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Gao S, Gong H, Li M, Lan P, Zhang M, Kuang P, Zhang Y, Hu X, Ding C, Li Y, Ding X, Xue W, Zheng J. HLA B eplet mismatches in the context of delayed graft function and low tacrolimus trough levels are risk factors influencing the generation of de novo donor-specific antibodies and acute rejection in the early stage after kidney transplantation. Transpl Immunol 2023; 81:101955. [PMID: 37931666 DOI: 10.1016/j.trim.2023.101955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND De novo donor-specific antibody (dnDSA) generation and acute rejection (AR) are the main factors affecting long-term graft survival. This study aims to investigate human leukocyte antigen (HLA) eplet mismatching (MM), delayed graft function (DGF), and tacrolimus (TAC) trough levels on the occurrence of dnDSA and AR in the early stages after kidney transplantation (KT). METHODS This retrospective study included 526 cases of deceased donation KT. The effects of DGF, HLA eplet MM, and TAC trough levels on dnDSA and AR occurrence were analyzed with logistic regression analysis. RESULTS Multivariate logistic regression analysis showed the independent risk factor of dnDSA generation was HLA B eplet MM (OR: 1.201, 95% CI: 1.007-1.431, P = 0.041). The independent risk factors of AR occurrence include DGF (OR: 4.045, 95% CI: 1.047-15.626, P = 0.043), HLA B eplet MM (OR: 1.090, 95% CI: 1.000-1.187, P = 0.050), and TAC trough levels at 12 months (OR: 0.750, 95% CI: 565-0.997, P = 0.048). HLA B eplet MM combined with DGF and TAC trough levels at 12 months increased the predictive value of dnDSA (AUC 0.735) and AR (AUC 0.730) occurrence. HLA B eplet MM > 9 and TAC trough levels below 5.95 ng/mL at 12 months could increase the risk of early AR occurrence. CONCLUSIONS HLA B eplet MM, DGF, and TAC trough levels at 12 months after KT could affect the occurrence of dnDSA and AR in the early stage of KT.
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Affiliation(s)
- Shan Gao
- Department of Renal Transplantation, Hospital of Nephrology, The First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an 710061, China
| | - Huilin Gong
- Department of Renal Transplantation, Hospital of Nephrology, The First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an 710061, China
| | - Meihe Li
- Department of Renal Transplantation, Hospital of Nephrology, The First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an 710061, China
| | - Ping Lan
- Department of Renal Transplantation, Hospital of Nephrology, The First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an 710061, China
| | - Minyue Zhang
- Department of Renal Transplantation, Hospital of Nephrology, The First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an 710061, China
| | - Peidan Kuang
- Department of Renal Transplantation, Hospital of Nephrology, The First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an 710061, China
| | - Ying Zhang
- Department of Renal Transplantation, Hospital of Nephrology, The First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an 710061, China
| | - Xiaojun Hu
- Department of Renal Transplantation, Hospital of Nephrology, The First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an 710061, China
| | - Chenguang Ding
- Department of Renal Transplantation, Hospital of Nephrology, The First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an 710061, China
| | - Yang Li
- Department of Renal Transplantation, Hospital of Nephrology, The First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an 710061, China
| | - Xiaoming Ding
- Department of Renal Transplantation, Hospital of Nephrology, The First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an 710061, China
| | - Wujun Xue
- Department of Renal Transplantation, Hospital of Nephrology, The First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an 710061, China.
| | - Jin Zheng
- Department of Renal Transplantation, Hospital of Nephrology, The First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an 710061, China.
