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Li F, Gragert L, Giovanni Biagini D, Patel JK, Kobashigawa JA, Trück J, Rodriguez O, Watson CT, Gibb DR, Zhang X, Kransdorf EP. IgM marks persistent IgG anti-human leukocyte antigen antibodies in highly sensitized heart transplant patients. J Heart Lung Transplant 2024; 43:314-323. [PMID: 37793509 DOI: 10.1016/j.healun.2023.09.022] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Sensitization to human leukocyte antigens (HLA) is a persistent problem in heart transplant (HT) candidates. We sought to characterize the anti-HLA antibody and circulating B cell repertoire in a cohort of highly sensitized HT candidates. METHODS We assessed immunoglobulin G (IgG) and immunoglobulin M (IgM) anti-HLA antibodies using Luminex single antigen bead assays in a cohort of 11 highly sensitized (HS; calculated panel reactive antibody ≥ 90%) and 3 mildly sensitized (MS) candidates. We also performed B cell receptor repertoire sequencing (BCRseq) in HS candidates and 33 non-candidate controls. HLA antibody strength was measured by mean fluorescence intensity (MFI). RESULTS We found that IgM anti-HLA antibodies were present in all HS candidates, but with a lower breadth and strength as compared to IgG. When anti-HLA IgG specificities intersected with IgM, binding strength was higher. In contrast, there were IgM but no intersecting IgG specificities for the MS group. In four candidates in the HS group, IgG anti-HLA antibodies decreased in both breadth and strength after HT, but the decrease in strength was smaller if the IgG possessed a specificity that intersected with pre-transplant IgM. BCRseq revealed larger B cell clonotypes in HS candidates but similar diversity as compared to controls. CONCLUSIONS IgM marks IgG anti-HLA antibodies with higher strength before HT and persistence after HT. The presence of IgM intersecting IgG for an anti-HLA specificity may be a useful approach to determine which donor HLA should be avoided for a sensitized candidate.
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Affiliation(s)
- Fang Li
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Loren Gragert
- Department of Pathology, Tulane University School of Medicine, New Orleans, Louisiana
| | - D Giovanni Biagini
- Department of Pathology, Tulane University School of Medicine, New Orleans, Louisiana
| | - Jignesh K Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Johannes Trück
- Division of Immunology, University Children's Hospital and Children's Research Center, University of Zurich (UZH), Zurich, Switzerland
| | - Oscar Rodriguez
- Department of Biochemistry and Molecular Genetics, University of Louisville, Louisville, Kentucky
| | - Corey T Watson
- Department of Biochemistry and Molecular Genetics, University of Louisville, Louisville, Kentucky
| | - David R Gibb
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Xiaohai Zhang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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DeFilippis EM, Kransdorf EP, Jaiswal A, Patel J, Kobashigawa JA, Baran DA, Kittleson MM. Reply to Comment on "Detection and management of HLA sensitization in candidates for adult heart transplantation". J Heart Lung Transplant 2023; 42:1480. [PMID: 37169041 DOI: 10.1016/j.healun.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 05/02/2023] [Indexed: 05/13/2023] Open
Affiliation(s)
- Ersilia M DeFilippis
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia University Irving Medical Center, New York, NY
| | - Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Abhishek Jaiswal
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT
| | - Jignesh Patel
- HLA and Immunogenetics Laboratory, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - David A Baran
- Cleveland Clinic, Heart Vascular and Thoracic Institute, Weston, FL
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Youn JC, Kim D, Jung MH, Kim JJ, Kim IC, Lee HS, Choi JO, Jeon ES, Nishihara K, Seguchi O, Kransdorf EP, Chang DH, Kittleson MM, Patel JK, Cole RM, Moriguchi JD, Ramzy D, Esmailian F, Kobashigawa JA. Three year post heart transplant outcomes of desensitized durable mechanical circulatory support patients. J Heart Lung Transplant 2023; 42:1408-1414. [PMID: 37150473 DOI: 10.1016/j.healun.2023.05.001] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 04/16/2023] [Accepted: 05/02/2023] [Indexed: 05/09/2023] Open
Abstract
BACKGROUND The risks and benefits of desensitization therapy (DST) in highly sensitized mechanical circulatory support (MCS) patients are not well known. We investigated 3 year post-transplant outcomes of desensitized durable MCS patients. METHODS Among 689 consecutively enrolled heart transplantation recipients between 2010 and 2016, we categorized them into Group A (desensitized MCS patients, n = 21), Group B (desensitized non-MCS patients, n = 28) and Group C (all nondesensitized patients, n = 640). Post-transplant outcomes included the incidence of primary graft dysfunction, 3-year survival, freedom from cardiac allograft vasculopathy, nonfatal major adverse cardiac events, any treated rejection, acute cellular rejection, antibody mediated rejection (AMR) and infectious complications. RESULTS The types of DST in Groups A and B were similar and included combinations of rituximab/intravenous immunoglobulin and plasmapheresis/bortezomib. Group A, compared with Group B, showed significantly higher pre-DST panel reactive antibody (PRA) (92.2 ± 9.8 vs. 83.3 ± 15.6, P = 0.007) and higher PRA reduction after DST (-22.2 ± 26.9 vs. -6.3 ± 7.5, P = 0.015). Groups A and C showed comparable primary graft dysfunction, 3-year survival, freedom from cardiac allograft vasculopathy, nonfatal major adverse cardiac events, any treated rejection, acute cellular rejection, and AMR. Although statistically not significant, Group A showed numerically higher 3-year freedom from AMR than Group B. Infectious complications were similar in both Groups A and B. CONCLUSIONS DST for MCS patients showed significant PRA reduction, resulting in an expansion of the donor pool. The post-transplant outcome of desensitized MCS patients showed comparable clinical outcomes to non-desensitized control patients in the same study period, revealing the safety and efficacy of DST.
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Affiliation(s)
- Jong-Chan Youn
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Darae Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Mi-Hyang Jung
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin-Jin Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - In-Cheol Kim
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin-Oh Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun-Seok Jeon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Keith Nishihara
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Osamu Seguchi
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Evan P Kransdorf
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - David H Chang
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jignesh K Patel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Robert M Cole
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jaime D Moriguchi
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Danny Ramzy
- Department of Cardiothoracic Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Fardad Esmailian
- Department of Cardiothoracic Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon A Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Holmstrom L, Chaudhary NS, Nakamura K, Chugh H, Uy-Evanado A, Norby F, Metcalf GA, Menon VK, Yu B, Boerwinkle E, Chugh SS, Akdemir Z, Kransdorf EP. Rare Genetic Variants Associated With Sudden Cardiac Arrest in the Young: A Prospective, Population-Based Study. Circ Genom Precis Med 2023; 16:404-405. [PMID: 37194601 PMCID: PMC10524160 DOI: 10.1161/circgen.123.004105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Affiliation(s)
- Lauri Holmstrom
- Center for Cardiac Arrest Prevention, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.H., K.N., H.C., A.U.-E., F.N., S.S.C., E.P.K.)
| | - Ninad S Chaudhary
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston (N.S.C., B.Y., E.B., Z.A.)
| | - Kotoka Nakamura
- Center for Cardiac Arrest Prevention, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.H., K.N., H.C., A.U.-E., F.N., S.S.C., E.P.K.)
| | - Harpriya Chugh
- Center for Cardiac Arrest Prevention, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.H., K.N., H.C., A.U.-E., F.N., S.S.C., E.P.K.)
| | - Audrey Uy-Evanado
- Center for Cardiac Arrest Prevention, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.H., K.N., H.C., A.U.-E., F.N., S.S.C., E.P.K.)
| | - Faye Norby
- Center for Cardiac Arrest Prevention, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.H., K.N., H.C., A.U.-E., F.N., S.S.C., E.P.K.)
| | - Ginger A Metcalf
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX (G.A.M., V.K.M., E.B.)
| | - Vipin K Menon
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX (G.A.M., V.K.M., E.B.)
| | - Bing Yu
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston (N.S.C., B.Y., E.B., Z.A.)
| | - Eric Boerwinkle
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston (N.S.C., B.Y., E.B., Z.A.)
