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Moinuddin I, Yakubu I, Bhati A, Morales M, Sterling RK, Gupta G. Ultrashort direct-acting antiviral prophylaxis for human immunodeficiency virus and hepatitis C virus coinfected donor positive to human immunodeficiency virus-positive kidney transplants. Am J Transplant 2024; 24:876-878. [PMID: 38097017 DOI: 10.1016/j.ajt.2023.12.008] [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: 10/12/2023] [Revised: 11/29/2023] [Accepted: 12/08/2023] [Indexed: 12/31/2023]
Affiliation(s)
- Irfan Moinuddin
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Idris Yakubu
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Aditya Bhati
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Megan Morales
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Richard K Sterling
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA.
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Jay JS, Patterson JA, Zhang Y, Ijioma SC, Carroll NV, Holdford DA, Sterling RK, Gupta G, Yakubu I. Cost minimization analysis of short-duration antiviral prophylaxis for hepatitis C positive donor kidney transplants. J Am Pharm Assoc (2003) 2023; 63:1700-1705.e4. [PMID: 37414279 DOI: 10.1016/j.japh.2023.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/09/2023] [Accepted: 06/29/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Trials describing 4-12 week courses of direct-acting antiviral drugs (DAAs) to treat hepatitis C virus (HCV) transmission from infected donors to uninfected kidney transplant recipients (D+/R-transplants), may be limited in application by costs and delayed access to expensive DAAs. A short prophylactic strategy may be safer and cost-effective. Here, we report a cost minimization analysis using the health system perspective to determine the least expensive DAA regimen, using available published strategies. OBJECTIVES To conduct cost-minimization analyses (CMAs) from the health system perspective of four DAA regimens to prevent and/or treat HCV transmission from D+/R-kidney transplants. METHODS CMAs comparing 4 strategies: 1) 7-day prophylaxis with generic sofosbuvir/velpatasvir (SOF/VEL), with 12-week branded glecaprevir/pibrentasvir (G/P) for those with transmission; 2) 8-day branded G/P prophylaxis, with 12-week branded SOF/VEL/voxilaprevir for those with transmission; 3) 4-week perioperative generic SOF/VEL prophylaxis, with 12-week branded G/P for those with transmission; and 4) 8-week branded G/P "transmit-and-treat." We included data from published literature to estimate the probability of viral transmission in patients who received DAA prophylaxis, and assumed a 100% transmission rate for those who received the "transmit-and-treat" approach. RESULTS In base-case analyses, strategies 1 (expected cost [EC]: $2326) and 2 (expected cost: $2646) were less expensive than strategies 3 (EC: $4859) and 4 (EC: $18,525). Threshold analyses for 7-day SOF/VEL versus 8-day G/P suggested that there were reasonable input levels at which the 8-day strategy may be least costly. The threshold values for the SOF/VEL prophylaxis strategies (7-day vs. 4- week) indicated that the 4-week strategy is unlikely to be less costly under any reasonable value of the input variables. CONCLUSIONS Short duration DAA prophylaxis using 7 days of SOF/VEL or 8 days of G/P has the potential to yield significant cost savings for D+/R- kidney transplants.
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Yakubu I, Moinuddin I, Gupta G. Use of belatacept in kidney transplantation: what's new? Curr Opin Organ Transplant 2023; 28:36-45. [PMID: 36326538 DOI: 10.1097/mot.0000000000001033] [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: 11/06/2022]
Abstract
PURPOSE OF REVIEW The advent of calcineurin inhibitors have led to a significant improvement in short term outcomes after kidney transplantation. However, long term outcomes are hindered by the cardiovascular, metabolic and chronic renal toxicity associated with these agents. Belatacept is a selective T cell costimulation blocker that is approved for prevention of rejection in kidney transplantation, and has been associated with favorable cardiovascular, metabolic and renal outcomes in kidney transplant recipients. This review provides an overview of recent updates in the use of belatacept in kidney transplant recipients. RECENT FINDINGS Belatacept may be a safe alternative to calcineurin inhibitors for select kidney transplant populations. Patients converted to belatacept from a calcineurin inhibitor-based immunosuppression generally experience improvement in renal function, and may be less likely to develop de novo donor specific antibodies or new onset diabetes after transplantation. Although, belatacept based immunosuppression may increase the risk of early acute cellular rejection, it may however be beneficial in stabilization of long-term renal function and improvement in inflammation in patients with chronic active antibody mediated rejection. These benefits need to be counterweighed with risks of lack of response to severe acute respiratory syndrome coronavirus 2 vaccination and other adverse infectious outcomes. SUMMARY Belatacept may be an alternative to calcineurin inhibitors and may contribute to improved long term metabolic and allograft outcomes in kidney transplant recipients. Careful selection of patients for belatacept-based immunosuppression is needed, to obviate the risk of acute rejection shown in clinical studies.
