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von Samson-Himmelstjerna FA, Kakavand N, Gleske C, Schraml F, Basta AA, Braunisch MC, Bräsen JH, Schmitz J, Kraus D, Weinmann-Menke J, Zacharias HU, Vaulet T, Naesens M, Krautter M, Schwenger V, Esser G, Kolbrink B, Amann K, Holzmann-Littig C, Echterdiek F, Kunzendorf U, Renders L, Schulte K, Heemann U. Potential and Uncertainties of RejectClass in Acute Kidney Graft Dysfunction: An Independent Validation Study. Transplantation 2024; 108:1228-1238. [PMID: 38196094 DOI: 10.1097/tp.0000000000004906] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND Kidney graft rejections are classified based on the Banff classification. The RejectClass algorithm, initially derived from a cohort comprising mostly protocol biopsies, identifies data-driven phenotypes of acute rejection and chronic pathology using Banff lesion scores. It also provides composite scores for inflammation activity and chronicity. This study independently evaluates the performance of RejectClass in a cohort consisting entirely of indication biopsies. METHODS We retrospectively applied RejectClass to 441 patients from the German TRABIO (TRAnsplant BIOpsies) cohort who had received indication biopsies. The primary endpoint was death-censored graft failure during 2 y of follow-up. RESULTS The application of RejectClass to our cohort demonstrated moderately comparable phenotypic features with the derivation cohort, and most clusters indicated an elevated risk of graft loss. However, the reproduction of all phenotypes and the associated risks of graft failure, as depicted in the original studies, was not fully accomplished. In contrast, adjusted Cox proportional hazards analyses substantiated that both the inflammation score and the chronicity score are independently associated with graft loss, exhibiting hazard ratios of 1.7 (95% confidence interval, 1.2-2.3; P = 0.002) and 2.2 (95% confidence interval, 1.8-2.6; P < 0.001), respectively, per 0.25-point increment (scale: 0.0-1.0). CONCLUSIONS The composite inflammation and chronicity scores may already have direct utility in quantitatively assessing the disease stage. Further refinement and validation of RejectClass clusters are necessary to achieve more reliable and accurate phenotyping of rejection.
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Affiliation(s)
| | - Nassim Kakavand
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
| | - Charlotte Gleske
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Florian Schraml
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Agathe A Basta
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Matthias C Braunisch
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Jan H Bräsen
- Nephropathology Unit, Department of Pathology, Hannover Medical School, Hannover, Germany
| | - Jessica Schmitz
- Nephropathology Unit, Department of Pathology, Hannover Medical School, Hannover, Germany
| | - Daniel Kraus
- Department of Nephrology, Department of Internal Medicine 1, University Medical Center Mainz, Mainz, Germany
| | - Julia Weinmann-Menke
- Department of Nephrology, Department of Internal Medicine 1, University Medical Center Mainz, Mainz, Germany
| | - Helena U Zacharias
- Peter L. Reichertz Institute for Medical Informatics of TU Braunschweig and Hannover Medical School, Hannover, Germany
| | - Thibaut Vaulet
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Naesens
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Markus Krautter
- Department of Nephrology, Transplant Center, Klinikum Stuttgart, Stuttgart, Germany
| | - Vedat Schwenger
- Department of Nephrology, Transplant Center, Klinikum Stuttgart, Stuttgart, Germany
| | - Grit Esser
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
| | - Benedikt Kolbrink
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
| | - Kerstin Amann
- Department of Nephropathology, University Hospital Erlangen, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Christopher Holzmann-Littig
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Fabian Echterdiek
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Ulrich Kunzendorf
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
| | - Lutz Renders
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Kevin Schulte
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
| | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
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Echterdiek F, Döhler B, Latus J, Schwenger V, Süsal C. Influence of Calcineurin Inhibitor Choice on Outcomes in Kidney Transplant Recipients Aged ≥60 Y: A Collaborative Transplant Study Report. Transplantation 2022; 106:e212-e218. [PMID: 35066544 DOI: 10.1097/tp.0000000000004060] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients aged ≥60 y represent the fastest growing population among kidney transplant recipients and waitlist patients. They show an elevated infection risk and are frequently transplanted with multiple human leukocyte antigen mismatches. Whether the choice of calcineurin inhibitor influences graft survival, mortality, or key secondary outcomes such as infections in this vulnerable recipient population is unknown. METHODS A total of 31 177 kidney transplants from deceased donors performed between 2000 and 2019 at European centers and reported to the Collaborative Transplant Study were analyzed using multivariable Cox and logistic regression analyses. All recipients were ≥60 y old and received tacrolimus (Tac) or cyclosporine A on an intention-to-treat basis, combined with mycophenolic acid or azathioprine plus/minus steroids. RESULTS The risk of 3-y death-censored graft loss and patient mortality did not differ significantly between Tac- and cyclosporine A-treated patients (hazard ratio 0.98 and 0.95, P = 0.74 and 0.20, respectively). No difference was found in the overall risk of hospitalization for infection (hazard ratio = 0.95, P = 0.19); however, a lower incidence of rejection treatment (hazard ratio = 0.81, P < 0.001) was observed in Tac-treated patients. Assessment of pathogen-specific hospitalizations revealed no difference in the risk of hospitalization due to bacterial infection (odds ratio = 1.00, P = 0.96), but a significantly higher risk of hospitalization due to human polyomavirus infection was found among Tac-treated patients (odds ratio = 2.45, P = 0.002). The incidence of de novo diabetes was higher for Tac-based immunosuppression (odds ratio = 1.79, P < 0.001). CONCLUSIONS Calcineurin inhibitor selection has no significant influence on death-censored graft survival, mortality, and overall infection risk in ≥60-y-old kidney transplant recipients.
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Affiliation(s)
- Fabian Echterdiek
- Department of Nephrology, Klinikum Stuttgart-Katharinenhospital, Stuttgart, Germany
| | - Bernd Döhler
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Joerg Latus
- Department of Nephrology, Klinikum Stuttgart-Katharinenhospital, Stuttgart, Germany
| | - Vedat Schwenger
- Department of Nephrology, Klinikum Stuttgart-Katharinenhospital, Stuttgart, Germany
| | - Caner Süsal
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
- Transplant Immunology Research Center of Excellence, Koç Üniversitesi, Istanbul, Turkey
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Bohaumilitzky L, Kluck K, Hüneburg R, Gallon R, Nattermann J, Kirchner M, Kristiansen G, Hommerding O, Pfuderer PL, Wagner L, Echterdiek F, Kösegi S, Müller N, Fischer K, Nelius N, Hartog B, Borthwick G, Busch E, Haag GM, Bläker H, Möslein G, von Knebel Doeberitz M, Seppälä TT, Ahtiainen M, Mecklin JP, Bishop DT, Burn J, Stenzinger A, Budczies J, Kloor M, Ahadova A. The Different Immune Profiles of Normal Colonic Mucosa in Cancer-Free Lynch Syndrome Carriers and Lynch Syndrome Colorectal Cancer Patients. Gastroenterology 2022; 162:907-919.e10. [PMID: 34863788 DOI: 10.1053/j.gastro.2021.11.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 11/02/2021] [Accepted: 11/22/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS Owing to the high load of immunogenic frameshift neoantigens, tumors arising in individuals with Lynch syndrome (LS), the most common inherited colorectal cancer (CRC) syndrome, are characterized by a pronounced immune infiltration. However, the immune status of normal colorectal mucosa in LS is not well characterized. We assessed the immune infiltrate in tumor-distant normal colorectal mucosa from LS CRC patients, sporadic microsatellite-unstable (MSI) and microsatellite-stable (MSS) CRC patients, and cancer-free LS carriers. METHODS CD3-positive, FOXP3-positive, and CD8-positive T cells were quantified in, respectively, 219, 233, and 201 formalin-fixed paraffin-embedded (FFPE) normal colonic mucosa tissue sections from CRC patients and cancer-free LS carriers and 26, 22, and 19 LS CRCs. CD3-positive T cells were also quantified in an independent cohort of 97 FFPE normal rectal mucosa tissue sections from LS carriers enrolled in the CAPP2 clinical trial. The expression of 770 immune-relevant genes was analyzed in a subset of samples with the use of the NanoString nCounter platform. RESULTS LS normal mucosa specimens showed significantly elevated CD3-, FOXP3-, and CD8-positive T-cell densities compared with non-LS control specimens. Gene expression profiling and cluster analysis revealed distinct immune profiles in LS carrier mucosa with and without cancer manifestation. Long-term follow-up of LS carriers within the CAPP2 trial found a correlation between mucosal T-cell infiltrate and time to subsequent tumor occurrence. CONCLUSIONS LS carriers show elevated mucosal T-cell infiltration even in the absence of cancer. The normal mucosa immune profile may be a temporary or permanent tumor risk modifier in LS carriers.