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Nguyen TVA, Nguyen HD, Nguyen TLH, Le VT, Nguyen XK, Tran VT, Le DT, Ta BT. Higher tacrolimus trough levels and time in the therapeutic range are associated with the risk of acute rejection in the first month after renal transplantation. BMC Nephrol 2023; 24:131. [PMID: 37158838 PMCID: PMC10169362 DOI: 10.1186/s12882-023-03188-0] [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: 01/12/2023] [Accepted: 04/27/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Tacrolimus trough levels (C0) are used in most transplant centres for therapeutic drug monitoring (TDM) of tacrolimus (Tac). The target range of Tac C0 has been remarkably changed, with a target as low as 3-7 ng/ml in the 2009 European consensus conference and a target of 4-12 ng/ml (preferably to 7-12 ng/ml) following the second consensus report in 2019. Our aim was to investigate whether reaching early Tac therapeutic targets and maintaining time in the therapeutic range (TTR) according to the new recommendations may be necessary for preventing acute rejection (AR) during the first month after transplantation. METHODS A retrospective study including 160 adult renal transplant patients (113 men and 47 women) with a median age of 36.3 (20-44) years was conducted between January 2018 and December 2019 at 103 Military Hospital (Vietnam). Tac trough levels were recorded in the first month, and episodes of AR were confirmed by kidney biopsy. Tac TTR was calculated as the percentage of time within the target range of 7-12 ng/ml, according to the 2019 second consensus report. Multivariate Cox analysis was performed to identify the correlation between the Tac target range and TTR with AR. RESULTS In the first month after RT, 14 (8.8%) patients experienced AR. There was a significant difference in the incidence of AR between the Tac level groups of < 4, 4-7 and > 7 ng/ml (p = 0.0096). In the multivariate Cox analysis, after adjusting for related factors, a mean Tac level > 7 ng/ml was associated with an 86% decreased risk of AR compared with that of 4-7 ng/ml in the first month (HR, 0.14; 95% CI, 0.03-0.66; p = 0.0131). Every 10% increase in TTR was associated with a 28% lower risk of AR (HR, 0.72; 95% CI, 0.55-0.94; p = 0.014). CONCLUSION Gaining and maintaining Tac C0 according to the 2019 second consensus report might reduce the risk of AR in the first month following transplantation.
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Affiliation(s)
- Thi Van Anh Nguyen
- Department of Pharmacy, 103 Military hospital, 261 Phung Hung, Ha Dong, Hanoi, Vietnam
| | - Huu Duy Nguyen
- Department of Clinical Pharmacy, Hanoi University of Pharmacy, 13-15 Le Thanh Tong Street, Hanoi, Vietnam
| | - Thi Lien Huong Nguyen
- Department of Clinical Pharmacy, Hanoi University of Pharmacy, 13-15 Le Thanh Tong Street, Hanoi, Vietnam
| | - Viet Thang Le
- Department of Renal and Haemodialysis, 103 Military hospital, 261 Phung Hung, Ha Dong, Hanoi, Vietnam
| | - Xuan Kien Nguyen
- Department of Military Medical Command and Organization, Vietnam Military Medical University, Hanoi, 10000, Vietnam
| | - Viet Tien Tran
- Department of Infectious Diseases, 103 Military Hospital, 261 Phung Hung, Ha Dong, Hanoi, Vietnam
| | - Dinh Tuan Le
- Department of Rheumatology and Endocrinology, 103 Military Hospital, 261 Phung Hung, Ha Dong, Hanoi, Vietnam
| | - Ba Thang Ta
- Respiratory Center, 103 Military hospital, 103 Military Hospital, 261 Phung Hung, Ha Dong, Hanoi, Vietnam
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Seeking Standardized Definitions for HLA-incompatible Kidney Transplants: A Systematic Review. Transplantation 2023; 107:231-253. [PMID: 35915547 DOI: 10.1097/tp.0000000000004262] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is no standard definition for "HLA incompatible" transplants. For the first time, we systematically assessed how HLA incompatibility was defined in contemporary peer-reviewed publications and its prognostic implication to transplant outcomes. METHODS We combined 2 independent searches of MEDLINE, EMBASE, and the Cochrane Library from 2015 to 2019. Content-expert reviewers screened for original research on outcomes of HLA-incompatible transplants (defined as allele or molecular mismatch and solid-phase or cell-based assays). We ascertained the completeness of reporting on a predefined set of variables assessing HLA incompatibility, therapies, and outcomes. Given significant heterogeneity, we conducted narrative synthesis and assessed risk of bias in studies examining the association between death-censored graft failure and HLA incompatibility. RESULTS Of 6656 screened articles, 163 evaluated transplant outcomes by HLA incompatibility. Most articles reported on cytotoxic/flow T-cell crossmatches (n = 98). Molecular genotypes were reported for selected loci at the allele-group level. Sixteen articles reported on epitope compatibility. Pretransplant donor-specific HLA antibodies were often considered (n = 143); yet there was heterogeneity in sample handling, assay procedure, and incomplete reporting on donor-specific HLA antibodies assignment. Induction (n = 129) and maintenance immunosuppression (n = 140) were frequently mentioned but less so rejection treatment (n = 72) and desensitization (n = 70). Studies assessing death-censored graft failure risk by HLA incompatibility were vulnerable to bias in the participant, predictor, and analysis domains. CONCLUSIONS Optimization of transplant outcomes and personalized care depends on accurate HLA compatibility assessment. Reporting on a standard set of variables will help assess generalizability of research, allow knowledge synthesis, and facilitate international collaboration in clinical trials.
