicine (Baltimore) 2015; 94:e1315. [PMID: 26376376 PMCID: PMC4635790 DOI: 10.1097/md.0000000000001315] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 06/25/2015] [Accepted: 07/13/2015] [Indexed: 01/28/2023] Open
Abstract
Extrarenal adverse effects (AEs) associated with calcineurin inhibitor (CNI) and mycophenolic acid (MPA) occur frequently but are unpredictable posttransplant complications. AEs may result from intracellular CNI accumulation and low activity of P-glycoprotein, encoded by the ABCB1 gene. Since ABCB1 single nucleotide polymorphisms (SNPs) and sex influence P-glycoprotein, we investigated haplotypes and extrarenal AEs. A prospective, cross-sectional study evaluated 149 patients receiving tacrolimus and enteric coated mycophenolate sodium or cyclosporine and mycophenolate mofetil. Immunosuppressive AE assessment determined individual and composite gastrointestinal, neurologic, aesthetic, and cumulative AEs. Lipids were quantitated after 12-hour fast. ABCB1 SNPs: c.1236C>T (rs1128503), c.2677G>T/A (rs2032582), and c.3435C>T (rs1045642) were determined with haplotype associations computed using the THESIAS program, and evaluated by immunosuppression, sex and race using multivariate general linear models. Tacrolimus patients exhibited more frequent and higher gastrointestinal AE scores compared with cyclosporine with association to CTT (P = 0.018) and sex (P = 0.01). Aesthetic AE score was 3 times greater for cyclosporine with TTC haplotype (P = 0.005). Females had higher gastrointestinal (P = 0.022), aesthetic (P < 0.001), neurologic (P = 0.022), and cumulative AE ratios (P < 0.001). Total cholesterol (TCHOL), low-density lipoproteins (LDL), and triglycerides were higher with cyclosporine. The TTC haplotype had higher TCHOL (P < 0.001) and LDL (P = 0.005). Higher triglyceride (P = 0.034) and lower high-density lipoproteins (P = 0.057) were associated with TTT with sex-adjusted analysis. ABCB1 haplotypes and sex were associated with extrarenal AEs. Using haplotypes, certain female patients manifested more AEs regardless of CNI. Haplotype testing may identify patients with greater susceptibility to AEs and facilitate CNI individualization.
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Affiliation(s)
- Rocco C Venuto
- From the Nephrology Division; Medicine, School of Medicine and Biomedical Sciences (RCV, SC, NL, AG, NN, KMT); Erie County Medical Center, Buffalo, New York (RCV, AG, KMT); Immunosuppressive Pharmacology Research Program, Translational Pharmacology Research Core, NYS Center of Excellence in Bioinformatics and Life Sciences (CJM, SEM, LMC, KMT); Pharmacy, School of Pharmacy and Pharmaceutical Sciences (CJM, SEM, KMT); Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York (JDC, GEW); and Department of Pharmaceutical Sciences, College of Pharmacy, University of New England, Portland, Maine (DB)
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Albring A, Wendt L, Harz N, Engler H, Wilde B, Kribben A, Lindemann M, Schedlowski M, Witzke O. Relationship between pharmacokinetics and pharmacodynamics of calcineurin inhibitors in renal transplant patients. Clin Transplant 2015; 29:294-300. [PMID: 25557538 DOI: 10.1111/ctr.12504] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2014] [Indexed: 11/30/2022]
Abstract
The calcineurin inhibitors (CNIs) cyclosporine A (CsA) and tacrolimus (Tac) are immunosuppressive drugs, which are typically employed in the field of organ transplantation. Both drugs have narrow therapeutic indices, highly variable pharmacokinetics, and are associated with severe adverse effects. In current clinical routine, the dose finding of CNIs is based on the measurement of their blood concentrations. However, this method is limited in its ability to determine the biological impact of the drug. Alternative monitoring strategies, focusing on the pharmacodynamics of CNIs, could help to personalize drug dosing and optimize the treatment with CNIs. Therefore, we analyzed the relationship between pharmacokinetic and pharmacodynamic of the CNIs CsA (n = 9) and Tac (n = 8) in stable renal transplant patients during a 12-h dosing period. We observed a significant decrease in the drug-blood concentration during the course of the day and in parallel a significant recovery of T cell function. In addition, our data document that analysis of intracellular interleukin (IL)-2 production and determination of the IL-2 release are accurate parameters for monitoring the pharmacodynamics of CNIs.