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Affiliation(s)
- Lena Bohaumilitzky
- Department of Applied Tumor Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany; Cooperation Unit Applied Tumor Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Klaus Kluck
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany; German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Robert Hüneburg
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany; National Center for Hereditary Tumor Syndromes, University Hospital Bonn, Bonn, Germany
| | - Richard Gallon
- Translational and Clinical Research Institute, Newcastle University, International Centre for Life, Central Parkway, Newcastle upon Tyne, United Kingdom
| | - Jacob Nattermann
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany; National Center for Hereditary Tumor Syndromes, University Hospital Bonn, Bonn, Germany
| | - Martina Kirchner
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | | | | | - Pauline L Pfuderer
- Department of Applied Tumor Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany; Cooperation Unit Applied Tumor Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Lelia Wagner
- Department of Applied Tumor Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany; Cooperation Unit Applied Tumor Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Fabian Echterdiek
- Department of Applied Tumor Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany; Cooperation Unit Applied Tumor Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Nephrology, Klinikum Stuttgart-Katharinenhospital, Stuttgart, Germany
| | - Svenja Kösegi
- Department of Applied Tumor Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany; Cooperation Unit Applied Tumor Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Nico Müller
- Department of Applied Tumor Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany; Cooperation Unit Applied Tumor Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Konstantin Fischer
- Department of Applied Tumor Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany; Cooperation Unit Applied Tumor Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Nina Nelius
- Department of Applied Tumor Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany; Cooperation Unit Applied Tumor Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Ben Hartog
- Translational and Clinical Research Institute, Newcastle University, International Centre for Life, Central Parkway, Newcastle upon Tyne, United Kingdom
| | - Gillian Borthwick
- Translational and Clinical Research Institute, Newcastle University, International Centre for Life, Central Parkway, Newcastle upon Tyne, United Kingdom
| | - Elena Busch
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Georg Martin Haag
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Hendrik Bläker
- Institute of Pathology, University Hospital Leipzig, Leipzig, Germany
| | - Gabriela Möslein
- Department of Surgery, Ev. Krankenhaus Bethesda Hospital, Duisburg, Germany
| | - Magnus von Knebel Doeberitz
- Department of Applied Tumor Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany; Cooperation Unit Applied Tumor Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Toni T Seppälä
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland; Applied Tumor Genomics Research Program, University of Helsinki, Helsinki, Finland
| | - Maarit Ahtiainen
- Department of Molecular Pathology, Central Finland Hospital Nova, Jyväskylä, Finland
| | - Jukka-Pekka Mecklin
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland; Department of Surgery, Central Finland Hospital Nova, Jyväskylä, Finland
| | - D Timothy Bishop
- Division of Haematology and Immunology, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom
| | - John Burn
- Translational and Clinical Research Institute, Newcastle University, International Centre for Life, Central Parkway, Newcastle upon Tyne, United Kingdom
| | - Albrecht Stenzinger
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany; German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jan Budczies
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany; German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Matthias Kloor
- Department of Applied Tumor Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany; Cooperation Unit Applied Tumor Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Aysel Ahadova
- Department of Applied Tumor Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany; Cooperation Unit Applied Tumor Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
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Echterdiek F, Kitterer D, Dippon J, Ott M, Paul G, Latus J, Schwenger V. Outcome of kidney transplantations from ≥65-year-old deceased donors with acute kidney injury. Clin Transplant 2022; 36:e14612. [PMID: 35148007 DOI: 10.1111/ctr.14612] [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: 09/25/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 11/30/2022]
Abstract
Kidney transplantation (KT) from donors with acute kidney injury (AKI) has been associated with delayed graft function (DGF) but similar graft survival compared with KT from donors without AKI. Kidneys from ≥65-year-old donors with comorbidities are more susceptible to cold ischemia time and DGF and it is unknown whether such elderly kidneys with AKI can also be transplanted with satisfactory outcomes. All KTs from ≥65-year-old donors performed at our centre from 1999 to 2019 (n = 233) were retrospectively analysed and short- as well as long-term outcomes were compared for KTs from donors with (n = 64) and without AKI (n = 169). There were no significant differences regarding the frequency of DGF as well as the estimated glomerular filtration rate (eGFR) one and three years post-transplant between the no-AKI and the AKI group (DGF: no-AKI 30.2% vs. AKI 40.6%, P = 0.17; eGFR at one-year: 31.9 ml/min/1.73m2 vs. 35.5 ml/min/1.73m2 , P = 0.32; at three-years: 33.8 ml/min/1.73m2 vs. 40.9 ml/min/1.73m2 , P = 0.18; respectively). Death-censored graft survival and patient survival were also not significantly different. Multivariable Cox regression analysis did not identify AKI as a significant risk factor for graft loss or death. Following careful donor and recipient selection, kidneys from ≥65-year-old AKI donors may potentially be transplanted with satisfactory outcomes. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Fabian Echterdiek
- Department of Nephrology, Klinikum Stuttgart - Katharinenhospital, Stuttgart, Germany
| | - Daniel Kitterer
- Department of Nephrology, Klinikum Stuttgart - Katharinenhospital, Stuttgart, Germany
| | - Jürgen Dippon
- Institute for Stochastics and Applications, University of Stuttgart, Germany
| | - Matthias Ott
- Department of Emergency and Intensive Care Medicine, Klinikum Stuttgart - Katharinenhospital, Stuttgart, Germany
| | - Gregor Paul
- Department of Gastroenterology, Hepatology, Pneumology and Infectious Diseases, Klinikum Stuttgart - Katharinenhospital, Stuttgart, Germany.,University of Cologne, Department I of Internal Medicine, Division of Infectious Diseases, Cologne, Germany
| | - Joerg Latus
- Department of Nephrology, Klinikum Stuttgart - Katharinenhospital, Stuttgart, Germany
| | - Vedat Schwenger
- Department of Nephrology, Klinikum Stuttgart - Katharinenhospital, Stuttgart, Germany
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Scheder-Bieschin J, Blümke B, de Buijzer E, Cotte F, Echterdiek F, Nacsa J, Ondresik M, Ott M, Paul G, Schilling T, Schmitt A, Wicks P, Gilbert S. Improving Emergency Department Patient-Physician Conversation Through an Artificial Intelligence Symptom-Taking Tool: Mixed Methods Pilot Observational Study. JMIR Form Res 2022; 6:e28199. [PMID: 35129452 PMCID: PMC8861871 DOI: 10.2196/28199] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 02/24/2021] [Revised: 05/21/2021] [Accepted: 12/14/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Establishing rapport and empathy between patients and their health care provider is important but challenging in the context of a busy and crowded emergency department (ED). OBJECTIVE We explore the hypotheses that rapport building, documentation, and time efficiency might be improved in the ED by providing patients a digital tool that uses Bayesian reasoning-based techniques to gather relevant symptoms and history for handover to clinicians. METHODS A 2-phase pilot evaluation was carried out in the ED of a German tertiary referral and major trauma hospital that treats an average of 120 patients daily. Phase 1 observations guided iterative improvement of the digital tool, which was then further evaluated in phase 2. All patients who were willing and able to provide consent were invited to participate, excluding those with severe injury or illness requiring immediate treatment, with traumatic injury, incapable of completing a health assessment, and aged <18 years. Over an 18-day period with 1699 patients presenting to the ED, 815 (47.96%) were eligible based on triage level. With available recruitment staff, 135 were approached, of whom 81 (60%) were included in the study. In a mixed methods evaluation, patients entered information into the tool, accessed by clinicians through a dashboard. All users completed evaluation Likert-scale questionnaires rating the tool's performance. The feasibility of a larger trial was evaluated through rates of recruitment and questionnaire completion. RESULTS Respondents strongly endorsed the tool for facilitating conversation (61/81, 75% of patients, 57/78, 73% of physician ratings, and 10/10, 100% of nurse ratings). Most nurses judged the tool as potentially time saving, whereas most physicians only agreed for a subset of medical specialties (eg, surgery). Patients reported high usability and understood the tool's questions. The tool was recommended by most patients (63/81, 78%), in 53% (41/77) of physician ratings, and in 76% (61/80) of nurse ratings. Questionnaire completion rates were 100% (81/81) by patients and 96% (78/81 enrolled patients) by physicians. CONCLUSIONS This pilot confirmed that a larger study in the setting would be feasible. The tool has clear potential to improve patient-health care provider interaction and could also contribute to ED efficiency savings. Future research and development will extend the range of patients for whom the history-taking tool has clinical utility. TRIAL REGISTRATION German Clinical Trials Register DRKS00024115; https://drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00024115.