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Hwang YH, Kim H, Min K, Yang J. Tacrolimus trough levels in kidney transplant recipients. BMC Nephrol 2021; 22:405. [PMID: 34876046 PMCID: PMC8650372 DOI: 10.1186/s12882-021-02622-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is very important that kidney transplant recipients (KTRs) take immunosuppressive drugs to prevent graft rejection. This study aimed to identify the tacrolimus trough levels (TTL)-mean, TTL-standard deviation (SD), and TTL- coefficient of variation (CV) as well as factors affecting these values over a 2-year period in clinically stable patients > 5 years after kidney transplantation (KT). METHODS This retrospective study analyzed data from 248 adult outpatients > 5 years after KT. Medical chart data, including TTL, graft rejection, and tacrolimus dose change during a 2-year period, between January 2017 and December 2018, were collected. Multivariable regression analyses were conducted to determine the factors influencing the TTL-mean, TTL-SD, and TTL-CV. RESULTS The TTL-mean, TTL-SD, and TTL-CV were 6.00 ± 1.07 ng/mL, 1.51 ± 1.09 ng/mL, and 0.25 ± 0.14, respectively. The TTL-mean, TTL-SD, and TTL-CV did not differ according to sex, type of donor, retransplant, pretransplant kidney disease, body mass index, or posttransplant time; hence, they are stable in kidney transplant recipients > 5 years after KT. The higher the TTL-mean, the higher the TTL-SD. Age and the TTL-SD significantly predicted the TTL-mean (p < .001). Tacrolimus dose change and the TTL-mean significantly predicted the TTL-SD (p < .001). Tacrolimus dose change significantly predicted the TTL-CV (p = .008). CONCLUSION In clinically stable KTRs, TTL-SD and TTL-CV change sensitively in relation to tacrolimus dose changes. Therefore, changes in TTL-SD and TTL-CV in stable KTRs with no tacrolimus dose change require medical interest and attention.
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Affiliation(s)
- Young Hui Hwang
- Department of Nursing, College of Medicine, University of Ulsan, Ulsan, South Korea
| | - Hyunjung Kim
- Divison of Nursing & Research Institute of Nursing Science, Hallym University, 1 Hallymdaehak-gil, Chuncheon, Gangwon-do, 24252, South Korea.
| | - Kyungok Min
- Transplant Center, Department of Nursing, Seoul National University Hospital, Seoul, South Korea
| | - Jaeseok Yang
- Division of Nephrology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
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Early Monitoring and Subsequent Gain of Tacrolimus Time-In-Therapeutic Range May Improve Clinical Outcomes After Living Kidney Transplantation. Ther Drug Monit 2021; 43:728-735. [PMID: 34780391 DOI: 10.1097/ftd.0000000000000881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/16/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND The early identification of recipients at high risk of graft loss is clinically relevant after kidney transplantation. The authors explored whether the earlier monitoring of tacrolimus (Tac) time-in-therapeutic range (TTR) is predictive of and a subsequent gain in TTR improves transplant outcomes. METHODS The TTR within 3, 6, 9, and 12 months was evaluated. Multivariate Cox analyses were performed to explore when TTR was predictive of transplant outcomes. Patients were divided into 3 groups based on incremental TTR change [TTR gain (increase >10%), TTR stable (maintained within 10%), and TTR loss (decrease >10%)] and 4 groups based on predefined cutoff values [low-low (LL), low-high (LH), high-low (HL), and high-high (HH)] using 6- and 12-month TTRs. Death-censored graft loss and patient death were primary outcomes. RESULTS Nonlinear associations were observed between 6-, 9-, and 12-month TTR and death-censored graft and patient survival rates. In multivariate analysis, every 10% increase in 6-, 9-, and 12-month TTRs was associated with reduced patient death [hazard ratio (HR): 0.83; HR: 0.68; HR: 0.61, respectively] and graft loss (HR: 0.88; HR: 0.73; HR: 0.66, respectively). A nonlinear relationship was observed between transplant outcomes and incremental changes in TTR. TTR gain and stable TTR contributed to higher graft survival (HR: 0.20; HR: 0.21) and patient survival (HR: 0.14; HR: 0.15) rates than TTR loss, whereas the former 2 had comparable outcomes. Furthermore, compared with those in the HH group, the LL and HL groups had inferior graft survival (HR: 3.33; HR: 5.17) and patient survival (HR: 5.15; HR: 8.94) rates, whereas the LH group had similar outcomes (P = 0.63, P = 0.97). Nonadherence was the main controllable risk factor for low TTR. CONCLUSIONS The 6-month TTR identified patients at higher risk of worse outcomes. The subsequent gain of TTR may contribute to better transplant outcomes.
