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Nelson J, Alvey N, Bowman L, Schulte J, Segovia M, McDermott J, Te HS, Kapila N, Levine DJ, Gottlieb RL, Oberholzer J, Campara M. Consensus recommendations for use of maintenance immunosuppression in solid organ transplantation: Endorsed by the American College of Clinical Pharmacy, American Society of Transplantation, and the International Society for Heart and Lung Transplantation. Pharmacotherapy 2022; 42:599-633. [DOI: 10.1002/phar.2716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/29/2022] [Accepted: 04/08/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Joelle Nelson
- Department of Pharmacotherapy and Pharmacy Services University Health San Antonio Texas USA
- Pharmacotherapy Education and Research Center University of Texas Health San Antonio San Antonio Texas USA
- Department of Pharmacy, Pharmacotherapy Division, College of Pharmacy The University of Texas at Austin Austin Texas USA
| | - Nicole Alvey
- Department of Pharmacy Rush University Medical Center Chicago Illinois USA
- Science and Pharmacy Roosevelt University College of Health Schaumburg Illinois USA
| | - Lyndsey Bowman
- Department of Pharmacy Tampa General Hospital Tampa Florida USA
| | - Jamie Schulte
- Department of Pharmacy Services Thomas Jefferson University Hospital Philadelphia Pennsylvania USA
| | | | - Jennifer McDermott
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health Grand Rapids Michigan USA
- Department of Medicine, Michigan State University College of Human Medicine Grand Rapids Michigan USA
| | - Helen S. Te
- Liver Transplantation, Center for Liver Diseases, Department of Medicine University of Chicago Medical Center Chicago Illinois USA
| | - Nikhil Kapila
- Department of Transplant Hepatology Duke University Hospital Durham North Carolina USA
| | - Deborah Jo Levine
- Division of Critical Care Medicine, Department of Medicine The University of Texas Health Science Center at San Antonio San Antonio Texas USA
| | - Robert L. Gottlieb
- Baylor University Medical Center and Baylor Scott and White Research Institute Dallas Texas USA
| | - Jose Oberholzer
- Department of Surgery/Division of Transplantation University of Virginia Charlottesville Virginia USA
| | - Maya Campara
- Department of Surgery University of Illinois Chicago Chicago Illinois USA
- Department of Pharmacy Practice University of Illinois Chicago Chicago Illinois USA
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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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Mangus RS, Bajpai S, Lutz AJ, Powelson JA, Goggins WC. Contrast Administration to the Deceased Kidney Donor Has No Impact on Post-Transplant Outcomes. J Surg Res 2020; 254:261-267. [PMID: 32480070 DOI: 10.1016/j.jss.2020.03.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/18/2020] [Accepted: 03/27/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Contrast-induced acute kidney injury may occur in patients undergoing imaging studies. This study reviews all deceased kidney donors at a single center during a 15-y period to determine if donor contrast exposure results in contrast-induced acute kidney injury in the donor or is associated with worse outcomes in the transplant recipient. METHODS Donor and recipient renal functions were recorded, including donor serum creatinine and recipient delayed graft function, creatinine clearance at 1 y, and early and late graft survival. Donor contrast exposure was recorded as the number of preprocurement contrasted studies. RESULTS Donor and recipient records were available for 1394 transplants (88%). There were 51% of donors who received any contrasted study (38%, one study; 12%, two studies, and 1%, three studies). Donor contrast exposure was not associated with significant differences in preprocurement serum creatinine levels. Post-transplant, donor contrast exposure was associated with risk of neither delayed graft function (4% for all) nor early kidney graft loss. Creatinine clearance at 1 y was equivalent. Five-year Cox regression demonstrated higher graft survival for contrast-exposed grafts (P = 0.03). CONCLUSIONS There is no negative effect of donor contrast administration on early and late kidney graft function. These findings included donor kidneys exposed to as many as three contrasted studies.
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Affiliation(s)
- Richard S Mangus
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Shivani Bajpai
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Andrew J Lutz
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - John A Powelson
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - William C Goggins
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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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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Wong TC, Lo CM, Fung JY. Emerging drugs for prevention of T-cell mediated rejection in liver and kidney transplantation. Expert Opin Emerg Drugs 2017; 22:123-136. [PMID: 28503959 DOI: 10.1080/14728214.2017.1330884] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Acute and chronic graft rejection continues to be an important problem after solid organ transplantation. With the introduction of potent immunosuppressive agents such as calcineurin inhibitors, the risk of rejection has been significantly reduced. However, the adverse effects of life-long immunosuppression remain a concern, and there exist a fine balance between over-immunosuppression and risk of rejection. Areas covered: In this review, the current standard of care in immunosuppressive therapy, including the use of steroids, calcineurin inhibitors, mycophenolate prodrugs and mammalian target of rapamycin inhibitors, will be discussed. Newer immunosuppressive agents showing promising early data after liver and kidney transplantation will also be explored. Expert Opinion: Currently, calcineurin inhibitors continue to be a vital component of immunosuppressive therapy after solid organ transplantation. Although minimization and avoidance strategies have been developed, the ultimate goal of inducing tolerance remains elusive. Newer emerging agents should have potent and specific immunosuppressive activity, with minimal associated side effects. An individualized approach should be adopted to tailor immunosuppression according to the different needs of recipients.