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Affiliation(s)
- Justus Scheder-Bieschin
- Department of Interdisciplinary Acute, Emergency and Intensive Care Medicine (DIANI), Klinikum Stuttgart, Stuttgart, Germany
| | | | | | | | | | | | | | - Matthias Ott
- Department of Interdisciplinary Acute, Emergency and Intensive Care Medicine (DIANI), Klinikum Stuttgart, Stuttgart, Germany
| | - Gregor Paul
- Department of Infectious Diseases, Klinikum Stuttgart, Stuttgart, Germany
| | - Tobias Schilling
- Department of Interdisciplinary Acute, Emergency and Intensive Care Medicine (DIANI), Klinikum Stuttgart, Stuttgart, Germany
| | | | | | - Stephen Gilbert
- Ada Health, Berlin, Germany.,The Else Kröner Fresenius Center for Digital Health, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
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Ott M, Krohn A, Bilfield LH, Dengler F, Jaki C, Echterdiek F, Schilling T, Heymer J. The authors respond: Alternatives to chest compression CPR. Am J Emerg Med 2021; 51:413. [PMID: 34756780 PMCID: PMC8547783 DOI: 10.1016/j.ajem.2021.10.020] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 10/13/2021] [Indexed: 10/30/2022] Open
Affiliation(s)
- Matthias Ott
- Department of Interdisciplinary Emergency and Intensive Care Medicine, Klinikum Stuttgart, Kriegsbergstr. 60, 70174 Stuttgart, Germany.
| | - Alexander Krohn
- Department of Interdisciplinary Emergency and Intensive Care Medicine, Klinikum Stuttgart, Kriegsbergstr. 60, 70174 Stuttgart, Germany
| | - Laurence H Bilfield
- Fellow of the American Academy of Orthopaedic Surgeons, Fellow of the American Board of Independent Medical Examiners; 4450 Belden Village St NW, Canton, Ohio, USA
| | - Florian Dengler
- Department of Interdisciplinary Emergency and Intensive Care Medicine, Klinikum Stuttgart, Kriegsbergstr. 60, 70174 Stuttgart, Germany
| | - Christina Jaki
- Simulation Center STUPS, Klinikum Stuttgart, Kriegsbergstr. 60, 70174 Stuttgart, Germany
| | - Fabian Echterdiek
- Department of Nephrology, Klinikum Stuttgart, Kriegsbergstr. 60, 70174 Stuttgart Stuttgart, Germany
| | - Tobias Schilling
- Department of Interdisciplinary Emergency and Intensive Care Medicine, Klinikum Stuttgart, Kriegsbergstr. 60, 70174 Stuttgart, Germany
| | - Johannes Heymer
- Department of Interdisciplinary Emergency and Intensive Care Medicine, Klinikum Stuttgart, Kriegsbergstr. 60, 70174 Stuttgart, Germany
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7
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Ott M, Krohn A, Bilfield LH, Dengler F, Jaki C, Echterdiek F, Schilling T, Heymer J. Leg-heel chest compression as an alternative for medical professionals in times of COVID-19. Am J Emerg Med 2021; 50:575-581. [PMID: 34560564 PMCID: PMC8420094 DOI: 10.1016/j.ajem.2021.09.007] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 08/04/2021] [Accepted: 09/01/2021] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE To evaluate leg-heel chest compression without previous training as an alternative for medical professionals and its effects on distance to potential aerosol spread during chest compression. METHODS 20 medical professionals performed standard manual chest compression followed by leg-heel chest compression after a brief instruction on a manikin. We compared percentage of correct chest compression position, percentage of full chest recoil, percentage of correct compression depth, average compression depth, percentage of correct compression rate and average compression rate between both methods. In a second approach, potential aerosol spread during chest compression was visualized. RESULTS Our data indicate no credible difference between manual and leg-heel compression. The distance to potential aerosol spread could have been increased by leg-heel method. CONCLUSION Under special circumstances like COVID-19-pandemic, leg-heel chest compression may be an effective alternative without previous training compared to manual chest compression while markedly increasing the distance to the patient.
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Affiliation(s)
- Matthias Ott
- Department of Interdisciplinary Emergency and Intensive Care Medicine, Klinikum Stuttgart, Kriegsbergstr. 60, 70174 Stuttgart, Germany.