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Affiliation(s)
| | - Irfan Moinuddin
- Division of Nephrology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University, Richmond, Virginia, USA
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Pechacek J, Yakubu I, Vissichelli NC, Bruno D, Morales MK. Successful expanded access use of rezafungin, a novel echinocandin, to eradicate refractory invasive candidiasis in a liver transplant recipient. J Antimicrob Chemother 2022; 77:2571-2573. [PMID: 35770840 DOI: 10.1093/jac/dkac206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Joseph Pechacek
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University, 1000 E. Marshall St., Richmond, VA 23298USA
| | - Idris Yakubu
- Department of Pharmacy, Virginia Commonwealth University Health, 1250 E. Marshall St., Richmond, VA 23298, USA
| | - Nicole C Vissichelli
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University, 1000 E. Marshall St., Richmond, VA 23298USA
| | - David Bruno
- Department of Surgery, Hume-Lee Transplant Center, Virginia Commonwealth University, 1250 E. Marshall St., Richmond, VA 23298, USA
| | - Megan K Morales
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University, 1000 E. Marshall St., Richmond, VA 23298USA
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Gupta G, Devarakonda T, Sharma A, Miles M, Yakubu I, Khan A, Sterling RK. Ultrashort Duration Prophylaxis for Hepatitis C Donor Positive to Recipient Negative Simultaneous Kidney/Pancreas Transplants. Transplantation 2022; 106:e234-e235. [PMID: 35333848 DOI: 10.1097/tp.0000000000004022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
| | | | - Aadi Sharma
- Virginia Commonwealth University, Richmond, VA
| | | | | | - Aamir Khan
- Virginia Commonwealth University, Richmond, VA
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Gupta G, Yakubu I, Zhang Y, Kimball P, Kang L, Mitchell K, Ijioma S, Carroll N, Patterson J, Shinbashi M, Kumar D, Moinuddin I, Kamal L, King A, Bhati C, Levy M, Cotterell A, Khan A, Sharma A, Sterling R. Outcomes of short-duration antiviral prophylaxis for hepatitis C positive donor kidney transplants. Am J Transplant 2021; 21:3734-3742. [PMID: 34212479 DOI: 10.1111/ajt.16747] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [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: 01/14/2021] [Revised: 06/22/2021] [Accepted: 06/22/2021] [Indexed: 01/25/2023]
Abstract
Trials describing 4- to 12-week courses of direct-acting antiviral drugs (DAAs) to treat hepatitis C virus (HCV) transmission from infected donors to uninfected kidney transplant recipients (D+/R- transplants) may be limited in "real-world" application by costs and delayed access to DAAs. We previously reported HCV transmission of 13% among D+/R- transplants with 2- to 4-day pangenotypic sofosbuvir/velpatasvir (SOF/VEL) perioperative prophylaxis, where one patient with HCV transmission was a nonresponder to first-line full-course DAA. Here, we report new data with a 7-day prophylaxis protocol (N = 50), as well as cumulative treatment and outcome data on all HCV D+/R- transplants (N = 102). Overall, nine patients (9/102; 9%; 95% CI: 5%-16%) developed HCV transmission, with a significant decline noted in the 7-day group (2/50; 4%; 95% CI: 0%-13%) compared with 2- to 4-day prophylaxis (7/52; 13%; 95% CI: 5%-25%). All patients with HCV transmission achieved sustained virologic response post full-course therapy (including one nonresponder from initial trial). A 1:1 matched analysis (N = 102) with contemporary HCV D-/R- transplants (controls) showed that although the pretransplant wait time was significantly shorter for D+/R- compared with D-/R- (mean: 1.8 vs. 4.4 years; p < .001), there were no differences in infections, rejection, development of de novo donor-specific antibody, or transplant outcomes up to 6 months of transplant.