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Kim HD, Chang JY, Chung BH, Kim CD, Lee SH, Kim YH, Yang CW. Effect of Everolimus with Low-Dose Tacrolimus on Development of New-Onset Diabetes After Transplantation and Allograft Function in Kidney Transplantation: A Multicenter, Open-Label, Randomized Trial. Ann Transplant 2021; 26:e927984. [PMID: 33479188 PMCID: PMC7836319 DOI: 10.12659/aot.927984] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background This randomized controlled trial aimed to investigate the effect of everolimus (EVL) with low-dose tacrolimus (Tac) on the development of post-transplantation diabetes mellitus (PTDM) in kidney transplantation (KT). Material/Methods Seventy-seven kidney transplant patients from 4 transplant centers were included. Patients were randomized to the “EVL group” (n=38) and the “TAC group” (n=39). The target Tac trough level was 2 to 5 ng/mL in the EVL group and 5 to 10 ng/mL in the TAC group. Results The 1-year cumulative incidence of PTDM in all patients was 7.8%, and no difference was found between the 2 groups (P=0.0819). Insulin resistance measured with the homeostatic model assessment for insulin resistance showed a significant increase only in the TAC group (1.11 to 1.30, P=0.0492). Allograft rejection rate and estimated glomerular filtration rate (eGFR) follow-ups every 3 months were not significantly different between the 2 groups. However, the EVL group showed a significant increase in the mean eGFR at 9 months and 12 months after KT compared to the baseline value (P=0.0242 and 0.0491, respectively). The EVL group showed lower insulin resistance and higher allograft function in comparison to the TAC group. Conclusions EVL-based immunosuppressive therapy with lower Tac exposure could be a safer alternative for maintenance treatment.
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Affiliation(s)
- Hyung Duk Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Ji-Yeun Chang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Byung Ha Chung
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Chan-Duck Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Deagu, South Korea
| | - Sang-Ho Lee
- Department of Internal Medicine, College of Medicine, Kyung Hee University, Seoul, South Korea
| | - Yeong Hoon Kim
- Department of Internal Medicine, College of Medicine, Inje University, Pusan, South Korea
| | - Chul Woo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Chamoun B, Torres IB, Gabaldón A, Sellarés J, Perelló M, Castellá E, Guri X, Salcedo M, Toapanta NG, Cidraque I, Moreso F, Seron D. Progression of Interstitial Fibrosis and Tubular Atrophy in Low Immunological Risk Renal Transplants Monitored by Sequential Surveillance Biopsies: The Influence of TAC Exposure and Metabolism. J Clin Med 2021; 10:jcm10010141. [PMID: 33406589 PMCID: PMC7796060 DOI: 10.3390/jcm10010141] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/21/2020] [Accepted: 12/30/2020] [Indexed: 02/06/2023] Open
Abstract
The combination of tacrolimus (TAC) and mycophenolate is the most widely employed maintenance immunosuppression in renal transplants. Different surrogates of tacrolimus exposure or metabolism such as tacrolimus trough levels (TAC-C0), coefficient of variation of tacrolimus (CV-TAC-C0), time in therapeutic range (TTR), and tacrolimus concentration dose ratio (C/D) have been associated with graft outcomes. We explore in a cohort of low immunological risk renal transplants (n = 85) treated with TAC, mycophenolate mofetil (MMF), and steroids and then monitored by paired surveillance biopsies the association between histological lesions and TAC-C0 at the time of biopsy as well as CV-TAC-C0, TTR, and C/D during follow up. Interstitial inflammation (i-Banff score ≥ 1) in the first surveillance biopsy was associated with TAC-C0 (odds ratio (OR): 0.69, 95% confidence interval (CI): 0.50–0.96; p = 0.027). In the second surveillance biopsy, inflammation was associated with time below the therapeutic range (OR: 1.05 and 95% CI: 1.01–1.10; p = 0.023). Interstitial inflammation in scarred areas (i-IFTA score ≥ 1) was not associated with surrogates of TAC exposure/metabolism. Progression of interstitial fibrosis/tubular atrophy (IF/TA) was observed in 35 cases (41.2%). Multivariate regression logistic analysis showed that mean C/D (OR: 0.48; 95% CI: 0.25–0.92; p = 0.026) and IF/TA in the first biopsy (OR: 0.43, 95% CI: 0.24–0.77, p = 0.005) were associated with IF/TA progression between biopsies. A low C/D ratio is associated with IF/TA progression, suggesting that TAC nephrotoxicity may contribute to fibrosis progression in well immunosuppressed patients. Our data support that TAC exposure is associated with inflammation in healthy kidney areas but not in scarred tissue.
