1
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Markmann JF, Burrell BE, Bromberg JS, Hartono C, Kaufman DB, Possselt AM, Naji A, Bridges ND, Breeden C, Kanaparthi S, Pardo J, Kopetskie H, Mason K, Lim N, Chandran S. Immunosuppression withdrawal in living-donor renal transplant recipients following induction with antithymocyte globulin and rituximab: Results of a prospective clinical trial. Am J Transplant 2024:S1600-6135(24)00202-8. [PMID: 38467375 DOI: 10.1016/j.ajt.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/19/2024] [Accepted: 03/05/2024] [Indexed: 03/13/2024]
Abstract
Durable tolerance in kidney transplant recipients remains an important but elusive goal. We hypothesized that adding B cell depletion to T cell depletion would generate an immune milieu postreconstitution dominated by immature transitional B cells, favoring tolerance. The Immune Tolerance Network ITN039ST Research Study of ATG and Rituximab in Renal Transplantation was a prospective multicenter pilot study of live donor kidney transplant recipients who received induction with rabbit antithymocyte globulin and rituximab and initiated immunosuppression (IS) withdrawal (ISW) at 26 weeks. The primary endpoint was freedom from rejection at 52 weeks post-ISW. Six of the 10 subjects successfully completed ISW. Of these 6 subjects, 4 restarted immunosuppressive medications due to acute rejection or recurrent disease, 1 remains IS-free for over 9 years, and 1 was lost to follow-up after being IS-free for 42 weeks. There were no cases of patient or graft loss. CD19+ B cell frequencies returned to predepletion levels by 26 weeks posttransplant; immunoglobulin D+CD27--naïve B cells predominated. In contrast, memory cells dominated the repopulation of the T cell compartment. A regimen of combined B and T cell depletion did not generate the tolerogenic B cell profile observed in preclinical studies and did not lead to durable tolerance in the majority of kidney transplant recipients.
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Affiliation(s)
- James F Markmann
- Massachusetts General Hospital, Center for Transplantation Sciences, Boston, Massachusetts, USA
| | - Bryna E Burrell
- Biomarker Discovery Group, Immune Tolerance Network, Bethesda, Maryland, USA
| | - Jonathan S Bromberg
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Choli Hartono
- Rogosin Institute, New York Presbyterian Hospital-Weill Cornell Medicine, New York, New York, USA
| | - Dixon B Kaufman
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Andrew M Possselt
- Department of Surgery, University of California-San Francisco Medical Center, San Francisco, California, USA
| | - Ali Naji
- Department of Surgery, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
| | - Nancy D Bridges
- Division of Allergy, Immunology and Transplantation, The National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Cynthia Breeden
- Immune Tolerance Network, Benaroya Research Institute at Virginia Mason, Seattle, Washington, USA
| | - Sai Kanaparthi
- Immune Tolerance Network, Benaroya Research Institute at Virginia Mason, Seattle, Washington, USA
| | - Jorge Pardo
- Immune Tolerance Network, Benaroya Research Institute at Virginia Mason, Seattle, Washington, USA
| | | | | | - Noha Lim
- Immune Tolerance Network, Benaroya Research Institute at Virginia Mason, Seattle, Washington, USA
| | - Sindhu Chandran
- Immune Tolerance Network, Clinical Trials Group at the University of California- San Francisco, San Francisco, California, USA.
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2
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Al Jurdi A, Liu EC, Salinas T, Aull MJ, Lubetzky M, Drelick AL, Small CB, Kapur S, Hartono C, Muthukumar T. Complications of rabbit anti-thymocyte globulin induction immunosuppression in HIV-infected kidney transplant recipients. Front Nephrol 2022; 2:1047170. [PMID: 37675034 PMCID: PMC10479633 DOI: 10.3389/fneph.2022.1047170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 11/29/2022] [Indexed: 09/08/2023]
Abstract
Background Kidney transplantation in HIV-infected individuals with end-stage kidney disease is associated with improved survival compared to dialysis. Rabbit anti-thymocyte globulin (rATG) induction in HIV-infected kidney transplant recipients has been associated with a lower risk of acute rejection, but data on the rates of de novo malignancy and BK viremia in these patients is lacking. Methods We performed a single-center retrospective cohort study of adult HIV-infected individuals who underwent kidney transplantation with rATG induction between January 2006 and December 2016. The primary outcome was the development of de novo malignancy. Secondary outcomes included the development of BK viremia, infections requiring hospitalization, HIV progression, biopsy-proven acute rejection, and patient and allograft survival. Results Twenty-seven HIV-infected individuals with end-stage kidney disease received deceased (n=23) or living (n=4) donor kidney transplants. The cumulative rate of malignancy at five years was 29%, of whom 29% died because of advanced malignancy. BK viremia was detected in six participants (22%), of whom one had biopsy-proven BK virus-associated nephropathy and all of whom cleared the BK viremia. Five-year acute rejection rates, patient survival and death-censored allograft survival were 17%, 85% and 80% respectively. Conclusion rATG induction in HIV-infected kidney transplant recipients was associated with a low risk of acute rejection, but a potentially higher risk of de novo malignancies and BK viremia in this cohort. Screening strategies to closely monitor for BK virus infection and malignancy post-transplantation may improve outcomes in HIV-infected kidney transplant recipients receiving rATG induction.
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Affiliation(s)
- Ayman Al Jurdi
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, United States
| | - Esther C. Liu
- Department of Pharmacy, NewYork Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
| | - Thalia Salinas
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- Department of Transplantation Medicine, NewYork Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
| | - Meredith J. Aull
- Division of Transplant Surgery, Department of Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Michelle Lubetzky
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- Department of Transplantation Medicine, NewYork Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
| | - Alexander L. Drelick
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Catherine B. Small
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Sandip Kapur
- Division of Transplant Surgery, Department of Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Choli Hartono
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- Department of Transplantation Medicine, NewYork Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
- The Rogosin Institute, New York, NY, United States
| | - Thangamani Muthukumar
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- Department of Transplantation Medicine, NewYork Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
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3
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Liu EC, Lee JH, Loo A, Mazur S, Sultan S, Aull M, Lee JB, Muthukumar T, Hartono C. Casirivimab-Imdevimab (REGN-COV2) for Mild to Moderate SARS-CoV-2 Infection in Kidney Transplant Recipients. Kidney Int Rep 2021; 6:2900-2902. [PMID: 34514186 PMCID: PMC8418987 DOI: 10.1016/j.ekir.2021.08.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 12/24/2022] Open
Affiliation(s)
- Esther C Liu
- Department of Pharmacy, New York Presbyterian Hospital-Weill Cornell, New York, New York, USA
| | - Jennifer H Lee
- Department of Pharmacy, New York Presbyterian Hospital-Weill Cornell, New York, New York, USA
| | - Angela Loo
- Department of Pharmacy, New York Presbyterian Hospital-Weill Cornell, New York, New York, USA
| | - Shawn Mazur
- Department of Pharmacy, New York Presbyterian Hospital-Weill Cornell, New York, New York, USA
| | - Sam Sultan
- Division of Transplant Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Meredith Aull
- Division of Transplant Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Jun B Lee
- Department of Transplantation Medicine, Weill Cornell Medicine, New York, New York, USA.,The Rogosin Institute, New York, New York, USA
| | - Thangamani Muthukumar
- Department of Transplantation Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Choli Hartono
- Department of Transplantation Medicine, Weill Cornell Medicine, New York, New York, USA.,The Rogosin Institute, New York, New York, USA
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4
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Jacobs SE, Kirou KA, Seshan SV, Walsh TJ, Hartono C. The Case | Knee pain and allograft dysfunction in a kidney transplant recipient. Kidney Int 2021; 97:429-430. [PMID: 31980084 DOI: 10.1016/j.kint.2019.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/12/2019] [Accepted: 07/18/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Samantha E Jacobs
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Kyriakos A Kirou
- Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Surya V Seshan
- Division of Renal Pathology, Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases Program, Departments of Medicine, Pediatrics, and Microbiology & Immunology, Weill Cornell Medicine, New York, New York, USA
| | - Choli Hartono
- Division of Nephrology and Hypertension, Weill Cornell Medical Center, New York-Presbyterian Hospital, New York, New York, USA
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5
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Abuhelaiqa E, Snopkowski C, Li C, Salvatore S, Lee JR, Muthukumar T, Lee JB, Hartono C, Ding R, Seshan SV, Suthanthiran M, Dadhania DM. Validation of a noninvasive prognostic signature for allograft failure following BK virus associated nephropathy. Clin Transplant 2021; 35:e14200. [PMID: 33349997 DOI: 10.1111/ctr.14200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/18/2020] [Indexed: 12/13/2022]
Abstract
Identifying kidney transplant recipients at risk for graft failure following BK virus nephropathy (BKVN) may allow personalization of therapy. We have reported that a noninvasive composite signature of urinary cell level of plasminogen activator inhibitor-1(PAI-1) mRNA and serum creatinine level, measured at the time of BKVN diagnosis, is prognostic of graft failure. In this investigation, we determined whether the composite signature is prognostic of graft failure in an independent cohort of 25 patients with BKVN. Of the 25 patients, 8 developed graft failure and 17 did not. We measured urinary cell levels of PAI-1 mRNA, 18S rRNA, and BKV VP1 mRNA at the time of BKVN diagnosis and evaluated clinical parameters including Banff pathology scores, acute rejection, and graft function. The area under the receiver operating characteristic curve for the noninvasive composite signature was 0.95 (P < .001) for prognosticating graft failure. The previously reported threshold of -0.858 predicted graft failure with a sensitivity of 75% and a specificity of 94%. Our current study validates the use of composite signature and the threshold of -0.858 to identify those at risk for graft failure following BKVN diagnosis, and supports future studies utilizing the composite signature score to personalize treatment of BKVN.