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Affiliation(s)
- Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA.,Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Idris Yakubu
- Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
| | - Yiran Zhang
- Global Health Economics & Outcomes Research, Indivior Inc., Richmond, Virginia, USA
| | - Pamela Kimball
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Le Kang
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Kimberly Mitchell
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Stephen Ijioma
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
| | - Norman Carroll
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
| | - Julie Patterson
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
| | - Meagan Shinbashi
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Dhiren Kumar
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Irfan Moinuddin
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Layla Kamal
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Anne King
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA.,Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Chandra Bhati
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Marlon Levy
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Adrian Cotterell
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Aamir Khan
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Amit Sharma
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Richard Sterling
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA.,Section of Hepatology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
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Doligalski CT, Anger LB, Dick T, Feist A, Harris M, Masters B, Pilch N, Quan D, Sparkes T, Suarez T, Yakubu I. Considerations and approaches to expansion of solid organ transplant pharmacist services. J Am Coll Clin Pharm 2021. [DOI: 10.1002/jac5.1514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | | | - Travis Dick
- Department of Pharmacy University of Rochester Medical Center Rochester New York USA
| | - Ashley Feist
- Department of Pharmacy UC San Diego San Diego California USA
| | - Matt Harris
- Department of Pharmacy Duke University Hospitals Durham North Carolina USA
| | - Brian Masters
- Department of Pharmacy University of Maryland Medical Center Baltimore Maryland USA
| | - Nicole Pilch
- Department of Transplant Medical University of South Carolina Charleston South Carolina USA
| | - David Quan
- Department of Clinical Pharmacy UCSF Health San Francisco California USA
| | - Tracy Sparkes
- Department of Pharmacy University of Maryland Medical Center Baltimore Maryland USA
| | - Tricia Suarez
- Department of Pharmacy University of Iowa Hospitals and Clinics Iowa City Iowa USA
| | - Idris Yakubu
- Department of Pharmacy Virginia Commonwealth University Health System Richmond Virginia USA
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Tinkham T, Song CC, Winstead R, Yakubu I, Brown A, Sterling S, Gupta G, Kumar D. Changes in cytomegalovirus-specific T-cell immunity with immunomodulation in serodiscordant high-risk transplant recipients. Transpl Infect Dis 2021; 23:e13678. [PMID: 34181802 DOI: 10.1111/tid.13678] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 06/09/2021] [Accepted: 06/16/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Tyler Tinkham
- Department of Pharmacy, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Chelsey Chenxi Song
- Department of Pharmacy, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Ryan Winstead
- Department of Pharmacy, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Idris Yakubu
- Department of Pharmacy, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Andrew Brown
- Department of Pharmacy, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Sara Sterling
- Department of Pharmacy, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Dhiren Kumar
- Division of Nephrology, Virginia Commonwealth University Health System, Richmond, VA, USA
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Song CC, Brown A, Winstead R, Yakubu I, Demehin M, Kumar D, Gupta G. Early initiation of sodium-glucose linked transporter inhibitors (SGLT-2i) and associated metabolic and electrolyte outcomes in diabetic kidney transplant recipients. Endocrinol Diabetes Metab 2021; 4:e00185. [PMID: 33855198 PMCID: PMC8029504 DOI: 10.1002/edm2.185] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [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: 07/11/2020] [Revised: 08/12/2020] [Accepted: 08/15/2020] [Indexed: 12/16/2022] Open
Abstract
There is a paucity of data on the use of SGLT2 inhibitors on outcomes in kidney transplant recipients. There may be concern in initiating these agents, especially within the first year post-transplant when renal function is more labile and immunosuppression more intense, due to a presumed high risk of urinary infections and acute kidney injury. This is a retrospective study on 50 kidney transplant recipients, half of whom were started on therapy within the first year of transplant. Over a follow-up period of 6 months, overall patients had a statistically significant improvement in weight by -2.95 kg [SD 3.54, P = <.0001 (CI: 3.53, 1.50)] as well as hypomagnesemia 0.13 [SD 1.73, P = .0004 (CI: 0.06, 0.20)]. Overall insulin usage declined by -3.7 units [SD 22.8, P = .17]. 14% of patients had at least one urinary tract infection although this rate is not different (~20%) than that reported historically in this high-risk population.