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Affiliation(s)
- Antje Albring
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, Essen, Germany
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Albring A, Wendt L, Harz N, Engler H, Wilde B, Witzke O, Schedlowski M. Short-term treatment with the calcineurin inhibitor cyclosporine A decreases HPA axis activity and plasma noradrenaline levels in healthy male volunteers. Pharmacol Biochem Behav 2014; 126:73-6. [PMID: 25220683 DOI: 10.1016/j.pbb.2014.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 08/29/2014] [Accepted: 09/07/2014] [Indexed: 10/24/2022]
Abstract
Treatment with the selective calcineurin inhibitor and immunosuppressive drug cyclosporine A (CsA) is associated with neurotoxicity and neurocognitive impairments. Whether and to what extent CsA is inducing alterations of the neuroendocrine status is unknown so far. Therefore, the present study investigated the effect of short-term CsA treatment on hypothalamus-pituitary-adrenal (HPA) axis activity and catecholamine release as well as state anxiety in healthy male subjects. Treatment with CsA significantly reduced plasma concentrations of adrenocorticotropic hormone (ACTH), cortisol, and noradrenaline whereas adrenaline levels and state anxiety remained unaffected. Future studies should analyze the mechanisms of CsA-induced effects on neuroendocrine variables, neurocognitive functions and mood.
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Affiliation(s)
- Antje Albring
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Laura Wendt
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Nino Harz
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Harald Engler
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Benjamin Wilde
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.
| | - Oliver Witzke
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Manfred Schedlowski
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Teplan V, Mahrova A, Piťha J, Racek J, Gürlich R, Teplan Jr V, Valkovsky I, Štollova M. Early Exercise Training After Renal Transplantation and Asymmetric Dimethylarginine: The Effect of Obesity. Kidney Blood Press Res 2014; 39:289-98. [DOI: 10.1159/000355806] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2014] [Indexed: 11/19/2022] Open
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Dundon BK, Torpey DK, Nelson AJ, Wong DTL, Duncan RF, Meredith IT, Faull RJ, Worthley SG, Worthley MI. Beneficial cardiovascular remodeling following arterio-venous fistula ligation post-renal transplantation: a longitudinal magnetic resonance imaging study. Clin Transplant 2014; 28:916-25. [DOI: 10.1111/ctr.12402] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Benjamin K. Dundon
- Cardiovascular Research Centre at the Royal Adelaide Hospital; University of Adelaide; Adelaide SA Australia
- Monash Cardiovascular Research Centre; Monash HEART; Monash Health; Melbourne Vic. Australia
| | - David K. Torpey
- Department of Renal Medicine; Royal Adelaide Hospital; Adelaide SA Australia
| | - Adam J. Nelson
- Cardiovascular Research Centre at the Royal Adelaide Hospital; University of Adelaide; Adelaide SA Australia
| | - Dennis T. L. Wong
- Cardiovascular Research Centre at the Royal Adelaide Hospital; University of Adelaide; Adelaide SA Australia
- Monash Cardiovascular Research Centre; Monash HEART; Monash Health; Melbourne Vic. Australia
| | - Rae F. Duncan
- Cardiovascular Research Centre at the Royal Adelaide Hospital; University of Adelaide; Adelaide SA Australia
| | - Ian T. Meredith
- Monash Cardiovascular Research Centre; Monash HEART; Monash Health; Melbourne Vic. Australia
| | - Randall J. Faull
- Cardiovascular Research Centre at the Royal Adelaide Hospital; University of Adelaide; Adelaide SA Australia
- Department of Renal Medicine; Royal Adelaide Hospital; Adelaide SA Australia
| | - Stephen G. Worthley
- Cardiovascular Research Centre at the Royal Adelaide Hospital; University of Adelaide; Adelaide SA Australia
| | - Matthew I. Worthley
- Cardiovascular Research Centre at the Royal Adelaide Hospital; University of Adelaide; Adelaide SA Australia
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Meaney CJ, Arabi Z, Venuto RC, Consiglio JD, Wilding GE, Tornatore KM. Validity and reliability of a novel immunosuppressive adverse effects scoring system in renal transplant recipients. BMC Nephrol 2014; 15:88. [PMID: 24925208 PMCID: PMC4062516 DOI: 10.1186/1471-2369-15-88] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 05/29/2014] [Indexed: 01/09/2023] Open
Abstract