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Affiliation(s)
- Essa Abuhelaiqa
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA
| | - Catherine Snopkowski
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA
| | - Carol Li
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA
| | - Steve Salvatore
- Department of Pathology, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA
| | - John R Lee
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA
| | - Thangamani Muthukumar
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA
| | - Jun B Lee
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA
| | - Choli Hartono
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA
| | - Ruchuang Ding
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA
| | - Surya V Seshan
- Department of Pathology, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA
| | - Manikkam Suthanthiran
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA
| | - Darshana M Dadhania
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA
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6
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Lubetzky M, Aull MJ, Craig-Schapiro R, Lee JR, Marku-Podvorica J, Salinas T, Gingras L, Lee JB, Sultan S, Kodiyanplakkal RP, Hartono C, Saal S, Muthukumar T, Kapur S, Suthanthiran M, Dadhania DM. Kidney allograft recipients, immunosuppression, and coronavirus disease-2019: a report of consecutive cases from a New York City transplant center. Nephrol Dial Transplant 2020; 35:1250-1261. [PMID: 32678882 PMCID: PMC7454827 DOI: 10.1093/ndt/gfaa154] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 05/27/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Kidney graft recipients receiving immunosuppressive therapy may be at heightened risk for coronavirus disease 2019 (Covid-19) and adverse outcomes. It is therefore important to characterize the clinical course and outcome of Covid-19 in this population and identify safe therapeutic strategies. METHODS We performed a retrospective chart review of 73 adult kidney graft recipients evaluated for Covid-19 from 13 March to 20 April 2020. Primary outcomes included recovery from symptoms, acute kidney injury, graft failure and case fatality rate. RESULTS Of the 73 patients screened, 54 tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-39 with moderate to severe symptoms requiring hospital admission and 15 with mild symptoms managed in the ambulatory setting. Hospitalized patients were more likely to be male, of Hispanic ethnicity and to have cardiovascular disease. In the hospitalized group, tacrolimus dosage was reduced in 46% of patients and mycophenolate mofetil (MMF) therapy was stopped in 61% of patients. None of the ambulatory patients had tacrolimus reduction or discontinuation of MMF. Azithromycin or doxycycline was prescribed at a similar rate among hospitalized and ambulatory patients (38% versus 40%). Hydroxychloroquine was prescribed in 79% of hospitalized patients. Graft failure requiring hemodialysis occurred in 3 of 39 hospitalized patients (8%) and 7 patients died, resulting in a case fatality rate of 13% among Covid-19-positive patients and 18% among hospitalized Covid-19-positive patients. CONCLUSIONS Data from our study suggest that a strategy of systematic triage to outpatient or inpatient care, early management of concurrent bacterial infections and judicious adjustment of immunosuppressive drugs rather than cessation is feasible in kidney transplant recipients with Covid-19.
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Affiliation(s)
- Michelle Lubetzky
- Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, NY, USA
- Department of Transplantation Medicine, New York Presbyterian Hospital–Weill Cornell Medicine, New York, NY, USA
| | - Meredith J Aull
- Department of Transplantation Medicine, New York Presbyterian Hospital–Weill Cornell Medicine, New York, NY, USA
- Division of Transplant Surgery, Weill Cornell Medicine, New York, NY, USA
| | | | - John R Lee
- Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, NY, USA
- Department of Transplantation Medicine, New York Presbyterian Hospital–Weill Cornell Medicine, New York, NY, USA
| | | | - Thalia Salinas
- Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, NY, USA
| | - Laura Gingras
- Department of Internal Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Jun B Lee
- Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, NY, USA
- Department of Transplantation Medicine, New York Presbyterian Hospital–Weill Cornell Medicine, New York, NY, USA
| | - Samuel Sultan
- Division of Transplant Surgery, Weill Cornell Medicine, New York, NY, USA
| | | | - Choli Hartono
- Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, NY, USA
- Department of Transplantation Medicine, New York Presbyterian Hospital–Weill Cornell Medicine, New York, NY, USA
| | - Stuart Saal
- Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, NY, USA
- Department of Transplantation Medicine, New York Presbyterian Hospital–Weill Cornell Medicine, New York, NY, USA
| | - Thangamani Muthukumar
- Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, NY, USA
- Department of Transplantation Medicine, New York Presbyterian Hospital–Weill Cornell Medicine, New York, NY, USA
| | - Sandip Kapur
- Department of Transplantation Medicine, New York Presbyterian Hospital–Weill Cornell Medicine, New York, NY, USA
- Division of Transplant Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Manikkam Suthanthiran
- Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, NY, USA
- Department of Transplantation Medicine, New York Presbyterian Hospital–Weill Cornell Medicine, New York, NY, USA
| | - Darshana M Dadhania
- Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, NY, USA
- Department of Transplantation Medicine, New York Presbyterian Hospital–Weill Cornell Medicine, New York, NY, USA
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7
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Lee JH, Muthukumar T, Kim J, Aull MJ, Watkins A, Kapur S, Hartono C. Antibiotic prophylaxis for ureteral stent removal after kidney transplantation. Clin Transplant 2019; 33:e13491. [DOI: 10.1111/ctr.13491] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/07/2019] [Accepted: 01/17/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Jennifer H. Lee
- Department of Pharmacy Weill Cornell Medical Center, NewYork‐Presbyterian Hospital New York New York
| | - Thangamani Muthukumar
- Division of Nephrology and Hypertension Weill Cornell Medical Center, NewYork‐Presbyterian Hospital New York New York
| | - Jim Kim
- Division of Transplant Surgery Weill Cornell Medical Center, NewYork‐Presbyterian Hospital New York New York
| | - Meredith J. Aull
- Division of Transplant Surgery Weill Cornell Medical Center, NewYork‐Presbyterian Hospital New York New York
| | - Anthony Watkins
- Division of Transplant Surgery Weill Cornell Medical Center, NewYork‐Presbyterian Hospital New York New York
| | - Sandip Kapur
- Division of Transplant Surgery Weill Cornell Medical Center, NewYork‐Presbyterian Hospital New York New York
| | - Choli Hartono
- Division of Nephrology and Hypertension Weill Cornell Medical Center, NewYork‐Presbyterian Hospital New York New York
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8
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Alkadi MM, Kim J, Aull MJ, Schwartz JE, Lee JR, Watkins A, Lee JB, Dadhania DM, Seshan SV, Serur D, Kapur S, Suthanthiran M, Hartono C, Muthukumar T. Kidney allograft failure in the steroid-free immunosuppression era: A matched case-control study. Clin Transplant 2018; 31. [PMID: 28921709 DOI: 10.1111/ctr.13117] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2017] [Indexed: 02/06/2023]
Abstract
We studied the causes and predictors of death-censored kidney allograft failure among 1670 kidney recipients transplanted at our center in the corticosteroid-free maintenance immunosuppression era. As of January 1, 2012, we identified 137 recipients with allograft failure; 130 of them (cases) were matched 1-1 for recipient age, calendar year of transplant, and donor type with 130 recipients with functioning grafts (controls). Median time to allograft failure was 29 months (interquartile range: 18-51). Physician-validated and biopsy-confirmed categories of allograft failure were as follows: acute rejection (21%), glomerular disease (19%), transplant glomerulopathy (13%), interstitial fibrosis tubular atrophy (10%), and polyomavirus-associated nephropathy (7%). Graft failures were attributed to medical conditions in 21% and remained unresolved in 9%. Donor race, donor age, human leukocyte antigen mismatches, serum creatinine, urinary protein, acute cellular rejection, acute antibody-mediated rejection, BK viremia, and CMV viremia were associated with allograft failure. Independent predictors of allograft failure were acute cellular rejection (odds ratio: 18.31, 95% confidence interval: 5.28-63.45) and urine protein ≥1 g/d within the first year post-transplantation (5.85, 2.37-14.45). Serum creatinine ≤1.5 mg/dL within the first year post-transplantation reduced the odds (0.29, 0.13-0.64) of allograft failure. Our study has identified modifiable risk factors to reduce the burden of allograft failure.