| | - Alexander Krohn
- Department of Interdisciplinary Emergency and Intensive Care Medicine, Klinikum Stuttgart, Kriegsbergstr. 60, 70174 Stuttgart, Germany
| | - Laurence H Bilfield
- Fellow of the American Academy of Orthopaedic Surgeons, Fellow of the American Board of Independent Medical Examiners, 4450 Belden Village St NW, Canton, OH, USA
| | - Florian Dengler
- Department of Interdisciplinary Emergency and Intensive Care Medicine, Klinikum Stuttgart, Kriegsbergstr. 60, 70174 Stuttgart, Germany
| | - Christina Jaki
- Simulation Center STUPS, Klinikum Stuttgart, Kriegsbergstr. 60, 70174 Stuttgart, Germany
| | - Fabian Echterdiek
- Department of Nephrology, Klinikum Stuttgart, Kriegsbergstr. 60, 70174 Stuttgart, Germany
| | - Tobias Schilling
- Department of Interdisciplinary Emergency and Intensive Care Medicine, Klinikum Stuttgart, Kriegsbergstr. 60, 70174 Stuttgart, Germany
| | - Johannes Heymer
- Department of Interdisciplinary Emergency and Intensive Care Medicine, Klinikum Stuttgart, Kriegsbergstr. 60, 70174 Stuttgart, Germany
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8
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Echterdiek F, Kitterer D, Dippon J, Paul G, Schwenger V, Latus J. Impact of cardiopulmonary resuscitation on outcome of kidney transplantations from braindead donors aged ≥65 years. Clin Transplant 2021; 35:e14452. [PMID: 34390272 DOI: 10.1111/ctr.14452] [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: 12/22/2020] [Revised: 07/23/2021] [Accepted: 07/31/2021] [Indexed: 11/28/2022]
Abstract
Patients with a history of cardiopulmonary resuscitation (CPR) and subsequent brain death are frequently evaluated for organ donation. Whether kidneys from ≥65-year-old braindead donors with a history of CPR can be transplanted with satisfactory outcomes is unknown. All kidney transplants (KT) from ≥65-year-old donors performed at our centre from 1999 to 2018 (n = 185) were retrospectively analysed and outcome was compared for KTs from donors with and without a history of CPR (n = 27 and n = 158, respectively). No significant differences in the incidence of delayed graft function (DGF) as well as one- and three-year graft function were observed between the CPR and the no-CPR group (DGF: 26.0% vs 31.0%, P = 0.76; one-year serum creatinine: 150.4 μmol/l vs 177.0 μmol/l, P = 0.11; three-year serum creatinine: 150.4 μmol/l vs 168.2 μmol/l, P = 0.52, respectively). Death-censored graft survival was comparable after one and five years (CPR group: 81.5% and 76.7% vs no-CPR group: 86.6% and 75.7%, P = 0.70). Likewise, patient survival was not significantly different. Multivariable Cox regression analysis also did not identify CPR as a significant risk factor for graft loss or death. Our study suggests that, following stringent donor selection, the outcome of KTs from ≥65-year-old braindead donors with and without a history of CPR is comparable. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Fabian Echterdiek
- Department of Nephrology, Klinikum Stuttgart - Katharinenhospital, Stuttgart, Germany
| | - Daniel Kitterer
- Department of Nephrology, Klinikum Stuttgart - Katharinenhospital, Stuttgart, Germany
| | - Jürgen Dippon
- Institute for Stochastics and Applications, University of Stuttgart, Germany
| | - Gregor Paul
- Department of Gastroenterology, Hepatology, Pneumology and Infectious Diseases, Klinikum Stuttgart - Katharinenhospital, Stuttgart, Germany.,University of Cologne, Department I of Internal Medicine, Division of Infectious Diseases, Cologne, Germany
| | - Vedat Schwenger
- Department of Nephrology, Klinikum Stuttgart - Katharinenhospital, Stuttgart, Germany
| | - Joerg Latus
- Department of Nephrology, Klinikum Stuttgart - Katharinenhospital, Stuttgart, Germany
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Trübner F, Steigert L, Echterdiek F, Jung N, Schmidt-Hellerau K, Zoller WG, Frick JS, Feng YS, Paul G. Predictors of COVID-19 in an outpatient fever clinic. PLoS One 2021; 16:e0254990. [PMID: 34288955 PMCID: PMC8294531 DOI: 10.1371/journal.pone.0254990] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 07/07/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The objective of this study was to identify clinical risk factors for COVID-19 in a German outpatient fever clinic that allow distinction of SARS-CoV-2 infected patients from other patients with flu-like symptoms. METHODS This is a retrospective, single-centre cohort study. Patients were included visiting the fever clinic from 4th of April 2020 to 15th of May 2020. Symptoms, comorbidities, and socio-demographic factors were recorded in a standardized fashion. Multivariate logistic regression was used to identify risk factors of COVID-19, on the bases of those a model discrimination was assessed using area under the receiver operation curves (AUROC). RESULTS The final analysis included 930 patients, of which 74 (8%) had COVID-19. Anosmia (OR 10.71; CI 6.07-18.9) and ageusia (OR 9.3; CI 5.36-16.12) were strongly associated with COVID-19. High-risk exposure (OR 12.20; CI 6.80-21.90), especially in the same household (OR 4.14; CI 1.28-13.33), was also correlated; the more household members, especially with flu-like symptoms, the higher the risk of COVID-19. Working in an essential workplace was also associated with COVID-19 (OR 2.35; CI 1.40-3.96), whereas smoking was inversely correlated (OR 0.19; CI 0.08-0.44). A model that considered risk factors like anosmia, ageusia, concomitant of symptomatic household members and smoking well discriminated COVID-19 patients from other patients with flu-like symptoms (AUROC 0.84). CONCLUSIONS We report a set of four readily available clinical parameters that allow the identification of high-risk individuals of COVID-19. Our study will not replace molecular testing but will help guide containment efforts while waiting for test results.
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Affiliation(s)
- Frank Trübner
- Department of Gastroenterology, Hepatology, Pneumology and Infectious diseases, Klinikum Stuttgart, Stuttgart, Germany
| | - Lisa Steigert
- Department of Gastroenterology, Hepatology, Pneumology and Infectious diseases, Klinikum Stuttgart, Stuttgart, Germany
- * E-mail:
| | | | - Norma Jung
- Division of Infectious Diseases, Department I of Internal Medicine, University of Cologne, Cologne, Germany
| | - Kirsten Schmidt-Hellerau
- Division of Infectious Diseases, Department I of Internal Medicine, University of Cologne, Cologne, Germany
| | - Wolfram G. Zoller
- Department of Gastroenterology, Hepatology, Pneumology and Infectious diseases, Klinikum Stuttgart, Stuttgart, Germany
| | - Julia-Stefanie Frick
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany
| | - You-Shan Feng
- Institute for Clinical Epidemiology and Applied Biometry, University of Tübingen, Tübingen, Germany
| | - Gregor Paul
- Department of Gastroenterology, Hepatology, Pneumology and Infectious diseases, Klinikum Stuttgart, Stuttgart, Germany
- Division of Infectious Diseases, Department I of Internal Medicine, University of Cologne, Cologne, Germany
- Department of Hospital Hygiene, Klinikum Stuttgart, Stuttgart, Germany
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10
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Morath C, Döhler B, Kälble F, Pego da Silva L, Echterdiek F, Schwenger V, Živčić-Ćosić S, Katalinić N, Kuypers D, Benöhr P, Haubitz M, Ziemann M, Nitschke M, Emmerich F, Pisarski P, Karakizlis H, Weimer R, Ruhenstroth A, Scherer S, Tran TH, Mehrabi A, Zeier M, Süsal C. Pre-transplant HLA Antibodies and Delayed Graft Function in the Current Era of Kidney Transplantation. Front Immunol 2020; 11:1886. [PMID: 32983110 PMCID: PMC7489336 DOI: 10.3389/fimmu.2020.01886] [Citation(s) in RCA: 3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 07/13/2020] [Indexed: 12/04/2022] Open
Abstract
Delayed graft function (DGF) occurs in a significant proportion of deceased donor kidney transplant recipients and was associated with graft injury and inferior clinical outcome. The aim of the present multi-center study was to identify the immunological and non-immunological predictors of DGF and to determine its influence on outcome in the presence and absence of human leukocyte antigen (HLA) antibodies. 1,724 patients who received a deceased donor kidney transplant during 2008–2017 and on whom a pre-transplant serum sample was available were studied. Graft survival during the first 3 post-transplant years was analyzed by multivariable Cox regression. Pre-transplant predictors of DGF and influence of DGF and pre-transplant HLA antibodies on biopsy-proven rejections in the first 3 post-transplant months were determined by multivariable logistic regression. Donor age ≥50 years, simultaneous pre-transplant presence of HLA class I and II antibodies, diabetes mellitus as cause of end-stage renal disease, cold ischemia time ≥18 h, and time on dialysis >5 years were associated with increased risk of DGF, while the risk was reduced if gender of donor or recipient was female or the reason for death of donor was trauma. DGF alone doubled the risk for graft loss, more due to impaired death-censored graft than patient survival. In DGF patients, the risk of death-censored graft loss increased further if HLA antibodies (hazard ratio HR=4.75, P < 0.001) or donor-specific HLA antibodies (DSA, HR=7.39, P < 0.001) were present pre-transplant. In the presence of HLA antibodies or DSA, the incidence of biopsy-proven rejections, including antibody-mediated rejections, increased significantly in patients with as well as without DGF. Recipients without DGF and without biopsy-proven rejections during the first 3 months had the highest fraction of patients with good kidney function at year 1, whereas patients with both DGF and rejection showed the lowest rate of good kidney function, especially when organs from ≥65-year-old donors were used. In this new era of transplantation, besides non-immunological factors, also the pre-transplant presence of HLA class I and II antibodies increase the risk of DGF. Measures to prevent the strong negative impact of DGF on outcome are necessary, especially during organ allocation for presensitized patients.