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Affiliation(s)
- Betty Chamoun
- Nephrology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (B.C.); (I.B.T.); (J.S.); (M.P.); (N.G.T.); (I.C.); (D.S.)
| | - Irina B. Torres
- Nephrology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (B.C.); (I.B.T.); (J.S.); (M.P.); (N.G.T.); (I.C.); (D.S.)
| | - Alejandra Gabaldón
- Pathology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (A.G.); (M.S.)
| | - Joana Sellarés
- Nephrology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (B.C.); (I.B.T.); (J.S.); (M.P.); (N.G.T.); (I.C.); (D.S.)
| | - Manel Perelló
- Nephrology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (B.C.); (I.B.T.); (J.S.); (M.P.); (N.G.T.); (I.C.); (D.S.)
| | - Eva Castellá
- Radiology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (E.C.); (X.G.)
| | - Xavier Guri
- Radiology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (E.C.); (X.G.)
| | - Maite Salcedo
- Pathology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (A.G.); (M.S.)
| | - Nestor G. Toapanta
- Nephrology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (B.C.); (I.B.T.); (J.S.); (M.P.); (N.G.T.); (I.C.); (D.S.)
| | - Ignacio Cidraque
- Nephrology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (B.C.); (I.B.T.); (J.S.); (M.P.); (N.G.T.); (I.C.); (D.S.)
| | - Francesc Moreso
- Nephrology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (B.C.); (I.B.T.); (J.S.); (M.P.); (N.G.T.); (I.C.); (D.S.)
- Department of Medicine, Autonomous University of Barcelona, 08035 Barcelona, Spain
- Correspondence: ; Tel.: +34-93-274-46-66
| | - Daniel Seron
- Nephrology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (B.C.); (I.B.T.); (J.S.); (M.P.); (N.G.T.); (I.C.); (D.S.)
- Department of Medicine, Autonomous University of Barcelona, 08035 Barcelona, Spain
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Gold A, Tönshoff B, Döhler B, Süsal C. Association of graft survival with tacrolimus exposure and late intra-patient tacrolimus variability in pediatric and young adult renal transplant recipients-an international CTS registry analysis. Transpl Int 2020; 33:1681-1692. [PMID: 32881096 DOI: 10.1111/tri.13726] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 06/30/2020] [Accepted: 08/24/2020] [Indexed: 01/03/2023]
Abstract
Adolescent and young adult age is a high-risk window with an alarmingly increased likelihood of premature kidney graft loss due to immunological rejection. Using the large database of the Collaborative Transplant Study, we analyzed whether a more intense and less variable exposure to tacrolimus could counteract this young age-related enhanced immunoreactivity. Kidney graft recipients aged 12-23 years (n = 964) with a 1-year tacrolimus trough level between 4.0 and 10.9 ng/ml had a 5-year graft survival rate of 85.1%, significantly better than the poor 66.1% rate in patients with a trough level below 4.0 ng/ml who showed a 2.38-fold increased risk of graft loss in the multivariable analysis (P < 0.001). This association was not apparent in young children aged 0-11 years (n = 455) and less pronounced in adults aged 24-34 years (n = 1466). However, an intra-patient variability of tacrolimus (IPV) trough level ≥1.5 at post-transplant years 1 and 2 was associated with an increased graft loss risk in both 12- to 23-year-old and 0- to 11-year-old recipients (P < 0.001 and P = 0.045). Patients with high IPV made up as many as 30% of kidney graft recipients, indicating that a more intense and less variable exposure to tacrolimus could improve graft survival strongly in this high-risk group.