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Affiliation(s)
- Mohamad M Alkadi
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,Division of Nephrology, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Jim Kim
- Division of Transplantation Surgery, Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Meredith J Aull
- Division of Transplantation Surgery, Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Joseph E Schwartz
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,Department of Psychiatry, Stony Brook University, Stony Brook, NY, USA
| | - John R Lee
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Anthony Watkins
- Division of Transplantation Surgery, Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Jun B Lee
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,The Rogosin Institute, New York, NY, USA
| | - Darshana M Dadhania
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Surya V Seshan
- Department of Pathology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - David Serur
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,The Rogosin Institute, New York, NY, USA
| | - Sandip Kapur
- Division of Transplantation Surgery, Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Manikkam Suthanthiran
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Choli Hartono
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,The Rogosin Institute, New York, NY, USA
| | - Thangamani Muthukumar
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
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9
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Serur D, Charlton M, Juluru K, Salama G, Locastro E, Bretzlaff G, Hartono C. Long term follow up of kidney donors with asymptomatic renal stones. Nephrology (Carlton) 2018; 22:649-651. [PMID: 28685942 DOI: 10.1111/nep.13036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 01/30/2017] [Accepted: 02/13/2017] [Indexed: 12/01/2022]
Abstract
Patients with asymptomatic kidney stones have a high rate of progression to becoming symptomatic kidney stones when followed for several years. Small kidney stones are often found incidentally on imaging when evaluating patients for kidney donation, and there is a concern that after nephrectomy, the donor may become symptomatic and incur damage to the remaining kidney. We reviewed kidney donors at our institution with asymptomatic stones and surveyed them several years after donation to see if the stones became clinically active.
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Affiliation(s)
- David Serur
- Division of Nephrology and the Rogosin Institute, New York Presbyterian Weill Cornell, New York, USA
| | - Marian Charlton
- Kidney and Pancreas Transplant Program, New York Presbyterian Weill Cornell, New York, USA
| | - Krishna Juluru
- Department of Radiology, New York Presbyterian Weill Cornell, New York, USA
| | - Gayle Salama
- Department of Radiology, New York Presbyterian Weill Cornell, New York, USA
| | - Eve Locastro
- Department of Radiology, New York Presbyterian Weill Cornell, New York, USA
| | - Gretchen Bretzlaff
- Kidney and Pancreas Transplant Program, New York Presbyterian Weill Cornell, New York, USA
| | - Choli Hartono
- Division of Nephrology and the Rogosin Institute, New York Presbyterian Weill Cornell, New York, USA
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Hartono C, Chung M, Perlman AS, Chevalier JM, Serur D, Seshan SV, Muthukumar T. Bortezomib for Reduction of Proteinuria in IgA Nephropathy. Kidney Int Rep 2018; 3:861-866. [PMID: 29988921 PMCID: PMC6035125 DOI: 10.1016/j.ekir.2018.03.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 03/01/2018] [Accepted: 03/05/2018] [Indexed: 11/26/2022] Open
Abstract
Introduction IgA nephropathy is the most common glomerulonephritis in the world. We conducted a pilot trial (NCT01103778) to test the effect of bortezomib in patients with IgA nephropathy and significant proteinuria. Methods We treated 8 consecutive subjects from July 2011 until March 2016 with 4 doses of bortezomib. All subjects had biopsy-proven IgA nephropathy and proteinuria of greater than 1 g per day. They were given 4 doses of bortezomib i.v. at 1.3 mg/m2 of body surface area per dose. Changes in proteinuria and renal function were followed for 1 year after enrollment. The primary endpoint was full remission defined as proteinuria of less than 300 mg per day. Results All 8 subjects received and tolerated 4 doses of bortezomib over a 2-week period during enrollment. The median baseline daily proteinuria was 2.46 g (interquartile range: 2.29–3.16 g). At 1-year follow-up, 3 subjects (38%) had achieved the primary endpoint. The 3 subjects who had complete remission had Oxford classification T scores of 0 before enrollment. Of the remaining 5 subjects, 1 was lost to follow-up within 1 month of enrollment and 4 (50%) did not have any response or had progression of disease. Conclusion Proteasome inhibition by bortezomib may reduce significant proteinuria in select cases of IgA nephropathy. Subjects who responded to bortezomib had Oxford classification T score of 0 and normal renal function.
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Affiliation(s)
- Choli Hartono
- Department of Medicine, Division of Nephrology and Hypertension, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA.,The Rogosin Institute, New York, New York, USA
| | - Miriam Chung
- Department of Medicine, Division of Nephrology, Mount Sinai Hospital, New York, New York, USA
| | - Alan S Perlman
- Department of Medicine, Division of Nephrology and Hypertension, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA.,The Rogosin Institute, New York, New York, USA
| | - James M Chevalier
- Department of Medicine, Division of Nephrology and Hypertension, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA.,The Rogosin Institute, New York, New York, USA
| | - David Serur
- Department of Medicine, Division of Nephrology and Hypertension, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA.,The Rogosin Institute, New York, New York, USA
| | - Surya V Seshan
- Department of Pathology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA
| | - Thangamani Muthukumar
- Department of Medicine, Division of Nephrology and Hypertension, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA
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11
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Constantiner M, Rosenthal-Asher D, Tedla F, Salifu M, Cukor J, Wyka K, Hartono C, Serur D, de Boccardo G, Cukor D. Differences in Attitudes Toward Immunosuppressant Therapy in a Multi-ethnic Sample of Kidney Transplant Recipients. J Clin Psychol Med Settings 2017; 25:11-19. [PMID: 29264730 DOI: 10.1007/s10880-017-9524-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Barriers for renal transplant patients to immunosuppressant medication adherence are poorly understood, despite the high rate and toll of non-adherence. We sought to assess factors that contribute to barriers to immunosuppressive medication adherence in an ethnically diverse sample of 312 renal transplant patients recruited from three transplant centers across New York City. Transplant patients who were at least 6 months post-transplant completed questionnaires while waiting for their medical appointment. Ethnic differences were observed on barriers to immunosuppressant adherence. Black and Hispanic participants reported significantly more barriers to adherence compared to Caucasian participants. Differences in perception about the potential harm and necessity of immunosuppressant medications also were present. Using hierarchical multiple regression, age and income were significant predictors of reported barriers to adherence, even while controlling for ethnicity. The most robust predictor of reported barriers was the perception of the medication cost-benefit differential, i.e., the balance between concerns about immunosuppressant medications and their perceived helpfulness (B = - 0.5, p < .001), indicating that varying beliefs about the medication's necessity and utility rather than ethnicity explain the differences in barriers to medication adherence. Future interventions targeting non-adherence should aim to reduce the barriers to adherence by addressing perceived risks and benefits of taking immunosuppressant medication.
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Affiliation(s)
- Melissa Constantiner
- Department of Psychiatry and Behavioral Science, SUNY Downstate Medical Center, 450 Clarkson Avenue, Box 1203, Brooklyn, NY, 11203-2098, USA
| | | | - Fasika Tedla
- Department of Medicine, SUNY Downstate Medical Center, New York, NY, USA
| | - Moro Salifu
- Brooklyn Health Disparities Center, Brooklyn, NY, USA.,Department of Medicine, SUNY Downstate Medical Center, New York, NY, USA
| | - Judith Cukor
- Department of Psychiatry, New York Presbyterian Hospital-Weill Cornell Medicine, New York, NY, USA
| | - Katarzyna Wyka
- Department of Psychiatry, New York Presbyterian Hospital-Weill Cornell Medicine, New York, NY, USA.,Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy City University of New York, New York, NY, USA
| | - Choli Hartono
- Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medicine, New York, NY, USA.,Rogosin Institute, New York, NY, USA
| | - David Serur
- Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medicine, New York, NY, USA.,Rogosin Institute, New York, NY, USA
| | - Graciela de Boccardo
- Montefiore-Einstein Center for Transplantation, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Daniel Cukor
- Department of Psychiatry and Behavioral Science, SUNY Downstate Medical Center, 450 Clarkson Avenue, Box 1203, Brooklyn, NY, 11203-2098, USA. .,Brooklyn Health Disparities Center, Brooklyn, NY, USA.