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Affiliation(s)
- Christian Morath
- Division of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Bernd Döhler
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Florian Kälble
- Division of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Fabian Echterdiek
- Department of Nephrology and Autoimmune Diseases, Transplantation Center, Klinikum Stuttgart, Stuttgart, Germany
| | - Vedat Schwenger
- Department of Nephrology and Autoimmune Diseases, Transplantation Center, Klinikum Stuttgart, Stuttgart, Germany
| | - Stela Živčić-Ćosić
- Department of Nephrology, Dialysis and Kidney Transplantation, Department of Internal Medicine, Clinical Hospital Center Rijeka, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
| | - Nataša Katalinić
- Tissue Typing Laboratory, Clinical Institute of Transfusion Medicine, Clinical Hospital Center Rijeka, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
| | - Dirk Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Peter Benöhr
- Department of Nephrology and Hypertension, Center for Internal Medicine and Medical Clinic III, Klinikum Fulda, Fulda, Germany
| | - Marion Haubitz
- Department of Nephrology and Hypertension, Center for Internal Medicine and Medical Clinic III, Klinikum Fulda, Fulda, Germany
| | - Malte Ziemann
- Institute of Transfusion Medicine, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - Martin Nitschke
- Medical Clinic 1, Transplantation Center, University of Lübeck, Lübeck, Germany
| | - Florian Emmerich
- Institute for Transfusion Medicine and Gene Therapy, University Medical Center, University of Freiburg, Freiburg, Germany
| | - Przemyslaw Pisarski
- Department of General and Digestive Surgery, University Medical Centre Freiburg, Freiburg, Germany
| | - Hristos Karakizlis
- Department of Internal Medicine, University of Giessen, Giessen, Germany
| | - Rolf Weimer
- Department of Internal Medicine, University of Giessen, Giessen, Germany
| | - Andrea Ruhenstroth
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Sabine Scherer
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thuong Hien Tran
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Zeier
- Division of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Caner Süsal
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
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11
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Echterdiek F, Latus J, Döhler B, Schwenger V, Süsal C. Impact of HLA compatibility in recipients of kidneys from expanded criteria donors: A Collaborative Transplant Study Report. Int J Immunogenet 2020; 48:201-210. [PMID: 32945128 DOI: 10.1111/iji.12512] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/06/2020] [Accepted: 08/16/2020] [Indexed: 01/03/2023]
Abstract
Due to a widespread organ shortage, the use of expanded criteria donors (ECDs) in kidney transplantation has increased persistently, reaching approximately 40% in recent years. Whether human leucocyte antigen (HLA) matching between donor and recipient should be part of allocation algorithms in transplantation of ECD kidneys, and especially of ECD kidneys from ≥70-year-old donors, is still in question. To this end, 135,529 kidney transplantations performed between 2000 and 2017 and reported to the Collaborative Transplant Study were analysed and the impact of HLA-A+B+DR mismatches on death-censored graft and patient survival as well as on rejection episodes was investigated. Results were stratified according to donor status (standard criteria donor (SCD) versus ECD) and age of ECD. HLA incompatibility increased the five-year death-censored graft failure risk similarly strong in recipients of ECD and SCD transplants (hazard ratio (HR) per HLA mismatch 1.078 and 1.075, respectively; p < .001 for both). Its impact on rejection treatments during the first post-transplant year was also significant but slightly weaker for recipients of ECD transplants (risk ratio (RR) per HLA mismatch 1.10 for ECD transplants and 1.13 for SCD transplants; p < .001 for both). Mortality increased gradually from zero to six HLA mismatches in recipients of SCD transplants, whereas for ECD transplants a significant increase was notable only from zero to more than zero mismatches. A significant but slightly less pronounced impact of HLA incompatibility on graft failure was observed in transplants from ≥70- compared with <70-year-old ECDs (HR per mismatch 1.047 and 1.093; p = .009 and < 0.001, respectively). The influence of HLA mismatches on rejection treatments was the same for both ECD age groups (RR = 1.10, p < .001 and p = .004, respectively). Our data indicate that HLA matching should be part of allocation algorithms not only in transplantation of kidneys from SCDs but also from ECDs.
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Affiliation(s)
- Fabian Echterdiek
- Department of Nephrology, Klinikum Stuttgart - Katharinenhospital, Stuttgart, Germany
| | - Joerg Latus
- Department of Nephrology, Klinikum Stuttgart - Katharinenhospital, Stuttgart, Germany
| | - Bernd Döhler
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Vedat Schwenger
- Department of Nephrology, Klinikum Stuttgart - Katharinenhospital, Stuttgart, Germany
| | - Caner Süsal
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
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12
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Paul G, Echterdiek F, Bohle W, Zoller W. Vocal Fold Paralysis is a Common Complication in Esophageal Cancer Patients with Esophagorespiratory Fistula. J Gastrointestin Liver Dis 2020; 29:11-17. [PMID: 32176744 DOI: 10.15403/jgld-580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 03/03/2020] [Indexed: 11/01/2022]
Abstract
BACKGROUND AND AIMS The development of an esophagorespiratory fistula (ERF) in patients with esophageal cancer (EC) is associated with poor prognosis. We observed a high rate of vocal fold paralysis (VFP) in patients with ERF. Data on prevalence and complications of VFP in ERF are lacking. The present study investigated the incidence of VFP in patients with malignant ERF and examined possible risk factors and the impact on survival. METHODS We performed a retrospective case-control study of 46 institutional cases of EC patients with ERF in a time period of eleven years. Patients were matched to 92 randomly selected controls (EC patients without ERF) in a 1:2 fashion for tumor localization and histology. Demographics, clinical characteristics, recurrence, treatment modalities as well as survival were analyzed. RESULTS Esophageal cancer patients with ERF developed more often VFP than EC patients without ERF (59% vs. 21%; p=0.02; odds ratio (OR) 4.9). Esophageal cancer patients with ERF had a more pronounced weight loss (7.1 vs. 11.5 kg; P = 0.008), as well as higher rates of esophageal (p=<0.001; OR 22.9) and tracheal stenting (p=<0.001; OR 76.8). Proximal tumor growth (p=0.004; OR 7.9), fistula formation to the trachea (p=<0.001; OR 17.2) and recurrent disease (p=0.04, OR 4.7) was associated with VFP development in EC patients with ERF. Vocal fold paralysis in ERF did not adversely affect five-year survival. CONCLUSIONS Vocal fold paralysis is a common complication in more than half of the patients with ERF in EC. It is associated with proximal tumor growth, fistula formation to the trachea and disease recurrence, but does not influence survival.