Background After renal transplantation, many patients experience adverse effects from maintenance immunosuppressive drugs. When these adverse effects occur, patient adherence with immunosuppression may be reduced and impact allograft survival. If these adverse effects could be prospectively monitored in an objective manner and possibly prevented, adherence to immunosuppressive regimens could be optimized and allograft survival improved. Prospective, standardized clinical approaches to assess immunosuppressive adverse effects by health care providers are limited. Therefore, we developed and evaluated the application, reliability and validity of a novel adverse effects scoring system in renal transplant recipients receiving calcineurin inhibitor (cyclosporine or tacrolimus) and mycophenolic acid based immunosuppressive therapy. Methods The scoring system included 18 non-renal adverse effects organized into gastrointestinal, central nervous system and aesthetic domains developed by a multidisciplinary physician group. Nephrologists employed this standardized adverse effect evaluation in stable renal transplant patients using physical exam, review of systems, recent laboratory results, and medication adherence assessment during a clinic visit. Stable renal transplant recipients in two clinical studies were evaluated and received immunosuppressive regimens comprised of either cyclosporine or tacrolimus with mycophenolic acid. Face, content, and construct validity were assessed to document these adverse effect evaluations. Inter-rater reliability was determined using the Kappa statistic and intra-class correlation. Results A total of 58 renal transplant recipients were assessed using the adverse effects scoring system confirming face validity. Nephrologists (subject matter experts) rated the 18 adverse effects as: 3.1 ± 0.75 out of 4 (maximum) regarding clinical importance to verify content validity. The adverse effects scoring system distinguished 1.75-fold increased gastrointestinal adverse effects (p = 0.008) in renal transplant recipients receiving tacrolimus and mycophenolic acid compared to the cyclosporine regimen. This finding demonstrated construct validity. Intra-class correlation was 0.81 (95% confidence interval: 0.65-0.90) and Kappa statistic of 0.68 ± 0.25 for all 18 adverse effects and verified substantial inter-rater reliability. Conclusions This immunosuppressive adverse effects scoring system in stable renal transplant recipients was evaluated and substantiated face, content and construct validity with inter-rater reliability. The scoring system may facilitate prospective, standardized clinical monitoring of immunosuppressive adverse drug effects in stable renal transplant recipients and improve medication adherence.
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Affiliation(s)
- Calvin J Meaney
- Immunosuppressive Pharmacology Research Program, Translational Pharmacology Core, NYS Center of Excellence in Bioinformatics and Life Sciences, 701 Ellicott Street, Buffalo, New York 14203, USA.
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Nashan B. Induction therapy and mTOR inhibition: minimizing calcineurin inhibitor exposure in de novo renal transplant patients. Clin Transplant 2014; 27 Suppl 25:16-29. [PMID: 23909498 DOI: 10.1111/ctr.12156] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2013] [Indexed: 12/18/2022]
Abstract
Use of induction therapy with mTOR inhibitor maintenance immunosuppression to facilitate reduced calcineurin inhibitor (CNI) exposure in de novo kidney transplant patients has been explored in a series of randomized trials. These studies have typically employed interleukin-2 receptor antagonist (IL-2RA) induction, in low or standard immunological risk recipients. Although no study has directly compared mTOR inhibition plus reduced CNI exposure with or without induction, inclusion of IL-2RA induction appears to permit a substantial reduction in CNI exposure without the need for high mTOR inhibitor dosing. IL-2RA induction with an mTOR inhibitor and steroids has consistently shown similar efficacy to standard-exposure CNI with mycophenolic acid and steroids and may improve renal function among patients who remain on the mTOR inhibitor-based regimen. With modern mTOR inhibitor dosing, wound healing complications are of less concern and may be no more frequent than in mycophenolic acid-based regimens. The incidence of cytomegalovirus infection appears lower in patients receiving de novo mTOR inhibition. The available evidence demonstrates that IL-2RA induction with an mTOR inhibitor can successfully reduce CNI exposure by at least half without a penalty in terms of rejection in low- or moderate-risk de novo transplant recipients and may offer renal and antiviral benefits.
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Affiliation(s)
- Björn Nashan
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Eppendorf, Hamburg, Germany.
