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Binari LA, Thorne P, Rega SA, Feurer ID, Shawar S, Naik R, Birdwell KA, Helderman JH, Langone A, Sarrell BA, Schaefer H, DuBray BJ, Eid K, Hickman L, Shaffer D, Concepcion BP, Forbes RC. Twelve-month kidney and liver outcomes of kidney transplantation from Hepatitis C Viremic deceased donors to aviremic recipients. Transpl Infect Dis 2024; 26:e14213. [PMID: 38112078 PMCID: PMC10922352 DOI: 10.1111/tid.14213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 11/08/2023] [Accepted: 11/28/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION Utilization of hepatitis C viremic (HCV+) deceased donor kidneys (DDKT) for aviremic recipients increases opportunities for transplantation with excellent short-term outcomes. Our primary aim was to understand longer-term outcomes, specifically assessing kidney and liver function in the first year posttransplant. METHODS This was a retrospective single-center study of adult DDKT recipients of HCV+ kidneys (cases) matched 1:1 to recipients of HCV- kidneys (comparators). Between-group outcomes were analyzed using comparisons of means and proportions, survival analysis methods, and multivariable mixed effects models. RESULTS Sixty-five cases and 65 comparators had statistically comparable demographic and clinical characteristics. There were no between-group differences in serum creatinine or estimated glomerular filtration rate at month 12 (p = .662) or in their trajectories over months 1-12 (p > .292). Within the first 60 days, rates of liver function values >3 times upper limit of normal among cases were comparable to comparators for aspartate aminotransferase (AST) (14% vs. 6%, p = .242) and higher for alanine transaminase (ALT) (23% vs. 6%, p = .011). AST declined during the first 8 weeks (p = .005) and stabilized for both groups (p = .406) during the following 10 months. ALT declined during the first 8 weeks (p < .001), continued to decline over months 3-12 (p = .016), and the trajectory was unrelated to antiviral therapy initiation among cases. CONCLUSIONS Aviremic recipients of HCV+ kidneys had comparable kidney outcomes to matched recipients of HCV- kidneys. Despite more HCV+ recipients having an elevation in ALT within the first 60 days, ALT values normalized with no identified liver complications attributed to HCV.
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Affiliation(s)
- Laura A Binari
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Peter Thorne
- Division of Nephrology and Hypertension, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Scott A Rega
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Irene D Feurer
- Department of Surgery, Department of Biostatistics, Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Saed Shawar
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ruchi Naik
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Kelly A Birdwell
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - J Harold Helderman
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anthony Langone
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bonnie Ann Sarrell
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Heidi Schaefer
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bernard John DuBray
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kareem Eid
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Laura Hickman
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David Shaffer
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Beatrice P Concepcion
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Rachel C Forbes
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Liu M, Shaver CM, Birdwell KA, Heeney SA, Shaffer CM, Van Driest SL. Composite CYP3A phenotypes influence tacrolimus dose-adjusted concentration in lung transplant recipients. Pharmacogenet Genomics 2022; 32:209-217. [PMID: 35389944 PMCID: PMC9177686 DOI: 10.1097/fpc.0000000000000472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Interpatient variability in tacrolimus pharmacokinetics is attributed to metabolism by cytochrome P-450 3A4/5 isoenzymes (encoded by CYP3A4 and CYP3A5). Guidelines for adjusting tacrolimus based on CYP3A5 test results are published; however, CYP3A4 variants also contribute to the variability in tacrolimus pharmacokinetics. The effects of composite phenotypes incorporating CYP3A5 and CYP3A4 increased (*1G, *1B) and decreased (*22) function variants have not been evaluated. The objective of this study is to investigate the impact of both increased and decreased function CYP3A variants on weight and dose-adjusted tacrolimus concentration (C0/D). METHODS We performed a single-center retrospective cohort study of lung transplant recipients to evaluate the median tacrolimus C0/D by composite CYP3A phenotype groups during the index transplant hospitalization. CYP3A4 and CYP3A5 alleles were used to classify patients into four CYP3A groups from least to most CYP3A activity. Exploratory analyses of ABCB1 and additional candidate genes were also assessed. RESULTS Of the 92 included individuals, most (58) were CYP3A Group 2. The median tacrolimus C0/D differed significantly between CYP3A groups (P = 0.0001). CYP3A Group 2 median tacrolimus C0/D was 190.5 (interquartile range: 147.6-267.5) (ng/ml)/(mg/kg/d) and significantly higher than Group 4 [107.9 (90.4-116.1), P = 0.0001)]. Group 2 median tacrolimus C0/D did not significantly differ from Group 1 and Group 3 [373.5 (149.2-490.3) and 81.4 (62.6-184.1), respectively]. No significant differences in tacrolimus C0/D were found for the ABCB1 diplotypes. CONCLUSION These data indicate that a composite CYP3A phenotype incorporating both increase and decrease variant information from CYP3A4 in addition to CYP3A5 may significantly influence tacrolimus C0/D during the early postoperative period.
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Affiliation(s)
- Michelle Liu
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ciara M. Shaver
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kelly A. Birdwell
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephanie A. Heeney
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christian M. Shaffer
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sara L. Van Driest
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of General Pediatrics, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
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Daniel LL, Dickson AL, Zanussi JT, Miller‐Fleming TW, Straub PS, Wei W, Plummer WD, Dupont WD, Liu G, Anandi P, Reese TS, Birdwell KA, Kawai VK, Hung AM, Cox NJ, Feng Q, Stein CM, Chung CP. Predicted expression of genes involved in the thiopurine metabolic pathway and azathioprine discontinuation due to myelotoxicity. Clin Transl Sci 2022; 15:859-865. [PMID: 35118815 PMCID: PMC9010278 DOI: 10.1111/cts.13243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/13/2022] [Accepted: 01/24/2022] [Indexed: 12/14/2022] Open
Abstract
TPMT and NUDT15 variants explain less than 25% of azathioprine-associated myelotoxicity. There are 25 additional genes in the thiopurine pathway that could also contribute to azathioprine myelotoxicity. We hypothesized that among TPMT and NUDT15 normal metabolizers, a score combining the genetically predicted expression of other proteins in the thiopurine pathway would be associated with a higher risk for azathioprine discontinuation due to myelotoxicity. We conducted a retrospective cohort study of new users of azathioprine who were normal TPMT and NUDT15 metabolizers. In 1201 White patients receiving azathioprine for an inflammatory disease, we used relaxed Least Absolute Shrinkage and Selection Operator (LASSO) regression to select genes that built a score for discontinuing azathioprine due to myelotoxicity. The score incorporated the predicted expression of AOX1 and NME1. Patients in the highest score tertile had a higher risk of discontinuing azathioprine compared to those in the lowest tertile (hazard ratio [HR] = 2.15, 95% confidence interval [CI] = 1.11-4.19, p = 0.024). Results remained significant after adjusting for a propensity score, including sex, tertile of calendar year at initial dose, initial dose, age at baseline, indication, prior TPMT testing, and the first 10 principal components of the genetic data (HR = 2.11, 95% CI = 1.08-4.13, p = 0.030). We validated the results in a cohort (N = 517 non-White patients and those receiving azathioprine to prevent transplant rejection) that included all other patients receiving azathioprine (HR = 2.00, (95% CI = 1.09-3.65, p = 0.024). In conclusion, among patients who were TPMT and NUDT15 normal metabolizers, a score combining the predicted expression of AOX1 and NME1 was associated with an increased risk for discontinuing azathioprine due to myelotoxicity.
