1
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Khalil K, Tsapepas D, West-Thielke P. Transplant Pharmacists' Experience With Telehealth During the COVID-19 Pandemic. J Pharm Pract 2024; 37:307-310. [PMID: 36218440 PMCID: PMC9554573 DOI: 10.1177/08971900221132594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background: The adoption of telehealth became a necessity for healthcare organizations during the COVID-19 pandemic. Transplant pharmacists are integral members of the multi-disciplinary care team who quickly adapted application of these technologies to ensure continuity of care. Objective: To assess transplant pharmacists' experience with telehealth during the COVID-19 pandemic. Methods: A 23-question online survey was developed to assess transplant pharmacists' experience with telehealth during the COVID-19 pandemic. Results: Forty-five pharmacists responded to the survey from a broad range of transplant centers. The majority of respondents indicated infrequent use of telehealth (98%) before the COVID-19 pandemic, but this was significantly changed during the pandemic with only 9% reporting infrequent use. Pharmacists anticipated a decrease in future use, but 91% of respondents stated they would like to continue utilization of telehealth in their practice post-pandemic. Conclusions: The adoption of telehealth during COVID-19 was widespread and has the potential to facilitate continuity of care. Though pharmacists anticipated a decrease in future use, a majority favored continued utilization of telehealth in their practice.
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Affiliation(s)
- Karen Khalil
- Department of Pharmacy, NYU Langone Health, New York, NY, USA
| | - Demetra Tsapepas
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
- Department of Transplantation, New York-Presbyterian Hospital, New York, NY, USA
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2
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Muran CS, Khamo N, Patel R, Patel S, West-Thielke P, Fayyaz N, Choi D. Evaluation of prior authorizations in transplant recipients at an urban institution. Clin Transplant 2023:e14964. [PMID: 36940175 DOI: 10.1111/ctr.14964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 01/24/2023] [Accepted: 02/27/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Increasing prior authorization (PA) requirements for immunosuppression remain a burden for solid organ transplant (SOT) recipients and transplant staff. The objective of this study was to evaluate the number of PAs required and the approval rates at an academic, urban transplant center. METHODS This was a retrospective study of SOT recipients at the University of Illinois Hospital and Health Sciences System (UI Health) that required PAs between 11/1/2019 and 12/1/2020. Inclusion criteria were SOT recipients greater than 18 years of age and prescribed a medication by the transplant team that required PA. Duplicate PA requests were excluded from the analysis. RESULTS A total of 879 PAs were included in the study. Of these PAs, 85% (747/879) were approved. Seventy-four percent of the denials were overturned by an appeal. Most PAs were in black (45.4%), kidney transplant (62%), Medicare (31.7%), and Medicaid recipients (33.2%). The median approval time was 1 day for PAs and 5 days for appeals. Tacrolimus extended release (XR) (35.4%), tacrolimus immediate release (IR) (9.7%),and mycophenolic acid (7%) required most PAs. Black recipients and immunosuppression were identified as predictors of eventual PA approval, whereas recipients with Medicaid were less likely to obtain approval. CONCLUSIONS At our transplant center, there was a high approval rate of PAs for immunosuppression, which calls into question the utility of PAs in this patient population, where these medications are standard of care. More black recipients and patients with Medicare and Medicaid had increased PA requirements, highlighting further disparities within the current system.