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Affiliation(s)
- Annika Gold
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Bernd Döhler
- Institute of Immunology, University Hospital Heidelberg, Heidelberg, Germany
| | - Caner Süsal
- Institute of Immunology, University Hospital Heidelberg, Heidelberg, Germany
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9
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Wiebe C, Rush DN, Gibson IW, Pochinco D, Birk PE, Goldberg A, Blydt‐Hansen T, Karpinski M, Shaw J, Ho J, Nickerson PW. Evidence for the alloimmune basis and prognostic significance of Borderline T cell-mediated rejection. Am J Transplant 2020; 20:2499-2508. [PMID: 32185878 PMCID: PMC7496654 DOI: 10.1111/ajt.15860] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/05/2020] [Accepted: 03/07/2020] [Indexed: 02/06/2023]
Abstract
Prognostic biomarkers of T cell-mediated rejection (TCMR) have not been adequately studied in the modern era. We evaluated 803 renal transplant recipients and correlated HLA-DR/DQ molecular mismatch alloimmune risk categories (low, intermediate, high) with the severity, frequency, and persistence of TCMR. Allograft survival was reduced in recipients with Banff Borderline (hazard ratio [HR] 2.4, P = .003) and Banff ≥ IA TCMR (HR 4.3, P < .0001) including a subset who never developed de novo donor-specific antibodies (P = .002). HLA-DR/DQ molecular mismatch alloimmune risk categories were multivariate correlates of Banff Borderline and Banff ≥ IA TCMR and correlated with the severity and frequency of rejection episodes. Recipient age, HLA-DR/DQ molecular mismatch category, and cyclosporin vs tacrolimus immunosuppression were independent correlates of Banff Borderline and Banff ≥ IA TCMR. In the subset treated with tacrolimus (720/803) recipient age, HLA-DR/DQ molecular mismatch category, and tacrolimus coefficient of variation were independent correlates of TCMR. The correlation of HLA-DR/DQ molecular mismatch category with TCMR, including Borderline, provides evidence for their alloimmune basis. HLA-DR/DQ molecular mismatch may represent a precise prognostic biomarker that can be applied to tailor immunosuppression or design clinical trials based on individual patient risk.
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Affiliation(s)
- Chris Wiebe
- Department of MedicineUniversity of ManitobaWinnipegCanada
- Shared Health Services ManitobaWinnipegCanada
- Department of ImmunologyUniversity of ManitobaWinnipegCanada
| | - David N. Rush
- Department of MedicineUniversity of ManitobaWinnipegCanada
| | - Ian W. Gibson
- Shared Health Services ManitobaWinnipegCanada
- Department of PathologyUniversity of ManitobaWinnipegCanada
| | | | - Patricia E. Birk
- Department of Pediatrics and Child HealthUniversity of ManitobaWinnipegCanada
| | - Aviva Goldberg
- Department of Pediatrics and Child HealthUniversity of ManitobaWinnipegCanada
| | - Tom Blydt‐Hansen
- Department of PediatricsUniversity of British ColumbiaWinnipegCanada
| | | | - Jamie Shaw
- Department of MedicineUniversity of ManitobaWinnipegCanada
| | - Julie Ho
- Department of MedicineUniversity of ManitobaWinnipegCanada
- Department of ImmunologyUniversity of ManitobaWinnipegCanada
| | - Peter W. Nickerson
- Department of MedicineUniversity of ManitobaWinnipegCanada
- Shared Health Services ManitobaWinnipegCanada
- Department of ImmunologyUniversity of ManitobaWinnipegCanada
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10
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Evaluation of Tacrolimus Trough Level in Patients Who Developed Post-transplant Diabetes Mellitus After Kidney Transplantation: A Retrospective Single-Center Study in Saudi Arabia. Transplant Proc 2020; 52:3160-3167. [PMID: 32636070 DOI: 10.1016/j.transproceed.2020.