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX (G.A.M., V.K.M., E.B.)
| | - Sumeet S Chugh
- Center for Cardiac Arrest Prevention, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.H., K.N., H.C., A.U.-E., F.N., S.S.C., E.P.K.)
| | - Zeynep Akdemir
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston (N.S.C., B.Y., E.B., Z.A.)
| | - Evan P Kransdorf
- Center for Cardiac Arrest Prevention, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.H., K.N., H.C., A.U.-E., F.N., S.S.C., E.P.K.)
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5
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DeFilippis EM, Kransdorf EP, Jaiswal A, Zhang X, Patel J, Kobashigawa JA, Baran DA, Kittleson MM. Detection and management of HLA sensitization in candidates for adult heart transplantation. J Heart Lung Transplant 2023; 42:409-422. [PMID: 36631340 DOI: 10.1016/j.healun.2022.12.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 12/13/2022] [Accepted: 12/17/2022] [Indexed: 12/28/2022] Open
Abstract
Heart transplantation (HT) remains the preferred therapy for patients with advanced heart failure. However, for sensitized HT candidates who have antibodies to human leukocyte antigens , finding a suitable donor can be challenging and can lead to adverse waitlist outcomes. In recent years, the number of sensitized patients awaiting HT has increased likely due to the use of durable and mechanical circulatory support as well as increasing number of candidates with underlying congenital heart disease. This State-of-the-Art review discusses the assessment of human leukocyte antigens antibodies, potential desensitization strategies including mechanisms of action and specific protocols, the approach to a potential donor including the use of complement-dependent cytotoxicity, flow cytometry, and virtual crossmatches, and peritransplant induction management.
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Affiliation(s)
- Ersilia M DeFilippis
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Abhishek Jaiswal
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Xiaohai Zhang
- HLA and Immunogenetics Laboratory, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - David A Baran
- Cleveland Clinic, Heart Vascular and Thoracic Institute, Weston, Florida
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6
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Rao RA, Kransdorf EP, Patel JK, Kobashigawa JA, Kittleson MM. How to Approach HLA Sensitization in Heart Transplant Candidates. JACC: Heart Failure 2023; 11:469-475. [PMID: 37019560 DOI: 10.1016/j.jchf.2023.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/16/2022] [Accepted: 01/10/2023] [Indexed: 04/05/2023]
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7
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Rushakoff JA, Kransdorf EP, Kittleson MM, Neyer JR, Luthringer D, Patel JK. Atypical cardiac amyloidosis phenotypes identified at transplant: a case series. Eur Heart J Case Rep 2023; 7:ytad105. [PMID: 36923113 PMCID: PMC10010473 DOI: 10.1093/ehjcr/ytad105] [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: 10/03/2022] [Revised: 11/22/2022] [Accepted: 02/23/2023] [Indexed: 03/02/2023]
Abstract
Background Transthyretin amyloidosis (TTR) is increasingly implicated as an aetiology of advanced cardiomyopathy. Typically, both genetic variant (TTRv) and wild-type (TTRwt) amyloidosis present with a restrictive phenotype. We present a series of three patients who were found to have cardiac amyloidosis on explant following heart transplant (HT) who had atypical, non-restrictive phenotypes. Case Summary All three patients were men, three were Black, and only one had an alternative pre-HT explanation for their advanced, dilated cardiomyopathy. Pre-HT transthoracic echocardiograms were notable for left ventricular (LV) dilation (>95th percentile for height and gender), low EF, and normal LV wall thickness. Explants showed varying amounts of amyloid deposition, ranging from diffuse biventricular patterns to perivascular involvement. Mass spectrometry confirmed the presence of TTRv (two cases) and TTRwt (one case). Discussion Patients with dilated cardiomyopathy may harbour cardiac amyloidosis. Uncertainty remains regarding the contribution of amyloidosis to the development of a dilated phenotype. The pathogenic Val142Ile variant seen in two of these patients, a variant common in Black patients, suggests a need for further investigation into the potential relationship between TTRv amyloidosis and dilated cardiomyopathy.
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Affiliation(s)
- Joshua A Rushakoff
- Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, A3107, Los Angeles, CA 90048, USA
| | - Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, A3107, Los Angeles, CA 90048, USA
| | - Michelle M Kittleson
- Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, A3107, Los Angeles, CA 90048, USA
| | - Jonathan R Neyer
- Division of Cardiology, Kaiser Permanente, 1526 N Edgemont St., Fl 2, Los Angeles, CA 90027, USA
| | - Daniel Luthringer
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA 90048, USA
| | - Jignesh K Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, A3107, Los Angeles, CA 90048, USA
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8
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Kransdorf EP, Rushakoff JA, Han J, Benck L, Malinoski D, Emerson D, Catarino P, Rampolla R, Kobashigawa JA, Khush KK, Patel JK. Donor hyperoxia is a novel risk factor for severe cardiac primary graft dysfunction. J Heart Lung Transplant 2023; 42:617-626. [PMID: 36682894 DOI: 10.1016/j.healun.2022.12.022] [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: 07/13/2022] [Revised: 11/29/2022] [Accepted: 12/28/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Primary graft dysfunction (PGD) is a major cause of early mortality following heart transplant (HT). Donor risk factors for the development of PGD are incompletely characterized. Donor management goals (DMG) are predefined critical care endpoints used to optimize donors. We evaluated the relationship between DMGs as well as non-DMG parameters, and the development of PGD after HT. METHODS A cohort of HT recipients from 2 transplant centers between 1/1/12 and 12/31/19 was linked to their respective donors in the United Network for Organ Sharing (UNOS) DMG Registry (n = 1,079). PGD was defined according to modified ISHLT criteria. Variables were subject to univariate and multivariable multinomial modeling with development of mild/moderate or severe PGD as the outcome variable. A second multicenter cohort of 4,010 donors from the DMG Registry was used for validation. RESULTS Mild/moderate and severe PGD occurred in 15% and 6% of the cohort. Multivariable modeling revealed 6 variables independently associated with mild/moderate and 6 associated with severe PGD, respectively. Recipient use of amiodarone plus beta-blocker, recipient mechanical circulatory support, donor age, donor fraction of inspired oxygen (FiO2), and donor creatinine increased risk whereas predicted heart mass ratio decreased risk of severe PGD. We found that donor age and FiO2 ≥ 40% were associated with an increased risk of death within 90 days post-transplant in a multicenter cohort. CONCLUSIONS Donor hyperoxia at heart recovery is a novel risk factor for severe primary graft dysfunction and early recipient death. These results suggest that excessive oxygen supplementation should be minimized during donor management.
