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Bang JB, Oh C, Kim YS, Kim SH, Yu HC, Kim C, Ju MK, So BJ, Lee SH, Han SY, Jung CW, Kim JK, Ahn HJ, Lee SH, Jeon JY. Safety and metabolic advantages of steroid withdrawal after 6 months posttransplant in de novo kidney transplantation: A 1‐year prospective cohort study. Immun Inflamm Dis 2022; 10:e576. [PMID: 34913271 PMCID: PMC8926512 DOI: 10.1002/iid3.576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 11/09/2021] [Accepted: 11/23/2021] [Indexed: 11/09/2022] Open
Abstract
Introduction This prospective multicenter study aimed at investigating the safety and metabolic advantages of steroid withdrawal (SW) therapy in kidney transplant recipients with tacrolimus–mycophenolate mofetil‐based immunosuppression. Methods We analyzed 179 recipients who received kidney transplantation from March 2016 and September 2018. In 179 recipients, 114 patients maintained an immunosuppressive regimen including steroids (steroid continuation [SC] group). The remaining 65 patients were determined to withdraw steroid therapy after 6 months posttransplant (SW group). Metabolic parameters and graft functions of the two groups were evaluated. Results The estimated glomerular filtration rates at 12 months posttransplant were 67.29 ± 20.29 ml/min/1.73 m2 in SC group and 73.72 ± 17.57 ml/min/1.73 m2 in SW group (p < .001). The acute rejection occurred to four recipients in the SC group (3.5%) and no acute rejection occurred to SW group recipients during the 6–2 months posttransplant period. Oral glucose tolerance tests revealed that recipients in the SW group were more improved in glucose metabolism than the SC group during 6–12 months posttransplant. In addition, cholesterol levels and blood pressure decreased after the withdrawal of steroids in the SW group. Conclusion In conclusion, a 6‐month withdrawal of steroids in recipients with low immunological risk and stable graft function can be safely conducted and result in improvement of metabolic profiles. Stable recipients without biopsy‐proven acute rejection and proteinuria can safely withdraw from steroids out of a maintenance immunosuppressive regimen 6‐months posttransplant. A long‐term follow‐up study is needed to verify our results.
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Affiliation(s)
- Jun B. Bang
- Department of Surgery Ajou University School of Medicine Suwon South Korea
| | - Chang‐Kwon Oh
- Department of Surgery Ajou University School of Medicine Suwon South Korea
| | - Yu S. Kim
- Department of Transplantation Surgery, Research Institute for Transplantation Yonsei University College of Medicine Seoul South Korea
| | - Sung H. Kim
- Department of Surgery, Wonju Severance Christian Hospital Yonsei University Wonju College of Medicine Wonju South Korea
| | - Hee C. Yu
- Department of Surgery Jeonbuk National University College of Medicine Jeonju South Korea
| | - Chan‐Duck Kim
- Department of Internal Medicine, Kyungpook National University Kyungpook National University Hospital Daegu South Korea
| | - Man Ki Ju
- Department of Surgery Yonsei University College of Medicine Seoul South Korea
| | - Byung J. So
- Department of Surgery Wonkwang University Hospital Iksan South Korea
| | - Sang Ho Lee
- Department of Internal Medicine Kyung Hee University Seoul South Korea
| | - Sang Y. Han
- Department of Internal Medicine Inje University Ilsan Paik Hospital Goyang South Korea
| | - Cheol W. Jung
- Department of Surgery Korea University College of Medicine Seoul South Korea
| | - Joong K. Kim
- Department of Internal Medicine Bong Seng Memorial Hospital Busan South Korea
| | - Hyung J. Ahn
- Department of Surgery Kyung Hee University School of Medicine Seoul South Korea
| | - Su H. Lee
- Department of Surgery Ajou University School of Medicine Suwon South Korea
| | - Ja Y. Jeon
- Department of Endocrinology and Metabolism Ajou University School of Medicine Suwon South Korea
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Kizilbash SJ, Jensen CJ, Kouri AM, Balani SS, Chavers B. Steroid avoidance/withdrawal and maintenance immunosuppression in pediatric kidney transplantation. Pediatr Transplant 2022; 26:e14189. [PMID: 34786800 DOI: 10.1111/petr.14189] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/30/2021] [Accepted: 10/06/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Corticosteroids have been an integral part of maintenance immunosuppression for pediatric kidney transplantation. However, prolonged steroid therapy is associated with significant toxicities resulting in several SW/avoidance strategies in recent years. METHOD/OBJECTIVE This comprehensive review aims to discuss steroid-related toxicities and the safety, efficacy, and benefit of steroid avoidance/withdrawal immunosuppression in pediatric kidney transplant recipients. RESULTS Initial studies of SW/avoidance conducted in the setting of CSA and AZA showed an increased incidence of AR but no increase in graft loss or mortality with SW/avoidance maintenance immunosuppression. Studies performed under modern immunosuppression (induction therapy, Tac, and MMF) show no significant increase in AR or graft loss with SW/avoidance immunosuppression. Furthermore, SW/avoidance immunosuppression is associated with significant improvement in growth, BMI, BP control, and lipid profile in pediatric kidney transplant recipients. Despite these data, SW/avoidance remains controversial, and only 40% of pediatric kidney transplant recipients in the United States are currently on SW/avoidance maintenance immunosuppression. CONCLUSION SW/avoidance maintenance immunosuppression is safe and associated with fewer side effects compared with steroid-inclusive maintenance immunosuppression in pediatric kidney transplant recipients.