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12
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Kim J, Schulman-Marcus J, Watkins AC, Feldman DN, Swaminathan R, Lee JB, Muthukumar T, Serur D, Kim L, Hartono C. In-Hospital Cardiovascular Complications After Pancreas Transplantation in the United States from 2003 to 2012. Am J Cardiol 2017; 120:682-687. [PMID: 28683901 DOI: 10.1016/j.amjcard.2017.05.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/03/2017] [Accepted: 05/03/2017] [Indexed: 11/30/2022]
Abstract
Large database studies detailing the risk of perioperative cardiovascular complications after pancreas transplant has been limited, perhaps because these outcomes are not captured by transplant registries. Greater data on the incidence and risks of such outcomes could provide additional insight for referring physicians and inform potential recipients of their risk. We performed a serial, cross-sectional analysis of the National Inpatient Sample, the largest publicly available inpatient database in the United States, to assess for the risk of cardiovascular complications after pancreas transplants in the United States from 2003 to 2012 (n = 13,399). Using multivariable logistic regression models, the risk of cardiovascular outcomes after simultaneous pancreas-kidney transplants (SPK) was compared with solitary pancreas transplants (pancreas after kidney and pancreas transplant alone [PAK + PTA]). The unadjusted prevalence of in-hospital cardiovascular complications was higher in SPK than PAK + PTA (5.5% vs 3.7%, p <0.001). After multivariable adjustment, SPK remained associated with significantly higher odds of any cardiovascular complication (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.21 to 1.80, p = 0.01), and particularly stroke (OR 13.41, 95% CI 4.78 to 37.63, p <0.001), compared with PAK + PTA. However, there was no difference in perioperative mortality (OR 0.78, 95% CI 0.54 to 1.12, p = 0.18). In conclusion, these findings highlight the association between uremia and stroke in pancreas transplant patients, as well as the need for improved preoperative cardiac risk assessment and perioperative management, especially in those who underwent SPK.
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Affiliation(s)
- Jim Kim
- Division of Transplant Surgery, Weill Cornell Medicine, New York, New York.
| | - Joshua Schulman-Marcus
- Division of Cardiology, Albany Medical Center, Albany, New York; Division of Cardiology, Weill Cornell Medicine, New York, New York
| | - Anthony C Watkins
- Division of Transplant Surgery, Weill Cornell Medicine, New York, New York
| | | | - Rajesh Swaminathan
- Division of Cardiology, Weill Cornell Medicine, New York, New York; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Jun B Lee
- Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, New York; The Rogosin Institute, New York, New York
| | | | - David Serur
- Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, New York; The Rogosin Institute, New York, New York
| | - Luke Kim
- Division of Cardiology, Weill Cornell Medicine, New York, New York
| | - Choli Hartono
- Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, New York; The Rogosin Institute, New York, New York
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13
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Patri P, Seshan SV, Matignon M, Desvaux D, Lee JR, Lee J, Dadhania DM, Serur D, Grimbert P, Hartono C, Muthukumar T. Development and validation of a prognostic index for allograft outcome in kidney recipients with transplant glomerulopathy. Kidney Int 2017; 89:450-8. [PMID: 26422505 PMCID: PMC4814368 DOI: 10.1038/ki.2015.288] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 07/05/2015] [Accepted: 07/31/2015] [Indexed: 01/29/2023]
Abstract
We studied 92 patients with transplant glomerulopathy to develop a prognostic index based on the risk factors for allograft failure within five years of diagnosis (Development cohort). During 60 months (median) follow up, 64 patients developed allograft failure. A chronic-inflammation score generated by combining Banff ci, ct and ti scores, serum creatinine and proteinuria at biopsy, were independent risk factors for allograft failure. Based on the Cox model, we developed a prognostic index and classified patients into risk groups. Compared to the low risk group (median allograft survival over 60 months from diagnosis), patients in the medium risk group had a hazard ratio of 2.83 (median survival 25 months), while those in the high risk group had a hazard ratio of 5.96 (median survival 3.7 months). We next evaluated the performance of the prognostic index in an independent external cohort of 47 patients with transplant glomerulopathy (Validation cohort). The hazard ratios were 2.18 (median survival 19 months) and 16.27 (median survival 1.6 months), respectively, for patients in the medium and high risk groups, compared to the low risk group (median survival 47 months). Our prognostic index model did well in measures of discrimination and calibration. Thus, risk stratification of transplant glomerulopathy based on our prognostic index may provide informative insight for both the patient and physician regarding prognosis and treatment.
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14
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Kamal L, Salvatore S, Hartono C, Perlman A. Concomitance of IgA nephropathy and diabetic nephropathy in a kidney allograft: case report and review of the literature. Transplant Proc 2015; 46:2396-9. [PMID: 25242794 DOI: 10.1016/j.transproceed.2014.06.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 06/17/2014] [Indexed: 10/24/2022]
Abstract
Whereas diabetic nephropathy is the most common cause of end-stage renal disease (ESRD), IgA nephropathy is the most common glomerulonephritis in the world. We report a case of a kidney transplant recipient whose native renal disease was presumptive diabetic nephropathy. Five years after transplantation, the patient developed proteinuria, hematuria, and allograft dysfunction. Transplant biopsy revealed IgA nephropathy superimposed on diabetic nephropathy.
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Affiliation(s)
- L Kamal
- New York Presbyterian Hospital-Cornell Medical College, New York, New York
| | - S Salvatore
- New York Presbyterian Hospital-Cornell Medical College, New York, New York
| | - C Hartono
- New York Presbyterian Hospital-Cornell Medical College, New York, New York; The Rogosin Institute, New York, New York
| | - A Perlman
- New York Presbyterian Hospital-Cornell Medical College, New York, New York; The Rogosin Institute, New York, New York.
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15
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16
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Srivatana V, Muthukumar T, Lee JB, Seshan SV, Hartono C. Quiz Page August 2015: Leukemoid Reaction and Acute Kidney Injury Following Kidney Transplantation. Am J Kidney Dis 2015. [PMID: 26210728 DOI: 10.1053/j.ajkd.2015.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Vesh Srivatana
- Division of Nephrology and Hypertension, Weill Cornell Medical College, New York, NY
| | - Thangamani Muthukumar
- Division of Nephrology and Hypertension, Weill Cornell Medical College, New York, NY
| | - Jun B Lee
- Division of Nephrology and Hypertension, Weill Cornell Medical College, New York, NY; The Rogosin Institute, New York, NY
| | - Surya V Seshan
- Department of Pathology, Weill Cornell Medical College, New York, NY
| | - Choli Hartono
- Division of Nephrology and Hypertension, Weill Cornell Medical College, New York, NY; The Rogosin Institute, New York, NY.
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17
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Chen T, Yuan J, Duncanson S, Hibert ML, Kodish BC, Mylavaganam G, Maker M, Li H, Sremac M, Santosuosso M, Forbes B, Kashiwagi S, Cao J, Lei J, Thomas M, Hartono C, Sachs D, Markmann J, Sambanis A, Poznansky MC. Alginate encapsulant incorporating CXCL12 supports long-term allo- and xenoislet transplantation without systemic immune suppression. Am J Transplant 2015; 15:618-27. [PMID: 25693473 DOI: 10.1111/ajt.13049] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 10/03/2014] [Accepted: 10/04/2014] [Indexed: 01/25/2023]
Abstract
Islet transplantation represents a potentially curative approach for individuals with Type I Diabetes. The requirement for systemic immune suppression to control immune-mediated rejection of transplanted islets and the limited human islet supply represent significant roadblocks to progress for this approach. Islet microencapsulation in alginate offers limited protection in the absence of systemic immunosuppression, but does not support long-term islet survival. The chemokine, CXCL12, can repel effector T cells while recruiting immune-suppressive regulatory T cells (Tregs) to an anatomic site while providing a prosurvival signal for beta-cells. We proposed that coating or encapsulating donor islets with CXCL12 would induce local immune-isolation and protect and support the function of an allo- or xenograft without systemic immune suppression. This study investigated the effect of alginate microcapsules incorporating CXCL12 on islet function. Islet transplantation was performed in murine models of insulin-dependent diabetes. Coating of islets with CXCL12 or microencapsulation of islets with alginate incorporating the chemokine, resulted in long-term allo- and xenoislet survival and function, as well as a selective increase in intragraft Tregs. These data support the use of CXCL12 as a coating or a component of an alginate encapsulant to induce sustained local immune-isolation for allo- or xenoislet transplantation without systemic immunosuppression.