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Affiliation(s)
- Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Joshua A Rushakoff
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jiho Han
- Division of Cardiovascular Medicine, Stanford University, Stanford, California; Section of Cardiology, University of Chicago, Chicago, Illinois
| | - Lillian Benck
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Darren Malinoski
- Critical Care and Acute Care Surgery, Oregon Health and Sciences University, Portland, Oregon
| | - Dominic Emerson
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Pedro Catarino
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Reinaldo Rampolla
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Jignesh K Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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9
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Jaiswal A, Bell J, DeFilippis EM, Kransdorf EP, Patel J, Kobashigawa JA, Kittleson MM, Baran DA. Assessment and management of allosensitization following heart transplant in adults. J Heart Lung Transplant 2022; 42:423-432. [PMID: 36702686 DOI: 10.1016/j.healun.2022.12.011] [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: 09/23/2022] [Revised: 11/29/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Immunological injury to the allograft, specifically by antibodies to de novo donor specific human leukocyte antigen (dnDSA) and antibody mediated injury and rejection are the major limitations to graft survival after heart transplantation (HT). As such, our approach to allosensitization remains limited by the inability of contemporaneous immunoassays to unravel pathogenic potential of dnDSA. Additionally, the role of dnDSA is continuously evaluated with emerging methods to detect rejection. Moreover, the timing and frequency of dnDSA monitoring for early detection and risk mitigation as well as management of dnDSA remain challenging. A strategic approach to dnDSA employs diagnostic assays to determine relevant antibodies in conjunction with clinical presentation and injury/rejection of allograft to tailor therapeutics. In this review, we aim to outline contemporary knowledge involving detection, monitoring and management of dnDSA after HT. Subsequently, we propose a diagnostic and therapeutic approach that may mitigate morbidity and mortality while balancing adverse reactions from pharmacotherapy.
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Affiliation(s)
- Abhishek Jaiswal
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut.
| | - Jennifer Bell
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Ersilia M DeFilippis
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Evan P Kransdorf
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jignesh Patel
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon A Kobashigawa
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michelle M Kittleson
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - David A Baran
- Cleveland Clinic, Heart, Vascular and Thoracic Institute, Advanced Heart Failure Program, Weston, Florida
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10
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Youn JC, Kim D, Kim KA, Kim JJ, Kim IC, Lee HS, Choi JO, Jeon ES, Nishihara K, Kransdorf EP, Chang DH, Kittleson MM, Patel JK, Ramzy D, Esmailian F, Kobashigawa JA. Characteristics and outcomes of heart transplant recipients with a pretransplant history of malignancy. Am J Transplant 2022; 22:2942-2950. [PMID: 36050598 DOI: 10.1111/ajt.17186] [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: 04/25/2022] [Revised: 08/29/2022] [Accepted: 08/29/2022] [Indexed: 01/25/2023]
Abstract
We aimed to investigate the characteristics and outcomes of HTx recipients with a history of pretransplant malignancy (PTM). Among 1062 HTx recipients between 1997 and 2013, 73 (7.1%) patients had PTMs (77 cancer cases). We analyzed post-HTx outcome, recurrence of PTM, and development of de novo malignancies. Post-HTx outcome included overall survival, 10-year survival, 10-year freedom from cardiac allograft vasculopathy (CAV), non-fatal major adverse cardiac events (NF-MACE), any treated rejection (ATR), acute cellular rejection (ACR), and antibody-mediated rejection (AMR). Four most common PTMs were lymphoproliferative disorders (18.2%), prostate cancers (18.2%), non-melanoma skin cancers (18.2%), and breast cancers (13.0%). Median time from PTM and HTx was 9.0 years. During a median follow-up of 8.6 years after HTx, patients with PTM, compared to those without, showed significantly higher incidence of posttransplant malignancies (43.8% vs. 20.8%, p < .001) including 9.6% (n = 7) of PTM recurrences. However, patients with PTM, compared to those without, showed comparable overall survival, 10-year survival, 10-year freedom from CAV, NF-MACE, ATR, ACR, and AMR. Therefore, a history of PTM should not disqualify patients from HTx listing, while further research is necessary for early detection of posttransplant malignancies in these patients.
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Affiliation(s)
- Jong-Chan Youn
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.,Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Darae Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyung An Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin-Jin Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - In-Cheol Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin-Oh Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun-Seok Jeon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Keith Nishihara
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Evan P Kransdorf
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - David H Chang
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jignesh K Patel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Danny Ramzy
- Department of Cardiothoracic Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Fardad Esmailian
- Department of Cardiothoracic Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jon A Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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11
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Lor KW, Kransdorf EP, Patel JK, Chang DH, Kobashigawa JA, Kittleson MM. Dapsone-Associated Anemia in Heart Transplant Recipients with Normal Glucose-6-Phosphate Dehydrogenase Activity. J Clin Med 2022; 11:6378. [PMID: 36362606 PMCID: PMC9658039 DOI: 10.3390/jcm11216378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 09/29/2022] [Revised: 10/20/2022] [Accepted: 10/26/2022] [Indexed: 03/26/2024] Open
Abstract
Dapsone is considered an alternative for pneumocystis jirovecii pneumonia (PJP) prophylaxis in sulfa-allergic or -intolerant transplant patients with normal glucose-6-phosphate dehydrogenase (G6PD) activity. Despite normal G6PD activity, anemia can still occur while on dapsone therapy. We retrospectively reviewed heart transplant patients transplanted at our center between January 2016 and June 2018 and identified those taking dapsone prophylaxis. There were 252 heart transplant recipients at our center between January 2016 and June 2018. 36 patients received dapsone prophylaxis. All had normal G6PD activity assessed prior to dapsone initiation. 8 (22%) patients developed significant anemia attributed to dapsone: 2 were hospitalized for anemia, 1 of whom required blood transfusion. These patients had a median reduction in hemoglobin of 2.1 g/dL from baseline prior to dapsone initiation. Overt evidence of hemolysis was present in six patients. Once dapsone was discontinued, Hgb increased by at least 2 g/dL in a median of 30 days. Anemia from dapsone may occur in a significant proportion of patients despite normal G6PD activity and resulting in significant morbidity. Careful monitoring of transplant recipients on dapsone prophylaxis is warranted, as well as consideration of alternative agents.
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Affiliation(s)
- Kevin W. Lor
- Department of Cardiology, Smidt Heart Institute, Cedars Sinai Medical Center, 127 S. San Vicente Blvd., Los Angeles, CA 90048, USA
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12
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Youn JC, Kim D, Kim IC, Lee HS, Choi JO, Jeon ES, Nishihara K, Kransdorf EP, Chang DH, Kittleson MM, Patel JK, Ramzy D, Esmailian F, Kobashigawa JA. Characteristics, outcomes, and predictors of de novo malignancy after heart transplantation. Front Cardiovasc Med 2022; 9:939275. [PMID: 36003907 PMCID: PMC9393331 DOI: 10.3389/fcvm.2022.939275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Post-transplant malignancy (PTM) causes long-term morbidity and mortality in heart transplant (HTx) recipients. However, the detailed characteristics or predictors of PTM are not well-known. We evaluated the incidence, characteristics, long-term outcomes, and predictors of de novo PTM using a single center large-volume database. Methods We retrospectively analyzed the types and characteristics of de novo PTM in 989 patients who underwent HTx. Univariate and multivariate logistic regression analyses were used for the PTM prediction model. Results Two hundred and six patients (20.8%) had de novo PTMs (241 cancers) during a median follow-up of 11.5 years. PTM patients were older than non-PTM patients, received immunosuppressive therapy for a longer period, and were more likely to be male and white. Skin cancers were the most frequent types of malignancy (60.6%) followed by prostate (9.5%), lung (7.1%), and breast (4.1%) cancers. Although most cancers (88.8%) were surgically resected at initial presentation, about half (47.3%) recurred or progressed. Patients with skin cancer and non-skin cancer had significantly lower overall survival (P < 0.001) than patients without cancer. Older age (P < 0.001), white race (P = 0.001), and longer time receiving immunosuppressive therapy (P < 0.001) were independent predictors for PTM. Conclusion Older age, white race, and longer administration of immunosuppressive therapies were independent risk factors for PTM, which was associated with increased mortality. Further research is necessary for the prevention and early detection of PTM in HTx recipients.