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Affiliation(s)
- Sarah J Kizilbash
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Chelsey J Jensen
- Solid Organ Transplant, University of Minnesota, Minneapolis, Minnesota, USA
| | - Anne M Kouri
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shanthi S Balani
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Blanche Chavers
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
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Adebiyi O, Umukoro P, Sharfuddin A, Taber T, Chen J, Lane KA, Li X, Goggins W, Yaqub MS. Patient and Graft Survival Outcomes During 2 Eras of Immunosuppression Protocols in Kidney Transplantation: Indiana University Retrospective Cohort Experience. Transplant Proc 2021; 53:2841-2852. [PMID: 34774307 DOI: 10.1016/j.transproceed.2021.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 09/24/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Since 1964 when Indiana University performed its first kidney transplant, immunosuppression protocol was steroid-based until 2004 when steroid-free immunosuppression protocol was adopted. We describe clinical outcomes on our patients administered early steroid withdrawal (ESW) protocol (5 days) compared with our historical cohort (HC), who were on chronic steroid-based immunosuppression. METHODS We performed a retrospective study evaluating kidney transplant recipients between 1993 and 2003 (HC, n = 1689) and between 2005 and 2016 (ESW cohort, n = 2097) at the Indiana University program, with a median follow-up of 10.5 years and 6.1 years, respectively. Primary outcomes were patient and death-censored graft survival at 1, 3, and 5 years in both study cohorts. Secondary outcomes were 1-year rates of biopsy-proven acute rejection; graft function at 1, 3, and 5 years; and risk of post-transplant infection (BK virus and cytomegalovirus) in the ESW cohort. Cox proportional model and Kaplan-Meier estimates were used to estimate survival probabilities. Fisher exact tests were used to compare episodes of acute rejection in the ESW cohort. RESULTS No difference was observed in patient survival between the ESW and HC cohorts (P = .13). Compared with the ESW cohort, death-censored graft survival was significantly worse in the HC (5 year: 86.4% vs 90.6%, log-rank P < .001). One-year acute rejection reported in the ESW cohort alone was 15.7% and significantly worse in Black patients and younger patients (P < .05). CONCLUSIONS In this sizeable single-center cohort study with significant ethnic diversity, ESW is a viable alternative to steroid-based immunosuppression protocol in kidney transplant recipients.