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Affiliation(s)
- Laura L. Daniel
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Alyson L. Dickson
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jacy T. Zanussi
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | | | - Peter S. Straub
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Wei‐Qi Wei
- Department of Biomedical InformaticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - W. Dale Plummer
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - William D. Dupont
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Ge Liu
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Prathima Anandi
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Tyler S. Reese
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Kelly A. Birdwell
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Vivian K. Kawai
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Adriana M. Hung
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA,Tennessee Valley Healthcare SystemNashvilleVirginiaUSA
| | - Nancy J. Cox
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - QiPing Feng
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - C. Michael Stein
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Cecilia P. Chung
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA,Tennessee Valley Healthcare SystemNashvilleVirginiaUSA
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4
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Yanis A, Haddadin Z, Spieker AJ, Waqfi D, Rankin DA, Talj R, Thomas L, Birdwell KA, Ezzell L, Blair M, Eason J, Varjabedian R, Warren CM, Nochowicz CH, Olson EC, Simmons JD, Yoder S, Guy M, Thomsen I, Chappell JD, Kalams SA, Halasa NB. Humoral and cellular immune responses to the SARS-CoV-2 BNT162b2 vaccine among a cohort of solid organ transplant recipients and healthy controls. Transpl Infect Dis 2022; 24:e13772. [PMID: 34905653 DOI: 10.1111/tid.13772] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/09/2021] [Accepted: 11/16/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with increased morbidity and mortality in solid organ transplant (SOT) recipients. Despite exclusion from SARS-CoV-2 vaccine clinical trials, these individuals were identified as high-risk and prioritized for vaccination in public health guidelines. METHODS We prospectively evaluated humoral and cellular immune responses to two doses of the SARS-CoV-2 mRNA vaccine, BNT162b2, in 56 SOT recipients and 26 healthy controls (HCs). Blood specimens collected from participants prior to each dose and following the second dose were tested for SARS-CoV-2-specific antibodies, as well as CD4+ and CD8+ T-cell responses. RESULTS SOT recipients demonstrated lower mean anti-SARS-CoV-2 antibody levels compared to HCs after each dose, and only 21.6% achieved an antibody response after the second dose within the range of HC responses. Similarly, the percentage of responsive CD4+ and CD8+ T cells in SOT recipients was lower than in HCs. While most HCs showed notable humoral and cellular responses, responses were less concordant in SOT recipients, with some showing evidence of either humoral or cellular response, but not both. CONCLUSION Humoral and cellular immune responses to the BNT162b2 vaccine are markedly reduced in SOT recipients as compared to HCs, suggesting that SOT recipients may benefit from more tailored regimens such as higher dose and/or additional vaccinations.
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Affiliation(s)
- Ahmad Yanis
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Zaid Haddadin
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrew J Spieker
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Danya Waqfi
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Danielle A Rankin
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Epidemiology PhD Program, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Rana Talj
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lora Thomas
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly A Birdwell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lauren Ezzell
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marcia Blair
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Joan Eason
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Rebekkah Varjabedian
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christian M Warren
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cynthia H Nochowicz
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eric C Olson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Joshua D Simmons
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sandra Yoder
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Madeline Guy
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Isaac Thomsen
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James D Chappell
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Spyros A Kalams
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University, Nashville, Tennessee, USA
| | - Natasha B Halasa
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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5
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Williams ML, Weeks HL, Beck C, Birdwell KA, Van Driest SL, Choi L. Sensitivity of Estimated Tacrolimus Population Pharmacokinetic Profile to Assumed Dose Timing and Absorption in Real World Data and Simulated Data. Br J Clin Pharmacol 2022; 88:2863-2874. [PMID: 34997625 DOI: 10.1111/bcp.15218] [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: 06/30/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 11/28/2022] Open
Abstract
A population pharmacokinetic (PK) study with 363 subjects was performed using real-world data extracted from electronic heath records (EHRs) to estimate the tacrolimus population PK profile. Data were extracted and built using our automated system, EHR2PKPD, suitable for quickly constructing large PK datasets from the EHR. Population PK studies for oral medications performed using EHR data often assume a regular dosing schedule as prescribed without incorporating exact dosing time. We assessed the sensitivity of the PK parameter estimates to assumptions about dose timing using last-dose times extracted by our own natural language processing system, medExtractR. We also investigated the sensitivity of estimates to absorption rate constants that are often fixed at a published value in tacrolimus population PK analyses. There was no appreciable difference in parameter estimates with assumed vs. extracted last-dose time, and our sensitivity analysis revealed little difference between parameters estimated across a range of assumed absorption rate constants. We conducted simulation studies to investigate how drug PK profiles and experimental designs such as concentration measurements design affect sensitivity to incorrect assumptions about dose timing and absorption rates. Our findings suggest that drugs with a slower elimination rate (or a longer half-life) are less sensitive to dose timing errors and that experimental designs which only allow for trough blood concentrations are usually insensitive to deviation in absorption rate.
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Affiliation(s)
- Michael L Williams
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Hannah L Weeks
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Cole Beck
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Kelly A Birdwell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Sara L Van Driest
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Leena Choi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
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6
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Dickson AL, Daniel LL, Zanussi J, Dale Plummer W, Wei WQ, Liu G, Reese T, Anandi P, Birdwell KA, Kawai V, Cox NJ, Dupont WD, Hung AM, Feng Q, Stein CM, Chung CP. TPMT and NUDT15 Variants Predict Discontinuation of Azathioprine for Myelotoxicity in Patients with Inflammatory Disease: Real-World Clinical Results. Clin Pharmacol Ther 2022; 111:263-271. [PMID: 34582038 PMCID: PMC8678305 DOI: 10.1002/cpt.2428] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/20/2021] [Indexed: 01/03/2023]
Abstract
Azathioprine is used frequently to treat several inflammatory conditions. However, treatment is limited by adverse events-in particular, myelotoxicity. Thiopurine-S-methyltransferase (TPMT) and nudix hydrolase-15 (NUDT15) are enzymes involved in azathioprine metabolism; variants in the genes encoding these enzymes increase the risk for azathioprine myelotoxicity. The Clinical Pharmacogenetics Implementation Consortium (CPIC) has recommended dose adjustments based on the results of TPMT and NUDT15 genotyping. However, little is known about the importance of this genetic information in routine clinical care. We hypothesized that in patients with inflammatory diseases, TPMT and NUDT15 genotype data predict the risk of discontinuing azathioprine due to myelotoxicity. This was a retrospective cohort study in 1,403 new adult azathioprine users for the management of inflammatory conditions for whom we had genetic information and clinical data. Among patients who discontinued azathioprine, we adjudicated the reason(s). Genotyping was performed using the Illumina Infinium Expanded Multi-Ethnic Genotyping Array plus custom content. We used CPIC guidelines to determine TPMT and NUDT15 metabolizer status; patients were grouped as either: (i) poor/intermediate, or (ii) normal/indeterminate metabolizers. We classified 110 patients as poor/intermediate, and 1,293 patients as normal/indeterminate metabolizers. Poor/intermediate status was associated with a higher risk for azathioprine discontinuation due to myelotoxicity compared to normal/indeterminate metabolizers (hazard ratio (HR) = 2.90, 95% confidence interval (CI): 1.58-5.31, P = 0.001). This association remained significant after adjustment for race, age at initiation, sex, primary indication, and initial daily dose of azathioprine (adjusted HR (aHR) = 2.67, 95% CI: 1.44-4.94, P = 0.002). In conclusion, TPMT and NUDT15 metabolizer status predicts discontinuation due to myelotoxicity for patients taking azathioprine for inflammatory conditions.