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Affiliation(s)
- Jong-Chan Youn
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
- Division of Cardiology, Department of Internal Medicine, Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
- *Correspondence: Jong-Chan Youn
| | - Darae Kim
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - In-Cheol Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, South Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, South Korea
| | - Jin-Oh Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Eun-Seok Jeon
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Keith Nishihara
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
| | - Evan P. Kransdorf
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
| | - David H. Chang
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
| | - Michelle M. Kittleson
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
| | - Jignesh K. Patel
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
| | - Danny Ramzy
- Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
| | - Fardad Esmailian
- Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
| | - Jon A. Kobashigawa
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
- Jon A. Kobashigawa
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13
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Rushakoff JA, Kransdorf EP, Patel JK, Kobashigawa JA, Sundaram V, Guindi M. Heterogeneity of liver fibrosis in patients with congestive hepatopathy: A biopsy and explant comparison series. Ann Diagn Pathol 2021; 56:151876. [PMID: 34920382 DOI: 10.1016/j.anndiagpath.2021.151876] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/19/2021] [Accepted: 12/09/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE Patients with end-stage heart failure and concomitant irreversible liver injury may be candidates for combined heart liver transplant (CHLT). Determining appropriate candidates for CHLT is essential given organ scarcity. Transjugular liver biopsy (TJLB) is used to evaluate the severity of parenchymal liver injury in transplant candidates. In patients with congestive hepatopathy (CH), the fibrosis pattern may be heterogenous. METHODS We reviewed all CHLT cases between 2007 and 2017, as well as lone-heart transplant cases with post-mortem autopsy. Pre-transplant TJLB was compared to explant to assess the performance of biopsy fibrosis staging. RESULTS 12 patients were included. Median age at time of transplant was 58 and the cohort was predominantly male (75%). Seven (64%) TJLB were predominantly stage 4 fibrosis and 4 (36%) were stage 1. Advanced fibrosis was the dominant pattern in 7 (70%) explants and 5 (50%) explants had heterogenous fibrosis. In 50% of CH cases, there was discordance between the TJLB and explant. In the autopsy cases, the TJLB and autopsy findings differed. CONCLUSIONS In this series of matched TJLB and explanted livers, we found variable performance of TJLB in predicting the predominant fibrosis stage present in the liver.
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Affiliation(s)
- Joshua A Rushakoff
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America.
| | - Jignesh K Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Vinay Sundaram
- Division of Gastroenterology and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Maha Guindi
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
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14
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Wang M, Patel NJ, Zhang X, Kransdorf EP, Azarbal B, Kittleson MM, Czer LSC, Kobashigawa JA, Patel JK. The effects of donor-specific antibody characteristics on cardiac allograft vasculopathy. Clin Transplant 2021; 35:e14483. [PMID: 34546613 DOI: 10.1111/ctr.14483] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 07/10/2021] [Revised: 08/30/2021] [Accepted: 09/08/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) causes late graft dysfunction and post-transplant mortality. Currently, the effects of different donor-specific antibodies (DSA) on the severity of CAV remain unclear. METHOD We evaluated 526 adult heart transplant recipients at a single center between January 2010 and August 2015. Subjects were divided into those with DSA (n = 142) and those without DSA (n = 384, control). The DSA group was stratified into persistent DSA (n = 34), transient DSA (n = 105), 1:8 dilution DSA (n = 45), complement-binding (C1q) DSA (n = 36), Class I DSA (n = 37), and Class II DSA (n = 105). The primary outcome was the incidence of moderate-to-severe CAV (CAV 2/3) at 5-year follow-up. RESULTS Subjects with persistent DSA, 1:8 dilution DSA, and C1q DSA had higher incidence of CAV 2/3 compared the control group (17.6%, 13.3%, and 16.7% vs. 3.1%, respectively; P≤ .001). The incidence of CAV 2/3 between subjects with transient DSA and the control group was similar (2.8% vs. 3.1%; P = .888). Subjects with Class II DSA also had higher incidence of CAV 2/3 (7.6% vs. 3.1%; P = .039). CONCLUSION DSA that are persistent, 1:8 dilution positive, C1q positive, and Class II are associated with more severe grades of CAV. These DSA characteristics may prognosticate disease and warrant consideration for treatment.
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Affiliation(s)
- Maggie Wang
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nikhil J Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Xiaohai Zhang
- HLA and Immunogenetics Laboratory, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Babak Azarbal
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michelle M Kittleson
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Lawrence S C Czer
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jignesh K Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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15
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Kittleson MM, Patel N, Chang DH, Kransdorf EP, Kobashigawa JA, Patel JK. Eculizumab for Antibody-Mediated Rejection in Heart Transplantation: A Case-Control Study. Clin Transplant 2021; 35:e14454. [PMID: 34402096 DOI: 10.1111/ctr.14454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 06/18/2021] [Revised: 07/27/2021] [Accepted: 08/06/2021] [Indexed: 11/30/2022]
Abstract
Complement inhibition offers a novel treatment approach for antibody-mediated rejection (AMR). We examined patients with hemodynamic compromise AMR 2010-2020, comparing 8 patients supplemented with eculizumab to 10 patients without; administration was at the treating physician's discretion. There were no significant differences between groups though eculizumab patients had a non-significantly higher inotrope score (208.8 mcg/kg/min vs 2.6 mcg/kg/min; p = 0.22), more ECMO (62.5% vs 20%; p = 0.066), and worse 1-year survival (37.5% vs 60%; p = 0.63). The role of eculizumab is uncertain in AMR; multicenter collaborative studies are essential to better define its role. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nikhil Patel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - David H Chang
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Evan P Kransdorf
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon A Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jignesh K Patel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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16
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Benck L, Kransdorf EP, Emerson DA, Rushakoff J, Kittleson MM, Klapper EB, Megna DJ, Esmailian F, Halprin C, Trento A, Ramzy D, Czer LSC, Chang DH, Ebinger JE, Kobashigawa JA, Patel JK. Recipient and surgical factors trigger severe primary graft dysfunction after heart transplant. J Heart Lung Transplant 2021; 40:970-980. [PMID: 34272125 DOI: 10.1016/j.healun.2021.06.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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: 12/27/2020] [Revised: 05/18/2021] [Accepted: 06/04/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Primary graft dysfunction (PGD) is a major cause of early mortality following heart transplant (HT). The International Society for Heart and Lung Transplantation (ISHLT) subdivides PGD into 3 grades of increasing severity. Most studies have assessed risk factors for PGD without distinguishing between PGD severity grade. We sought to identify recipient, donor and surgical risk factors specifically associated with mild/moderate or severe PGD. METHODS We identified 734 heart transplant recipients at our institution transplanted between January 1, 2012 and December 31, 2018. PGD was defined according to modified ISHLT criteria. Recipient, donor and surgical variables were analyzed by multinomial logistic regression with mild/moderate or severe PGD as the response. Variables significant in single variable modeling were subject to multivariable analysis via penalized logistic regression. RESULTS PGD occurred in 24% of the cohort (n = 178) of whom 6% (n = 44) had severe PGD. One-year survival was reduced in recipients with severe PGD but not in those with mild or moderate PGD. Multivariable analysis identified 3 recipient factors: prior cardiac surgery, recipient treatment with ACEI/ARB/ARNI plus MRA, recipient treatment with amiodarone plus beta-blocker, and 3 surgical factors: longer ischemic time, more red blood cell transfusions, and more platelet transfusions, that were associated with severe PGD. We developed a clinical risk score, ABCE, which provided acceptable discrimination and calibration for severe PGD. CONCLUSIONS Risk factors for mild/moderate PGD were largely distinct from those for severe PGD, suggesting a differing pathophysiology involving several biological pathways. Further research into mechanisms underlying the development of PGD is urgently needed.