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Affiliation(s)
| | - Peter Umukoro
- Indiana University Health Transplant, Indianapolis, Indiana
| | | | - Tim Taber
- Indiana University Health Transplant, Indianapolis, Indiana
| | - Jeanne Chen
- Indiana University Health Transplant, Indianapolis, Indiana
| | - Kathleen A Lane
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis Indiana
| | - Xiaochun Li
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis Indiana
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Thongprayoon C, Jadlowiec CC, Leeaphorn N, Bruminhent J, Acharya PC, Acharya C, Pattharanitima P, Kaewput W, Boonpheng B, Cheungpasitporn W. Feature Importance of Acute Rejection among Black Kidney Transplant Recipients by Utilizing Random Forest Analysis: An Analysis of the UNOS Database. MEDICINES (BASEL, SWITZERLAND) 2021; 8:medicines8110066. [PMID: 34822363 PMCID: PMC8621202 DOI: 10.3390/medicines8110066] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 11/16/2022]
Abstract
Background: Black kidney transplant recipients have worse allograft outcomes compared to White recipients. The feature importance and feature interaction network analysis framework of machine learning random forest (RF) analysis may provide an understanding of RF structures to design strategies to prevent acute rejection among Black recipients. Methods: We conducted tree-based RF feature importance of Black kidney transplant recipients in United States from 2015 to 2019 in the UNOS database using the number of nodes, accuracy decrease, gini decrease, times_a_root, p value, and mean minimal depth. Feature interaction analysis was also performed to evaluate the most frequent occurrences in the RF classification run between correlated and uncorrelated pairs. Results: A total of 22,687 Black kidney transplant recipients were eligible for analysis. Of these, 1330 (6%) had acute rejection within 1 year after kidney transplant. Important variables in the RF models for acute rejection among Black kidney transplant recipients included recipient age, ESKD etiology, PRA, cold ischemia time, donor age, HLA DR mismatch, BMI, serum albumin, degree of HLA mismatch, education level, and dialysis duration. The three most frequent interactions consisted of two numerical variables, including recipient age:donor age, recipient age:serum albumin, and recipient age:BMI, respectively. Conclusions: The application of tree-based RF feature importance and feature interaction network analysis framework identified recipient age, ESKD etiology, PRA, cold ischemia time, donor age, HLA DR mismatch, BMI, serum albumin, degree of HLA mismatch, education level, and dialysis duration as important variables in the RF models for acute rejection among Black kidney transplant recipients in the United States.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Correspondence: (C.T.); (P.P.); (W.K.); (W.C.)
| | | | - Napat Leeaphorn
- Renal Transplant Program, University of Missouri-Kansas City School of Medicine/Saint Luke’s Health System, Kansas City, MO 64131, USA;
| | - Jackrapong Bruminhent
- Excellence Center for Organ Transplantation, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand, Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand;
| | - Prakrati C. Acharya
- Division of Nephrology, Texas Tech Health Sciences Center El Paso, El Paso, TX 79905, USA; (P.C.A.); (C.A.)
| | - Chirag Acharya
- Division of Nephrology, Texas Tech Health Sciences Center El Paso, El Paso, TX 79905, USA; (P.C.A.); (C.A.)
| | - Pattharawin Pattharanitima
- Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand
- Correspondence: (C.T.); (P.P.); (W.K.); (W.C.)
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand
- Correspondence: (C.T.); (P.P.); (W.K.); (W.C.)
| | | | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Correspondence: (C.T.); (P.P.); (W.K.); (W.C.)
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Wojciechowski D, Wiseman A. Long-Term Immunosuppression Management: Opportunities and Uncertainties. Clin J Am Soc Nephrol 2021; 16:1264-1271. [PMID: 33853841 PMCID: PMC8455033 DOI: 10.2215/cjn.15040920] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The long-term management of maintenance immunosuppression in kidney transplant recipients remains complex. The vast majority of patients are treated with the calcineurin inhibitor tacrolimus as the primary agent in combination with mycophenolate, with or without corticosteroids. A tacrolimus trough target 5-8 ng/ml seems to be optimal for rejection prophylaxis, but long-term tacrolimus-related side effects and nephrotoxicity support the ongoing evaluation of noncalcineurin inhibitor-based regimens. Current alternatives include belatacept or mammalian target of rapamycin inhibitors. For the former, superior kidney function at 7 years post-transplant compared with cyclosporin generated initial enthusiasm, but utilization has been hampered by high initial rejection rates. Mammalian target of rapamycin inhibitors have yielded mixed results as well, with improved kidney function tempered by higher risk of rejection, proteinuria, and adverse effects leading to higher discontinuation rates. Mammalian target of rapamycin inhibitors may play a role in the secondary prevention of squamous cell skin cancer as conversion from a calcineurin inhibitor to an mammalian target of rapamycin inhibitor resulted in a reduction of new lesion development. Early withdrawal of corticosteroids remains an attractive strategy but also is associated with a higher risk of rejection despite no difference in 5-year patient or graft survival. A major barrier to long-term graft survival is chronic alloimmunity, and regardless of agent used, managing the toxicities of immunosuppression against the risk of chronic antibody-mediated rejection remains a fragile balance.