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Affiliation(s)
- Alyson L Dickson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Laura L Daniel
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jacy Zanussi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - W Dale Plummer
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Wei-Qi Wei
- Department of Bioinformatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ge Liu
- Department of Bioinformatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Tyler Reese
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Prathima Anandi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly A Birdwell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Vivian Kawai
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nancy J Cox
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Genetics Institute, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - William D Dupont
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adriana M Hung
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Tennessee Valley Healthcare System - Nashville Campus, Nashville, Tennessee, USA
| | - QiPing Feng
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - C Michael Stein
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cecilia P Chung
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Genetics Institute, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Tennessee Valley Healthcare System - Nashville Campus, Nashville, Tennessee, USA
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7
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Fallahzadeh MK, Birdwell KA. Waitlist Mortality for Second Kidney Transplants. Clin J Am Soc Nephrol 2022; 17:6-7. [PMID: 34965956 PMCID: PMC8763152 DOI: 10.2215/cjn.15021121] [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] [Indexed: 01/03/2023]
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8
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Abstract
Cardiovascular disease remains a leading cause of death and morbidity in kidney transplant recipients and a common reason for post-transplant hospitalization. Several traditional and nontraditional cardiovascular risk factors exist, and many of them present pretransplant and worsened, in part, due to the addition of immunosuppression post-transplant. We discuss optimal strategies for identification and treatment of these risk factors, including the emerging role of sodium-glucose cotransporter 2 inhibitors in post-transplant diabetes and cardiovascular disease. We present common types of cardiovascular disease observed after kidney transplant, including coronary artery disease, heart failure, pulmonary hypertension, arrhythmia, and valvular disease. We also discuss screening, treatment, and prevention of post-transplant cardiac disease. We highlight areas of future research, including the need for goals and best medications for risk factors, the role of biomarkers, and the role of screening and intervention.
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Affiliation(s)
- Kelly A. Birdwell
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Meyeon Park
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California
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9
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Muhammad A, Aka IT, Birdwell KA, Gordon AS, Roden DM, Wei WQ, Mosley JD, Van Driest SL. Genome-Wide Approach to Measure Variant-Based Heritability of Drug Outcome Phenotypes. Clin Pharmacol Ther 2021; 110:714-722. [PMID: 34151428 DOI: 10.1002/cpt.2323] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/16/2021] [Indexed: 12/18/2022]
Abstract
Pharmacogenomic studies have successfully identified variants-typically with large effect sizes in drug target and metabolism enzymes-that predict drug outcome phenotypes. However, these variants may account for a limited proportion of phenotype variability attributable to the genome. Using genome-wide common variation, we measured the narrow-sense heritability ( h SNP 2 ) of seven pharmacodynamic and five pharmacokinetic phenotypes across three cardiovascular drugs, two antibiotics, and three immunosuppressants. We used a Bayesian hierarchical mixed model, BayesR, to model the distribution of genome-wide variant effect sizes for each drug phenotype as a mixture of four normal distributions of fixed variance (0, 0.01%, 0.1%, and 1% of the total additive genetic variance). This model allowed us to parse h SNP 2 into bins representing contributions of no-effect, small-effect, moderate-effect, and large-effect variants, respectively. For the 12 phenotypes, a median of 969 (range 235-6,304) unique individuals of European ancestry and a median of 1,201,626 (range 777,427-1,514,275) variants were included in our analyses. The number of variants contributing to h SNP 2 ranged from 2,791 to 5,356 (median 3,347). Estimates for h SNP 2 ranged from 0.05 (angiotensin-converting enzyme inhibitor-induced cough) to 0.59 (gentamicin concentration). Small-effect and moderate-effect variants contributed a majority to h SNP 2 for every phenotype (range 61-95%). We conclude that drug outcome phenotypes are highly polygenic. Thus, larger genome-wide association studies of drug phenotypes are needed both to discover novel variants and to determine how genome-wide approaches may improve clinical prediction of drug outcomes.
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Affiliation(s)
- Ayesha Muhammad
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Ida T Aka
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly A Birdwell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adam S Gordon
- Department of Pharmacology, Northwestern University, Chicago, Illinois, USA.,Center for Genetic Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dan M Roden
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Wei-Qi Wei
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan D Mosley
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Rangaswami J, Mathew RO, Parasuraman R, Tantisattamo E, Lubetzky M, Rao S, Yaqub MS, Birdwell KA, Bennett W, Dalal P, Kapoor R, Lerma EV, Lerman M, McCormick N, Bangalore S, McCullough PA, Dadhania DM. Cardiovascular disease in the kidney transplant recipient: epidemiology, diagnosis and management strategies. Nephrol Dial Transplant 2020; 34:760-773. [PMID: 30984976 DOI: 10.1093/ndt/gfz053] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [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: 01/23/2019] [Indexed: 12/19/2022] Open
Abstract
Kidney transplantation (KT) is the optimal therapy for end-stage kidney disease (ESKD), resulting in significant improvement in survival as well as quality of life when compared with maintenance dialysis. The burden of cardiovascular disease (CVD) in ESKD is reduced after KT; however, it still remains the leading cause of premature patient and allograft loss, as well as a source of significant morbidity and healthcare costs. All major phenotypes of CVD including coronary artery disease, heart failure, valvular heart disease, arrhythmias and pulmonary hypertension are represented in the KT recipient population. Pre-existing risk factors for CVD in the KT recipient are amplified by superimposed cardio-metabolic derangements after transplantation such as the metabolic effects of immunosuppressive regimens, obesity, posttransplant diabetes, hypertension, dyslipidemia and allograft dysfunction. This review summarizes the major risk factors for CVD in KT recipients and describes the individual phenotypes of overt CVD in this population. It highlights gaps in the existing literature to emphasize the need for future studies in those areas and optimize cardiovascular outcomes after KT. Finally, it outlines the need for a joint 'cardio-nephrology' clinical care model to ensure continuity, multidisciplinary collaboration and implementation of best clinical practices toward reducing CVD after KT.