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Affiliation(s)
- Chelsey Chenxi Song
- Hume‐Lee Transplant CenterVirginia Commonwealth University HealthRichmondVAUSA
| | - Andrew Brown
- Hume‐Lee Transplant CenterVirginia Commonwealth University HealthRichmondVAUSA
| | - Ryan Winstead
- Hume‐Lee Transplant CenterVirginia Commonwealth University HealthRichmondVAUSA
| | - Idris Yakubu
- Hume‐Lee Transplant CenterVirginia Commonwealth University HealthRichmondVAUSA
| | - Moses Demehin
- Hume‐Lee Transplant CenterVirginia Commonwealth University HealthRichmondVAUSA
| | - Dhiren Kumar
- Hume‐Lee Transplant CenterVirginia Commonwealth University HealthRichmondVAUSA
| | - Gaurav Gupta
- Hume‐Lee Transplant CenterVirginia Commonwealth University HealthRichmondVAUSA
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Winstead RJ, Kumar D, Brown A, Yakubu I, Song C, Thacker L, Gupta G. Letermovir prophylaxis in solid organ transplant—Assessing CMV breakthrough and tacrolimus drug interaction. Transpl Infect Dis 2021; 23:e13570. [DOI: 10.1111/tid.13570] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/16/2020] [Accepted: 01/03/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Ryan J. Winstead
- Department of Pharmacy Virginia Commonwealth University Health Richmond VA USA
| | - Dhiren Kumar
- Division of Nephrology Virginia Commonwealth University Richmond VA USA
| | - Andrew Brown
- Department of Pharmacy Virginia Commonwealth University Health Richmond VA USA
| | - Idris Yakubu
- Department of Pharmacy Virginia Commonwealth University Health Richmond VA USA
| | - Chelsey Song
- Department of Pharmacy Virginia Commonwealth University Health Richmond VA USA
| | - Leroy Thacker
- Department of Biostatistics Virginia Commonwealth University Richmond VA USA
| | - Gaurav Gupta
- Division of Nephrology Virginia Commonwealth University Richmond VA USA
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11
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Gupta G, Raynaud M, Kumar D, Sanghi P, Chang J, Kimball P, Kang L, Levy M, Sharma A, Bhati CS, Kamal L, Yakubu I, Massey HD, Kidd C, King AL, Halloran PF. Impact of belatacept conversion on kidney transplant function, histology, and gene expression - a single-center study. Transpl Int 2020; 33:1458-1471. [PMID: 32790889 DOI: 10.1111/tri.13718] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 05/04/2020] [Revised: 05/28/2020] [Accepted: 08/07/2020] [Indexed: 11/28/2022]
Abstract
Prior studies on belatacept conversion from calcineurin inhibitor (CNI) have been limited by an absence of postconversion surveillance biopsies that could underestimate subclinical rejection, or a case-controlled design. A total of 53 adult patients with allograft dysfunction underwent belatacept conversion (median: 6 months) post-transplant. At a median follow-up = 2.5 years, patient survival was 94% with a death-censored graft survival of 85%. Seven (13%) patients had acute rejection (including 3 subclinical) at median 6 months postconversion. Overall, eGFR improved (P = <0.001) from baseline = 31±15 to 40.2 ± 17.6 ml/min/1.73m2 by 6 months postconversion, but then stayed stable. This improvement was also observed (P < 0.001) in comparison with a propensity matched control cohort on CNI, where eGFR stayed stable (mean ~ 32ml/min/1.72m2 ) over 2-year follow-up. Patients converted < 6 months post-transplant were more likely to have a long-term improvement in kidney function. Paired gene expression analysis of 30 (of 53) consecutive pre- and postconversion surveillance biopsies did not reveal changes in inflammation/acute injury; although atrophy-fibrosis score worsened (mean = 0.28 to 0.44; P = 0.005). Thus, improvement in renal function with belatacept conversion occurred early and then sustained in comparison with controls where renal function remained unchanged overtime. We were unable to show molecular signals that could be related to CNI administration and regressed after withdrawal.