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Three-year outcomes in kidney transplant patients randomized to steroid-free immunosuppression or steroid withdrawal, with enteric-coated mycophenolate sodium and cyclosporine: the infinity study. J Transplant 2014; 2014:171898. [PMID: 24829794 PMCID: PMC3960772 DOI: 10.1155/2014/171898] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 01/04/2014] [Accepted: 01/06/2014] [Indexed: 12/18/2022] Open
Abstract
In a six-month, multicenter, open-label trial, de novo kidney transplant recipients at low immunological risk were randomized to steroid avoidance or steroid withdrawal with IL-2 receptor antibody (IL-2RA) induction, enteric-coated mycophenolate sodium (EC-MPS: 2160 mg/day to week 6, 1440 mg/day thereafter), and cyclosporine. Results from a 30-month observational follow-up study are presented. Of 166 patients who completed the core study on treatment, 131 entered the follow-up study (70 steroid avoidance, 61 steroid withdrawal). The primary efficacy endpoint of treatment failure (clinical biopsy-proven acute rejection (BPAR) graft loss, death, or loss to follow-up) occurred in 21.4% (95% CI 11.8–31.0%) of steroid avoidance patients and 16.4% (95% CI 7.1–25.7%) of steroid withdrawal patients by month 36 (P = 0.46). BPAR had occurred in 20.0% and 11.5%, respectively (P = 0.19). The incidence of adverse events with a suspected relation to steroids during months 6–36 was 22.9% versus 37.1% (P = 0.062). By month 36, 32.4% and 51.7% of patients in the steroid avoidance and steroid withdrawal groups, respectively, were receiving oral steroids. In conclusion, IL-2RA induction with early intensified EC-MPS dosing and CNI therapy in de novo kidney transplant patients at low immunological risk may achieve similar three-year efficacy regardless of whether oral steroids are withheld for at least three months.
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Kahvecioglu S, Ersoy A, Gullulu M, Dirican M. Effects of calcineurin inhibitors on paraoxonase and arylesterase activity after a kidney transplant. EXP CLIN TRANSPLANT 2014; 12:334-42. [PMID: 24447269 DOI: 10.6002/ect.2013.0110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Cardiovascular disease is a common cause of morbidity and mortality in patients with chronic kidney failure, before and after a kidney transplant. Oxidation of lipoproteins that contain apolipoprotein B may contribute to the initiation of atherosclerosis. Paraoxonase may prevent cardiovascular disease. We compared the effects of different calcineurin inhibitors on risk factors for cardiovascular disease in kidney transplant recipients. MATERIALS AND METHODS In 16 kidney transplant recipients, treatment included tacrolimus in 8 patients and cyclosporine in 8 patients. Hemoglobin, glucose, renal function, lipid parameters, high-sensitivity C-reactive protein, homocysteine, malondialdehyde, paraoxonase activity, and arylesterase activity were measured before transplant and at 1, 6, and 12 months after the transplant. RESULTS The levels of homocysteine and malondialdehyde did not change significantly in patients who received either tacrolimus or cyclosporine. The high-sensitivity C-reactive protein was decreased (tacrolimus group, 1 mo) and increased (cyclosporine group, 6 and 12 mo) after the kidney transplant. Paraoxonase activity was increased (tacrolimus group, 1 mo). Arylesterase activity was increased (tacrolimus group, 1, 6, and 12 mo; cyclosporine group, 1 and 6 mo). The percentage of change in arylesterase activity was higher at 12 months in the tacrolimus than in the cyclosporine group. CONCLUSIONS Tacrolimus may be more effective than cyclosporine in improving risk factors for cardiovascular disease after kidney transplant.
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Affiliation(s)
- Serdar Kahvecioglu
- Department of Nephrology, Bursa Sevket Yilmaz Training and Research Hospital, Bursa, Turkey
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Annaloro C, Airaghi L, Saporiti G, Onida F, Cortelezzi A, Deliliers GL. Metabolic syndrome in patients with hematological diseases. Expert Rev Hematol 2014; 5:439-58. [DOI: 10.1586/ehm.12.35] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Lee J. Use of antioxidants to prevent cyclosporine a toxicity. Toxicol Res 2013; 26:163-70. [PMID: 24278520 PMCID: PMC3834483 DOI: 10.5487/tr.2010.26.3.163] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Revised: 07/30/2010] [Accepted: 08/11/2010] [Indexed: 01/05/2023] Open
Abstract
Cyclosporine A (CsA) is a potent immunosuppressor that is widely used in transplant surgery and the treatment of several autoimmune diseases. However, major side effects of CsA such as nephrotoxicity, hepatotoxicity, neurotoxicity and cardiovascular diseases have substantially limited its usage. Although molecular mechanisms underlying these adverse effects are not clearly understood, there is some evidence that suggests involvement of reactive oxygen species (ROS) . In parallel, protective effects of various antioxidants have been demonstrated by many research groups. Extensive studies of CsA-induced nephrotoxcity have confirmed that the antioxidants can restore the damaged function and structure of kidney. Subsequently, there have appeared numerous reports to demonstrate the positive antioxidant effects on liver and other organ damages by CsA. It may be timely to review the ideas to envisage the relationship between ROS and the CsA-induced toxicity. This review is comprised of a brief description of the immunosuppressive action and the secondary effects of CsA, and a synopsis of reports regarding the antioxidant treatments against the ROS-linked CsA toxicity. A plethora of recent reports suggest that antioxidants can help reduce many CsA’s adverse effects and therefore might help develop more effective CsA treatment regimens.