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Affiliation(s)
- Cassie S Muran
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA.,Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Nehrin Khamo
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ruchik Patel
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | | | | | - Nida Fayyaz
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - David Choi
- Department of Pharmacy, Division of Gastroenterology and Hepatology, University of Chicago Medicine, Chicago, Illinois, USA
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3
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Leung T, Cober T, Hickey J, Stach L, Kawano A, Szczepanik A, Watson A, Imamura Y, Weems J, West-Thielke P. Clinical Utility of the OmniGraf Biomarker Panel in the Care of Kidney Transplant Recipients (CLARITY): Protocol for a Prospective, Multisite Observational Study. JMIR Res Protoc 2022; 11:e41020. [PMID: 36515980 PMCID: PMC9798265 DOI: 10.2196/41020] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/23/2022] [Accepted: 09/30/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Death with a functioning allograft has become the leading category of graft loss in kidney transplant recipients at all time points. Previous analyses have demonstrated that causes of death in kidney transplant recipients are predominated by comorbidities strongly associated with immunosuppressant medications. Adverse drug events (ADEs) have been strongly associated with nonadherence, health care utilization, and graft loss; clinicians face a difficult decision on whether making immunosuppressant adjustments in the face of ADEs will improve symptomology or simply increase the risk of acute rejection. Clinicians also face a treatment quandary in 50% of kidney transplant recipients with stage 3 or worse chronic kidney disease at 1 year post transplantation, as progressive decline in renal function has been strongly associated with inferior allograft survival. OBJECTIVE The primary objective of the CLinical Utility of the omnigrAf biomarkeR Panel In The Care of kidneY Transplant Recipients (CLARITY) trial is to evaluate change in renal function over time in kidney transplant recipients who are undergoing OmniGraf monitoring in conjunction with monitoring of their medication-related symptom burden (MRSB). A secondary objective of this study is to identify the impact of OmniGraf use in conjunction with patient-reported MRSB as part of clinical care on patients' self-efficacy and quality of life. METHODS CLARITY is a 3-year prospective, multisite, observational study of 2000 participants with a matched control, measuring the impact of real-time patients' MRSB and the OmniGraf biomarker panel on change in renal function over time. Secondary outcome measures include the Patient-Reported Outcomes Measurement Information System (PROMIS) Self-Efficacy for Managing Chronic Conditions-Managing Medications and Treatment-Short Form 4a; the PROMIS-29 Profile (version 2.1); the PROMIS Depression Scale, hospitalizations-subcategorized for hospitalizations owing to infections; treated rejections, MRSB, and proportion of participants with overall graft survival at year 3 post transplantation; graft loss or death during the 3-year study follow-up period; and change in provider satisfaction. RESULTS The primary outcome measure of the study will be a comparison of the slope change in estimated glomerular filtration rate from baseline to the end of follow-up between study participants and a matched control group. Secondary outcome measures include changes over time in PROMIS Self-Efficacy for Managing Chronic Conditions-Managing Medications and Treatment-Short Form 4a, the PROMIS-29 Profile (version 2.1), and PROMIS Depression Scale in the study group, as well as a comparison of hospitalizations and causes, rejections, and graft and patient survival compared between participants and a matched cohort. The anticipated first enrollment in the study is October 2022 with data analysis and publication expected in October 2027. CONCLUSIONS Through this report, we describe the study design, methods, and outcome measures that will be utilized in the ongoing CLARITY trial. TRIAL REGISTRATION ClinicalTrials.gov NCT05482100; https://clinicaltrials.gov/ct2/show/NCT05482100. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/41020.