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Affiliation(s)
- Gregor Paul
- Department of General Internal Medicine and Gastroenterology, Katharinenhospital, Stuttgart; University of Cologne, Department I of Internal Medicine, Division of Infectious Diseases, Cologne, Germany.
| | | | - Wolfram Bohle
- Department of General Internal Medicine and Gastroenterology, Katharinenhospital, Stuttgart, Germany.
| | - Wolfram Zoller
- Department of General Internal Medicine and Gastroenterology, Katharinenhospital, Stuttgart, Germany.
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13
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Echterdiek F, Schwenger V, Döhler B, Latus J, Kitterer D, Heemann U, Süsal C. Kidneys From Elderly Deceased Donors-Is 70 the New 60? Front Immunol 2019; 10:2701. [PMID: 31827468 PMCID: PMC6890834 DOI: 10.3389/fimmu.2019.02701] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 08/05/2019] [Accepted: 11/04/2019] [Indexed: 01/26/2023] Open
Abstract
There is a growing shortage of kidney donors leading to extended transplant waiting times associated with increased mortality. To expand the donor pool, clinicians nowadays regularly accept organs from elderly donors, including those aged ≥70 years. There is only limited and conflicting data whether kidneys from these elderly donors allow for satisfactory allograft outcome rates. To asses this question, the 5-year death censored graft survival of 116,870 adult first deceased donor kidney allograft recipients that were transplanted at European centers between 1997 and 2016 and reported to the “Collaborative Transplant Study” were analyzed using Kaplan–Meier analysis and country stratified Cox regression. The combinations of the two transplant periods 1997–2006 and 2007–2016 with the donor age categories 18–49, 50–59, 60–69, and ≥70 years were considered. From 1997–2006 to 2007–2016, the median donor age increased from 50 to 55 years and the proportion of kidneys from ≥60-year-old donors rose from 24.1 to 38.8%. At the same time, the proportion of kidneys from ≥70-year-old donors more than doubled (6.7 vs. 15.4%). Between 1997–2006 and 2007–2016, the 5-year graft survival improved in all donor age categories. During 2007–2016, the 5-year death censored graft survival of kidneys from ≥70-year-old donors was comparable to that of kidneys from 60 to 69-year-old donors during 1997–2006. This was true both for younger recipients (18–64 years) and older recipients (≥65 years). Among the younger recipients, 45–64-year-old recipients showed the best death censored graft survival rates for kidneys from old donors. In the country-stratified Cox regression analysis, compared to the reference of grafts from 18 to 49-year-old donors, the hazard ratio for grafts from ≥70-year-old donors during 2007–2016 was 1.92, exactly the same as the hazard ratio for grafts from 60 to 69-year-old donors during 1997–2006. Our analysis indicates that within only one further decade (1997–2006 vs. 2007–2016) the 5-year death censored graft survival of kidneys from ≥70-year old donors improved to the level of kidneys from 60 to 69-year-old donors in the previous decade.
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Affiliation(s)
| | - Vedat Schwenger
- Department of Nephrology, Klinikum Stuttgart, Stuttgart, Germany
| | - Bernd Döhler
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Joerg Latus
- Department of Nephrology, Klinikum Stuttgart, Stuttgart, Germany
| | - Daniel Kitterer
- Department of Nephrology, Klinikum Stuttgart, Stuttgart, Germany
| | - Uwe Heemann
- Department of Nephrology, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Caner Süsal
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
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14
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Echterdiek F, Kitterer D, Schwenger V, Latus J. Severe acute kidney injury due to violent sadomasochistic play. BMJ Case Rep 2018; 2018:bcr-2018-224813. [DOI: 10.1136/bcr-2018-224813] [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: 11/04/2022] Open
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15
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Janikovits J, Müller M, Krzykalla J, Körner S, Echterdiek F, Lahrmann B, Grabe N, Schneider M, Benner A, Doeberitz MVK, Kloor M. High numbers of PDCD1 (PD-1)-positive T cells and B2M mutations in microsatellite-unstable colorectal cancer. Oncoimmunology 2017; 7:e1390640. [PMID: 29308317 DOI: 10.1080/2162402x.2017.1390640] [Citation(s) in RCA: 25] [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] [Received: 06/30/2017] [Revised: 09/22/2017] [Accepted: 10/05/2017] [Indexed: 12/31/2022] Open
Abstract
DNA mismatch repair (MMR)-deficient cancers accumulate high numbers of coding microsatellite mutations, which lead to the generation of highly immunogenic frameshift peptide (FSP) neoantigens. MMR-deficient cells can grow out to clinically manifest cancers either if they evade immune cell attack or if local T-cells get exhausted. Therefore, a subset of MSI cancer patients responds particularly well to treatment with immune checkpoint inhibitors. We analyzed whether immune evasion in MMR-deficient cancer mediated by loss of HLA class I or II antigens is related to local immune cell activation status. Microsatellites located in Beta2-microglobulin (B2M) and the HLA class II-regulatory genes RFX5 and CIITA were analyzed for mutations in MMR-deficient colorectal cancers (n = 53). The results were related to CD3-positive and PDCD1 (PD-1)-positive T-cell infiltration. PDCD1 (PD-1)-positive T-cell counts were significantly higher in B2M-mutant compared to B2M-wild type tumors (median: 22.2 cells per 0.25 mm2 vs. 2.0 cells per 0.25 mm2, Wilcoxon test p = 0.002). Increasing PDCD1 (PD-1)-positive T-cell infiltration was significantly related to an increased likelihood of B2M mutations (OR = 1.81). HLA class II antigen expression status was significantly associated with enhanced overall T-cell infiltration, but not related to PDCD1 (PD-1)-positive T-cells. These results suggest that immune evasion mediated by B2M mutation-induced loss of HLA class I antigen expression predominantly occurs in an environment of activated PDCD1 (PD-1)-positive T cell infiltration. If B2M mutations interfere with anti-PDCD1 (PD-1)/CD274 (PD-L1) therapy success, we predict that resistance towards anti-PDCD1 (PD-1) therapy may - counterintuitively - be particularly common in patients with MMR-deficient cancers that show high PDCD1 (PD-1)-positive T cell infiltration.