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 02/19/2020] [Accepted: 05/12/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Post-transplant diabetes mellitus (PTDM) is a complication after kidney transplantation. Studies showed an association between high trough levels of tacrolimus FK506 and PTDM. This study aims to investigate the association between FK506 trough levels during the first year after kidney transplant and the incidence of PTDM. METHODS This retrospective study included adult kidney transplant patients who were not diabetic before transplantation from 2011 to 2014. The analysis evaluated FK506 trough levels at different time points post-transplant, as well as other variables to determine whether they were associated with PTDM. RESULTS The cumulative incidence of PTDM was 22.5% with a median time to PTDM diagnosis of 10 months. PTDM patients had higher first FK506 (ng/mL) levels (P = .001), and more patients in the PTDM group had FK506 level >10 ng/mL during the first 3 months (P = .004). After 12 months of transplant, PTDM patients had higher body mass index (BMI) 28.3 ± 6.9 kg/m2 compared to non-PTDM patients 26.4 ± 6.7 kg/m2 (P = .015). Binary logistic regression analysis showed that age ≥40 years (odds ratio [OR] = 2.75, P = .004), BMI ≥25 kg/m2 (OR = 2.04, P = .040), and FK506 level ≥10 ng/mL during the first 3 months (OR = 2.65, P = .009) were significantly related to PTDM development. CONCLUSION Patients with FK506 trough level >10 ng/mL during the first 3 months after transplantation are at higher risk of PTDM, especially in patients >40 years of age and/or who are overweight. These results may strengthen the notion that there is a connection between high FK506 trough levels and PTDM development.
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Jung HY, Seo MY, Jeon Y, Huh KH, Park JB, Jung CW, Lee S, Han SY, Ro H, Yang J, Ahn C, Choi JY, Cho JH, Park SH, Kim YL, Kim CD. Tacrolimus trough levels higher than 6 ng/mL might not be required after a year in stable kidney transplant recipients. PLoS One 2020; 15:e0235418. [PMID: 32614859 PMCID: PMC7332007 DOI: 10.1371/journal.pone.0235418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/15/2020] [Indexed: 12/02/2022] Open
Abstract
Background Little is known regarding optimal tacrolimus (TAC) trough levels after 1 year post-transplant in stable kidney transplant recipients (KTRs) who have not experienced renal or cardiovascular outcomes. This study aimed to investigate the effect of 1-year post-transplant TAC trough levels on long-term renal and cardiovascular outcomes and opportunistic infections in stable KTRs. Methods KTRs receiving TAC with mycophenolate-based immunosuppression who did not experience renal or cardiovascular outcomes within 1 year post-transplant were enrolled from a multicenter observational cohort study. Renal outcome was defined as a composite of biopsy-proven acute rejection, interstitial fibrosis and tubular atrophy, and death-censored graft loss. Cardiovascular outcome was defined as a composite of de novo cardiomegaly, left ventricular hypertrophy, and cardiovascular events. Opportunistic infections were defined as the occurrence of BK virus or cytomegalovirus infections. Results A total of 603 eligible KTRs were divided into the low-level TAC (LL-TAC) and high-level TAC (HL-TAC) groups based on a median TAC level of 5.9 ng/mL (range 1.3–14.3) at 1 year post-transplant. The HL-TAC group had significantly higher TAC trough levels at 2, 3, 4, and 5 years compared with the levels of the LL-TAC group. During the mean follow-up of 63.7 ± 13.0 months, there were 121 renal outcomes and 224 cardiovascular outcomes. In multivariate Cox regression analysis, LL-TAC and HL-TAC were not independent risk factors for renal and cardiovascular outcomes, respectively. No significant differences in the development of opportunistic infections and de novo donor-specific anti-human leukocyte antigen antibodies and renal allograft function were observed between the two groups. Conclusions TAC trough levels after 1 year post-transplant remained at a similar level until the fifth year after kidney transplantation and were not directly associated with long-term outcomes in stable Korean KTRs who did not experience renal or cardiovascular outcomes. Therefore, in Asian KTRs with a stable clinical course, TAC trough levels higher than approximately 6 ng/mL might not be required after a year of kidney transplantation.