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Affiliation(s)
- David Wojciechowski
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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Aref A, Sharma A, Halawa A. Does steroid-free immunosuppression improve the outcome in kidney transplant recipients compared to conventional protocols? World J Transplant 2021; 11:99-113. [PMID: 33954088 PMCID: PMC8058645 DOI: 10.5500/wjt.v11.i4.99] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/22/2021] [Accepted: 03/19/2021] [Indexed: 02/06/2023] Open
Abstract
Steroids continue to be the cornerstone of immune suppression since the early days of organ transplantation. Steroids are key component of induction protocols, maintenance therapy and in the treatment of various forms of rejection. Prolonged steroid use resulted in significant side effects on almost all the body organs owing to the presence of steroid receptors in most of the mammalian cells. Kidney allograft recipients had to accept the short and long term complications of steroids because of lack of effective alternatives. This situation changed with the intro-duction of newer and more effective immune suppression agents with a relatively more acceptable side effect profile. As a result, the clinicians have been contemplating if it is the time to abandon the unquestionable reliance on maintenance steroids in modern transplantation practice. This review aims to evaluate the safety and efficacy of various steroid-minimization approaches (steroid avoidance, early steroid withdrawal, and late steroid withdrawal) in kidney transplant recipients. A meticulous electronic search was conducted through the available data resources like SCOPUS, MEDLINE, and Liverpool University library e-resources. Relevant articles obtained through our search were included. A total number of 90 articles were eligible to be included in this review [34 randomised controlled trials (RCT) and 56 articles of other research modalities]. All articles were evaluating the safety and efficacy of various steroid-free approaches in comparison to maintenance steroids. We will cover only the RCT articles in this review. If used in right clinical context, steroid-free protocols proved to be comparable to steroid-based maintenance therapy. The appropriate approach should be tailored individually according to each recipient immuno-logical challenges and clinical condition.
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Affiliation(s)
- Ahmed Aref
- Department of Nephrology, Sur hospital, Sur 411, Oman
| | - Ajay Sharma
- Department of Transplantation, Royal Liverpool University Hospitals, Liverpool 111, United Kingdom
| | - Ahmed Halawa
- Department of Transplantation, Sheffield Teaching Hospitals, Sheffield S5 7AU, United Kingdom
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7
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Okihara M, Takeuchi H, Kikuchi Y, Akashi I, Kihara Y, Konno O, Iwamoto H, Oda T, Tanaka S, Unezaki S, Hirano T. Individual Lymphocyte Sensitivity to Steroids as a Reliable Biomarker for Clinical Outcome after Steroid Withdrawal in Japanese Renal Transplantation. J Clin Med 2021; 10:jcm10081670. [PMID: 33924724 PMCID: PMC8070672 DOI: 10.3390/jcm10081670] [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: 03/09/2021] [Revised: 04/09/2021] [Accepted: 04/10/2021] [Indexed: 11/17/2022] Open
Abstract
Recently, steroid reduction/withdrawal regimens have been attempted to minimize the side effects of steroids in renal transplantation. However, some recipients have experienced an increase/resumption of steroid administrations and acute graft rejection (AR). Therefore, we investigated the relationship between the individual lymphocyte sensitivity to steroids and the clinical outcome after steroid reduction/withdrawal. We cultured peripheral blood mononuclear cells (PBMCs) isolated from 24 recipients with concanavalin A (Con A) in the presence of methylprednisolone (MPSL) or cortisol (COR) for four days, and the 50% of PBMC proliferation (IC50) values and the PBMC sensitivity to steroids were calculated. Regarding the experience of steroid increase/resumption and incidence of AR within one year of steroid reduction/withdrawal, the IC50 values of these drugs before transplantation in the clinical event group were significantly higher than those in the event-free group. The cumulative incidence of steroid increase/resumption and AR in the PBMC high-sensitivity groups to these drugs before transplantation were significantly lower than those in the low-sensitivity groups. These observations suggested that an individual’s lymphocyte sensitivity to steroids could be a reliable biomarker to predict the clinical outcome after steroid reduction/withdrawal and to select the patients whose dose of steroids can be decreased and/or withdrawn after transplantation.
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Affiliation(s)
- Masaaki Okihara
- Department of Kidney Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan; (M.O.); (I.A.); (Y.K.); (O.K.); (H.I.)
| | - Hironori Takeuchi
- Department of Pharmacy, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan;
| | - Yukiko Kikuchi
- Department of Practical Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan; (Y.K.); (S.U.)
| | - Isao Akashi
- Department of Kidney Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan; (M.O.); (I.A.); (Y.K.); (O.K.); (H.I.)
| | - Yu Kihara
- Department of Kidney Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan; (M.O.); (I.A.); (Y.K.); (O.K.); (H.I.)
| | - Osamu Konno
- Department of Kidney Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan; (M.O.); (I.A.); (Y.K.); (O.K.); (H.I.)