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Affiliation(s)
- T Chen
- Vaccine and Immunotherapy Center, Massachusetts General Hospital, Charlestown, MA
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18
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Matignon M, Ding R, Dadhania DM, Mueller FB, Hartono C, Snopkowski C, Li C, Lee JR, Sjoberg D, Seshan SV, Sharma VK, Yang H, Nour B, Vickers AJ, Suthanthiran M, Muthukumar T. Urinary cell mRNA profiles and differential diagnosis of acute kidney graft dysfunction. J Am Soc Nephrol 2014; 25:1586-97. [PMID: 24610929 DOI: 10.1681/asn.2013080900] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Noninvasive tests to differentiate the basis for acute dysfunction of the kidney allograft are preferable to invasive allograft biopsies. We measured absolute levels of 26 prespecified mRNAs in urine samples collected from kidney graft recipients at the time of for-cause biopsy for acute allograft dysfunction and investigated whether differential diagnosis of acute graft dysfunction is feasible using urinary cell mRNA profiles. We profiled 52 urine samples from 52 patients with biopsy specimens indicating acute rejection (26 acute T cell-mediated rejection and 26 acute antibody-mediated rejection) and 32 urine samples from 32 patients with acute tubular injury without acute rejection. A stepwise quadratic discriminant analysis of mRNA measures identified a linear combination of mRNAs for CD3ε, CD105, TLR4, CD14, complement factor B, and vimentin that distinguishes acute rejection from acute tubular injury; 10-fold cross-validation of the six-gene signature yielded an estimate of the area under the curve of 0.92 (95% confidence interval, 0.86 to 0.98). In a decision analysis, the six-gene signature yielded the highest net benefit across a range of reasonable threshold probabilities for biopsy. Next, among patients diagnosed with acute rejection, a similar statistical approach identified a linear combination of mRNAs for CD3ε, CD105, CD14, CD46, and 18S rRNA that distinguishes T cell-mediated rejection from antibody-mediated rejection, with a cross-validated estimate of the area under the curve of 0.81 (95% confidence interval, 0.68 to 0.93). Incorporation of these urinary cell mRNA signatures in clinical decisions may reduce the number of biopsies in patients with acute dysfunction of the kidney allograft.
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Affiliation(s)
- Marie Matignon
- Division of Nephrology and Hypertension, Department of Medicine and Assistance Publique-Hôpitaux de Paris, Groupe Henri Mondor-Albert Chenevier, Nephrology and Transplantation Department, Centre d'Investigation Clinique-BioThérapies 504 and Institut National de la Santé et de la Recherche Médicale U955 and Paris XII University, Créteil, France
| | - Ruchuang Ding
- Division of Nephrology and Hypertension, Department of Medicine and
| | - Darshana M Dadhania
- Division of Nephrology and Hypertension, Department of Medicine and Departments of Transplantation Medicine and
| | - Franco B Mueller
- Division of Nephrology and Hypertension, Department of Medicine and
| | - Choli Hartono
- Division of Nephrology and Hypertension, Department of Medicine and Departments of Transplantation Medicine and
| | | | - Carol Li
- Division of Nephrology and Hypertension, Department of Medicine and
| | - John R Lee
- Division of Nephrology and Hypertension, Department of Medicine and Departments of Transplantation Medicine and
| | - Daniel Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York; and
| | - Surya V Seshan
- Pathology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Vijay K Sharma
- Division of Nephrology and Hypertension, Department of Medicine and
| | - Hua Yang
- Division of Nephrology and Hypertension, Department of Medicine and
| | - Bakr Nour
- Department of Surgery, Weill Cornell Medical College in Qatar, Doha, Qatar
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York; and
| | - Manikkam Suthanthiran
- Division of Nephrology and Hypertension, Department of Medicine and Departments of Transplantation Medicine and
| | - Thangamani Muthukumar
- Division of Nephrology and Hypertension, Department of Medicine and Departments of Transplantation Medicine and
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Hartono C, Muthukumar T. Treating IgA nephropathy: quid novi? Discov Med 2014; 17:131-138. [PMID: 24641955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
IgA nephropathy is a common autoimmune renal disease resulting in kidney failure for patients with significant proteinuria. The therapeutic options are limited including non-specific treatment to reduce proteinuria accomplished by renin-angiotensin blockade. Strategies to control intrarenal inflammation include the administration of fish oil and for severe disease the use of immunosuppressive agents such as cyclophosphamide, glucocorticosteroids, and mycophenolate mofetil. In light of the limited option, there is an unmet need for novel therapeutic intervention in patients with progressive disease. Herein, we review the evidence for existing treatment choices and explore new immunopharmacologic agents being investigated for IgA nephropathy.
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Affiliation(s)
- Choli Hartono
- The Rogosin Institute, 505 East 70th St., Box 102, New York, NY 10021, USA and Division of Nephrology and Hypertension, Weill Cornell Medical College, 525 East 68th St., New York, NY 10065, USA
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Hartono C, Chung M, Kuo SF, Seshan SV, Muthukumar T. Bortezomib therapy for nephrotic syndrome due to idiopathic membranous nephropathy. J Nephrol 2014; 27:103-6. [PMID: 24430762 DOI: 10.1007/s40620-013-0028-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 12/12/2013] [Indexed: 10/25/2022]
Abstract
Idiopathic membranous nephropathy is a common cause of nephrotic syndrome in adults. The nephrotic syndrome due to idiopathic membranous nephropathy is often resistant to glucocorticosteroids and requires an alkylating agent such as chlorambucil or cyclophosphamide to induce remission. Recent studies illustrate that antibodies against the autoantigen M-type phospholipase A2 receptor contribute to a vast majority but not all cases of idiopathic membranous nephropathy. Herein, we report a patient with nephrotic syndrome due to membranous nephropathy that was resistant to 6 months of therapy with ramipril and high-dose glucocorticosteroids but responded to a single cycle of bortezomib infusion.
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Affiliation(s)
- Choli Hartono
- The Rogosin Institute, 505 East 70th Street, Box 102, New York, NY, 10021, USA,
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Abstract
The first successful kidney transplantation between monozygotic identical twins did not require any immunosuppressive drugs. Clinical application of azathioprine and glucocorticosteroids allowed the transfer of organs between genetically disparate donors and recipients. Transplantation is now the standard of care, a life-saving procedure for patients with failed organs. Progress in our understanding of the immunobiology of rejection has been translated to the development of immunosuppressive agents targeting T cells, B cells, plasma cells, costimulatory signals, complement products, and antidonor antibodies. Modern immunopharmacologic interventions have contributed to the clinical success observed following transplantation but challenges remain in personalizing immunosuppressive therapy.
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Affiliation(s)
- Choli Hartono
- Division of Nephrology and Hypertension, Departments of Medicine and Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, New York 10065
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Serur D, Kapur S, Saal S, Leeser D, Gerber LM, Wang J, Hartono C, Lee J, Dadhania D, Kim K, Muthukumar T, Lee J, Seshan S, Chiu YL, Levine D, Parker T, Riggio R, Smith B, Cheigh J. Excellent outcomes with expanded criteria donor kidneys: the role of the recipient's age. Clin Transpl 2013:85-91. [PMID: 25095495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
At the present time, the number of deceased donor kidney transplants performed annually has remained unchanged for 4 years. Desire for standard criteria donor (SCD) kidneys by recipients, coupled with high discard rates of donor kidneys, contributes to a lack of procedures being performed. A subgroup of recipients, those under age 50, may fare as well with an expanded criteria donor (ECD) allograft as those who receive an SCD kidney. The use of ECD allografts in recipients over 50 years of age, while projected to have poorer allograft survival than that produced with an SCD graft, still results in better recipient survival than patients who have elected to remain on dialysis.