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Affiliation(s)
- Tiffany Cl Wong
- a Department of Surgery, Department of Medicine , Queen Mary Hospital, The University of Hong Kong , Hong Kong , Hong Kong S.A.R
| | - Chung-Mau Lo
- a Department of Surgery, Department of Medicine , Queen Mary Hospital, The University of Hong Kong , Hong Kong , Hong Kong S.A.R
| | - James Yy Fung
- a Department of Surgery, Department of Medicine , Queen Mary Hospital, The University of Hong Kong , Hong Kong , Hong Kong S.A.R
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Prashar R, Venkat K. Immunosuppression Minimization and Avoidance Protocols: When Less Is Not More. Adv Chronic Kidney Dis 2016; 23:295-300. [PMID: 27742383 DOI: 10.1053/j.ackd.2016.09.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Kidney transplantation is well established as the best treatment option for end-stage kidney disease. It confers not only a better quality of life but also a significant survival advantage compared to dialysis. However, despite significant improvement in short-term kidney transplant graft survival over the past three decades, long-term graft survival remains suboptimal. Concerns about the possible contribution of chronic calcineurin inhibitor (CNI) nephrotoxicity to late allograft failure and other serious adverse effects of currently used immunosuppressive agents (especially corticosteroids) have led to increasing interest in developing regimens which may better preserve kidney allograft function and minimize other immunosuppression-related problems without increasing the risk of rejection. The availability of newer immunosuppressive agents has provided the opportunity to formulate such regimens. Approaches to this end include minimization, withdrawal, or avoidance of corticosteroids and CNIs. Currently, replacement of a CNI with a mammalian target of rapamycin inhibitor while continuing mycophenolate and discontinuation of corticosteroids within the first post-transplant week is being increasingly utilized. Belatacept-based, CNI-free immunosuppression is an emerging alternative approach to avoiding CNI-mediated nephrotoxicity. We also discuss the evolution, results, and pros and cons of corticosteroid- and CNI minimization protocols. Recent studies suggest that chronic alloimmune damage rather than chronic CNI nephrotoxicity is the major contributor to late kidney allograft failure. The implications of this finding for the use of CNI minimization protocols are also discussed.
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Khalil AK, Slaven JE, Mujtaba MA, Yaqub MS, Mishler DP, Taber TE, Sharfuddin AA. Re-transplants compared to primary kidney transplants recipients: a mate kidney paired analysis of the OPTN/UNOS database. Clin Transplant 2016; 30:566-78. [PMID: 26915071 DOI: 10.1111/ctr.12722] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2016] [Indexed: 01/13/2023]
Abstract
Outcomes of kidney re-transplant recipients (RTR) were compared to primary recipients (FTR) from paired donor kidneys. Organ Procurement and Transplantation Network (OPTN) database was used to identify deceased donors (n = 6266) who donated one kidney to an RTR and the mate kidney to an FTR between January 2000 to December 2010. As compared to FTR, RTR were younger (45 vs. 52 yr, p < 0.001) and had higher proportion of plasma reactive antibody >80 (25% vs 7%, p < 0.001). There were higher 0 mismatches in RTR (19% vs. 16%, p < 0.001). There were more pre-emptive transplants in RTR (24% vs. 21%, p = 0.002). Delayed graft function (28% vs. 25%, p = 0.007) was higher in RTR. Patient survival was similar in FTR and RTR groups at one, three, and five yr (95.7%, 90.2%, and 82.5% vs. 95.2%, 89.8% and 82.7%). Allograft survival rates were higher in FTR group compared to RTR group at one, three, and five yr (91.1%, 82.4%, and 70.9% vs. 87.8%, 77.4%, and 66.1% p < 0.001). Death-censored allograft survival rates were higher in FTR group at one, three, and five yr (91.3%, 82.7% and 71.4% vs. 88%, 77.7% and 66.5% p < 0.001). In today's era of modern immunosuppression, graft survival in RTR has improved but remains inferior to FTR when controlling for donor factors.