| | - Hitoshi Iwamoto
- Department of Kidney Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan; (M.O.); (I.A.); (Y.K.); (O.K.); (H.I.)
| | - Takashi Oda
- Department of Nephrology, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan;
| | - Sachiko Tanaka
- Clinical Pharmacology, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan;
| | - Sakae Unezaki
- Department of Practical Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan; (Y.K.); (S.U.)
| | - Toshihiko Hirano
- Clinical Pharmacology, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan;
- Correspondence: ; Tel.: +81-042-676-5794
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8
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Werbel WA, Bae S, Yu S, Al Ammary F, Segev DL, Durand CM. Early steroid withdrawal in HIV-infected kidney transplant recipients: Utilization and outcomes. Am J Transplant 2021; 21:717-726. [PMID: 32681603 PMCID: PMC7927911 DOI: 10.1111/ajt.16195] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 06/10/2020] [Accepted: 06/28/2020] [Indexed: 01/25/2023]
Abstract
Kidney transplant (KT) outcomes for HIV-infected (HIV+) persons are excellent, yet acute rejection (AR) is common and optimal immunosuppressive regimens remain unclear. Early steroid withdrawal (ESW) is associated with AR in other populations, but its utilization and impact are unknown in HIV+ KT. Using SRTR, we identified 1225 HIV+ KT recipients between January 1, 2000, and December 31, 2017, without AR, graft failure, or mortality during KT admission, and compared those with ESW with those with steroid continuation (SC). We quantified associations between ESW and AR using multivariable logistic regression and interval-censored survival analysis, as well as with graft failure and mortality using Cox regression, adjusting for donor, recipient, and immunologic factors. ESW utilization was 20.4%, with more zero HLA mismatch (8% vs 4%), living donors (26% vs 20%), and lymphodepleting induction (64% vs 46%) compared to the SC group. ESW utilization varied widely across 129 centers, with less use at high- versus moderate-volume centers (6% vs 21%, P < .001). AR was more common with ESW by 1 year (18.4% vs 12.3%; aOR: 1.08 1.612.41 , P = .04) and over the study period (aHR: 1.02 1.391.90 , P = .03), without difference in death-censored graft failure (aHR 0.60 0.911.36 , P = .33) or mortality (aHR: 0.75 1.151.77 , P = .45). To reduce AR after HIV+ KT, tailoring of ESW utilization is reasonable.
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Affiliation(s)
- William A. Werbel
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sunjae Bae
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Sile Yu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Fawaz Al Ammary
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dorry L. Segev
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland,Scientific Registry of Transplant Recipients, Minneapolis, Minnesota
| | - Christine M. Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Cho JM, Jun H, Jo HA, Han KH, Kim HS, Han SY. A case of successful late steroid withdrawal after ABO-incompatible kidney transplantation. KOREAN JOURNAL OF TRANSPLANTATION 2020; 34:121-125. [PMID: 35769349 PMCID: PMC9188928 DOI: 10.4285/kjt.2020.34.2.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/04/2020] [Accepted: 06/10/2020] [Indexed: 11/24/2022] Open
Abstract
Few data exist regarding steroid withdrawal in ABO-incompatible (ABO-i) kidney transplantation (KT). Here, we report a case of steroid withdrawal after ABO-i KT. A 46-year-old man diagnosed with Henoch-Schonlein purpura received ABO-i KT from his 42-year-old sister. The recipient and donor blood types were O and AB, respectively. His preoperative ABO antibody titers were anti-A of 1:16 and anti-B of 1:8 in isoagglutinin test. HLA mismatch was 0 and he received a single 325 mg/m2 dose of intravenous (IV) rituximab 4 weeks before KT. Three sessions of plasma exchange were undertaken before KT and low-dose IV immunoglobulin of 0.1 g/kg was administered after plasma exchange. On the day of the operation, ABO antibody titer decreased to anti-A of 1:4 and anti-B of 1:2. Renal function remained stable after KT. The patient wished to stop steroid treatment despite the risk of rejection after withdrawal. Steroid tapering was initiated at 20 months and accomplished at 26 months after KT. At that time, serum creatinine level was 1.13 mg/dL, and anti-A and anti-B titers were 1:8 and 1:2, respectively. No issues were observed after steroid withdrawal. At 48 months after KT, serum creatinine level was 1.21 mg/dL, and anti-A and anti-B antibody titers were 1:32 and 1:2, respectively. Steroid withdrawal in ABO-i KT might be considered in immunologically low-risk patients.