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Affiliation(s)
- Lillian Benck
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Dominic A Emerson
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joshua Rushakoff
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Ellen B Klapper
- Transfusion Medicine, Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Dominick J Megna
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Fardad Esmailian
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Chelsea Halprin
- Transfusion Medicine, Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Alfredo Trento
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Danny Ramzy
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Lawrence S C Czer
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - David H Chang
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joseph E Ebinger
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jignesh K Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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17
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Kransdorf EP, Pando MJ, Stewart D, Lindblad K, Bray R, Murphey C, Kaur N, Patel JK, Kim I, Zhang X, Maiers M, Kobashigawa JA, Gragert L. Stem cell donor HLA typing improves CPRA in kidney allocation. Am J Transplant 2021; 21:138-147. [PMID: 32558252 DOI: 10.1111/ajt.16156] [Citation(s) in RCA: 6] [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] [Received: 04/08/2020] [Revised: 05/19/2020] [Accepted: 06/13/2020] [Indexed: 01/25/2023]
Abstract
The Organ Procurement and Transplantation Network (OPTN) Kidney Allocation System provides a priority to sensitized candidates based on the calculated panel reactive antibody (CPRA) value. The human leukocyte antigen (HLA) haplotype reference panel used for calculation of the CPRA by the United Network for Organ Sharing (UNOS), the OPTN contractor, has limitations. We derived a novel panel from the National Marrow Donor Program HLA haplotype data set and compared the accuracy of CPRA values generated with this panel (NMDP-CPRA) to those generated from the UNOS panel (UNOS-CPRA), using predicted and actual deceased donor kidney offers for a cohort of 24 282 candidates. The overall accuracy for kidney offers was similar using NMDP-CPRA and UNOS-CPRA. Accuracy was slightly higher for NMDP-CPRA than UNOS-CPRA for candidates in several highly sensitized CPRA categories, with deviations in linkage disequilibrium for Caucasians and the smaller size of the UNOS panel as contributing factors. HLA data derived from stem cell donors yields CPRA values that are comparable to those derived from deceased kidney donors while improving upon several problems with the current reference panel. Consideration should be given to using stem cell donors as the reference panel for calculation of CPRA to improve equity in kidney transplant allocation.
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Affiliation(s)
- Evan P Kransdorf
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, California, USA
| | - Marcelo J Pando
- Transplant Immunology Laboratory, Scott & White Medical Center, Temple, Texas, USA
| | - Darren Stewart
- Research Department, United Network for Organ Sharing, Richmond, Virginia, USA
| | - Kelsi Lindblad
- Research Department, United Network for Organ Sharing, Richmond, Virginia, USA
| | - Robert Bray
- HLA Laboratory, Emory University Medical Center, Atlanta, Georgia, USA
| | - Cathi Murphey
- HLA Laboratory, Southwest Immunodiagnostics, San Antonio, Texas, USA
| | - Navchetan Kaur
- Department of Pathology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Jignesh K Patel
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, California, USA
| | - Irene Kim
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Xiaohai Zhang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Martin Maiers
- National Marrow Donor Program, Minneapolis, Minnesota, USA
| | - Jon A Kobashigawa
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, California, USA.,Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Loren Gragert
- Department of Pathology, Tulane University School of Medicine, New Orleans, Louisiana, USA.,National Marrow Donor Program, Minneapolis, Minnesota, USA
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18
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Ivey-Miranda JB, Kunnirickal S, Bow L, Maulion C, Testani JM, Jacoby D, Kransdorf EP, Bellumkonda L. Differential Impact of Class I and Class II Panel Reactive Antibodies on Post-Heart Transplant Outcomes. J Card Fail 2020; 27:40-47. [PMID: 32750489 DOI: 10.1016/j.cardfail.2020.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 03/14/2020] [Revised: 07/13/2020] [Accepted: 07/22/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Sensitized patients awaiting heart transplantation spend a longer time on the waitlist and have higher mortality. We are now able to further characterize sensitization by discriminating antibodies against class I and II, but the differential impact of these has not been assessed systematically. METHODS AND RESULTS Using United Network for Organ Sharing data (2004-2015), we analyzed 17,361 adult heart transplant patients whose class I and II panel reactive antibodies were reported. Patients were divided into 4 groups: class I and II ≤25% (group 1); class I ≤25% and class II ˃25% (group 2); class II ≤25% and class I >25% (group 3); and both class I and II >25% (group 4). Outcomes assessed were treated rejection at 1-year mortality, all-cause mortality, and rejection-related mortality. Compared with group 1, only group 4 was associated with a higher risk of treated rejection at 1 year (odds ratio 1.31, 95% confidence interval [CI] 1.05-1.64), all-cause mortality (hazard ratio 1.24, 95% CI 1.06-1.46), and mortality owing to rejection (subhazard ratio 1.84, 95% CI 1.18-2.85), whereas groups 2 and 3 were not (P > .05). CONCLUSIONS Combined elevation in class I and II panel reactive antibodies seem to increase the risk of treated rejection and all-cause mortality, whereas risk with isolated elevation is unclear.
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Affiliation(s)
- Juan B Ivey-Miranda
- Division of Cardiology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut; Hospital de Cardiologia, Centro Medico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | | | - Laurine Bow
- Department of Transplantation Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Christopher Maulion
- Division of Cardiology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jeffrey M Testani
- Division of Cardiology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Daniel Jacoby
- Division of Cardiology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Lavanya Bellumkonda
- Division of Cardiology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut.
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19
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Kransdorf EP, Patterson CM, Mehra MR, Stehlik J. Donor-recipient size match in thoracic transplantation: back to fundamentals. J Heart Lung Transplant 2019; 38:1007-1014. [PMID: 31548027 DOI: 10.1016/j.healun.2019.08.015] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/12/2019] [Accepted: 08/12/2019] [Indexed: 11/19/2022] Open
Affiliation(s)
- Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Caroline M Patterson
- Departments of Lung Transplantation and Interstitial Lung Disease, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom of Great Britain and Northern Ireland
| | - Mandeep R Mehra
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Josef Stehlik
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah.