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Affiliation(s)
- Janani Rangaswami
- Einstein Medical Center, Philadelphia, PA, USA.,Sidney Kimmel College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Roy O Mathew
- Columbia Veterans Affairs Health Care System, Columbia, SC, USA
| | | | | | - Michelle Lubetzky
- Weill Cornell Medicine-New York Presbyterian Hospital, New York, NY, USA
| | - Swati Rao
- University of Virginia, Charlottesville, VA, USA
| | | | | | | | | | - Rajan Kapoor
- Augusta University Medical Center, Augusta, GA, USA
| | - Edgar V Lerma
- UIC/Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Mark Lerman
- Medical City Dallas Hospital, Dallas, TX, USA
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11
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Freedman BI, Moxey-Mims MM, Alexander AA, Astor BC, Birdwell KA, Bowden DW, Bowen G, Bromberg J, Craven TE, Dadhania DM, Divers J, Doshi MD, Eidbo E, Fornoni A, Gautreaux MD, Gbadegesin RA, Gee PO, Guerra G, Hsu CY, Iltis AS, Jefferson N, Julian BA, Klassen DK, Koty PP, Langefeld CD, Lentine KL, Ma L, Mannon RB, Menon MC, Mohan S, Moore JB, Murphy B, Newell KA, Odim J, Ortigosa-Goggins M, Palmer ND, Park M, Parsa A, Pastan SO, Poggio ED, Rajapakse N, Reeves-Daniel AM, Rosas SE, Russell LP, Sawinski D, Smith SC, Spainhour M, Stratta RJ, Weir MR, Reboussin DM, Kimmel PL, Brennan DC. APOL1 Long-term Kidney Transplantation Outcomes Network (APOLLO): Design and Rationale. Kidney Int Rep 2020; 5:278-288. [PMID: 32154449 PMCID: PMC7056919 DOI: 10.1016/j.ekir.2019.11.022] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 11/22/2019] [Accepted: 11/25/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Much of the higher risk for end-stage kidney disease (ESKD) in African American individuals relates to ancestry-specific variation in the apolipoprotein L1 gene (APOL1). Relative to kidneys from European American deceased-donors, kidneys from African American deceased-donors have shorter allograft survival and African American living-kidney donors more often develop ESKD. The National Institutes of Health (NIH)-sponsored APOL1 Long-term Kidney Transplantation Outcomes Network (APOLLO) is prospectively assessing kidney allograft survival from donors with recent African ancestry based on donor and recipient APOL1 genotypes. METHODS APOLLO will evaluate outcomes from 2614 deceased kidney donor-recipient pairs, as well as additional living-kidney donor-recipient pairs and unpaired deceased-donor kidneys. RESULTS The United Network for Organ Sharing (UNOS), Association of Organ Procurement Organizations, American Society of Transplantation, American Society for Histocompatibility and Immunogenetics, and nearly all U.S. kidney transplant programs, organ procurement organizations (OPOs), and histocompatibility laboratories are participating in this observational study. APOLLO employs a central institutional review board (cIRB) and maintains voluntary partnerships with OPOs and histocompatibility laboratories. A Community Advisory Council composed of African American individuals with a personal or family history of kidney disease has advised the NIH Project Office and Steering Committee since inception. UNOS is providing data for outcome analyses. CONCLUSION This article describes unique aspects of the protocol, design, and performance of APOLLO. Results will guide use of APOL1 genotypic data to improve the assessment of quality in deceased-donor kidneys and could increase numbers of transplanted kidneys, reduce rates of discard, and improve the safety of living-kidney donation.
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Affiliation(s)
- Barry I. Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Marva M. Moxey-Mims
- Division of Nephrology, Children's National Health System, Washington, DC, USA
| | - Amir A. Alexander
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Brad C. Astor
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kelly A. Birdwell
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University, Nashville, Tennessee, USA
| | - Donald W. Bowden
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Jonathan Bromberg
- Department of Surgery, Division of Transplantation, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Microbiology and Immunology, Division of Transplantation, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Timothy E. Craven
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Darshana M. Dadhania
- Division of Nephrology, Weill Cornell Medicine, New York, New York, USA
- Department of Transplantation Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Jasmin Divers
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Mona D. Doshi
- Division of Nephrology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Elling Eidbo
- Association of Organ Procurement Organizations, Vienna, Virginia, USA
| | - Alessia Fornoni
- Katz Family Division of Nephrology and Hypertension, Peggy and Harold Katz Drug Discovery Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Michael D. Gautreaux
- Human Leukocyte Antigen/Immunogenetics and Immunodiagnostics Laboratories, Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Rasheed A. Gbadegesin
- Department of Pediatrics, Division of Nephrology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Patrick O. Gee
- APOLLO Community Advisory Council, Cleveland Clinic, Cleveland, Ohio, USA
| | - Giselle Guerra
- Katz Family Division of Nephrology and Hypertension, Peggy and Harold Katz Drug Discovery Center, University of Miami Miller School of Medicine, Miami, Florida, USA
- Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Chi-yuan Hsu
- Department of Medicine, Division of Nephrology, University of California, San Francisco, San Francisco, California, USA
| | - Ana S. Iltis
- Center for Bioethics, Health and Society, Department of Philosophy, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Nichole Jefferson
- APOLLO Steering Committee, APOLLO Community Advisory Council, Dallas, Texas, USA
| | - Bruce A. Julian
- Department of Medicine, Division of Nephrology, University of Alabama School of Medicine in Birmingham, Birmingham, Alabama, USA
| | - David K. Klassen
- United Network for Organ Sharing, Office of the Chief Medical Officer, Richmond, Virginia, USA
| | - Patrick P. Koty
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Carl D. Langefeld
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Krista L. Lentine
- Department of Medicine, Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Lijun Ma
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Roslyn B. Mannon
- Department of Medicine, Division of Nephrology, University of Alabama School of Medicine in Birmingham, Birmingham, Alabama, USA
| | - Madhav C. Menon
- Department of Nephrology, Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Recanati-Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - J. Brian Moore
- Institutional Review Board, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Barbara Murphy
- Department of Nephrology, Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Recanati-Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kenneth A. Newell
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jonah Odim
- Transplantation Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Mariella Ortigosa-Goggins
- Katz Family Division of Nephrology and Hypertension, Peggy and Harold Katz Drug Discovery Center, University of Miami Miller School of Medicine, Miami, Florida, USA
- Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Nicholette D. Palmer
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Meyeon Park
- Department of Medicine, Division of Nephrology, University of California, San Francisco, San Francisco, California, USA
| | - Afshin Parsa
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Stephen O. Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Emilio D. Poggio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nishadi Rajapakse
- National Institutes of Health, National Institute on Minority Health and Health Disparities, Division of Scientific Programs, Bethesda, Maryland, USA
| | - Amber M. Reeves-Daniel
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Sylvia E. Rosas
- Kidney and Hypertension Unit, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts, USA
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Laurie P. Russell
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Deirdre Sawinski
- Renal Electrolyte and Hypertension Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - S. Carrie Smith
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Mitzie Spainhour
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Robert J. Stratta
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Matthew R. Weir
- Department of Medicine, Division of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - David M. Reboussin
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Paul L. Kimmel
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Daniel C. Brennan
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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12
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Choi L, Beck C, McNeer E, Weeks HL, Williams ML, James NT, Niu X, Abou-Khalil BW, Birdwell KA, Roden DM, Stein CM, Bejan CA, Denny JC, Van Driest SL. Development of a System for Postmarketing Population Pharmacokinetic and Pharmacodynamic Studies Using Real-World Data From Electronic Health Records. Clin Pharmacol Ther 2020; 107:934-943. [PMID: 31957870 DOI: 10.1002/cpt.1787] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 12/17/2019] [Indexed: 12/16/2022]
Abstract
Postmarketing population pharmacokinetic (PK) and pharmacodynamic (PD) studies can be useful to capture patient characteristics affecting PK or PD in real-world settings. These studies require longitudinally measured dose, outcomes, and covariates in large numbers of patients; however, prospective data collection is cost-prohibitive. Electronic health records (EHRs) can be an excellent source for such data, but there are challenges, including accurate ascertainment of drug dose. We developed a standardized system to prepare datasets from EHRs for population PK/PD studies. Our system handles a variety of tasks involving data extraction from clinical text using a natural language processing algorithm, data processing, and data building. Applying this system, we performed a fentanyl population PK analysis, resulting in comparable parameter estimates to a prior study. This new system makes the EHR data extraction and preparation process more efficient and accurate and provides a powerful tool to facilitate postmarketing population PK/PD studies using information available in EHRs.