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Affiliation(s)
- Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Dhiren Kumar
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | - Pooja Sanghi
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | - Jessica Chang
- Alberta Transplant Applied Genomics Center, Edmonton, AB, Canada
| | - Pam Kimball
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Le Kang
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Marlon Levy
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Amit Sharma
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Chandra S Bhati
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Layla Kamal
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | - Idris Yakubu
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Hugh D Massey
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Chelsea Kidd
- Department of Pathology, Virginia Commonwealth University, Richmond, VA, USA
| | - Anne L King
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
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Kataria A, Yakubu I, Winstead R, Gowda M, Gupta G. COVID-19 in Kidney Transplantation: Epidemiology, Management Considerations, and the Impact on Kidney Transplant Practice. Transplant Direct 2020; 6:e582. [PMID: 33134506 PMCID: PMC7581117 DOI: 10.1097/txd.0000000000001031] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/12/2020] [Accepted: 06/14/2020] [Indexed: 12/13/2022] Open
Abstract
The novel severe acute respiratory syndrome coronavirus 2 was identified in the late 2019 as the cause of coronavirus disease 2019 (COVID-19), an acute respiratory viral illness. Patients with chronic underlying conditions may have an increased risk of morbidity and mortality from COVID-19. Kidney transplant recipients may be at a uniquely increased risk of serious complications from COVID-19 as compared to the general population because of a chronically immunosuppressed state and a high prevalence of comorbidities like diabetes, heart disease, and lung disease. Early data suggest that the mortality of patients on dialysis may be comparable to those with kidney transplants, although more research is needed. This concise review aims to describe the epidemiology of COVID-19 in kidney transplant recipients, manifestations, appropriate management, and clinical outcomes based on the available literature. Current evidence on many of the specific antiviral measures against COVID-19 has not shown a clear-cut benefit in smaller studies and the results of several ongoing larger clinical trials are awaited. In addition, we also highlight the impact of COVID-19 on kidney transplant center practice and volumes; potential living or deceased donors, recipients; and induction immunosuppression and surgical strategies.
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Affiliation(s)
| | - Idris Yakubu
- Virginia Commonwealth University Health System, Richmond, VA
| | - Ryan Winstead
- Virginia Commonwealth University Health System, Richmond, VA
| | | | - Gaurav Gupta
- Virginia Commonwealth University Health System, Richmond, VA
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Kumar D, Yakubu I, Safavi F, Levy M, Moinuddin I, Kimball P, Kamal L, King A, Massey D, Halloran P, Gupta G. Lack of Histological and Molecular Signature Response to Tocilizumab in Kidney Transplants with Chronic Active Antibody Mediated Rejection: A Case Series. Kidney360 2020; 1:663-670. [PMID: 35372943 DOI: 10.34067/kid.0000182019] [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] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 04/21/2020] [Indexed: 02/08/2023]
Abstract
Background Traditional therapies for caAbMR have unclear efficacy with significant side effects in recipients of kidney transplants (KTs). A recent single-center case series suggested tocilizumab (TCZ) could stabilize renal function and improve microvascular inflammation. Here we report our findings of the use of TCZ in patients with caAbMR. Methods Ten adult recipients of KTs with biopsy-proven caAbMR were treated with TCZ at 8 mg/kg per month. Patients were monitored for adverse events, and therapy was interrupted in the setting of serious infections. Six patients (60%) underwent post-treatment biopsies. Results Patients (mean age of 43 years) were initiated on TCZ at a median of 36 months post-KT. A majority of patients were black (70%), underwent regrafts (40%), and were sensitized (mean cPRA=41%). Patients received a median of six doses of TCZ (range=3-10). At a median follow-up of 12 months (range=8-24 months), renal function did not show improvement (mean eGFR, 42±18 ml/min per 1.73 m2 to 37±24 ml/min per 1.73 m2; P=0.27). The slope of decline in eGFR remained unchanged (-0.14±0.9 to -0.33±1.1; P=0.25). There was no improvement in mean MVI (g+ptc) (4.8±1.4 to 4.2±2.0; P=0.39) scores or Molecular Microscope Diagnostic System (MMDx) AbMR scores (0.79±0.17 to 0.78±0.26; P=0.86). There was a numeric worsening of chronicity (ci+ct) scores (2.5±0.8 to 3.3±1.7; P=0.38) and MMDx atrophy fibrosis scores (0.36±0.24 to 0.58±0.15; P=0.21). Patient survival was 90%, with one patient death due to complications from a hip infection. Overall death-censored graft survival was 80%, with two graft losses in patients who had recurrent infections requiring hospitalization. Conclusions In this early experience, we report a lack of efficacy and toxicity with the use of TCZ for caAbMR. Prospective clinical trials are needed to clarify the role of IL-6 blockade and the possibility of increased incidence of infections in patients with caAbMR who are treated with TCZ.