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23
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Leeser DB, Aull MJ, Afaneh C, Dadhania D, Charlton M, Walker JK, Hartono C, Serur D, Del Pizzo JJ, Kapur S. Living donor kidney paired donation transplantation: experience as a founding member center of the National Kidney Registry. Clin Transplant 2012; 26:E213-22. [DOI: 10.1111/j.1399-0012.2012.01606.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- David B. Leeser
- Division of Transplant Surgery; Department of Surgery; Weill Cornell Medical College; New York; NY; USA
| | - Meredith J. Aull
- Division of Transplant Surgery; Department of Surgery; Weill Cornell Medical College; New York; NY; USA
| | - Cheguevara Afaneh
- Division of Transplant Surgery; Department of Surgery; Weill Cornell Medical College; New York; NY; USA
| | - Darshana Dadhania
- Division of Nephrology; Department of Medicine; Weill Cornell Medical College; New York; NY; USA
| | - Marian Charlton
- Division of Transplant Surgery; Department of Surgery; Weill Cornell Medical College; New York; NY; USA
| | - Jennifer K. Walker
- Division of Transplant Surgery; Department of Surgery; Weill Cornell Medical College; New York; NY; USA
| | - Choli Hartono
- Division of Nephrology; Department of Medicine; Weill Cornell Medical College; New York; NY; USA
| | - David Serur
- Division of Nephrology; Department of Medicine; Weill Cornell Medical College; New York; NY; USA
| | | | - Sandip Kapur
- Division of Transplant Surgery; Department of Surgery; Weill Cornell Medical College; New York; NY; USA
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Abstract
BACKGROUND In kidney, liver, heart, and lung transplantation, extremes of body mass index (BMI) have been reported to influence post-operative outcomes and even survival. Given the limited data in pancreas transplantation, we sought to elucidate the influence of BMI on outcomes. METHODS We reviewed 139 consecutive pancreas transplants performed at our institution and divided them into four categories based on BMI: underweight (≤18.5 kg/m(2)), normal (18.6-24.9 kg/m(2)), overweight (25-29.9 kg/m(2)), and obese (≥30 kg/m(2)). Parameters analyzed included post-operative complications, early graft loss, one-yr acute rejection rate (AR), non-surgical infections, and survival. RESULTS Demographic data were similar between the groups. Compared with normal, only obese patients trended toward more post-operative complications (p = 0.06). Underweight and obese patients had significantly more post-operative infectious complications than normal (p = 0.0005 and p = 0.03, respectively). Obese patients had more complications requiring percutaneous drainage compared with normal (p = 0.03). Overweight and obese patients had significantly more complications requiring re-laparotomy (p = 0.03 and p = 0.048, respectively). Early graft loss, AR, non-surgical infections, and patient and graft survival rates were not different between normal and underweight, overweight, or obese patients (p > 0.05). CONCLUSIONS Extremes of BMI were associated with increased morbidity. Donors and recipients should be carefully selected to maximize potential for successful outcomes.
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Affiliation(s)
- Cheguevara Afaneh
- Division of Transplantation, Department of Surgery, Weill Cornell Medical College, New York, NY, USA.
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Chen C, Jhaveri KD, Hartono C, Seshan SV. An uncommon glomerular disease in an HIV patient: value of renal biopsy and review of the literature. Clin Nephrol 2011; 75:80-88. [PMID: 21176755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
Renal disease is not uncommon in those infected with HIV. The most common manifestation of HIV in the kidney is HIV-associated nephropathy (HIVAN). Other HIV- and non-HIV-related causes have been described in the literature. Immunotactoid glomerulonephritis (ITG) is a rare disorder found in 0.06% of renal biopsies characterized by organized tubular immune complex deposits, observed more often in Caucasians. ITG tends to occur in an older age group and in some patients has been associated with a hemopoietic malignancy. In this report, we describe a case of ITG occurring in an HIV-positive, hepatitis C (HCV)- and hepatitis B (HBV)-negative female, who presented with microscopic hematuria and proteinuria. A percutaneous kidney biopsy showed diffuse membranous glomerulopathy, with mild mesangial proliferation and segmental sclerosing lesions containing mainly IgG, Kappa- and C3-positive deposits. Electron microscopy revealed diffuse subepithelial tubular deposits diagnostic of ITG. Out of 5 reported HIV-positive cases and ITG in the literature, 3 were HCV+, 2 were Caucasian and 3 were African-American (AA) without detectable hematologic malignancy. We report another case of ITG in an HCV- and HBV-negative, AA female.
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Affiliation(s)
- C Chen
- Department of Medicine, Tufts Medical Center, Boston, MA, USA
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Serur D, Saal S, Wang J, Sullivan J, Bologa R, Hartono C, Dadhania D, Lee J, Gerber LM, Goldstein M, Kapur S, Stubenbord W, Belenkaya R, Marin M, Seshan S, Ni Q, Levine D, Parker T, Stenzel K, Smith B, Riggio R, Cheigh J. Deceased-donor kidney transplantation: improvement in long-term survival. Nephrol Dial Transplant 2010; 26:317-24. [DOI: 10.1093/ndt/gfq415] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Lubetzky M, Auli MJ, Walker J, Leeser D, Kapur S, Hartono C, Dadhania D. Reduction in proteinuria with bortezomib based therapy for antibody mediated rejection. Clin Transpl 2010:437-440. [PMID: 21696061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Michelle Lubetzky
- Department of Transplantation Medicine, New York Presbyterian Hospital/Weill Cornell Medical College, New York, USA
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Aull MJ, Saal S, Dadhania D, Hartono C, Kapur S. Modulation of antibody response in a sensitized patient with ongoing antibody-mediated injury. Clin Transpl 2009:495-498. [PMID: 20524322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- Meredith J Aull
- Division of Transplantation Surgery, Weill Cornell Medical College/NewYork-Presbyterian Hospital, New York, New York, USA
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Hartono C, Lubetzky M, Aull MJ, Saal S, Figueiro J, Kapur S, Dadhania D. Use of bortezomib for prevention and treatment of rejection in sensitized patients. Clin Transpl 2009:499-503. [PMID: 20524323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
We report 2 cases of sensitized patients who were successfully treated with bortezomib therapy resulting in reduction of donor-specific antibodies (DSA). Our cases illustrate the synergistic effects of combination therapy that includes bortezomib on prevention and treatment of AMR in highly sensitized patients. Moving forward, long-term data on sensitized patients treated with bortezomib are needed to fully evaluate the impact of this therapy.
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Affiliation(s)
- Choli Hartono
- Department of Transplantation Medicine, Weill Cornell Medical College/New York-Presbyterian Hospital, New York, New York, USA
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Saidi R, Kennealey P, Elias N, Kawai T, Hertl M, Farrell M, Goes N, Hartono C, Tolkoff-Rubin N, Cosimi A, Ko D. Deceased Donor Kidney Transplantation in Elderly Patients: Is There a Difference in Outcomes? Transplant Proc 2008; 40:3413-7. [DOI: 10.1016/j.transproceed.2008.08.127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Accepted: 08/29/2008] [Indexed: 10/21/2022]
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Saidi RF, Elias N, Kawai T, Hertl M, Farrell ML, Goes N, Wong W, Hartono C, Fishman JA, Kotton CN, Tolkoff-Rubin N, Delmonico FL, Cosimi AB, Ko DSC. Outcome of kidney transplantation using expanded criteria donors and donation after cardiac death kidneys: realities and costs. Am J Transplant 2007; 7:2769-74. [PMID: 17927805 DOI: 10.1111/j.1600-6143.2007.01993.x] [Citation(s) in RCA: 138] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Expanded criteria donors (ECDs) and donation after cardiac death (DCD) provide more kidneys in the donor pool. However, the financial impact and the long-term benefits of these kidneys have been questioned. From 1998 to 2005, we performed 271 deceased donor kidney transplants into adult recipients. There were 163 (60.1%) SCDs, 44 (16.2%) ECDs, 53 (19.6%) DCDs and 11 (4.1%) ECD/DCDs. The mean follow-up was 50 months. ECD and DCD kidneys had a significantly higher incidence of delayed graft function, longer time to reach serum creatinine below 3 (mg/dL), longer length of stay and more readmissions compared to SCDs. The hospital charge was also higher for ECD, ECD/DCD and DCD kidneys compared to SCDs, primarily due to the longer length of stay and increased requirement for dialysis (70,030 dollars, 72,438 dollars, 72,789 dollars and 47,462 dollars, respectively, p < 0.001). Early graft survival rates were comparable among all groups. However, after a mean follow-up of 50 months, graft survival was significantly less in the ECD group compared to other groups. Although our observations support the utilization of ECD and DCD kidneys, these transplants are associated with increased costs and resource utilization. Revised reimbursement guidelines will be required for centers that utilize these organs.