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Affiliation(s)
- Hee-Yeon Jung
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Min Young Seo
- Department of Internal Medicine, Pohang St. Mary’s Hospital, Pohang, South Korea
| | - Yena Jeon
- Department of Statistics, Kyungpook National University, Daegu, South Korea
| | - Kyu Ha Huh
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae Berm Park
- Department of Surgery, Sungkyunkwan University, Seoul Samsung Medical Center, Seoul, South Korea
| | - Cheol Woong Jung
- Department of Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Sik Lee
- Department of Internal Medicine, Chonbuk National University Hospital, Jeonju, South Korea
| | - Seung-Yeup Han
- Department of Internal Medicine, Keimyung University, Dongsan Medical Center, Daegu, South Korea
| | - Han Ro
- Department of Internal Medicine, Gachon University, Gil Hospital, Incheon, South Korea
| | - Jaeseok Yang
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Curie Ahn
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Ji-Young Choi
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Jang-Hee Cho
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Sun-Hee Park
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Yong-Lim Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Chan-Duck Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
- * E-mail:
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Jung HY, Lee S, Jeon Y, Choi JY, Cho JH, Park SH, Kim YL, Kim HK, Huh S, Won DI, Kim CD. Mycophenolic Acid Trough Concentration and Dose Are Associated with Hematologic Abnormalities but Not Rejection in Kidney Transplant Recipients. J Korean Med Sci 2020; 35:e185. [PMID: 32567256 PMCID: PMC7308135 DOI: 10.3346/jkms.2020.35.e185] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/21/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Little is known regarding the safe fixed dose of mycophenolic acid (MPA) for preventing biopsy-proven acute rejection (BPAR) in kidney transplant recipients (KTRs). We investigated the correlation of MPA trough concentration (MPA C₀) and dose with renal transplant outcomes and adverse events. METHODS This study included 79 consecutive KTRs who received MPA with tacrolimus (TAC) and corticosteroids. The MPA C₀ of all the enrolled KTRs was measured, which was determined monthly by using particle-enhanced turbidimetric inhibition immunoassay for 12 months, and clinical data were collected at each time point. The clinical endpoints included BPAR, any cytopenia, and BK or cytomegalovirus infections. RESULTS No differences in MPA C₀ and dose were observed between KTRs with or without BPAR or viral infections under statistically comparable TAC concentrations. MPA C₀ was significantly higher in patients with leukopenia (P = 0.021) and anemia (P = 0.002) compared with those without cytopenia. The MPA dose was significantly higher in patients with thrombocytopenia (P = 0.002) compared with those without thrombocytopenia. MPA C₀ ≥ 3.5 μg/mL was an independent risk factor for leukopenia (adjusted odds ratio [AOR], 3.80; 95% confidence interval [CI], 1.24-11.64; P = 0.019) and anemia (AOR, 5.90; 95% CI, 1.27-27.51; P = 0.024). An MPA dose greater than the mean value of 1,188.8 mg/day was an independent risk factor for thrombocytopenia (AOR, 3.83; 95% CI, 1.15-12.78; P = 0.029). However, an MPA dose less than the mean value of 1,137.3 mg/day did not increase the risk of BPAR. CONCLUSION Either a higher MPA C₀ or dose is associated with an increased risk of cytopenia, but neither a lower MPA C₀ nor dose is associated with BPAR within the first year of transplantation. Hence, a reduced MPA dose with TAC and corticosteroids might be safe in terms of reducing hematologic abnormalities without causing rejection.
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Affiliation(s)
- Hee Yeon Jung
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Sukyung Lee
- Department of Internal Medicine, Pohang St. Mary's Hospital, Pohang, Republic of Korea
| | - Yena Jeon
- Department of Statistics, College of Natural Sciences, Kyungpook National University, Daegu, Republic of Korea
| | - Ji Young Choi
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Jang Hee Cho
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Sun Hee Park
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Yong Lim Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Hyung Kee Kim
- Department of Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Seung Huh
- Department of Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Dong Il Won
- Department of Clinical Pathology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Chan Duck Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea.
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