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Affiliation(s)
- Jeong Min Cho
- Department of Internal Medicine, Inje University College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Heungman Jun
- Department of Surgery, Inje University College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Hyung Ah Jo
- Department of Internal Medicine, Inje University College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Kum Hyun Han
- Department of Internal Medicine, Inje University College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Han-Seong Kim
- Department of Pathology, Inje University College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Sang Youb Han
- Department of Internal Medicine, Inje University College of Medicine, Ilsan Paik Hospital, Goyang, Korea
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Vock DM, Matas AJ. Rapid discontinuation of prednisone in kidney transplant recipients from at-risk subgroups: an OPTN/SRTR analysis. Transpl Int 2019; 33:181-201. [PMID: 31557340 DOI: 10.1111/tri.13530] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 07/30/2019] [Accepted: 09/19/2019] [Indexed: 12/23/2022]
Abstract
Although rapid discontinuation of prednisone (RDP) after kidney transplantation has been successful in low-risk recipients, there is concern about RDP use in recipients at increased risk for rejection or recurrent disease. Using SRTR, we compared outcomes for RDP versus maintenance prednisone-treated recipients for all adult 1st and 2nd transplants (n = 169 479) and the following 1st transplant subgroups: African American (AA); highly sensitized; those with a potentially recurrent disease; and pediatric recipients. For all adult 1st LD and DD transplants, RDP was associated with better patient and graft survival. For all LD subgroups, RDP and maintenance prednisone were associated with similar patient, graft, and death-censored (DC) graft survival. For 1st transplant DD subgroups, RDP was associated with better patient survival in AA, those with potentially recurrent disease, and pediatric recipients; graft survival with RDP was better in AAs. For adult 2nd DD transplants, RDP was associated with worse DC-graft survival. Importantly, for all differences, the effect size was small. With the exception of 2nd DD transplants, RDP protocols can be used without decreasing patient or graft survival for subgroups of 1st DD and LD kidney transplant recipients and for 2nd LD transplant recipients, at increased risk of rejection or recurrent disease.
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Affiliation(s)
- David M Vock
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Arthur J Matas
- Division of Transplantation, Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN, USA
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Song T, Jiang Y, Liu J, Wang Z, Zeng J, Huang Z, Fan Y, Wang X, Lin T. Steroid withdrawal or avoidance is safe in high‐risk kidney transplants: A systematic review and meta‐analysis. Kaohsiung J Med Sci 2019; 35:350-357. [PMID: 30942560 DOI: 10.1002/kjm2.12064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 03/03/2019] [Indexed: 12/11/2022] Open
Affiliation(s)
- Tu‐Run Song
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Ya‐Mei Jiang
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Jin‐Peng Liu
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Zhi‐Ling Wang
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Jun Zeng
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Zhong‐Li Huang
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Yu Fan
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Xian‐Ding Wang
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Tao Lin
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
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Randomized, Open-Label, Phase IV, Korean Study of Kidney Transplant Patients Converting From Cyclosporine to Prolonged-Release Tacrolimus Plus Standard- or Reduced-Dose Corticosteroids. Transplant Proc 2019; 51:749-760. [PMID: 30979460 DOI: 10.1016/j.transproceed.2019.01.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 01/17/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND This 24-week, multicenter, randomized, exploratory, comparative, open-label, phase-IV study assessed the safety and efficacy of prolonged-release tacrolimus (PR-T) with reduced-dose versus standard-dose corticosteroids in stable kidney transplant recipients in Korea after converting from cyclosporine-based therapy. METHODS At baseline, patients were converted from cyclosporine-based to PR-T-based immunosuppression and randomized (1:1) to receive either corticosteroids maintained at prestudy dose (standard-dose group) or tapered from week 4 to 50% of the prestudy dose by week 12 (reduced-dose group). Patients were seen at baseline and weeks 1, 4, 12, and 24. The primary endpoint was change in estimated glomerular filtration rate (Modification-of-Diet-in-Renal-Disease-4) between baseline and week 24. Secondary endpoints included either acute rejection or patient-reported satisfaction with PR-T. Adverse events (AEs) were recorded. RESULTS Overall, 150 patients were randomized into a reduced-dose group (n = 73) and a standard-dose group (n = 77). At week 24, mean ± standard deviation for corticosteroid dose was 2.5 ± 0.9 mg and 5.0 ± 1.3 mg, respectively. Mean change in estimated glomerular filtration rate from baseline to week 24 was +1.5 ± 9.1 mL/min/1.73 m2 (P = .1567) and +3.4 ± 10.6 mL/min/1.73 m2 (P = .0065), respectively, and not significantly different between groups. There were no acute rejection episodes. Most respondents (>70%) considered PR-T more convenient than cyclosporine. AE incidence was similar between groups. The most common AEs experienced by ≥3% of patients in either treatment group were gastrointestinal events (20.8% and 28.6% of patients receiving reduced- and standard-dose corticosteroids, respectively). Most AEs in both treatment groups were mild or moderate in severity. CONCLUSION Renal function was maintained following conversion from cyclosporine to PR-T, irrespective of corticosteroid regimen; PR-T enables reduced corticosteroid dosage.