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Affiliation(s)
- R F Saidi
- Department of Surgery, Transplantation Unit, Massachusetts General Hospital, Boston, MA, USA
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Muthukumar T, Dadhania D, Ding R, Snopkowski C, Naqvi R, Lee JB, Hartono C, Li B, Sharma VK, Seshan SV, Kapur S, Hancock WW, Schwartz JE, Suthanthiran M. Messenger RNA for FOXP3 in the urine of renal-allograft recipients. N Engl J Med 2005; 353:2342-51. [PMID: 16319383 DOI: 10.1056/nejmoa051907] [Citation(s) in RCA: 426] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The outcome of renal transplantation after an episode of acute rejection is difficult to predict, even with an allograft biopsy. METHODS We studied urine specimens from 36 subjects with acute rejection, 18 subjects with chronic allograft nephropathy, and 29 subjects with normal biopsy results. Levels of messenger RNA (mRNA) for FOXP3, a specification and functional factor for regulatory T lymphocytes, and mRNA for CD25, CD3epsilon, perforin, and 18S ribosomal RNA (rRNA) were measured with a kinetic, quantitative polymerase-chain-reaction assay. We examined associations of mRNA levels with acute rejection, rejection reversal, and graft failure. RESULTS The log-transformed mean (+/-SE) ratio of FOXP3 mRNA copies to 18S ribosomal RNA copies was higher in urine from the group with acute rejection (3.8+/-0.5) than in the group with chronic allograft nephropathy (1.3+/-0.7) or the group with normal biopsy results (1.6+/-0.4) (P<0.001 by the Kruskal-Wallis test). FOXP3 mRNA levels were inversely correlated with serum creatinine levels measured at the time of biopsy in the acute-rejection group (Spearman's correlation coefficient = -0.38, P=0.02) but not in the group with chronic allograft nephropathy or the group with normal biopsy results. Analyses of receiver-operating-characteristic curves demonstrated that reversal of acute rejection can be predicted with 90 percent sensitivity and 73 percent specificity with use of the optimal identified cutoff for FOXP3 mRNA of 3.46 (P=0.001). FOXP3 mRNA levels identified subjects at risk for graft failure within six months after the incident episode of acute rejection (relative risk for the lowest third of FOXP3 mRNA levels, 6; P=0.02). None of the other mRNA levels were predictive of reversal of acute rejection or graft failure. CONCLUSIONS Measurement of FOXP3 mRNA in urine may offer a noninvasive means of improving the prediction of outcome of acute rejection of renal transplants.
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Affiliation(s)
- Thangamani Muthukumar
- Division of Nephrology, Department of Medicine, Weill Medical College of Cornell University, New York, USA
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Tatapudi RR, Muthukumar T, Dadhania D, Ding R, Li B, Sharma VK, Lozada-Pastorio E, Seetharamu N, Hartono C, Serur D, Seshan SV, Kapur S, Hancock WW, Suthanthiran M. Noninvasive detection of renal allograft inflammation by measurements of mRNA for IP-10 and CXCR3 in urine. Kidney Int 2004; 65:2390-7. [PMID: 15149352 DOI: 10.1111/j.1523-1755.2004.00663.x] [Citation(s) in RCA: 155] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND We explored the hypothesis that measurements of mRNA encoding interferon-inducible protein-10 (IP-10) or the chemokine receptor CXCR3 in urinary cells offer a noninvasive means of elucidating cellular traffic causing acute rejection of human renal allografts. METHODS We obtained 63 urine specimens from 58 renal allograft recipients who underwent 63 allograft biopsies to resolve the basis for graft dysfunction, and 27 additional urine samples from 24 other patients with stable allograft function. Twenty-seven of the 63 biopsies were classified as acute rejection, 20 as other, and 16 as chronic allograft nephropathy. We measured the levels of transcripts for IP-10 and CXCR3, and a constitutively expressed gene 18S rRNA in the urine specimens and correlated transcript levels with renal allograft diagnosis. RESULTS mRNA levels of IP-10 (P < 0.0001) or CXCR3 (P < 0.0001) but not the levels of 18S rRNA (P= 0.56) predicted intragraft cellular traffic causing acute rejection. Receiver-operating characteristic curve analysis demonstrated that acute rejection can be predicted with a sensitivity of 100% and a specificity of 78% using the (log-transformed) cutoff value of 9.11 copies of IP-10, and with a sensitivity of 63% and a specificity of 83% using the cutoff value of 11.59 copies of CXCR3. Immunohistologic analysis of allograft biopsies showed exuberant expression of IP-10 and CXCR3 during acute rejection whereas both were absent in grafts with stable function. CONCLUSION Our investigation demonstrates that intragraft cellular events associated with acute rejection of human renal allografts can be noninvasively identified by measurements of mRNA for IP-10 and CXCR3 in urinary cells.
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Affiliation(s)
- Ravi Raju Tatapudi
- Department of Medicine, Weill Medical College of Cornell University, New York, New York, USA
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Abstract
Accurate diagnosis of acute rejection remains a formidable challenge in organ transplantation. The current gold standard diagnostic test for acute rejection is histological examination of the transplanted organ. However, biopsy procedures are invasive and complications occur. Furthermore, sampling errors may bias the histological diagnosis. Not uncommonly, empiric anti-rejection therapy has to be provided prior to the availability of a confirmatory histological report. Thus, there is an urgent need for specific and sensitive noninvasive biomarkers of acute rejection. Herein, we review noninvasive strategies for the diagnosis of acute rejection of solid organ transplants.
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Affiliation(s)
- Choli Hartono
- The Rogosin Institute, New York-Presbyterian Hospital, New York, NY 10021, USA
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Dadhania D, Muthukumar T, Ding R, Li B, Hartono C, Serur D, Seshan SV, Sharma VK, Kapur S, Suthanthiran M. Molecular signatures of urinary cells distinguish acute rejection of renal allografts from urinary tract infection. Transplantation 2003; 75:1752-4. [PMID: 12777869 DOI: 10.1097/01.tp.0000063931.08861.56] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute rejection (AR) and urinary tract infection (UTI) continue to plague renal transplantation. We tested the hypotheses that UTI does not increase granzyme B mRNA levels in urinary cells, and that the levels distinguish AR from UTI. We measured the levels of granzyme B mRNA in 15 urine specimens from renal allograft recipients with UTI, 29 specimens from patients with AR but without UTI, and 14 specimens from patients without AR and without UTI. We also measured transcript levels in urine specimens from 41 nontransplant individuals, 11 with UTI and 30 without UTI. UTI did not increase granzyme B mRNA levels. Granzyme B mRNA levels were lower in renal allograft recipients with UTI compared with those with AR (P<0.0001). We conclude that bacterial UTI is unlikely to confound AR diagnosis made by measurement of granzyme B mRNA levels in urinary cells.
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Affiliation(s)
- Darshana Dadhania
- Division of Nephrology, Department of Medicine, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, USA
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Muthukumar T, Ding R, Dadhania D, Medeiros M, Li B, Sharma VK, Hartono C, Serur D, Seshan SV, Volk HD, Reinke P, Kapur S, Suthanthiran M. Serine proteinase inhibitor-9, an endogenous blocker of granzyme B/perforin lytic pathway, is hyperexpressed during acute rejection of renal allografts. Transplantation 2003; 75:1565-70. [PMID: 12792516 DOI: 10.1097/01.tp.0000058230.91518.2f] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Serine proteinase inhibitor (PI)-9 with a reactive center P1 (Glu)-P1' is a natural antagonist of granzyme B and is expressed in high levels in cytotoxic T lymphocytes (CTL). In view of the role of CTL in acute rejection, we explored the hypothesis that PI-9 would be hyperexpressed during acute rejection. Because PI-9 can protect CTL from its own fatal arsenal and potentially enhance the vitality of CTL, we examined whether PI-9 levels correlate with the severity of rejection as well as predict subsequent graft function. METHODS We obtained 95 urine specimens from 87 renal allograft recipients. RNA was isolated from the urinary cells and mRNA encoding PI-9, granzyme B, or perforin and a constitutively expressed 18S rRNA was measured with the use of real-time quantitative polymerase chain reaction assay, and the level of expression was correlated with allograft status. RESULTS The levels of PI-9 (P=0.001), granzyme B (P<0.0001), and perforin mRNAs (P<0.0001), but not the levels of 18S rRNA (P=0.54), were higher in the urinary cells from the 29 patients with a biopsy-confirmed acute rejection than in the 58 recipients without acute rejection. PI-9 levels were significantly higher in patients with type II or higher acute rejection changes compared with those with less than type II changes (P=0.01). Furthermore, PI-9 levels predicted subsequent graft function (r=0.43, P=0.01). CONCLUSIONS PI-9 mRNA levels in urinary cells are diagnostic of acute rejection, predict renal allograft histology grade, and predict functional outcome following an acute rejection episode.