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Affiliation(s)
- Leena Choi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cole Beck
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Elizabeth McNeer
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hannah L Weeks
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael L Williams
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nathan T James
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Xinnan Niu
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bassel W Abou-Khalil
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly A Birdwell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dan M Roden
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - C Michael Stein
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cosmin A Bejan
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Joshua C Denny
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sara L Van Driest
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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13
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Rangaswami J, Bangalore S, Kaplan B, Birdwell KA, Wiseman AC, McCullough PA, Dadhania DM. Cardiovascular disease care fragmentation in kidney transplantation: a call for action. Kidney Int 2019; 96:568-571. [DOI: 10.1016/j.kint.2019.04.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 03/27/2019] [Accepted: 04/23/2019] [Indexed: 11/16/2022]
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14
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Bock F, Stewart TG, Robinson-Cohen C, Morse J, Kabagambe EK, Cavanaugh KL, Birdwell KA, Hung AM, Abdel-Kader K, Siew ED, Akwo EA, Blot WJ, Ikizler TA, Lipworth L. Racial disparities in end-stage renal disease in a high-risk population: the Southern Community Cohort Study. BMC Nephrol 2019; 20:308. [PMID: 31390993 PMCID: PMC6686512 DOI: 10.1186/s12882-019-1502-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [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: 10/04/2018] [Accepted: 07/29/2019] [Indexed: 12/31/2022] Open
Abstract
Introduction The Southern Community Cohort Study is a prospective study of low socioeconomic status (SES) blacks and whites from the southeastern US, where the burden of end-stage renal disease (ESRD) and its risk factors are high. We tested whether the 2.4-fold elevated risk of ESRD we previously observed in blacks compared to whites was explained by differences in baseline kidney function. Methods We conducted a case-cohort study of incident ESRD cases (n = 737) with stored blood and a probability sampled subcohort (n = 4238) and calculated estimated glomerular filtration rate (eGFR) from serum creatinine. 86% of participants were enrolled from community health centers in medically underserved areas and 14% from the general population in 12 states in the southeastern United States. Incident ESRD after entry into the cohort was ascertained by linkage of the cohort with the US Renal Data System (USRDS). Results Median (25th, 75th percentile) eGFR at baseline was 63.3 (36.0, 98.2) ml/min/1.73m2 for ESRD cases and 103.2 (86.0, 117.9) for subcohort. Black ESRD cases had higher median (25th, 75th) eGFR [63.3 (35.9, 95.9)] compared to whites [59.1 (39.4, 99.2)]. In multivariable Cox models accounting for sampling weights, baseline eGFR was a strong predictor of ESRD risk, and an interaction with race was detected (P = 0.029). The higher ESRD risk among blacks relative to whites persisted (hazard ratio: 2.58; 95% confidence interval: 1.65, 4.03) after adjustment for eGFR. Conclusion In this predominantly lower SES cohort, the racial disparity in ESRD risk is not explained by differences in baseline kidney function. Electronic supplementary material The online version of this article (10.1186/s12882-019-1502-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Fabian Bock
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt-O'Brien Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Thomas G Stewart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cassianne Robinson-Cohen
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt-O'Brien Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jennifer Morse
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edmond K Kabagambe
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, 2525 West End Ave, Ste 600, Nashville, TN, 37203, USA
| | - Kerri L Cavanaugh
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt-O'Brien Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kelly A Birdwell
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt-O'Brien Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Adriana M Hung
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt-O'Brien Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt-O'Brien Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward D Siew
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt-O'Brien Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elvis A Akwo
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt-O'Brien Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - William J Blot
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, 2525 West End Ave, Ste 600, Nashville, TN, 37203, USA
| | - T Alp Ikizler
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt-O'Brien Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Loren Lipworth
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, 2525 West End Ave, Ste 600, Nashville, TN, 37203, USA. .,Vanderbilt-O'Brien Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, TN, USA.
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15
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Stapleton CP, Birdwell KA, McKnight AJ, Maxwell AP, Mark PB, Sanders ML, Chapman FA, van Setten J, Phelan PJ, Kennedy C, Jardine A, Traynor JP, Keating B, Conlon PJ, Cavalleri GL. Polygenic risk score as a determinant of risk of non-melanoma skin cancer in a European-descent renal transplant cohort. Am J Transplant 2019; 19:801-810. [PMID: 30085400 PMCID: PMC6367067 DOI: 10.1111/ajt.15057] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 07/26/2018] [Accepted: 07/26/2018] [Indexed: 01/25/2023]
Abstract
Renal transplant recipients have an increased risk of non-melanoma skin cancer (NMSC) compared to in the general population. Here, we show polygenic risk scores (PRS) calculated from genome-wide association studies (GWAS) of NMSC in a general, nontransplant setting, can predict risk of, and time to posttransplant skin cancer. Genetic variants, reaching predefined P-value thresholds were chosen from published squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) nontransplant GWAS. Using these GWAS, BCC and SCC PRS were calculated for each sample across three European ancestry renal transplant cohorts (n = 889) and tested as predictors of case:control status and time to NMSC posttransplant. BCC PRS calculated at P-value threshold 1 × 10-5 was the most significant predictor of case:control status of NMSC posttransplant (OR = 1.61; adjusted P = .0022; AUC [full model adjusted for clinical predictors and PRS] = 0.81). SCC PRS at P-value threshold 1 × 10-5 was the most significant predictor of time to posttransplant NMSC (adjusted P = 9.39 × 10-7 ; HR = 1.41, concordance [full model] = 0.74). PRS of nontransplant NMSC is predictive of case:control status and time to NMSC posttransplant. These results are relevant to how genomics can risk stratify patients to help develop personalized treatment regimens.