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Affiliation(s)
- Jinhwa Lee
- Dept. of Clinical Lab Science, Dongseo University, Jurea 2-dong, Sasang-gu, Busan 617-716, Korea
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Urinary excretion of oxidative damage markers in a rat model of vascularized composite allotransplantation. Plast Reconstr Surg 2013; 132:530e-541e. [PMID: 24076700 DOI: 10.1097/prs.0b013e3182a0141f] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Vascularized composite allotransplantation is an emerging field of transplantation that provides a potential treatment for complex tissue defects after traumatic loss or tumor resection and for the repair of congenital abnormalities. However, vascularized composite allotransplantation recipients have suffered from acute and chronic graft rejection that is associated with oxidative stress. This study investigated the oxidative damage in a rat vascularized composite allotransplantation model by measuring three urinary biomarkers, 8-oxo-7,8-dihydroguanine (8-oxoGua), 8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxodG), and malondialdehyde. METHODS Rats received two different immunosuppressants, including cyclosporine A and mycophenolate mofetil after transplantation, with one group also receiving mesenchymal stem cells before transplantation. Urine was collected and analyzed for 8-oxo-7,8-dihydroguanine, 8-oxo-7,8-dihydro-2'-deoxyguanosine, and malondialdehyde by liquid chromatography coupled to tandem mass spectometry methods. RESULTS Rats undergoing vascularized composite allotransplantation had higher urinary levels of 8-oxo-7,8-dihydroguanine, 8-oxo-7,8-dihydro-2'-deoxyguanosine, and malondialdehyde compared with rats undergoing syngeneic transplantation. Cyclosporine A/mycophenolate mofetil following treatment prolonged the allograft survival in a dose-dependent manner. Compared with rats undergoing vascularized composite allotransplantation with cyclosporine A/mycophenolate mofetil treatment alone, rats undergoing mesenchymal stem cell combined treatment showed the longest allograft survival, and had approximately 50 percent lower urinary levels of malondialdehyde together with approximately 2.7-times higher levels of 8-oxo-7,8-dihydroguanine. CONCLUSIONS Mesenchymal stem cell combined treatment efficiently managed oxidative stress in rats undergoing vascularized composite allotransplantation, and urinary 8-oxo-7,8-dihydroguanine and malondialdehyde could be regarded as good responders to the mesenchymal stem cell therapy.
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Opelz G, Döhler B. Association between steroid dosage and death with a functioning graft after kidney transplantation. Am J Transplant 2013; 13:2096-105. [PMID: 23750878 DOI: 10.1111/ajt.12313] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 04/17/2013] [Accepted: 04/23/2013] [Indexed: 01/25/2023]
Abstract
Death with a functioning graft remains a major challenge following kidney transplantation. Steroid dosing may be a modifiable risk factor. Collaborative Transplant Study (CTS) data were analyzed to assess the relationship between long-term steroid dose and death with function during years 2-5 posttransplant in 41 953 adult recipients of a deceased-donor kidney transplant during 1995-2010. Steroid dose at year 1 correlated significantly with death with function overall, and with death due to cardiovascular disease or infection (all p < 0.001). In patients with optimal graft function (serum creatinine <130 µmol/L) and no anti-rejection treatment during (a) year 1 (b) years 1 and 2, these significant associations remained (all p < 0.001). The center-specific incidence of steroid withdrawal during year 2 showed a significant inverse association with death due to cardiovascular disease (p < 0.001) or infection (p < 0.001) overall, and within the subpopulation with good graft function and no rejection during year 1 (p = 0.002 and p < 0.001, respectively). Maintenance steroid dose shows a highly significant association with death with a functioning graft caused by cardiovascular disease or infection during years 2-5 after kidney transplantation, even in patients with good graft outcomes in whom steroid treatment would appear to be unnecessary.
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Affiliation(s)
- G Opelz
- Department of Transplantation Immunology, University of Heidelberg, Heidelberg, Germany.