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Affiliation(s)
- Ali K Khalil
- Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - James E Slaven
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Muhammad A Mujtaba
- Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Muhammad S Yaqub
- Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Dennis P Mishler
- Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Tim E Taber
- Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Asif A Sharfuddin
- Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
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Zsom L, Wagner L, Fülöp T. Minimization vs tailoring: Where do we stand with personalized immunosuppression during renal transplantation in 2015? World J Transplant 2015; 5:73-80. [PMID: 26421259 PMCID: PMC4580929 DOI: 10.5500/wjt.v5.i3.73] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 06/13/2015] [Accepted: 07/14/2015] [Indexed: 02/05/2023] Open
Abstract
The introduction of novel immunosuppressive agents over the last two decades and the improvement of our diagnostic tools for early detection of antibody-mediated injury offer us an opportunity, if not a mandate, to better match the immunosuppression needs of the individual patients with side effects of the therapy. However, immunosuppressive regimens in the majority of programs remain mostly protocol-driven, with relatively little inter-program heterogeneity in certain areas of the world. Emerging data showing different outcomes with a particular immunosuppressive strategy in populations with varying immunological risks underscore a real potential for “personalized medicine” in renal transplantation. Studies demonstrating marked differences in the adverse-effect profiles of individual drugs including the risk for viral infections, malignancy and renal toxicity call for a paradigm shift away from a “one size fits all” approach to an individually tailored immunosuppressive therapy for renal transplant recipients, assisted by both screening for predictors of graft loss and paying close attention to dose or class-related adverse effects. Our paper explores some of the opportunities during the care of these patients. Potential areas of improvements may include: (1) a thorough assessment of immunological and metabolic risk profile of each renal transplant recipient; (2) screening for predictors of graft loss and early signs of antibody-mediated rejection with donor-specific antibodies, protocol biopsies and proteinuria (including close follow up of adverse effects with dose adjustments or conversions as necessary); and (3) increased awareness of the possible link between poor tolerance of a given drug at a given dose and non-adherence with the prescribed regimen. Altogether, these considerations may enable the most effective use of the drugs we already have.
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Suszynski TM, Gillingham KJ, Rizzari MD, Dunn TB, Payne WD, Chinnakotla S, Finger EB, Sutherland DER, Najarian JS, Pruett TL, Matas AJ, Kandaswamy R. Prospective randomized trial of maintenance immunosuppression with rapid discontinuation of prednisone in adult kidney transplantation. Am J Transplant 2013; 13:961-970. [PMID: 23432755 PMCID: PMC3621067 DOI: 10.1111/ajt.12166] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 11/26/2012] [Accepted: 12/26/2012] [Indexed: 01/25/2023]
Abstract
Rapid discontinuation of prednisone (RDP) has minimized steroid-related complications following kidney transplant (KT). This trial compares long-term (10-year) outcomes with three different maintenance immunosuppressive protocols following RDP in adult KT. Recipients (n=440; 73% living donor) from March 2001 to April 2006 were randomized into one of three arms: cyclosporine (CSA) and mycophenolate mofetil (MMF) (CSA/MMF, n=151); high-level tacrolimus (TAC, 8-12 μg/L) and low-level sirolimus (SIR, 3-7 μg/L) (TACH/SIRL, n=149) or low-level TAC (3-7 μg/L) and high-level SIR (8-12 μg/L) (TACL/SIR(H) , n=140). Median follow-up was ∼7 years. There were no differences between arms in 10-year actuarial patient, graft and death-censored graft survival or in allograft function. There were no differences in the 10-year actuarial rates of biopsy-proven acute rejection (30%, 26% and 20% in CSA/MMF, TACH/SIRL and TACL/SIRH) and chronic rejection (38%, 35% and 31% in CSA/MMF, TACH/SIRL and TACL/SIRH). Rates of new-onset diabetes mellitus were higher with TACH/SIRL (p=0.04), and rates of anemia were higher with TACH/SIRL and TACL/SIRH (p=0.04). No differences were found in the overall rates of 16 other post-KT complications. These data indicate that RDP-based protocol yield acceptable 10-year outcomes, but side effects differ based on the maintenance regimen used and should be considered when optimizing immunosuppression following RDP.