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Affiliation(s)
- Dhiren Kumar
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - Idris Yakubu
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - Frough Safavi
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - Marlon Levy
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - Irfan Moinuddin
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - Pamela Kimball
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - Layla Kamal
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - Anne King
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - Davis Massey
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - Philip Halloran
- Alberta Transplant Applied Genomics Center, Edmonton, Alberta, Canada
| | - Gaurav Gupta
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
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Gupta G, Yakubu I, Bhati CS, Zhang Y, Kang L, Patterson JA, Andrews-Joseph A, Alam A, Ferreira-Gonzalez A, Kumar D, Moinuddin IK, Kamal L, King AL, Levy M, Sharma A, Cotterell A, Reichman TW, Khan A, Kimball P, Stiltner R, Baldecchi M, Brigle N, Gehr T, Sterling RK. Ultra-short duration direct acting antiviral prophylaxis to prevent virus transmission from hepatitis C viremic donors to hepatitis C negative kidney transplant recipients. Am J Transplant 2020; 20:739-751. [PMID: 31652392 DOI: 10.1111/ajt.15664] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [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: 07/15/2019] [Revised: 10/10/2019] [Accepted: 10/13/2019] [Indexed: 01/25/2023]
Abstract
We conducted an adaptive design single-center pilot trial between October 2017 and November 2018 to determine the safety and efficacy of ultra-short-term perioperative pangenotypic direct acting antiviral (DAA) prophylaxis for deceased hepatitis C virus (HCV)-nucleic acid test (NAT) positive donors to HCV negative kidney recipients (D+/R-). In Group 1, 10 patients received one dose of SOF/VEL (sofusbuvir/velpatasvir) pretransplant and one dose on posttransplant Day 1. In Group 2A (N = 15) and the posttrial validation (Group 2B; N = 25) phase, patients received two additional SOF/VEL doses (total 4) on Days 2 and 3 posttransplant. Development of posttransplant HCV transmission triggered 12-week DAA therapy. For available donor samples (N = 27), median donor viral load was 1.37E + 06 IU/mL (genotype [GT]1a: 70%; GT2: 7%; GT3: 23%). Overall viral transmission rate was 12% (6/50; Group 1:30% [3/10]; Group 2A:13% [2/15]; Group 2B:4% [1/25]). For the 6 viremic patients, 5 (83%) achieved sustained virologic response (3 with first-line DAA therapy; and two after retreatment with second-line DAA). At a median follow-up of 8 months posttransplant, overall patient and allograft survivals were 98%, respectively. The 4-day strategy reduced viral transmission to 7.5% (3/40; 95% confidence interval [CI]: 1.8%-20.5%) and could result in avoidance of prolonged posttransplant DAA therapy for most D+/R - transplants.