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Schlitt HJ, Jonas S, Ganten TM, Grannas G, Moench C, Rauchfuss F, Obed A, Tisone G, Pinna AD, Gerunda GE, Beckebaum S. Effects of mycophenolate mofetil introduction in liver transplant patients: results from an observational, non-interventional, multicenter study (LOBSTER). Clin Transplant 2013; 27:368-78. [PMID: 23405863 DOI: 10.1111/ctr.12097] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2012] [Indexed: 12/13/2022]
Abstract
The benefits of calcineurin inhibitor (CNI)-sparing regimens on renal function following liver transplantation (LT) have been demonstrated in clinical studies. This observational study assessed the real-life effects of mycophenolate mofetil (MMF) introduction in LT patients. Four hundred and ninety-seven patients in whom MMF was introduced according to local standards or clinical considerations were entered. Patients were grouped by time between transplantation and start of MMF (start of study): Group A (n = 263): ≤6 d; Group B (n = 64): >6 d to ≤1 month; Group C (n = 74): >1 month to ≤1 yr; and Group D (n = 96): >1 yr. CNI sparing occurred in all groups, particularly in Groups C and D. Mean MMF doses at 12 months were 1202.7, 1363.5, 1504.7, and 1578.1 mg/d, respectively, in Groups A-D. At introduction of MMF, median glomerular filtration rate was 73.3, 81.7, 62.7, and 53.7 mL/min/1.73 m(2) in Groups A-D. At 12 months, this decreased to 66 mL/min/1.73 m(2) in Groups A and B, remained stable in Group C, and increased in Group D (64.8 mL/min/1.73 m(2) ). Serious adverse drug reactions were lowest in Group D. In conclusion, MMF with a subsequent decrease in CNI was well tolerated and improved renal function even years after transplantation. A more forceful MMF dosing strategy with greater CNI sparing may further improve renal function.
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Affiliation(s)
- Hans J Schlitt
- Department of Surgery, University of Regensburg, Regensburg, Germany
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Øzbay LA, Stubbe J, Jespersen B, Jensen BL. The effects of calcineurin inhibitors on prostanoid synthesis: a randomized cross-over study in healthy humans. Transpl Int 2012. [DOI: 10.1111/tri.12004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Lara Aygen Øzbay
- Department of Nephrology; Aarhus University Hospital; Skejby; Aarhus; Denmark
| | - Jane Stubbe
- Department of Cardiovascular and Renal Research; Institute of Molecular Medicine; University of Southern Denmark; Odense; Denmark
| | - Bente Jespersen
- Department of Nephrology; Aarhus University Hospital; Skejby; Aarhus; Denmark
| | - Boye L. Jensen
- Department of Cardiovascular and Renal Research; Institute of Molecular Medicine; University of Southern Denmark; Odense; Denmark
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Renal Function and NODM in De Novo Renal Transplant Recipients Treated with Standard and Reduced Levels of Tacrolimus in Combination with EC-MPS. J Transplant 2012; 2012:941640. [PMID: 23227307 PMCID: PMC3512323 DOI: 10.1155/2012/941640] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 08/21/2012] [Indexed: 11/17/2022] Open
Abstract
Information is lacking concerning concomitant administration of enteric-coated mycophenolate sodium with tacrolimus (EC-MPS+Tac) in renal transplant recipients (RTxR). In this 6-month, prospective, open-label, multicenter study, de novo RTxR were randomized (1 : 1) to low-dose (LD) or standard-dose (SD) Tac with basiliximab, EC-MPS 720 mg bid, and steroids. Primary objective was to compare renal function at 6-month posttransplantation. Secondary objectives were to compare the incidences of biopsy-proven acute rejection (BPAR), graft loss and death, and new-onset diabetes mellitus (NODM). 292 patients (LD n = 151, SD n = 141) were included. Mean Tac levels were at the low end of the target range in standard-exposure patients (SD, n = 141) and exceeded target range in low-exposure patients (LD = 151) throughout the study. There was no significant difference in mean glomerular filtration rate (GFR) between treatments (ITT-population: 63.6 versus 61.0 mL/min). Incidence of BPAR was similar (10.6% versus 9.9%). NODM was significantly less frequent in LD Tac (17% versus 31%; P = 0.02); other adverse effects (AEs) were comparable. EC-MPS+Tac (LD/SD) was efficacious and well tolerated with well-preserved renal function. No renal function benefits were demonstrated, possibly related to poor adherence to reduced Tac exposure.