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20
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Kaur N, Kransdorf EP, Pando MJ, Maiers M, Ray B, Lee JH, Lalli P, Murphey CL, Bray RA, Gragert L. Mapping molecular HLA typing data to UNOS antigen equivalents. Hum Immunol 2018; 79:781-789. [DOI: 10.1016/j.humimm.2018.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/04/2018] [Accepted: 08/08/2018] [Indexed: 11/27/2022]
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21
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Kransdorf EP, Kittleson MM, Benck LR, Patel JK, Chung JS, Esmailian F, Kearney BL, Chang DH, Ramzy D, Czer LSC, Kobashigawa JA. Predicted heart mass is the optimal metric for size match in heart transplantation. J Heart Lung Transplant 2018; 38:156-165. [PMID: 30528987 DOI: 10.1016/j.healun.2018.09.017] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [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: 05/15/2018] [Revised: 09/18/2018] [Accepted: 09/19/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Donor-recipient size match is traditionally assessed by body weight. We assessed the ability of 5 size match metrics-predicted heart mass (PHM), weight, height, body mass index (BMI) and body surface area (BSA)-to predict 1-year mortality after heart transplant and to assess the effect of size match on donor heart turn down for size. METHODS The study cohort comprised 19,168 adult heart transplant recipients in the United Network for Organ Sharing registry between 2007 and 2016. Each size match metric was divided into 7 equally sized groups using the donor-recipient ratio for each metric. Single and multivariable Cox proportional hazard models for mortality 1 year after transplant were constructed. RESULTS Recipients in the severely (donor-recipient PHM ratio 0.54-0.86) undersized group for PHM experienced increased mortality, with a hazard ratio of 1.34 (95% confidence interval, 1.13-1.59; p < 0.001). There was no increased risk of death at 1 year if donors were undersized for weight, height, BMI, or BSA. We found that 32% of heart offers turned down for donor size would be acceptable using a PHM threshold of 0.86 or greater and that 14% of offers accepted (most of which are female donor to male recipient) were below this threshold. CONCLUSIONS PHM is the optimal donor-recipient size match metric for prediction of mortality after heart transplant. Many offers turned down for donor size were above the threshold for adequacy of size match by PHM identified, and thus, the use of PHM could improve donor heart utilization and post-transplant survival.
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Affiliation(s)
- Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
| | | | - Lillian R Benck
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jignesh K Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joshua S Chung
- Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Fardad Esmailian
- Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Brenda L Kearney
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - David H Chang
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Danny Ramzy
- Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Lawrence S C Czer
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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22
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Kransdorf EP, Pando MJ. Corrigendum to "Calculated panel reactive antibody with decimals: A refined metric of access to transplantation for highly sensitized candidates" [Hum. Immunol. 78(3) (2017) 252-256]. Hum Immunol 2017; 78:522. [PMID: 28743386 DOI: 10.1016/j.humimm.2017.07.009] [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: 10/19/2022]
Affiliation(s)
| | - Marcelo J Pando
- Department of Surgery, Baylor Scott & White Health, Temple, TX, USA.
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Cheng R, Kransdorf EP, Wei J, Patel JK, Kobashigawa JA, Azarbal B. Angiogenesis on coronary angiography is a marker for accelerated cardiac allograft vasculopathy as assessed by intravascular ultrasound. Clin Transplant 2017; 31. [PMID: 28786501 DOI: 10.1111/ctr.13069] [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] [Accepted: 08/01/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Errant neovascularization and coronary artery fistulae (CAF) are frequently observed after cardiac transplantation. The relationship between angiographic neovascularization/CAF and coronary plaque progression is unknown. METHODS Angiography and intravascular ultrasound were routinely performed at 4-6 weeks and 1-year post-transplant. Pts were divided into three groups: no angiographic angiogenesis (Group 1), neovascularization only (Group 2), and CAF (Group 3). First-year changes in maximal intimal thickness (MIT), maximal intimal area (MIA), and percent atheroma volume (PAV) were compared between groups. RESULTS The 106 pts were included, 40/106 in Group 1, 42/106 in Group 2, and 24/106 in Group 3. Respectively, first-year ΔMIT was 0.14 ± 0.13 mm, 0.32 ± 0.26 mm, and 0.50 ± 0.34 mm, P < .001. ΔMIA was 0.6 ± 0.6 mm2 , 1.7 ± 1.8 mm2 , and 3.0 ± 2.6 mm2 , P < .001. ΔPAV was 2.3 ± 2.5%, 6.0 ± 5.1%, and 9.6 ± 9.0%, P < .001. Rapid plaque progression occurred in 1/40 (2.5%) pts in Group 1, 12/42 (28.6%) in Group 2, and 12/24 (50%) in Group 3, P < .001. Multivariate analysis identified both antithymocyte globulin and presence of CAF as independently associated with rapid plaque progression: OR 0.29 (P = .038) and 4.04 (P = .014). CONCLUSION Neovascularization and CAF are commonly present on surveillance angiography after cardiac transplantation and may signify amplified angiogenesis. Their presence is associated with accelerated coronary plaque progression by IVUS.
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Affiliation(s)
| | | | - Janet Wei
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
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24
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25
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Kransdorf EP, Loghmanpour NA, Kanwar MK, Temkit MH, Stehlik J. Prediction model for cardiac allograft vasculopathy: Comparison of three multivariable methods. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.12925] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Evan P. Kransdorf
- Cedars-Sinai Heart Institute; Cedars-Sinai Medical Center; Los Angeles CA USA
| | | | - Manreet K. Kanwar
- Cardiovascular Institute; Allegheny General Hospital; Pittsburgh PA USA
| | - M'hamed H. Temkit
- Division of Health Sciences Research; Mayo Clinic Arizona; Scottsdale AZ USA
| | - Josef Stehlik
- Division of Cardiovascular Medicine; University of Utah School of Medicine; Salt Lake City UT USA
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26
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Kransdorf EP, Pando MJ. Calculated panel reactive antibody with decimals: A refined metric of access to transplantation for highly sensitized candidates. Hum Immunol 2017; 78:252-256. [PMID: 28069404 DOI: 10.1016/j.humimm.2016.12.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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: 08/23/2016] [Revised: 12/16/2016] [Accepted: 12/27/2016] [Indexed: 01/03/2023]
Abstract
The use of the calculated panel reactive antibody (CPRA) value and the implementation of allocation points for sensitized candidates by the United Network for Organ Sharing (UNOS) have improved access to kidney transplantation for highly sensitized candidates (98% CPRA and above). Despite this, a large population of highly sensitized candidates remain awaiting transplantation. To better define this population, we propose the use of two refinements of the standard UNOS CPRA, the CPRA with decimals or CPRAd, and the likelihood of a compatible donor (LCD). These refined metrics of the standard UNOS CPRA will allow transplant programs to describe their patients' access to transplantation with increased granularity and will help in decisions regarding the use of desensitization.
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Affiliation(s)
| | - Marcelo J Pando
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Phoenix, AZ, USA.
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27
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Kransdorf EP, Fishbein MC, Czer LSC, Patel JK, Velleca A, Tazelaar HD, Roy RR, Steidley DE, Kobashigawa JA, Luthringer DJ. Pathology of Chronic Chagas Cardiomyopathy in the United States: A Detailed Review of 13 Cardiectomy Cases. Am J Clin Pathol 2016; 146:191-8. [PMID: 27425387 DOI: 10.1093/ajcp/aqw098] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES The pathologic features of chronic Chagas cardiomyopathy may not be widely appreciated in the United States. We sought to describe the gross, microscopic, immunohistochemical, and molecular pathology features useful to diagnose chronic Chagas cardiomyopathy. METHODS The features from a case series of cardiectomy specimens of patients undergoing heart transplantation (12 patients) or mechanical circulatory support device implantation (one patient) for chronic Chagas cardiomyopathy at three institutions in the United States are reported and analyzed. RESULTS Gross findings included enlarged and dilated ventricles (100% of cases), mural thrombi (54%), epicardial plaques (42%), and left ventricular aneurysm (36%). Microscopic evaluation revealed myocarditis (100% of cases) characterized by mononuclear cell infiltration, fibrosis (100%), nonnecrotizing granulomas (62%), and giant cells (38%). Two specimens (15%) showed rare intracellular amastigotes. Immunohistochemical assays for Trypanosoma cruzi organisms were negative in all cardiectomy specimens, whereas tissue polymerase chain reaction was positive in six (54%) of 11 cases. CONCLUSIONS The gross and microscopic features of chronic Chagas cardiomyopathy in the United States appear similar to those reported in endemic countries. Importantly, tissue polymerase chain reaction may be useful to confirm the diagnosis.