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Affiliation(s)
- Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, Virginia.,Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Idris Yakubu
- Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Chandra S Bhati
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Yiran Zhang
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Le Kang
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - Julie A Patterson
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Ayana Andrews-Joseph
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Anam Alam
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | | | - Dhiren Kumar
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Irfan K Moinuddin
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Layla Kamal
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Anne L King
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, Virginia.,Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Marlon Levy
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Amit Sharma
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Adrian Cotterell
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Trevor W Reichman
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Aamir Khan
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Pamela Kimball
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Rodney Stiltner
- Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Mary Baldecchi
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Nathaniel Brigle
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Todd Gehr
- Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Richard K Sterling
- Division of Transplantation, Hume-Lee Transplant Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia.,Section of Hepatology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
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15
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Winstead RJ, Demehin M, Yakubu I, Song C, Brown A, Levy M, Gupta G. Sodium zirconium cyclosilicate use in solid organ transplant recipients and its effect on potassium and immunosuppression. Clin Transplant 2020; 34:e13791. [PMID: 31991491 DOI: 10.1111/ctr.13791] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 01/22/2020] [Indexed: 12/01/2022]
Affiliation(s)
| | - Moses Demehin
- Virginia Commonwealth University Health, Richmond, VA, USA
| | - Idris Yakubu
- Virginia Commonwealth University Health, Richmond, VA, USA
| | - Chelsey Song
- Virginia Commonwealth University Health, Richmond, VA, USA
| | - Andrew Brown
- Virginia Commonwealth University Health, Richmond, VA, USA
| | - Marlon Levy
- Virginia Commonwealth University Health, Richmond, VA, USA
| | - Gaurav Gupta
- Virginia Commonwealth University Health, Richmond, VA, USA
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16
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Yakubu I, Ravichandran B, Sparkes T, Barth RN, Haririan A, Masters B. Comparison of Alemtuzumab Versus Basiliximab Induction Therapy in Elderly Kidney Transplant Recipients: A Single-Center Experience. J Pharm Pract 2019; 34:199-206. [PMID: 31315501 DOI: 10.1177/0897190019850934] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The optimal choice of induction immunosuppression for elderly kidney transplant recipients remains unclear. Although alemtuzumab has been associated with escalating risk of death and graft loss in this population, this risk has not been adequately explored. The purpose of this study was to compare the safety and efficacy of alemtuzumab with basiliximab induction in this population. METHODS This is a retrospective matched cohort study of kidney transplant recipients aged ≥65 years. Patients who received alemtuzumab induction were matched (1:2) to a basiliximab control. The primary outcome was allograft survival. The incidence of acute rejection, infection, and all-cause mortality was measured. RESULTS Fifty-one and 102 patients were included in the alemtuzumab and basiliximab groups, respectively. Baseline demographics were similar between groups, except for more living donor transplant recipients in the alemtuzumab group (26/51 [51%] vs 31/102 [30.4%], P = .02). Acute cellular rejection occurred more frequently within the first year in the basiliximab group (P = .02). There was no difference in rates of infection within the first year. Graft and patient survival rates were similar over the follow-up period. Patients receiving basiliximab had a higher glomerular filtration rate at 2 years posttransplant (59 mL/min/1.73 m2 vs 49 mL/min/1.73 m2, P = .03). CONCLUSIONS Alemtuzumab induction is associated with similar outcomes to basiliximab in elderly kidney transplant recipients.
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Affiliation(s)
- Idris Yakubu
- Pharmacy, 21668University of Maryland Medical Center, Baltimore, MD, USA
| | | | - Tracy Sparkes
- Pharmacy, 21668University of Maryland Medical Center, Baltimore, MD, USA
| | - Rolf N Barth
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Abdolreza Haririan
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brian Masters
- Pharmacy, 21668University of Maryland Medical Center, Baltimore, MD, USA
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17