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Renal Function and NODM in De Novo Renal Transplant Recipients Treated with Standard and Reduced Levels of Tacrolimus in Combination with EC-MPS. J Transplant 2012. [PMID: 23227307 DOI: 10.1155/2012/94164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Information is lacking concerning concomitant administration of enteric-coated mycophenolate sodium with tacrolimus (EC-MPS+Tac) in renal transplant recipients (RTxR). In this 6-month, prospective, open-label, multicenter study, de novo RTxR were randomized (1 : 1) to low-dose (LD) or standard-dose (SD) Tac with basiliximab, EC-MPS 720 mg bid, and steroids. Primary objective was to compare renal function at 6-month posttransplantation. Secondary objectives were to compare the incidences of biopsy-proven acute rejection (BPAR), graft loss and death, and new-onset diabetes mellitus (NODM). 292 patients (LD n = 151, SD n = 141) were included. Mean Tac levels were at the low end of the target range in standard-exposure patients (SD, n = 141) and exceeded target range in low-exposure patients (LD = 151) throughout the study. There was no significant difference in mean glomerular filtration rate (GFR) between treatments (ITT-population: 63.6 versus 61.0 mL/min). Incidence of BPAR was similar (10.6% versus 9.9%). NODM was significantly less frequent in LD Tac (17% versus 31%; P = 0.02); other adverse effects (AEs) were comparable. EC-MPS+Tac (LD/SD) was efficacious and well tolerated with well-preserved renal function. No renal function benefits were demonstrated, possibly related to poor adherence to reduced Tac exposure.
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Opelz G, Döhler B. Association of HLA mismatch with death with a functioning graft after kidney transplantation: a collaborative transplant study report. Am J Transplant 2012; 12:3031-8. [PMID: 22900931 DOI: 10.1111/j.1600-6143.2012.04226.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
HLA mismatches may correlate with risk of death with a functioning graft (DWFG) because of requirement for higher immunosuppression doses and more antirejection therapy. Deceased-donor kidney transplants (n = 177 584) performed 1990-2009 and reported to the Collaborative Transplant Study were analyzed. The incidence of DWFG was found to be 4.8% during year 1 posttransplant and 7.7% during years 2-5 (Kaplan-Meier estimates). Most frequent causes of DWFG were infection, cardiovascular disease and malignancy (32.2%, 30.9% and 3.6% in year 1; 16.4%, 29.6% and 15.9% in years 2-5). HLA-A + B + DR mismatches were significantly associated with DWFG during year 1 (p < 0.001), a correlation that diminished but persisted during years 2-5 (p < 0.001). HLA mismatch was associated with DWFG because of infection (p < 0.001 during year 1, p = 0.043 during years 2-5) or cardiovascular disease (p < 0.001 during year 1, p = 0.030 during years 2-5) but not malignancy. There was also a significant association between HLA mismatch and hospitalization for viral (p < 0.001) or bacterial (p = 0.002) infection. Multivariable analysis showed that mismatches for HLA class II were more strongly associated with both hospitalization and DWFG than mismatches for HLA class I.
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Affiliation(s)
- G Opelz
- Department of Transplantation Immunology, University of Heidelberg, Heidelberg, Germany.
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Budde K, Lehner F, Sommerer C, Arns W, Reinke P, Eisenberger U, Wüthrich RP, Scheidl S, May C, Paulus EM, Mühlfeld A, Wolters HH, Pressmar K, Stahl R, Witzke O. Conversion from cyclosporine to everolimus at 4.5 months posttransplant: 3-year results from the randomized ZEUS study. Am J Transplant 2012; 12:1528-40. [PMID: 22642473 DOI: 10.1111/j.1600-6143.2012.03994.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The long-term effect of conversion from calcineurin inhibitor (CNI) therapy to an mTOR inhibitor requires clarification. Following completion of the 12-month, open-label, multicenter ZEUS study, in which 300 kidney transplant recipients were randomized to continue cyclosporine (CsA) or convert to everolimus at 4.5 months posttransplant, outcomes were assessed at month 36 (n = 284; 94.7%). CNI therapy was reintroduced in 28.4% of everolimus patients by month 36. The primary efficacy endpoint, estimated glomerular filtration rate (Nankivell, ANCOVA) was significantly higher with everolimus versus the CsA group at month 24 (7.6 mL/min/1.73 m(2) , 95%CI 4.3, 11.0 mL/min/1.73 m(2) ; p < 0.001) and month 36 (7.5 mL/min/1.73 m(2) , 95%CI 3.6, 11.4 mL/min/1.73 m(2) ; p < 0.001). The incidence of biopsy-proven acute rejection from randomization to month 36 was 13.0% in the everolimus arm and 4.8% in the CsA arm (p = 0.015). Patient and graft survival, as well as incidences of malignancy, severe infections and hospitalization, were similar between groups. Kidney transplant patients who are converted from CsA to everolimus at month 4.5 and who remain on everolimus thereafter may achieve a significant improvement in renal function that is maintained to 3 years. There was a significantly higher rate of rejection in the everolimus arm but this did not exert a deleterious effect by 3 years posttransplant.