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Affiliation(s)
- T M Suszynski
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - K J Gillingham
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - M D Rizzari
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - T B Dunn
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - W D Payne
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - S Chinnakotla
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - E B Finger
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | | | - J S Najarian
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - T L Pruett
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - A J Matas
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - R Kandaswamy
- Department of Surgery, University of Minnesota, Minneapolis, MN
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Mujtaba MA, Fridell JA, Higgins N, Sharfuddin AA, Yaqub MS, Kandula P, Chen J, Mishler DP, Lobashevsky A, Book B, Powelson J, Taber TE. Early findings of prospective anti-HLA donor specific antibodies monitoring study in pancreas transplantation: Indiana University Health Experience. Clin Transplant 2012; 26:E492-9. [DOI: 10.1111/ctr.12005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Muhammad A. Mujtaba
- Division of Nephrology; Department of Medicine; Indiana University School of Medicine; Indianapolis; IN; USA
| | - Jonathan A. Fridell
- Division of Transplant; Department of Surgery; Indiana University School of Medicine; Indianapolis; IN; USA
| | - Nancy Higgins
- Transplant Immunology lab; Indiana University School of Medicine; Indianapolis; IN; USA
| | - Asif A. Sharfuddin
- Division of Nephrology; Department of Medicine; Indiana University School of Medicine; Indianapolis; IN; USA
| | - Muhammad S. Yaqub
- Division of Nephrology; Department of Medicine; Indiana University School of Medicine; Indianapolis; IN; USA
| | - Praveen Kandula
- Division of Nephrology; Department of Medicine; Indiana University School of Medicine; Indianapolis; IN; USA
| | - Jeanne Chen
- Division of Transplant; Department of Surgery; Indiana University School of Medicine; Indianapolis; IN; USA
| | - Dennis P. Mishler
- Division of Nephrology; Department of Medicine; Indiana University School of Medicine; Indianapolis; IN; USA
| | - Andrew Lobashevsky
- Transplant Immunology lab; Indiana University School of Medicine; Indianapolis; IN; USA
| | - Benita Book
- Division of Transplant; Department of Surgery; Indiana University School of Medicine; Indianapolis; IN; USA
| | - John Powelson
- Division of Transplant; Department of Surgery; Indiana University School of Medicine; Indianapolis; IN; USA
| | - Tim E. Taber
- Division of Nephrology; Department of Medicine; Indiana University School of Medicine; Indianapolis; IN; USA
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Current world literature. Curr Opin Organ Transplant 2011; 16:650-60. [PMID: 22068023 DOI: 10.1097/mot.0b013e32834dd969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Libório AB, Mendoza TR, Esmeraldo RM, Oliveira MLMB, Paes FJVN, Silva Junior GB, Daher EF. Induction antibody therapy in renal transplantation using early steroid withdrawal: long-term results comparing anti-IL2 receptor and anti-thymocyte globulin. Int Immunopharmacol 2011; 11:1832-6. [PMID: 21835269 DOI: 10.1016/j.intimp.2011.07.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2011] [Revised: 06/10/2011] [Accepted: 07/17/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND The present study intends to investigate the effects of anti-IL2 receptors (anti-IL2R) vs. lymphocyte-depleting agents in the early steroid withdrawal (ESW) scheme. METHODS This is a retrospective cohort of 167 consecutive adult renal transplant recipients. Immunosuppression was based on tacrolimus and mycophenolate mofetil. Antibody induction therapy was carried out with lymphocyte-depleting agent (thymoglobulin) or anti-IL2R (Basiliximab or Daclizumab). ESW protocol was performed by administering intravenous methlyprednisolone as follows: 500 mg on day 0, 250 mg on day 1, 125 mg on day 2, 60 mg on day 3, and then stopped. RESULTS Among the 167 studied patients, 79 (47.3%) received anti-IL2R and 88 (52.7%) received thymoglobulin induction. Significantly fewer episodes of acute rejection were seen at one year in patients treated with thymoglobulin as compared to anti-IL2R (25.6% vs. 11.4%, p=0.01). At five years, a significant difference in graft survival was observed in anti-IL2R-treated patients compared with thymoglobulin (83.5% vs. 95.5%, p=0.01). Multivariate analysis disclosed that female sex, antibody induction therapy using thymoglobulin and a trough tacrolimus level higher than 10 were protective factors against acute rejection, while there was a trend to increased risk of acute rejection at first year post-transplantation in patients presenting delayed graft function (DGF). Antibody induction was independently associated with patient and graft survival at five years (OR 0.213, 95% CI 0.046-0.991, p=0.04). CONCLUSION ESW scheme seems to be safe and its use is beneficial since there are fewer adverse effects. Thymoglobulin induction therapy is associated with fewer rejection episodes. Induction therapy with thymoglobulin is associated with higher patient and allograft survival when comparing with anti-IL2R.
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Affiliation(s)
- Alexandre B Libório
- Division of Nephrology, Hospital Geral de Fortaleza, Fortaleza, Ceará, Brazil.
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