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Affiliation(s)
| | - Mike C Fishbein
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA
| | | | | | | | - Henry D Tazelaar
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, AZ
| | - R Raina Roy
- Department of Cardiology, Maricopa Integrated Health System, Phoenix, AZ
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28
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Kransdorf EP, Kransdorf LN, Fortuin FD, Sweeney JP, Wilansky S. Stepwise Progression of Right-to-Left Atrial Shunting through a Combination of Patent Foramen Ovale and Tricuspid Regurgitation. Tex Heart Inst J 2016; 43:171-4. [PMID: 27127438 DOI: 10.14503/thij-14-4913] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Patent foramen ovale is a common clinical finding that generally becomes a concern in the presence of transient ischemic attack or stroke. Rarely, patent foramen ovale is associated with hypoxemia in the presence of substantial right-to-left atrial shunting. We present the case of an 86-year-old woman with a pacemaker, who was initially asymptomatic notwithstanding a patent foramen ovale. Over 1.5 years, her symptoms progressed in a stepwise fashion, in the setting of progressive pacemaker-associated tricuspid regurgitation. Ultimately, the patient's symptoms and her hypoxemia resolved after percutaneous closure of her patent foramen ovale with use of a 25-mm "Cribriform" occluder device. This case highlights the fact that clinically significant right-to-left shunting requires an anatomic lesion, such as patent foramen ovale, together with elevated right atrial pressure, which in this case was contributed by severe tricuspid regurgitation.
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29
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Morris AA, Kransdorf EP, Coleman BL, Colvin M. Racial and ethnic disparities in outcomes after heart transplantation: A systematic review of contributing factors and future directions to close the outcomes gap. J Heart Lung Transplant 2016; 35:953-61. [PMID: 27080415 DOI: 10.1016/j.healun.2016.01.1231] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [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: 02/15/2015] [Revised: 12/24/2015] [Accepted: 01/26/2016] [Indexed: 10/22/2022] Open
Abstract
The demographics of patients undergoing heart transplantation in the United States have shifted over the last 10 years, with an increasing number of racial and ethnic minorities undergoing heart transplant. Multiple studies have shown that survival of African American patients after heart transplantation is lower compared with other ethnic groups. We review the data supporting the presence of this outcome disparity and examine the multiple mechanisms that contribute. With an increasingly diverse population in the United States, knowledge of these disparities, their mechanisms, and ways to improve outcomes is essential.
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Affiliation(s)
| | - Evan P Kransdorf
- Division of Cardiovascular Diseases, Cedars-Sinai Heart Institute, Beverly Hills, California
| | - Bernice L Coleman
- Nursing Research and Development, Cedars Sinai Medical Center, Los Angeles, California
| | - Monica Colvin
- Division of Cardiology, University of Michigan, Ann Arbor, Michigan
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30
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Gray EB, Benedict T, Rivera H, Huprikar S, Zakowski PC, Kubak B, Pereira MR, Dhand A, Kransdorf EP, Stenehjem E, Schmidt M, Katugaha S, Stocks L, Carpini KWD, Fuentes JR, Kiros LS, Montgomery S. Trypanosoma cruzi Infections in Solid Organ Transplant Recipients, 2014. Open Forum Infect Dis 2015. [DOI: 10.1093/ofid/ofv131.54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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31
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Abstract
Paradoxical coronary artery embolism is a rare, but often an underdiagnosed cause of acute myocardial infarction. It should be considered in patient who presents with chest pain and otherwise having a low risk profile for atherosclerosis coronary artery disease. We describe a case of paradoxical coronary artery embolism causing ST segment elevation myocardial infarction in a patient with upper extremity venous thrombosis. Echocardiography demonstrated a patent foramen ovale (PFO) with bidirectional shunt. In addition to treatment of acute coronary event closure of the PFO should be considered to prevent a recurrence.
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Affiliation(s)
- Fayaz A Hakim
- Department of Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona, USA
| | - Evan P Kransdorf
- Department of Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona, USA
| | - Muaz M Abudiab
- Department of Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona, USA
| | - John P Sweeney
- Department of Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona, USA
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32
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Kransdorf EP, Stehlik J. Reply: heart donation and the Grinch effect. J Heart Lung Transplant 2014; 34:137. [PMID: 25130552 DOI: 10.1016/j.healun.2014.07.003] [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: 06/20/2014] [Accepted: 07/03/2014] [Indexed: 10/25/2022] Open
Affiliation(s)
- Evan P Kransdorf
- Division of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, Arizona
| | - Josef Stehlik
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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33
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Kransdorf EP, Czer LSC, Luthringer DJ, Patel JK, Montgomery SP, Velleca A, Mirocha J, Zakowski PC, Zabner R, Gaultier CR, Qvarnstrom Y, Benedict T, Steurer F, Bosserman E, Paddock CD, Rafiei M, Kobashigawa JA. Heart transplantation for Chagas cardiomyopathy in the United States. Am J Transplant 2013; 13:3262-8. [PMID: 24165397 PMCID: PMC10183729 DOI: 10.1111/ajt.12507] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [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: 06/24/2013] [Revised: 08/12/2013] [Accepted: 09/12/2013] [Indexed: 01/25/2023]
Abstract
Since an initial case in 2006, we noted multiple patients undergoing heart transplantation (HTx) for Chagas cardiomyopathy (CC) at our transplant program. The clinical characteristics, laboratory results and outcomes of patients with CC undergoing HTx in the United States have not been reported previously. In 2010, we implemented a systematic screening and management program for patients undergoing HTx for CC. Before HTx, all patients with idiopathic dilated cardiomyopathy who were born in a Chagas disease endemic country were screened for Trypanosoma cruzi (TC) infection with serology. After HTx, monitoring for TC reactivation was performed using clinical visits, echocardiography, endomyocardial biopsy and serial whole blood polymerase chain reaction (PCR) testing. Between June 2006 and January 2012, 11 patients underwent HTx for CC. One patient was empirically treated due to the presence of TC amastigotes in explanted cardiac tissue. Two patients experienced allograft dysfunction due to TC reactivation and three patients experienced subclinical reactivation (positive PCR results), which were treated. Chagas disease is a common cause of dilated cardiomyopathy in patients from endemic countries undergoing HTx at a transplant program in the United States. Reactivation is common after transplantation and can cause adverse outcomes.
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34
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Abstract
Since Christiaan Barnard performed the first heart transplant in 1967, over 100,000 heart transplants have been performed worldwide. As was true then, rejection remains the major threat to the function and survival of the allograft. The development of the endomyocardial biopsy as a means to monitor for rejection has allowed heart transplantation to thrive as a therapy for patients with end-stage heart disease. The need for a noninvasive method of rejection surveillance led to the development of the first genetic test for allograft rejection, the AlloMap®. In this article, after presenting the pathological and clinical features of cardiac allograft rejection, the authors discuss the development and application of gene-expression testing for the detection of cardiac allograft rejection. We then explore emerging 'omic' approaches that will be the rejection detection methods of the future.
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Affiliation(s)
- Evan P Kransdorf
- Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
| | - Jon A Kobashigawa
- Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA.