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Affiliation(s)
- Jonas Janikovits
- Department of Applied Tumour Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany, and Clinical Cooperation Unit Applied Tumour Biology, DKFZ (German Cancer Research Center) Heidelberg, Heidelberg, Germany, and Molecular Medicine Partnership Unit (MMPU), Heidelberg University Hospital and EMBL Heidelberg
| | - Meike Müller
- Department of Applied Tumour Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany, and Clinical Cooperation Unit Applied Tumour Biology, DKFZ (German Cancer Research Center) Heidelberg, Heidelberg, Germany, and Molecular Medicine Partnership Unit (MMPU), Heidelberg University Hospital and EMBL Heidelberg
| | - Julia Krzykalla
- Division of Biostatistics, DKFZ (German Cancer Research Center), Heidelberg, Germany
| | - Sandrina Körner
- Department of Applied Tumour Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany, and Clinical Cooperation Unit Applied Tumour Biology, DKFZ (German Cancer Research Center) Heidelberg, Heidelberg, Germany, and Molecular Medicine Partnership Unit (MMPU), Heidelberg University Hospital and EMBL Heidelberg
| | - Fabian Echterdiek
- Department of Applied Tumour Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany, and Clinical Cooperation Unit Applied Tumour Biology, DKFZ (German Cancer Research Center) Heidelberg, Heidelberg, Germany, and Molecular Medicine Partnership Unit (MMPU), Heidelberg University Hospital and EMBL Heidelberg
| | - Bernd Lahrmann
- Hamamatsu Tissue Imaging and Analysis (TIGA) Center, Heidelberg, Germany
| | - Niels Grabe
- Hamamatsu Tissue Imaging and Analysis (TIGA) Center, Heidelberg, Germany
| | - Martin Schneider
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Axel Benner
- Division of Biostatistics, DKFZ (German Cancer Research Center), Heidelberg, Germany
| | - Magnus von Knebel Doeberitz
- Department of Applied Tumour Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany, and Clinical Cooperation Unit Applied Tumour Biology, DKFZ (German Cancer Research Center) Heidelberg, Heidelberg, Germany, and Molecular Medicine Partnership Unit (MMPU), Heidelberg University Hospital and EMBL Heidelberg
| | - Matthias Kloor
- Department of Applied Tumour Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany, and Clinical Cooperation Unit Applied Tumour Biology, DKFZ (German Cancer Research Center) Heidelberg, Heidelberg, Germany, and Molecular Medicine Partnership Unit (MMPU), Heidelberg University Hospital and EMBL Heidelberg
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Kloor M, Janikovits J, Krzykalla J, Benner A, Grabe N, Echterdiek F, Mueller M, Koerner S, Ahadova A, Doeberitz MVK. Abstract A085: Immune evasion and PD-1-positive T cell infiltration in DNA mismatch repair-deficient colorectal cancer. Cancer Immunol Res 2016. [DOI: 10.1158/2326-6066.imm2016-a085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background and Aims: DNA mismatch repair-deficient cancers show microsatellite instability (MSI) and accumulate high numbers of somatic insertion/deletion mutations at repetitive sequence stretches. The high mutational load of MSI cancers leads to the generation of multiple frameshift peptide (FSP) neoantigens, which are highly immunogenic and recognized by the immune system as foreign antigens. MSI cancers respond particularly well to treatment with immune checkpoint inhibitors such as anti-PD-1 antibodies. We systematically analyzed immune evasion phenomena in MSI cancers and aimed to identify factors that are related to and potentially determine PD-1 expression on tumor-infiltrating lymphocytes, focusing on alterations of HLA class I and II antigen presentation pathways in cancer cells.
Methods: Microsatellites located in Beta2-microglobulin (B2M) and the HLA class II-regulatory genes RFX5 and CIITA were analyzed for mutations in MSI colorectal cancer specimens (n = 53). HLA class I and II antigen expression was examined by immunohistochemistry. In addition, tumor-infiltrating lymphocytes (CD3-positive T cells, PD-1-positive T cells) were quantified using a semi-automated system.
Results: We related B2M mutation and HLA class II antigen expression status of MSI colorectal cancer specimens (n = 56) to CD3- and PD-1 positive T cell infiltration in the tumor. PD-1-positive T cell infiltration was significantly higher in B2M-mutant (mt) compared to B2M-wild type (wt) tumors (median: 22.2 cells per 0.25 mm2 in B2M-mt vs. 2.0 cells per 0.25 mm2 in B2M-wt, Wilcoxon's rank sum test p = 0.002). Increasing PD-1-positive T cell infiltration was significantly related to an increased likelihood of B2M mutation and loss of HLA class I antigen expression (OR = 1.81). In contrast, HLA class II antigen expression status was not related to the proportion of PD-1-positive lymphocytes, but significantly associated with enhanced overall T cell infiltration.
Conclusions: These results suggest that immune evasion mediated by B2M mutation-induced loss of HLA class I antigen expression predominantly occurs in an environment of activated PD-1-positive T cell infiltration, supporting the validity of the immunoediting concept in MSI colorectal cancers. Moreover, B2M mutation status may predict therapy resistance against anti-PD-1 therapy.
Note: This abstract was not presented at the conference.
Citation Format: Matthias Kloor, Jonas Janikovits, Julia Krzykalla, Axel Benner, Niels Grabe, Fabian Echterdiek, Meike Mueller, Sandrina Koerner, Aysel Ahadova, Magnus von Knebel Doeberitz. Immune evasion and PD-1-positive T cell infiltration in DNA mismatch repair-deficient colorectal cancer [abstract]. In: Proceedings of the Second CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; 2016 Sept 25-28; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2016;4(11 Suppl):Abstract nr A085.
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Affiliation(s)
| | | | - Julia Krzykalla
- 2Division of Biostatistics, DKFZ Heidelberg, Heidelberg, Germany
| | - Axel Benner
- 2Division of Biostatistics, DKFZ Heidelberg, Heidelberg, Germany
| | - Niels Grabe
- 3Hamamatsu Tissue Imaging and Analysis (TIGA) Center, Bioquant, Heidelberg, Germany
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17
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Subramanian V, Chatu S, Echterdiek F, Banerjee A, Finlayson C, Pollok RCG. Patients with Endoscopically Visible Polypoid Adenomatous Lesions Within the Extent of Ulcerative Colitis Have an Increased Risk of Colorectal Cancer Despite Endoscopic Resection. Dig Dis Sci 2016; 61:3031-3036. [PMID: 27405991 DOI: 10.1007/s10620-016-4246-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 07/04/2016] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Ulcerative colitis (UC) is associated with an increased risk of colorectal cancer (CRC). Few studies have looked at long-term outcomes of endoscopically visible adenomatous lesions removed by endoscopic resection in these patients. We aimed to assess the risk of developing CRC in UC patients with adenomatous lesions that develop within the segment of colitis compared to the remainder of an ulcerative colitis cohort. METHODS We identified patients with a confirmed histological diagnosis of UC from 1991 to 2004 and noted outcomes till June 2011. The Kaplan-Meier method was used to estimate cumulative probability of subsequent CRC. Factors associated with risk of CRC were assessed in a Cox proportional hazards model. RESULTS Twenty-nine of 301 patients with UC had adenomatous lesions noted within the segment of colitis. The crude incidence rate of developing colon cancer in patients with UC was 2.45 (95 % CI 1.06-4.83) per 1000 PYD and in those with UC and polypoid adenomas within the extent of inflammation was 11.07 (95 % CI 3.59-25.83) per 1000 PYD. Adjusted hazards ratio of developing CRC on follow-up in UC patients with polypoid dysplastic adenomatous lesions within the extent of inflammation was 4.0 (95 % CI 1.3-12.4). CONCLUSIONS The risk of developing CRC is significantly higher in UC patients with polypoid adenomatous lesions, within the extent of inflammation, despite endoscopic resection. Patients and physicians should take the increased risk into consideration during follow-up of these patients.
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Affiliation(s)
- Venkataraman Subramanian
- Molecular Gastroenterology, Leeds Institute Biomedical and Clinical Sciences, St James University Hospital, University of Leeds, Leeds, UK.,Department of Gastroenterology, St George's Healthcare NHS Trust, Tooting, London, UK
| | - Sukhdev Chatu
- Department of Gastroenterology, St George's Healthcare NHS Trust, Tooting, London, UK
| | - Fabian Echterdiek
- Department of Gastroenterology, St George's Healthcare NHS Trust, Tooting, London, UK
| | - Ashwini Banerjee
- Department of Gastroenterology, St George's Healthcare NHS Trust, Tooting, London, UK
| | - Caroline Finlayson
- Department of Histopathology, St George's Healthcare NHS Trust, Tooting, London, UK
| | - Richard C G Pollok
- Department of Gastroenterology, St George's Healthcare NHS Trust, Tooting, London, UK.