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Affiliation(s)
- K Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany.
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Thierry A, Mourad G, Büchler M, Kamar N, Villemain F, Heng AE, Le Meur Y, Choukroun G, Toupance O, Legendre C, Lepogamp P, Kessler M, Merville P, Moulin B, Quéré S, Terpereau A, Chaouche-Teyara K, Touchard G. Steroid avoidance with early intensified dosing of enteric-coated mycophenolate sodium: a randomized multicentre trial in kidney transplant recipients. Nephrol Dial Transplant 2012; 27:3651-9. [PMID: 22645323 DOI: 10.1093/ndt/gfs146] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Short-term intensified dosing using enteric-coated mycophenolate sodium (EC-MPS) reduces rejection after kidney transplantation without compromising safety and may facilitate steroid avoidance. METHODS In a 6-month, multicentre open-label trial, 222 de novo kidney transplant recipients at low-immunological risk were randomized to steroid avoidance or maintenance steroids with interleukin (IL)-2 receptor antibody (IL-2RA) induction, EC-MPS (2160 mg/day to Week 6, 1440 mg/day thereafter) and cyclosporine. RESULTS The primary end point; treatment failure at Month 6 [biopsy-proven acute rejection (BPAR), graft loss, death or loss to follow-up], occurred in 17.9% (20/112) of steroid-avoidance patients and 14.5% (16/110) of controls (difference 3.4%, 95% confidence interval -6.3 to 13.1, P = 0.47 for superiority testing). BPAR occurred in 11.6 and 7.3% of patients in the steroid-avoidance and control arms, respectively (P = 0.27). Creatinine clearance was similar at Month 6 (steroid-avoidance 56 ± 18 mL/min/1.73 m(2), controls 60 ± 22 mL/min/1.73 m(2), P = 0.34). Cytomegalovirus infection, as reported by investigators, occurred in 12.5% of steroid-avoidance patients and 22.7% of controls (P = 0.045). CONCLUSIONS A regimen of early intensified EC-MPS dosing with calcineurin inhibitor and IL-2RA induction permits oral steroid avoidance in adult kidney transplant patients at low-immunological risk without compromising efficacy at 6 months' follow-up.
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Affiliation(s)
- Antoine Thierry
- Service de Néphrologie et Transplantation Rénale, Hôpital La Milétrie, Poitiers, France
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Israni AK, Snyder JJ, Skeans MA, Kasiske BL. Clinical diagnosis of metabolic syndrome: predicting new-onset diabetes, coronary heart disease, and allograft failure late after kidney transplant. Transpl Int 2012; 25:748-57. [PMID: 22548293 DOI: 10.1111/j.1432-2277.2012.01488.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Metabolic syndrome is associated with coronary heart disease (CHD) and new-onset diabetes after kidney transplant (NODAT). Using data collected from transplant centers worldwide for the Patient Outcomes in Renal Transplantation study, we examined associations of metabolic syndrome (n = 2253 excluding recipients with diabetes pretransplant), CHD (n = 2253), and NODAT (n = 1840 further excluding recipients with diabetes in the first year post-transplant), with the primary outcome of allograft failure. We assessed risk factors associated with secondary outcomes of metabolic syndrome, NODAT, and CHD after adjusting for type of baseline immunosuppression and transplant center effects. Metabolic syndrome prevalence was 39.8% at 12-24 months post-transplant and 35.4% at 36-48 months. Metabolic syndrome was independently associated with NODAT (hazard ratio 3.46, 95% confidence interval 2.40-4.98, P < 0.0001), CHD (2.03, 1.16-3.52, P = 0.013), and allograft failure (1.36, 1.03-1.79, P = 0.028). Allograft failure occurred in 218 patients (14.6%). After adjustment for metabolic syndrome, NODAT (1.63, 1.18-2.24, P = 0.003) and CHD (5.48, 3.27-9.20, P < 0.0001) remained strongly associated with increased risk of allograft failure. Metabolic syndrome, NODAT, and CHD are risk factors for allograft failure. NODAT and CHD are risk factors for allograft failure, independent of metabolic syndrome.
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Affiliation(s)
- Ajay K Israni
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN 55415, USA.
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