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35
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Kransdorf EP, Kittleson MM. Dissecting the "CHF admission": an evidence-based review of the evaluation and management of acute decompensated heart failure for the hospitalist. J Hosp Med 2012; 7:439-45. [PMID: 22371370 DOI: 10.1002/jhm.1919] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Revised: 12/16/2011] [Accepted: 01/08/2012] [Indexed: 11/09/2022]
Abstract
Acute decompensated heart failure (ADHF) is one of the most common conditions managed by hospitalists. Here we review the most recent evidence applicable to hospitalists for the diagnosis, risk stratification, and management of patients presenting with ADHF. By following a structured approach based on the patient's symptoms, history, physical examination, and laboratory testing, the clinician can make the diagnosis of heart failure efficiently. Because patients exhibit a wide spectrum of risk for adverse outcomes, both in the hospital and after discharge, assessing for clinical factors associated with these outcomes is essential. Congestion should be managed primarily with diuretics, and vasodilators may be helpful in certain patients. Given high rates of readmission, hospitalists should ensure that patients received evidence-based therapy, heart failure education is performed, and follow-up is in place before discharge.
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Affiliation(s)
- Evan P Kransdorf
- Department of Heart Failure and Heart Transplantation, Cedars-Sinai Heart Institute, Los Angeles, California, USA
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36
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Abstract
Background—
Septal reduction for obstructive hypertrophic cardiomyopathy may be performed by surgical myectomy or alcohol septal ablation (ASA). Unlike surgical myectomy, ASA creates an intramyocardial scar that may potentiate the risk of ventricular arrhythmias and sudden cardiac death (SCD).
Methods and Results—
Systematic reviews for ASA and surgical myectomy were performed. Study selection and data extraction were completed independently by 2 investigators. Comparative data analyses were completed using a random effects model and regression analysis. Kappa statistics for agreement on initial study inclusion were high for both ASA (0.78; 95% CI, 0.68 to 0.88) and surgical myectomy studies (0.95; 95% CI, 0.84 to 1.0). Nineteen ASA studies (2207 patients) and 8 surgical myectomy studies (1887 patients) were included. Median follow-up was shorter for ASA than for myectomy studies (51 versus 1266 patient-years;
P
<0.001). For ASA and surgical myectomy, unadjusted rates (events/patient-years) of all-cause mortality (0.021 versus 0.018, respectively;
P
=0.37) and SCD (0.004 versus 0.003, respectively;
P
=0.36) were similar. Patients treated with ASA were older (weighted mean, 55 versus 44 years;
P
<0.001) and had less septal hypertrophy (weighted mean, 21 versus 23 mm;
P
<0.001) compared with those treated with myectomy. After adjustment for available baseline characteristics, odds ratios for treatment effect on all-cause mortality and SCD were 0.28 (95% CI, 0.16 to 0.46) and 0.32 (95% CI, 0.11 to 0.97), respectively, favoring ASA.
Conclusions—
Rates of all-cause mortality and SCD after both ASA and surgical myectomy were similarly low. Adjusted for baseline characteristics, the odds ratios for treatment effect on all-cause mortality and SCD were lower in ASA cohorts compared with surgical myectomy cohorts.
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Affiliation(s)
- Robert A. Leonardi
- From the Medical University of South Carolina (R.A.L.), Charleston, SC; Duke University Medical Center (E.P.K., A.W.), Durham, NC; and Durham Veterans Affairs Medical Center and Duke University Medical Center (D.L.S.), Durham, NC
| | - Evan P. Kransdorf
- From the Medical University of South Carolina (R.A.L.), Charleston, SC; Duke University Medical Center (E.P.K., A.W.), Durham, NC; and Durham Veterans Affairs Medical Center and Duke University Medical Center (D.L.S.), Durham, NC
| | - David L. Simel
- From the Medical University of South Carolina (R.A.L.), Charleston, SC; Duke University Medical Center (E.P.K., A.W.), Durham, NC; and Durham Veterans Affairs Medical Center and Duke University Medical Center (D.L.S.), Durham, NC
| | - Andrew Wang
- From the Medical University of South Carolina (R.A.L.), Charleston, SC; Duke University Medical Center (E.P.K., A.W.), Durham, NC; and Durham Veterans Affairs Medical Center and Duke University Medical Center (D.L.S.), Durham, NC
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37
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Ginder GD, Kransdorf EP, Rupon JW, Wang SZ, Zhu SZ, Gnanapragasam M, Lloyd J, Gaensler K. The role of methyl binding domain protein 2 (MBD2) in developmental globin gene regulation. Blood Cells Mol Dis 2007. [DOI: 10.1016/j.bcmd.2006.10.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Kransdorf EP, Wang SZ, Zhu SZ, Langston TB, Rupon JW, Ginder GD. MBD2 is a critical component of a methyl cytosine-binding protein complex isolated from primary erythroid cells. Blood 2006; 108:2836-45. [PMID: 16778143 PMCID: PMC1895583 DOI: 10.1182/blood-2006-04-016394] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [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: 01/02/2023] Open
Abstract
The chicken embryonic beta-type globin gene, rho, is a member of a small group of vertebrate genes whose developmentally regulated expression is mediated by DNA methylation. Previously, we have shown that a methyl cytosine-binding complex binds to the methylated rho-globin gene in vitro. We have now chromatographically purified and characterized this complex from adult chicken primary erythroid cells. Four components of the MeCP1 transcriptional repression complex were identified: MBD2, RBAP48, HDAC2, and MTA1. These 4 proteins, as well as the zinc-finger protein p66 and the chromatin remodeling factor Mi2, were found to coelute by gel-filtration analysis and pull-down assays. We conclude that these 6 proteins are components of the MeCPC. In adult erythrocytes, significant enrichment for MBD2 is seen at the inactive rho-globin gene by chromatin immunoprecipitation assay, whereas no enrichment is observed at the active beta(A)-globin gene, demonstrating MBD2 binds to the methylated and transcriptionally silent rho-globin gene in vivo. Knock-down of MBD2 resulted in up-regulation of a methylated rho-gene construct in mouse erythroleukemic (MEL)-rho cells. These results represent the first purification of a MeCP1-like complex from a primary cell source and provide support for a role for MBD2 in developmental gene regulation.
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Affiliation(s)
- Evan P Kransdorf
- Department of Internal Medicine, Massey Cancer Center, Virginia Commonwealth University, 401 College Street, PO Box 980037, Richmond, VA 23298-0037, USA
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Basu P, Sargent TG, Redmond LC, Aisenberg JC, Kransdorf EP, Wang SZ, Ginder GD, Lloyd JA. Evolutionary conservation of KLF transcription factors and functional conservation of human γ-globin gene regulation in chicken☆. Genomics 2004; 84:311-9. [PMID: 15233995 DOI: 10.1016/j.ygeno.2004.02.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [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] [Received: 11/25/2003] [Accepted: 02/18/2004] [Indexed: 11/17/2022]
Abstract
The Krüppel-like factors (KLFs) are a family of Cys2His2 zinc-finger DNA binding proteins with homology to Drosophila Krüppel. KLFs can bind to CACCC elements, which are important in controlling developmental programs. The CACCC promoter element is critical for the developmental regulation of the human gamma-globin gene. In the present study, chicken homologues of the human KLF2, 3, 4, 5, 9, 11, 12, 13, and 15 genes were identified. Phylogenetic analysis confirms that these genes are more closely related to their human homologues than they are to other chicken KLFs. This work also represents the first systematic study of the expression patterns of KLFs during erythroid development. In addition, transient transfections of human globin constructs into 5-day (primitive) chicken red blood cells show that human gamma-globin expression is regulated via its CACCC promoter element. This indicates that a CACCC-binding factor(s) important for gamma-globin expression functions in 5-day chicken red cells.
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Affiliation(s)
- Priyadarshi Basu
- Department of Human Genetics, Virginia Commonwealth University, P.O. Box 980033, 1101 E. Marshall Street, Richmond, VA 23298-0033, USA
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