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Affiliation(s)
- Caragh P. Stapleton
- Department of Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Kelly A. Birdwell
- Department of Medicine, Vanderbilt University Medical Centre, Tennessee, USA
| | | | | | - Patrick B. Mark
- Institute of Cardiovascular and Medical Sciences, BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | | | - Fiona A. Chapman
- Institute of Cardiovascular and Medical Sciences, BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Jessica van Setten
- Department of Cardiology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Paul J. Phelan
- Department of Nephrology, Royal Infirmary of Edinburgh, NHS Lothian, UK
| | - Claire Kennedy
- Department of Nephrology, Beaumont Hospital, Dublin, Ireland
| | - Alan Jardine
- Institute of Cardiovascular and Medical Sciences, BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Jamie P. Traynor
- Institute of Cardiovascular and Medical Sciences, BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Brendan Keating
- Department of Surgery, Penn Transplant Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter J. Conlon
- Department of Nephrology, Beaumont Hospital, Dublin, Ireland
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Gianpiero L. Cavalleri
- Department of Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin, Ireland
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16
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Affiliation(s)
| | - Cecilia P. Chung
- Division of Rheumatology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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17
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O'Leary JM, Assad TR, Xu M, Birdwell KA, Farber-Eger E, Wells QS, Hemnes AR, Brittain EL. Pulmonary hypertension in patients with chronic kidney disease: invasive hemodynamic etiology and outcomes. Pulm Circ 2017; 7:674-683. [PMID: 28660793 PMCID: PMC5841902 DOI: 10.1177/2045893217716108] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Pulmonary hypertension (PH) is common in patients with chronic kidney disease (CKD) and associated with increased mortality but the hemodynamic profiles, clinical risk factors, and outcomes have not been well characterized. Our objective was to define the hemodynamic profile and related risk factors for PH in CKD patients. We extracted clinical and hemodynamic data from Vanderbilt's de-identified electronic medical record on all patients undergoing right heart catheterization during 1998-2014. CKD (stages III-V) was defined by estimated glomerular filtration rate thresholds. PH was defined as mean pulmonary pressure ≥ 25 mmHg and categorized into pre-capillary and post-capillary according to consensus recommendations. In total, 4635 patients underwent catheterization: 1873 (40%) had CKD; 1518 (33%) stage 3, 230 (5%) stage 4, and 125 (3%) stage 5. PH was present in 1267 (68%) of these patients. Post-capillary (n = 965, 76%) was the predominant PH phenotype among CKD patients versus 302 (24%) for pre-capillary ( P < 0.001). CKD was independently associated with pulmonary hypertension (odds ratio = 1.4, 95% confidence interval = 1.18-1.65). Mortality among CKD patients rose with worsening stage and was significantly increased by PH status. PH is common and independently associated with mortality among CKD patients referred for right heart catheterization. Post-capillary was the most common etiology of PH. These data suggest that PH is an important prognostic co-morbidity among CKD patients and that CKD itself may have a role in the development of pulmonary vascular disease in some patients.
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Affiliation(s)
- Jared M O'Leary
- 1 Vanderbilt University Medical Center Division of Cardiovascular Medicine, Nashville, TN, USA
| | - Tufik R Assad
- 2 Vanderbilt University Medical Center Division of Allergy, Pulmonary and Critical Care Medicine, Nashville, TN, USA
| | - Meng Xu
- 3 Vanderbilt University Department of Biostatistics, Nashville, TN, USA
| | - Kelly A Birdwell
- 4 Vanderbilt University Medical Center Division of Nephrology, Nashville, TN, USA
| | - Eric Farber-Eger
- 1 Vanderbilt University Medical Center Division of Cardiovascular Medicine, Nashville, TN, USA
| | - Quinn S Wells
- 1 Vanderbilt University Medical Center Division of Cardiovascular Medicine, Nashville, TN, USA
| | - Anna R Hemnes
- 2 Vanderbilt University Medical Center Division of Allergy, Pulmonary and Critical Care Medicine, Nashville, TN, USA
| | - Evan L Brittain
- 1 Vanderbilt University Medical Center Division of Cardiovascular Medicine, Nashville, TN, USA
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Kensinger C, Hernandez A, Bian A, Fairchild M, Chen G, Lipworth L, Ikizler TA, Birdwell KA. Longitudinal assessment of cardiac morphology and function following kidney transplantation. Clin Transplant 2016; 31. [PMID: 27801526 DOI: 10.1111/ctr.12864] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2016] [Indexed: 01/06/2023]
Abstract
BACKGROUND Abnormal cardiac morphology is a risk factor for cardiovascular complications in kidney transplant patients. A supraphysiologic level of fibroblast growth factor 23 (FGF-23) has been associated with myocardial hypertrophy in this patient population. Our aim was to evaluate the change in cardiac morphology and function following kidney transplantation and to evaluate the association between the change in FGF-23 concentrations and cardiac morphology. METHODS We performed a longitudinal, prospective cohort study of 143 kidney transplant recipients (73% male, 75% white) measuring left ventricular (LV) mass index, left atrial (LA) volume index, and ejection fraction (EF) by echocardiography at months 1, 12, and 24 post-transplant. FGF-23 levels were measured at months 1 and 24 post-transplant. RESULTS Unadjusted and adjusted linear mixed-effects models were used to examine changes in outcomes over time. In the adjusted model, LV mass index (P<.001) and LA volume index (P<.001) decreased and EF (P=.009) increased significantly over time. There was a significant association between decreasing FGF-23 levels and improving LV mass index following transplant (P=.036) in the unadjusted model; however, there was no significant relationship in the adjusted model (0.195). CONCLUSION Understanding the progression of unique cardiovascular risk factors associated with kidney transplantation may provide potential opportunities to improve survival.
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Affiliation(s)
- Clark Kensinger
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Antonio Hernandez
- Department of Clinical Anesthesiology, Division of Critical Care Medicine and Cardiothoracic Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aihua Bian
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Meagan Fairchild
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Guanhua Chen
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Loren Lipworth
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - T Alp Ikizler
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kelly A Birdwell
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
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Lipworth L, Abdel-Kader K, Morse J, Stewart TG, Kabagambe EK, Parr SK, Birdwell KA, Matheny ME, Hung AM, Blot WJ, Ikizler TA, Siew ED. High prevalence of non-steroidal anti-inflammatory drug use among acute kidney injury survivors in the southern community cohort study. BMC Nephrol 2016; 17:189. [PMID: 27881100 PMCID: PMC5122006 DOI: 10.1186/s12882-016-0411-7] [Citation(s) in RCA: 29] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 11/18/2016] [Indexed: 12/24/2022] Open
Abstract
Background Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used and have been linked to acute kidney injury (AKI), chronic kidney disease (CKD) and cardiovascular disease (CVD). Patients who survive an AKI episode are at risk for future adverse kidney and cardiovascular outcomes. The objective of our study was to examine the prevalence and predictors of NSAID use among AKI survivors. Methods The Southern Community Cohort Study is a prospective study of low-income adults aged 40–79 in the southeastern US. Through linkage with Centers for Medicare and Medicaid Services, 826 participants with an AKI diagnosis (ICD-9 584.5-584.9) at any age prior to cohort enrollment were identified. At baseline, data were collected on regular use of prescription and over-the-counter NSAIDs, as well as demographic, medical and other characteristics. Additional comorbidities were ascertained via linkage with CMS or the US Renal Data System. Results One hundred fifty-four AKI survivors (19%) reported regular NSAID use at cohort enrollment (52 prescription, 81 OTC, 21 both) and the percentage of NSAID users did not vary by time since AKI event. Over 58% of users were taking NSAIDS regularly both before and after their AKI event. Hypertension (83%), arthritis (71%), heart failure (44%), CKD (36%) and diabetes (35%) were prevalent among NSAID users. In a multivariable model, history of arthritis (OR: 3.00; 95% CI: 1.92, 4.68) and acetaminophen use (OR: 2.43; 95% CI: 1.50, 3.93) were significantly associated with NSAID use, while prevalent CKD (OR: 0.63; 95% CI: 0.41, 0.98) and diabetes (OR: 0.44; 95% CI: 0.29, 0.69) were significantly inversely associated. Conclusions NSAID use among AKI survivors is common and highlights the need to understand physician and patient decision-making around NSAIDs and to develop effective strategies to reduce NSAID use in this vulnerable population. Electronic supplementary material The online version of this article (doi:10.1186/s12882-016-0411-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Loren Lipworth
- Department of Medicine, Division of Epidemiology, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Nashville, TN, USA
| | - Khaled Abdel-Kader
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Nashville, TN, USA.,Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jennifer Morse
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Thomas G Stewart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edmond K Kabagambe
- Department of Medicine, Division of Epidemiology, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Nashville, TN, USA
| | - Sharidan K Parr
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Nashville, TN, USA.,Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Healthcare System (TVHS) VA Medical Center, TVHS Geriatric Research Education and Clinical Centers (GRECC), Veteran's Health Administration, Nashville, TN, USA
| | - Kelly A Birdwell
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Nashville, TN, USA.,Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael E Matheny
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Nashville, TN, USA.,Tennessee Valley Healthcare System (TVHS) VA Medical Center, TVHS Geriatric Research Education and Clinical Centers (GRECC), Veteran's Health Administration, Nashville, TN, USA
| | - Adriana M Hung
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Nashville, TN, USA.,Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Healthcare System (TVHS) VA Medical Center, TVHS Geriatric Research Education and Clinical Centers (GRECC), Veteran's Health Administration, Nashville, TN, USA
| | - William J Blot
- Department of Medicine, Division of Epidemiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - T Alp Ikizler
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Nashville, TN, USA.,Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Healthcare System (TVHS) VA Medical Center, TVHS Geriatric Research Education and Clinical Centers (GRECC), Veteran's Health Administration, Nashville, TN, USA
| | - Edward D Siew
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for Acute Kidney Injury Research (VIP-AKI), Nashville, TN, USA. .,Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA. .,Tennessee Valley Healthcare System (TVHS) VA Medical Center, TVHS Geriatric Research Education and Clinical Centers (GRECC), Veteran's Health Administration, Nashville, TN, USA.