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Cilião HL, Camargo-Godoy RBO, Souza MFD, Zanuto A, Delfino VDA, Cólus IMDS. Polymorphisms in IMPDH2, UGT2B7, and CES2 genes influence the risk of graft rejection in kidney transplant recipients taking mycophenolate mofetil. MUTATION RESEARCH-GENETIC TOXICOLOGY AND ENVIRONMENTAL MUTAGENESIS 2018; 836:97-102. [DOI: 10.1016/j.mrgentox.2018.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 04/11/2018] [Accepted: 06/01/2018] [Indexed: 01/07/2023]
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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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Liu A, Woodside KJ, Augustine JJ, Sarabu N. Racial disparity in kidney transplant survival relates to late rejection and is independent of steroid withdrawal. Clin Transplant 2018; 32:e13381. [PMID: 30098053 DOI: 10.1111/ctr.13381] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 07/24/2018] [Accepted: 08/06/2018] [Indexed: 01/06/2023]
Abstract
Black kidney transplant recipients have more acute rejection (AR) and inferior graft survival. We sought to determine whether early steroid withdrawal (ESW) had an impact on AR and death-censored graft loss (DCGL) in blacks. From 2006 to 2012, AR and graft survival were analyzed in 483 kidney recipients (208 black and 275 non-black). Rates of ESW were similar between blacks (65%) and non-blacks (67%). AR was defined as early (≤3 months) or late (>3 months). The impact of black race, early AR, and late AR on death-censored graft failure was analyzed using univariate and multivariate Cox models. Blacks had greater dialysis vintage, more deceased donor transplants, and less HLA matching, yet rates of early AR were comparable between blacks and non-blacks. However, black race was a risk factor for late AR (HR: 3.48 (95% CI: 1.87-6.47)) Blacks had a greater rate of DCGL, partially driven by late AR (HR with late AR: 5.6; 95% CI: 3.3-9.3). ESW had no significant interaction with black race for risk of early AR, late AR, or DCGL. Independent of ESW, black kidney recipients had a higher rate of late AR after kidney transplantation. Late AR was highly predictive of DCGL and contributed to inferior graft survival in blacks.
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Affiliation(s)
- Angela Liu
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | | | - Nagaraju Sarabu
- Case Western Reserve University School of Medicine, Cleveland, Ohio.,Division of Nephrology, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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Taber DJ, Gebregziabher M, Srinivas T, Egede LE, Baliga PK. Transplant Center Variability in Disparities for African-American Kidney Transplant Recipients. Ann Transplant 2018; 23:119-128. [PMID: 29449524 PMCID: PMC6019128 DOI: 10.12659/aot.907226] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Disparities research has traditionally focused on patient-level variables to ascertain predominant risk factors driving differences in outcomes for African-American (AA) kidney transplant recipients. Our objectives were to determine the magnitude and impact of transplant center variability for graft outcome disparities. Material/Methods This was a retrospective cohort study analyzing 25 years of U.S. national transplant registry data at both the patient and center levels using univariate descriptive statistics and multivariable modeling. Results A total of 257,024 recipients from 191 centers were analyzed; AAs represented 31.1% of recipients. After adjusting for baseline characteristics, AAs had 42% higher risk of graft loss (aHR 1.42, 95% CI 1.39 to 1.45; p<0.001). Center variability for graft outcome disparities in AAs was significant (race*center interaction term p<0.05), with the aHRs ranging from 0.5 to 4.9; 46% of centers demonstrated a non-statistically significant disparity (aHR p>0.05) and 25% of centers had a large AA disparity (aHR >1.75). In a more recent transplant time period (2000–14), overall racial disparities decreased but center-level disparities increased in variability. Center-level factors significantly associated with increasing disparity included higher acute rejection rates, fewer transplants per year, longer length of stay, lower use of calcineurin inhibitors (CNI), and lower living donor rates. Conclusions There is evidence of significant center-level variability in graft outcome disparities for AA kidney recipients. Further, there appears to be a number of center-level factors associated with this variability, including acute rejection rates, CNI use, number of transplants per year, and, in recent years, low living donor rates.