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18
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Echterdiek F, Janikovits J, Staffa L, Müller M, Lahrmann B, Frühschütz M, Hartog B, Nelius N, Benner A, Tariverdian M, von Knebel Doeberitz M, Grabe N, Kloor M. Low density of FOXP3-positive T cells in normal colonic mucosa is related to the presence of beta2-microglobulin mutations in Lynch syndrome-associated colorectal cancer. Oncoimmunology 2015; 5:e1075692. [PMID: 27057447 DOI: 10.1080/2162402x.2015.1075692] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [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: 03/25/2015] [Revised: 07/10/2015] [Accepted: 07/17/2015] [Indexed: 12/26/2022] Open
Abstract
Microsatellite instability (MSI-H) is caused by DNA mismatch repair deficiency and occurs in 15% of colorectal cancers. MSI-H cancers generate highly immunogenic frameshift peptide (FSP) antigens, which elicit pronounced local immune responses. A subset of MSI-H colorectal cancers develops in frame of Lynch syndrome, which represents an ideal human model for studying the concept of immunoediting. Immunoediting describes how continuous anti-tumoral immune surveillance of the host eventually leads to the selection of tumor cells that escape immune cell recognition and destruction. Between 30 and 40% of Lynch syndrome-associated colorectal cancers display loss of HLA class I antigen expression as a result of Beta2-microglobulin (B2M) mutations. Whether B2M mutations result from immunoediting has been unknown. To address this question, we related B2M mutation status of Lynch syndrome-associated colorectal cancer specimens (n = 30) to CD3-positive, CD8-positive and FOXP3-positive T cell infiltration in both tumor and normal mucosa. No significant correlation between B2M mutations and immune cell infiltration was observed in tumor tissue. However, FOXP3-positive T cell infiltration was significantly lower in normal mucosa adjacent to B2M-mutant (mt) compared to B2M-wild type (wt) tumors (mean: 0.98% FOXP3-positive area/region of interest (ROI) in B2M-wt vs. 0.52% FOXP3-positive area/ROI in B2M-mt, p = 0.023). Our results suggest that in the absence of immune-suppressive regulatory T cells (Treg), the outgrowth of less immunogenic B2M-mt tumor cells is favored. This finding supports the immunoediting concept in human solid cancer development and indicates a critical role of the immune milieu in normal colonic mucosa for the course of disease.
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Affiliation(s)
- Fabian Echterdiek
- Department of Applied Tumour Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany, and Clinical Cooperation Unit Applied Tumour Biology, DKFZ (German Cancer Research Center) Heidelberg, Im Neuenheimer Feld 280, Heidelberg, Germany, and Molecular Medicine Partnership Unit, University Hospital Heidelberg and EMBL Heidelberg , Germany
| | - Jonas Janikovits
- Department of Applied Tumour Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany, and Clinical Cooperation Unit Applied Tumour Biology, DKFZ (German Cancer Research Center) Heidelberg, Im Neuenheimer Feld 280, Heidelberg, Germany, and Molecular Medicine Partnership Unit, University Hospital Heidelberg and EMBL Heidelberg , Germany
| | - Laura Staffa
- Department of Applied Tumour Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany, and Clinical Cooperation Unit Applied Tumour Biology, DKFZ (German Cancer Research Center) Heidelberg, Im Neuenheimer Feld 280, Heidelberg, Germany, and Molecular Medicine Partnership Unit, University Hospital Heidelberg and EMBL Heidelberg , Germany
| | - Meike Müller
- Department of Applied Tumour Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany, and Clinical Cooperation Unit Applied Tumour Biology, DKFZ (German Cancer Research Center) Heidelberg, Im Neuenheimer Feld 280, Heidelberg, Germany, and Molecular Medicine Partnership Unit, University Hospital Heidelberg and EMBL Heidelberg , Germany
| | - Bernd Lahrmann
- Hamamatsu Tissue Imaging and Analysis (TIGA) Center , Heidelberg, Germany
| | - Monika Frühschütz
- Department of Applied Tumour Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany, and Clinical Cooperation Unit Applied Tumour Biology, DKFZ (German Cancer Research Center) Heidelberg, Im Neuenheimer Feld 280, Heidelberg, Germany, and Molecular Medicine Partnership Unit, University Hospital Heidelberg and EMBL Heidelberg , Germany
| | - Benjamin Hartog
- Department of Applied Tumour Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany, and Clinical Cooperation Unit Applied Tumour Biology, DKFZ (German Cancer Research Center) Heidelberg, Im Neuenheimer Feld 280, Heidelberg, Germany, and Molecular Medicine Partnership Unit, University Hospital Heidelberg and EMBL Heidelberg , Germany
| | - Nina Nelius
- Department of Applied Tumour Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany, and Clinical Cooperation Unit Applied Tumour Biology, DKFZ (German Cancer Research Center) Heidelberg, Im Neuenheimer Feld 280, Heidelberg, Germany, and Molecular Medicine Partnership Unit, University Hospital Heidelberg and EMBL Heidelberg , Germany
| | - Axel Benner
- Division of Biostatistics, DKFZ (German Cancer Research Center) , Heidelberg, Germany
| | - Mirjam Tariverdian
- Department of General, Visceral and Accident Surgery, University Hospital Heidelberg , Heidelberg, Germany
| | - Magnus von Knebel Doeberitz
- Department of Applied Tumour Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany, and Clinical Cooperation Unit Applied Tumour Biology, DKFZ (German Cancer Research Center) Heidelberg, Im Neuenheimer Feld 280, Heidelberg, Germany, and Molecular Medicine Partnership Unit, University Hospital Heidelberg and EMBL Heidelberg , Germany
| | - Niels Grabe
- Hamamatsu Tissue Imaging and Analysis (TIGA) Center , Heidelberg, Germany
| | - Matthias Kloor
- Department of Applied Tumour Biology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany, and Clinical Cooperation Unit Applied Tumour Biology, DKFZ (German Cancer Research Center) Heidelberg, Im Neuenheimer Feld 280, Heidelberg, Germany, and Molecular Medicine Partnership Unit, University Hospital Heidelberg and EMBL Heidelberg , Germany
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Dihlmann S, Tao S, Echterdiek F, Herpel E, Jansen L, Chang-Claude J, Brenner H, Hoffmeister M, Kloor M. Lack of Absent in Melanoma 2 (AIM2) expression in tumor cells is closely associated with poor survival in colorectal cancer patients. Int J Cancer 2014; 135:2387-96. [PMID: 24729378 DOI: 10.1002/ijc.28891] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 03/10/2014] [Accepted: 03/28/2014] [Indexed: 12/31/2022]
Abstract
Functional studies on colorectal cancer cells indicated a protective role of the interferon-inducible dsDNA sensor Absent in Melanoma 2 (AIM2) in cancer progression. Given that a high mutation rate and lack of AIM2 expression was previously detected in a subset of colorectal cancers, we here investigated the association of AIM2 expression in tumor cells and patient prognosis (5-year follow-up). A tissue microarray analysis of 476 matched tissue pairs (colorectal tumor and adjacent normal colon epithelium) was performed by two independent observers. Samples from 62 patients were excluded because of missing follow-up information or due to neo-adjuvant therapy before tissue sampling. Out of the remaining 414 tissue pairs, 279 (67.4%) displayed reduced AIM2 expression in cancer cells when compared to epithelial cells of their normal counterpart. Thirty-eight patients (9.18%) had completely lost AIM2 expression in tumor cells. After adjustment for sex, age, cancer stage, tumor site, tumor grade and chemotherapy, complete lack of AIM2 expression was associated with an up to 3-fold increase in overall mortality (HR=2.40; 95% CI=1.44-3.99) and disease specific mortality (HR=3.14; 95% CI=1.75-5.65) in comparison to AIM2-positive tumor samples. Our results demonstrate that lack of AIM2 expression is closely associated with poor outcome in colorectal cancer. The data thus strongly substantiate a protective role of AIM2 against progression of colorectal tumors. Further studies are required to assess whether lack of AIM2 expression may be used as a biomarker for the identification of colorectal cancer patients with poor prognosis.
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Affiliation(s)
- Susanne Dihlmann
- Department of Vascular and Endovascular Surgery, University of Heidelberg, Heidelberg, Germany
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