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20
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O’Leary JM, Assad T, Hemnes A, Xu M, Wells Q, Farber-Eger E, Birdwell KA, Brittain E. PULMONARY HYPERTENSION AND CHRONIC KIDNEY DISEASE: INVASIVE HEMODYNAMIC ETIOLOGY AND OUTCOMES IN A LARGE ELECTRONIC MEDICAL RECORD-BASED COHORT. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)32049-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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21
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Birdwell KA, Decker B, Barbarino JM, Peterson JF, Stein CM, Sadee W, Wang D, Vinks AA, He Y, Swen JJ, Leeder JS, van Schaik R, Thummel KE, Klein TE, Caudle KE, MacPhee IAM. Clinical Pharmacogenetics Implementation Consortium (CPIC) Guidelines for CYP3A5 Genotype and Tacrolimus Dosing. Clin Pharmacol Ther 2015; 98:19-24. [PMID: 25801146 DOI: 10.1002/cpt.113] [Citation(s) in RCA: 439] [Impact Index Per Article: 48.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/03/2015] [Indexed: 12/11/2022]
Abstract
Tacrolimus is the mainstay immunosuppressant drug used after solid organ and hematopoietic stem cell transplantation. Individuals who express CYP3A5 (extensive and intermediate metabolizers) generally have decreased dose-adjusted trough concentrations of tacrolimus as compared with those who are CYP3A5 nonexpressers (poor metabolizers), possibly delaying achievement of target blood concentrations. We summarize evidence from the published literature supporting this association and provide dosing recommendations for tacrolimus based on CYP3A5 genotype when known (updates at www.pharmgkb.org).
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Affiliation(s)
- K A Birdwell
- Division of Nephrology Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - B Decker
- Division of Nephrology and Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - J M Barbarino
- Department of Genetics, Stanford University, Stanford, California, USA
| | - J F Peterson
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee, USA
| | - C M Stein
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA.,Department of Pharmacology, Vanderbilt University, Nashville, Tennessee, USA
| | - W Sadee
- Center for Pharmacogenomics, School of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - D Wang
- Center for Pharmacogenomics, School of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - A A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Y He
- Institute of Clinical Pharmacology, Central South University, Changsha, Hunan, Peoples Republic of China
| | - J J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - J S Leeder
- Division of Clinical Pharmacology and Therapeutic Innovation, Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Rhn van Schaik
- Department of Clinical Chemistry, Erasmus MC Rotterdam, The Netherlands
| | - K E Thummel
- Department of Pharmaceutics, University of Washington, Seattle, Washington, USA
| | - T E Klein
- Department of Genetics, Stanford University, Stanford, California, USA
| | - K E Caudle
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - I A M MacPhee
- Institute of Medical and Biomedical Education, Renal Medicine, St. George's, University of London, London, UK
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Oliveira da Fonseca E, Jittirat A, Birdwell KA, Fogo AB. Myoglobin cast nephropathy in a kidney transplant patient with normal creatine kinase. Am J Kidney Dis 2014; 65:628-31. [PMID: 25441432 DOI: 10.1053/j.ajkd.2014.07.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 07/27/2014] [Indexed: 11/11/2022]
Abstract
Delayed graft function in kidney transplant recipients is a known complication associated with increased risk of acute rejection and reduced transplant survival after 1 year. There are multiple risk factors, including prolonged cold ischemia time, donor age, and cause of donor's death. Major causes of delayed graft function are acute kidney injury in the donor, often from prolonged terminal ischemia, reflected by acute tubular injury in the recipient. However, the differential diagnosis of delayed graft function includes acute rejection, recurrence of the primary glomerular diseases, and other less commonly encountered conditions. A transplant kidney biopsy usually is required to elucidate the correct cause and initiate the right treatment, which is crucial for transplant survival. We report a case of a transplant recipient who developed delayed graft function due to an uncommon cause. After correct diagnosis, the patient's transplant function improved.
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Affiliation(s)
- Elissa Oliveira da Fonseca
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN
| | - Arksarapuk Jittirat
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Kelly A Birdwell
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Agnes B Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN; Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN.