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Assi M, Engracia D, Yakubu I, Gupta G, Kurbanova N, Cruz ODL. 1138. Retrospective Cohort Analysis of Amphotericin B Nephrotoxicity in Kidney Transplant Recipients. Open Forum Infect Dis 2018. [PMCID: PMC6253972 DOI: 10.1093/ofid/ofy210.971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Treatment of invasive fungal infections with amphotericin B is a concern in kidney transplant patients due to fear of allograft loss. Reluctance to use amphotericin B may lead to suboptimal therapy and poor treatment outcomes. The risk of amphotericin B-related nephrotoxicity and allograft dysfunction has not been studied in kidney transplant patients. Our aim was to study the association between amphotericin B and acute kidney injury (AKI) as defined by the Acute Kidney Injury Network classification, allograft loss and patient mortality in kidney transplant recipients. Methods We used SPSS to conduct a descriptive analysis of a retrospective cohort of 30 adult kidney transplant recipients who were admitted to Virginia Commonwealth University Medical Center and received treatment with amphotericin B from 2005 to 2015. Results The median age in our cohort was 57. 40% were female, 60% were male. 60% had received a kidney transplant from a deceased donor; 13.3% from a living related donor; 13.3% from a living unrelated donor; and 13.3% had received a combined kidney–pancreas transplant. 63.3% of patients had received liposomal amphotericin B; 33.3% had received lipid-complex amphotericin B; 3.3% had received conventional amphotericin B. We found an association between cumulative amphotericin B doses above 5,000 mg and AKI, whereby 64.7% of patients exposed to less than 5,000 mg of amphotericin B developed AKI and 100% of patients exposed to more than 5,000 mg of amphotericin B developed AKI (P = 0.017). We did not find an association between cumulative amphotericin B doses above 5,000 mg and return to dialysis at 3 months and 12 months post-exposure (P = 0.436 and 0.288, respectively). We also did not find an association between such doses of amphotericin B and mortality at 30 and 90 days (P = 0.869 and 0.193, respectively). Conclusion In the first descriptive analysis of a retrospective cohort of kidney transplant patients exposed to amphotericin B, our results suggest that the risk of nephrotoxicity may be significantly increased when a cumulative dose of 5,000 milligrams is exceeded. Our results also suggest that amphotericin B doses associated with nephrotoxicity in kidney transplant patients may not have an effect on allograft survival and patient mortality. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Mariam Assi
- Internal Medicine, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Dominic Engracia
- School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Idris Yakubu
- Virginia Commonwealth University Health System, Richmond, Virginia
| | - Gaurav Gupta
- Nephrology, Virginia Commonwealth University Health System, Richmond, Virginia
| | | | - Oveimar De La Cruz
- Infectious Diseases, Virginia Commonwealth University Health System, Richmond, Virginia
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18
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Kumar D, Yakubu I, Cooke RH, Halloran PF, Gupta G. Belatacept rescue for delayed kidney allograft function in a patient with previous combined heart-liver transplant. Am J Transplant 2018; 18:2613-2614. [PMID: 29981184 DOI: 10.1111/ajt.15003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Dhiren Kumar
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | - Idris Yakubu
- Department of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA
| | - Richard H Cooke
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
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19
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Murphy JA, Schroeder MN, Rarus RE, Yakubu I, McKee SOP, Martin SJ. Implementation of a Cardiac Transitions of Care Pilot Program: A Prospective Study of Inpatient and Outpatient Clinical Pharmacy Services for Patients With Heart Failure Exacerbation or Acute Myocardial Infarction. J Pharm Pract 2017; 32:68-76. [PMID: 29183253 DOI: 10.1177/0897190017743129] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND: Pharmacists may assist with reducing 30-day readmission rates for patients with heart failure (HF) exacerbation or acute myocardial infarction (AMI) by promoting medication adherence. OBJECTIVE: To determine the change in 30-day readmission rates for patients with HF exacerbation or AMI after implementation of a "high-touch" standard of care. METHODS: Patients admitted with HF exacerbation, non-ST-segment elevation AMI, or ST-segment elevation AMI from August 1, 2013, to June 30, 2015, were included in this prospective study. Patients were educated while in the inpatient setting and followed up in the outpatient setting through telephone contact and scheduling a medication therapy management (MTM) appointment with a pharmacist. Data were collected by pharmacy personnel involved in the implementation of the intervention. RESULTS: Within the HF and AMI arms, 100 and 93 patients, respectively, were included in the study. The 30-day readmission rates were 24% and 17.2% for HF and AMI, respectively, which were not statistically significant when compared to historical institutional readmission rates prior to study initiation (18.2% for HF, P = .238; 11.4% for AMI, P = .252). CONCLUSION: A "high-touch" pharmacist-driven transitions of care program may affect 30-day readmission rates for patients with HF exacerbation or AMI; potential processes for initiating transitions of care programs are provided.
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Affiliation(s)
- Julie A Murphy
- 1 Department of Pharmacy Practice, University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, OH, USA
| | - Michelle N Schroeder
- 1 Department of Pharmacy Practice, University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, OH, USA
| | - Rachel E Rarus
- 2 Department of Pharmacy Services, University of Toledo Medical Center, Toledo, OH, USA
| | - Idris Yakubu
- 3 Virginia Commonwealth University Health System, Richmond, VA, USA
| | | | - Steven J Martin
- 5 College of Pharmacy, Ohio Northern University, Ada, OH, USA
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