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Affiliation(s)
- Thangamani Muthukumar
- Division of Nephrology, Department of Medicine, Weill Medical College of Cornell University, New York-Presbyterian Hospital, NY, USA
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Ding R, Li B, Muthukumar T, Dadhania D, Medeiros M, Hartono C, Serur D, Seshan SV, Sharma VK, Kapur S, Suthanthiran M. CD103 mRNA levels in urinary cells predict acute rejection of renal allografts. Transplantation 2003; 75:1307-12. [PMID: 12717221 DOI: 10.1097/01.tp.0000064210.92444.b5] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND CD103 is displayed on the cell surface of alloreactive CD8 cytotoxic T lymphocytes (CTLs) and is a critical component for the intraepithelial homing of T cells. Because intratubular localization of mononuclear cells is a feature of acute cellular rejection of renal allografts, we explored the hypothesis that CD103 messenger (m)RNA levels in urinary cells predict acute rejection. METHODS We collected 89 urine specimens from 79 recipients of renal allografts. RNA was isolated from the urinary cells, and we measured CD103 mRNA levels and a constitutively expressed 18S ribosomal (r)RNA with the use of real-time quantitative polymerase chain reaction assay. RESULTS CD103 mRNA levels, but not 18S rRNA levels, were higher in urinary cells from 30 patients with an episode of acute rejection (32 biopsies and 32 urine samples) compared with the levels in 12 patients with other findings on allograft biopsy (12 biopsies and 12 urine samples), 12 patients with biopsy evidence of chronic allograft nephropathy (12 biopsies and 12 urine samples), and 25 patients with stable graft function after renal transplantation (0 biopsies and 33 urine samples) (P = 0.001; one-way analysis of variance). Acute rejection was predicted with a sensitivity of 59% and a specificity of 75% using natural log-transformed value 8.16 CD103 copies per microgram as the cutoff value (P = 0.001). CONCLUSION CD103 mRNA levels in urinary cells are diagnostic of acute rejection of renal allografts. Because CD103 is a cell surface marker of intratubular CD8 CTLs, a noninvasive assessment of cellular traffic into the allograft may be feasible by the measurement of CD103 mRNA levels in urinary cells.
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Affiliation(s)
- Ruchuang Ding
- 2 Division of Nephrology, Department of Medicine, Department of Transplantation Medicine, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY
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Blumenfeld JD, Catanzaro DF, Kinkhabwala M, Cheigh J, Hartono C, Serur D, Kapur S, Stubenbord WT, Haschemeyer R, Riggio R. Renin system activation and delayed function of the renal transplant. Am J Hypertens 2001; 14:1270-2. [PMID: 11775137 DOI: 10.1016/s0895-7061(01)02264-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Delayed graft function (DGF), defined as persistent renal failure that requires dialysis within the first week after kidney transplantation, occurs commonly after cadaveric renal transplantation (CRT). This has important implications for long-term outcome because the 1-year allograft survival rate is significantly reduced when DGF occurs. The mechanisms contributing to the development of DGF are not well established. However, several lines of evidence indicate that excess renin system activity, in both the cadaver kidney donor and recipient, contributes importantly to the pathogenesis of DGF. If this hypothesis can be verified in clinical studies, then pharmacologic agents that interrupt the renin-angiotensin system (eg, type 1 angiotensin II receptor blockade, angiotensin converting enzyme inhibition, and beta-adrenergic blockade) in the donor and recipient might significantly improve the outcome of cadaveric renal transplants.
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Affiliation(s)
- J D Blumenfeld
- Rogosin Institute, Department of Surgery, New York Presbyterian Hospital, Weill Medical College of Cornell University, New York 10021, USA.
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40
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Li B, Hartono C, Ding R, Sharma VK, Kracker D, Dadhania D, Serur D, Mouradian J, Seshan S, Schwartz JE, Suthanthiran M. Renal allograft surveillance by mRNA profiling of urinary cells. Transplant Proc 2001; 33:3280-2. [PMID: 11750404 DOI: 10.1016/s0041-1345(01)02393-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- B Li
- Division of Nephrology, Department of Medicine, Weill Medical College of Cornell University, New York, NY, USA
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Li B, Hartono C, Ding R, Sharma VK, Ramaswamy R, Qian B, Serur D, Mouradian J, Schwartz JE, Suthanthiran M. Noninvasive diagnosis of renal-allograft rejection by measurement of messenger RNA for perforin and granzyme B in urine. N Engl J Med 2001; 344:947-54. [PMID: 11274620 DOI: 10.1056/nejm200103293441301] [Citation(s) in RCA: 458] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute rejection is a serious and frequent complication of renal transplantation, and its diagnosis is contingent on the invasive procedure of allograft biopsy. A noninvasive diagnostic test for rejection could improve the outcome of transplantation. METHODS We obtained 24 urine specimens from 22 renal-allograft recipients with a biopsy-confirmed episode of acute rejection and 127 samples from 63 recipients without evidence of acute rejection. RNA was isolated from the urinary cells. Messenger RNA (mRNA) encoding the cytotoxic proteins perforin and granzyme B and a constitutively expressed cyclophilin B gene were measured with the use of a competitive, quantitative polymerase chain reaction, and the level of expression was correlated with allograft status. RESULTS The log-transformed mean (+/-SE) levels of perforin mRNA and granzyme B mRNA, which encode cytotoxic proteins, but not the levels of constitutively expressed cyclophiiin B mRNA, were higher in the urinary cells from the 22 patients with a biopsy-confirmed episode of acute rejection than in the 63 recipients without an episode of acute rejection (perforin, 1.4+/-0.3 vs. -0.6+/-0.2 fg per microgram of total RNA; P<0.001; and granzyme B, 1.2+/-0.3 vs. -0.9+/-0.2 fg per microgram of total RNA; P<0.001). Analysis involving the receiver-operating-characteristic curve demonstrated that acute rejection can be predicted with a sensitivity of 83 percent and a specificity of 83 percent with the use of a cutoff value of 0.9 fg of perforin mRNA per microgram of total RNA, and with a sensitivity of 79 percent and a specificity of 77 percent with the use of a cutoff value of 0.4 fg of granzyme B mRNA per microgram of total RNA. Sequential urine samples were obtained from 37 patients during the first nine days after transplantation; and measurements of the levels of mRNA that encoded cytotoxic proteins identified those in whom acute rejection developed. CONCLUSIONS Measurement of mRNA encoding cytotoxic proteins in urinary cells offers a noninvasive means of diagnosing acute rejection of renal allografts.
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Affiliation(s)
- B Li
- Department of Medicine, Weill Medical College of Cornell University, New York, USA
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Gillespie DL, Cordts PR, Hartono C, Woodson J, Obi-Tabot E, LaMorte WW, Menzoian JO. The role of air plethysmography in monitoring results of venous surgery. J Vasc Surg 1992; 16:674-8. [PMID: 1433653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The development of an objective, noninvasive method to assess the hemodynamic effects of venous surgery has long been awaited. Previous methods used to evaluate the results of surgery for varicose veins and venous stasis ulceration have been limited in their quantitative assessment. Now, by use of air plethysmography (APG), we can accurately quantify the effectiveness of corrective venous surgery. Twenty-five extremities that had evidence of venous insufficiency were examined with use of APG before and after venous surgical procedures. Surgery was directed at specific sites of venous incompetence as defined by physical examination and high-resolution duplex imaging. Twenty-one extremities underwent ligation and stripping of the greater saphenous vein. In these patients, APG showed an improvement in venous reflux as demonstrated by a decrease in the venous filling index from 6.6 +/- 0.7 ml/sec to 1.8 +/- 0.3 ml/sec (p = 0.0001) and venous volume from 177.1 +/- 14.5 ml to 139.2 +/- 8.9 ml (p = 0.0008). In addition, these patients showed a mild improvement in calf muscle pump function as noted by an improvement in ejection fraction from 45.8 +/- 2.0% to 50.8% +/- 2.5% (p = 0.07). The residual volume fraction decreased from 45.0% +/- 3.4% to 42.0% +/- 3.7%, a difference that was not statistically significant (p = 0.4). Four extremities with grade III chronic venous insufficiency underwent popliteal vein valve transplantation with use of an autogenous axillary vein valve.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- D L Gillespie
- Department of Surgery, Boston University School of Medicine, MA
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43
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Cordts PR, Hartono C, LaMorte WW, Menzoian JO. Physiologic similarities between extremities with varicose veins and with chronic venous insufficiency utilizing air plethysmography. Am J Surg 1992; 164:260-4. [PMID: 1415926 DOI: 10.1016/s0002-9610(05)81082-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Air plethysmography (APG) was used to measure maximal venous outflow rate (MVO), a test for proximal venous obstruction; venous volume; venous filling index, an estimate of valvular incompetence; ejection fraction (EF), a test of calf-muscle pump efficiency; and residual volume fraction (RVF), an estimate of ambulatory venous pressure. MVO was lower in patients with chronic venous insufficiency (CVI) than in those with varicose veins (VV), but the difference was small (p = 0.06). RVF was significantly greater in extremities with CVI when compared with those with VV (p less than 0.01). However, the degree of abnormality in venous volume, venous filling index, and EF was similar in CVI and VV extremities. In summary, although RVF tends to be higher in extremities with CVI when compared with those with VV, there is tremendous overlap between VV and CVI for each of the hemodynamic variables measured by APG. Therefore, the pathophysiology of CVI is likely to involve not only hemodynamic abnormalities but also other factors that have not yet been clearly identified.
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Affiliation(s)
- P R Cordts
- Section of Vascular Surgery, Boston University Medical Center, Massachusetts 02118
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