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Oetjens M, Bush WS, Birdwell KA, Dilks HH, Bowton EA, Denny JC, Wilke RA, Roden DM, Crawford DC. Utilization of an EMR-biorepository to identify the genetic predictors of calcineurin-inhibitor toxicity in heart transplant recipients. Pac Symp Biocomput 2014:253-264. [PMID: 24297552 PMCID: PMC3923429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Calcineurin-inhibitors CI are immunosuppressive agents prescribed to patients after solid organ transplant to prevent rejection. Although these drugs have been transformative for allograft survival, long-term use is complicated by side effects including nephrotoxicity. Given the narrow therapeutic index of CI, therapeutic drug monitoring is used to prevent acute rejection from underdosing and acute toxicity from overdosing, but drug monitoring does not alleviate long-term side effects. Patients on calcineurin-inhibitors for long periods almost universally experience declines in renal function, and a subpopulation of transplant recipients ultimately develop chronic kidney disease that may progress to end stage renal disease attributable to calcineurin inhibitor toxicity (CNIT). Pharmacogenomics has the potential to identify patients who are at high risk for developing advanced chronic kidney disease caused by CNIT and providing them with existing alternate immunosuppressive therapy. In this study we utilized BioVU, Vanderbilt University Medical Center's DNA biorepository linked to de-identified electronic medical records to identify a cohort of 115 heart transplant recipients prescribed calcineurin-inhibitors to identify genetic risk factors for CNIT We identified 37 cases of nephrotoxicity in our cohort, defining nephrotoxicity as a monthly median estimated glomerular filtration rate (eGFR)<30 mL/min/1.73 m2 at least six months post-transplant for at least three consecutive months. All heart transplant patients were genotyped on the Illumina ADME Core Panel, a pharmacogenomic genotyping platform that assays 184 variants across 34 genes. In Cox regression analysis adjusting for age at transplant, pre-transplant chronic kidney disease, pre-transplant diabetes, and the three most significant principal components (PCAs), we did not identify any markers that met our multiple-testing threshold. As a secondary analysis we also modeled post-transplant eGFR directly with linear mixed models adjusted for age at transplant, cyclosporine use, median BMI, and the three most significant principal components. While no SNPs met our threshold for significance, a SNP previously identified in genetic studies of the dosing of tacrolimus CYP34A rs776746, replicated in an adjusted analysis at an uncorrected p-value of 0.02 (coeff(S.E.)=14.60(6.41)). While larger independent studies will be required to further validate this finding, this study underscores the EMRs usefulness as a resource for longitudinal pharmacogenetic study designs.
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Affiliation(s)
| | - William S. Bush
- Department of Biomedical Informatics, Center for Human Genetics Research
| | | | - Holli H. Dilks
- Vanderbilt Technologies for Advanced Genomics Core Facility
| | | | | | | | - Dan M. Roden
- Department of Medicine, Department of Pharmacology, Office of Personalized Medicine
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Birdwell KA, Ikizler MR, Wang L, Byrne DW, Sannella EC, Wright PF, Ikizler TA. Seasonal maintenance of influenza vaccine-induced antibody response in kidney transplant recipients. Am J Nephrol 2012; 36:201-7. [PMID: 22906930 DOI: 10.1159/000341653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 07/03/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Although annual influenza vaccination is recommended for kidney transplant recipients, efficacy as reflected by serum antibody titers has not been well studied beyond 1 month in kidney transplant recipients. METHODS We performed a single-center prospective cohort study of 51 kidney transplant recipients and 102 healthy controls receiving the 2006-2007 influenza vaccine. Anti-hemagglutinin antibody titers to A/H1N1, A/H3N2, and B were measured before and 1 month after vaccination, and again at the end of influenza season. The primary outcome was the proportion of participants maintaining seroprotection (antibody titer ≥1:32) for the duration of the influenza season after influenza vaccination. RESULTS Median follow-up time was 175 and 155 days in the transplant and control groups, respectively. For types A/H1N1 and B, a similar high proportion of the transplant and control groups (88.5 and 81.6% vs. 83.7 and 74.2% for A/H1N1 and B, respectively) maintained seroprotection. For type A/H3N2, significantly less of the transplant group (66.7%) versus the control group (90%) maintained a protective influenza vaccine response (odds ratio 0.21, 95% confidence interval 0.07-0.64). This difference disappeared in adjusted analyses. Actual geometric mean titers decreased significantly within both groups (p < 0.001) but this did not differ between groups. CONCLUSIONS Once they have developed protective vaccine-induced antibody responses to influenza vaccine, kidney transplant recipients are able to maintain adequate protective levels of antibody compared with healthy controls.
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Affiliation(s)
- Kelly A Birdwell
- Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN, USA.
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Xu H, Doan S, Birdwell KA, Cowan JD, Vincz AJ, Haas DW, Basford MA, Denny JC. An automated approach to calculating the daily dose of tacrolimus in electronic health records. Summit Transl Bioinform 2010; 2010:71-5. [PMID: 21347153 PMCID: PMC3041548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Clinical research often requires extracting detailed drug information, such as medication names and dosages, from Electronic Health Records (EHR). Since medication information is often recorded as both structured and unstructured formats in the EHR, extracting all the relevant drug mentions and determining the daily dose of a medication for a selected patient at a given date can be a challenging and time-consuming task. In this paper, we present an automated approach using natural language processing to calculate daily doses of medications mentioned in clinical text, using tacrolimus as a test case. We evaluated this method using data sets from four different types of unstructured clinical data. Our results showed that the system achieved precisions of 0.90-1.00 and recalls of 0.81-1.00.
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Affiliation(s)
- Hua Xu
- Department of Biomedical Informatics
| | - Son Doan
- Department of Biomedical Informatics
| | | | | | | | - David W. Haas
- Department of Medicine;,Department of Microbiology and Immunology
| | - Melissa A. Basford
- Vanderbilt Institute for Clinical and Translational Research, School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Joshua C. Denny
- Department of Biomedical Informatics;,Department of Medicine
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Birdwell KA, Ikizler MR, Sannella EC, Wang L, Byrne DW, Ikizler TA, Wright PF. Decreased antibody response to influenza vaccination in kidney transplant recipients: a prospective cohort study. Am J Kidney Dis 2009; 54:112-21. [PMID: 19185404 DOI: 10.1053/j.ajkd.2008.09.023] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2008] [Accepted: 09/30/2008] [Indexed: 11/11/2022]
Abstract
BACKGROUND Antibody response to the inactivated influenza vaccine is not well described in kidney transplant recipients administered newer, but commonly used, immunosuppression medications. We hypothesized that kidney transplant recipient participants administered tacrolimus-based regimens would have decreased antibody response compared with healthy controls. STUDY DESIGN Prospective cohort study of 53 kidney transplant recipients and 106 healthy control participants during the 2006-2007 influenza season. All participants received standard inactivated influenza vaccine. SETTING & PARTICIPANTS Kidney transplant recipients administered tacrolimus-based regimens at a single academic medical center and healthy controls. PREDICTOR Presence of kidney transplant. OUTCOMES Proportion of participants achieving seroresponse (4-fold increase in antibody titer) and seroprotection (antibody titer > or = 1:32) 1 month after vaccination. MEASUREMENTS Antibody titers before and 1 month after vaccination by means of hemagglutinin inhibition assays for influenza types A/H1N1, A/H3N2, and B. RESULTS A smaller proportion of the transplantation group compared with the healthy control group developed the primary outcomes of seroresponse or seroprotection for all 3 influenza types at 1 month after vaccination. The response to influenza type A/H3N2 was statistically different; the transplantation group had 69% decreased odds of developing seroresponse (95% confidence interval, 0.16 to 0.62; P = 0.001) and 78% decreased odds of developing seroprotection (95% confidence interval, 0.09 to 0.53; P = 0.001) compared with healthy controls. When participants less than 6 months from the time of transplantation were considered, this group had a significantly decreased response to the vaccine compared with healthy controls. LIMITATIONS Decreased sample size, potential for confounders, outcome measure used is the standard but does not give information about vaccine efficacy. CONCLUSIONS Kidney transplant recipients, especially within 6 months of transplantation, had diminished antibody response to the 2006-2007 inactivated influenza vaccine.
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Affiliation(s)
- Kelly A Birdwell
- Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN, USA
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