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Affiliation(s)
- David J Taber
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.,Department of Pharmacy Services, Ralph H Johnson Va Medical Center, Charleston, SC, USA
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Titte Srinivas
- Department of Transplant Nephrology, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Leonard E Egede
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Prabhakar K Baliga
- Department of Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
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Wehmeier C, Hirt-Minkowski P, Amico P, Georgalis A, Hopfer H, Steiger J, Dickenmann M, Schaub S. Successful steroid withdrawal guided by surveillance biopsies-A single-center experience. Clin Transplant 2018; 32:e13181. [DOI: 10.1111/ctr.13181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Caroline Wehmeier
- Clinic for Transplantation Immunology and Nephrology; University Hospital Basel; Basel Switzerland
| | - Patricia Hirt-Minkowski
- Clinic for Transplantation Immunology and Nephrology; University Hospital Basel; Basel Switzerland
| | - Patrizia Amico
- Clinic for Transplantation Immunology and Nephrology; University Hospital Basel; Basel Switzerland
- HLA-Diagnostics and Immunogenetics; Department of Laboratory Medicine; University Hospital Basel; Basel Switzerland
| | - Argyrios Georgalis
- Clinic for Transplantation Immunology and Nephrology; University Hospital Basel; Basel Switzerland
| | - Helmut Hopfer
- Institute for Pathology; University Hospital Basel; Basel Switzerland
| | - Jürg Steiger
- Clinic for Transplantation Immunology and Nephrology; University Hospital Basel; Basel Switzerland
| | - Michael Dickenmann
- Clinic for Transplantation Immunology and Nephrology; University Hospital Basel; Basel Switzerland
| | - Stefan Schaub
- Clinic for Transplantation Immunology and Nephrology; University Hospital Basel; Basel Switzerland
- HLA-Diagnostics and Immunogenetics; Department of Laboratory Medicine; University Hospital Basel; Basel Switzerland
- Department of Biomedicine; Transplantation Immunology and Nephrology; University Basel; Basel Switzerland
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Cytolytic Induction Therapy Improves Clinical Outcomes in African-American Kidney Transplant Recipients. Ann Surg 2017; 266:450-456. [PMID: 28654544 DOI: 10.1097/sla.0000000000002366] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Determine the impact of cytolytic versus IL-2 receptor antibody (IL-2RA) induction on acute rejection, graft loss and death in African-American (AA) kidney transplant (KTX) recipients. BACKGROUND AAs are underrepresented in clinical trials in transplantation; thus, there is controversy regarding the optimal choice of perioperative antibody induction in KTX to improve outcomes. METHODS National cohort study using US transplant registry data from January 1, 2000 to December 31, 2009 in adult solitary AA KTX recipients, with at least 5 years of follow-up. Multivariable logistic and Cox regression were utilized to assess the outcomes of acute rejection, graft loss, and mortality, with interaction terms to assess effect modification. RESULTS Twenty-five thousand eighty-four adult AAs receiving solitary KTX were included, 16,927 (67.5%) received cytolytic induction and 8157 (32.5%) received IL-2RA induction. After adjustment for recipient sociodemographics, donor, and transplant characteristics, the use of cytolytic induction therapy reduced the risk of acute rejection by 32% (OR 0.68, 0.62-0.75), graft loss by 9% (HR 0.91, 0.86-0.97), and death by 12% (HR 0.88, 0.83-0.94). There were a number of significant effect modifiers, including public insurance, panel reactive antibody, delayed graft function, and steroid withdrawal; in these groups, cytolytic induction substantially improved clinical outcomes. CONCLUSIONS These data demonstrate that cytolytic induction therapy, as compared with IL-2RA, reduces the risk of rejection, graft loss, and death in adult AA KTX recipients, particularly in those who are sensitized, receive public insurance, develop delayed graft function, or undergo steroid withdrawal.
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Augustine JJ. Early Steroid Withdrawal in Black Transplant Patients: A Selective Process. Clin J Am Soc Nephrol 2017; 12:7-9. [PMID: 27979978 PMCID: PMC5220666 DOI: 10.2215/cjn.11731116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Joshua J Augustine
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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