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Affiliation(s)
| | - Timothy Cober
- Transplant Genomics, Inc, Framingham, MA, United States
| | | | - Leslie Stach
- Transplant Genomics, Inc, Framingham, MA, United States
| | | | | | - Alicia Watson
- Transplant Genomics, Inc, Framingham, MA, United States
| | - Yuka Imamura
- Transplant Genomics, Inc, Framingham, MA, United States
| | - Juston Weems
- Transplant Genomics, Inc, Framingham, MA, United States
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4
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Choi DK, Patel S, Muran C, Khamo N, Patel R, Fayyaz N, West-Thielke P. Prior Authorization Burden on the Use of LCP-Tacrolimus in Abdominal Solid Organ Transplant Recipients. Ann Pharmacother 2021; 56:856-857. [PMID: 34612712 DOI: 10.1177/10600280211050641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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5
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Kaufman D, Woodle ES, Shields A, Leone J, Matas A, Wiseman A, West-Thielke P, Sa T, King E, Alloway R. Belatacept for Simultaneous Calcineurin Inhibitor and Chronic Corticosteroid Immunosuppression Avoidance. Clin J Am Soc Nephrol 2021; 16:1387-1397. [PMID: 34233921 PMCID: PMC8729588 DOI: 10.2215/cjn.13100820] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 06/23/2021] [Indexed: 11/23/2022]
Abstract
Immunosuppressive therapy in kidney transplantation is associated with numerous toxicities. CD28-mediated T cell costimulation blockade using belatacept may reduce long-term nephrotoxicity, compared with calcineurin inhibitor-based immunosuppression. The efficacy and safety of simultaneous calcineurin inhibitor avoidance and rapid steroid withdrawal were tested in a randomized, prospective, multi-center study. Methods All kidney transplants were performed using rapid steroid withdrawal immunosuppression. Recipients were randomized to 1:1:1 to receive belatacept with alemtuzumab induction, belatacept with rabbit antithymocyte globulin (rATG) induction, or tacrolimus with rATG induction. The composite endpoint consisted of death, kidney allograft loss, or an MDRD calculated eGFR of <45 ml/min/1.73m2 at 2 years. Results The composite endpoint was observed for 11/107 (10%) participants assigned to belatacept/alemtuzumab, 13/104 (13%) assigned to belatacept /rATG, and 21/105 (21%) assigned to tacrolimus/rATG (belatacept/alemtuzumab vs tacrolimus/rATG p = 0.99: belatacept/rATG vs tacrolimus/rATG p = 0.66). Patient and graft survival rates were similar between all groups. eGFR <45 ml/min/1.73m2 was observed for 9/107 (8%) participants assigned to belatacept/alemtuzuab, 8/104 (8%) participants assigned to belatacept/rATG, and 20/105 (19%) participants assigned to tacrolimus/rATG (p<0.05 for each belatacept group vs tacrolimus/rATG). Biopsy-proven acute rejection was observed for 20/107 (19%) participants assigned to belatacept/alemtuzuab, 26/104 (25%) participants assigned to belatacept/rATG, and 7/105 (7%) participants assigned to tacrolimus/rATG (belatacept/alemtuzumab vs tacrolimus/rATG p = 0.006: belatacept/rATG vs tacrolimus/rATG p < 0.001). Gastrointestinal and neurologic adverse events were less frequent with belatacept versus calcineurin based immunosuppression. Conclusions Overall two-year outcomes were similar comparing maintenance immunosuppression based on belatacept versus tacrolimus, each protocol with rapid steroid withdrawal. The incidence of eGFR <45 ml/min/1.73m2 was significantly lower but the incidence of biopsy proven acute rejection significantly higher with belatacept compared with tacrolimus.
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Affiliation(s)
- Dixon Kaufman
- D Kaufman, University of Wisconsin-Madison, Madison, United States
| | - E Steve Woodle
- E Woodle, University of Cincinnati College of Medicine, Cincinnati, United States
| | - Adele Shields
- A Shields, University of Cincinnati College of Medicine, Cincinnati, United States
| | - John Leone
- J Leone, Tampa General Hospital, Tampa, United States
| | - Arthur Matas
- A Matas, University of Minnesota, Minneapolis, United States
| | | | | | - Ting Sa
- T Sa, Biostastics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, United States
| | - Eileen King
- E King, University of Cincinnati College of Medicine, Cincinnati, United States
| | - Rita Alloway
- R Alloway, University of Cincinnati College of Medicine, Cincinnati, United States
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6
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Lichvar A, Pierce D, Benken J, West-Thielke P, Tzvetanov I, Benedetti E. Obesity impacts acute rejection but not allograft function improvement in the setting of belatacept conversion. Clin Transplant 2021; 35:e14290. [PMID: 33772879 DOI: 10.1111/ctr.14290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Alicia Lichvar
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA.,Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Dana Pierce
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
| | - Jamie Benken
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA.,Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Ivo Tzvetanov
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Enrico Benedetti
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
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7
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Maldonado AQ, West-Thielke P, Joyal K, Rogers C. Advances in personalized medicine and noninvasive diagnostics in solid organ transplantation. Pharmacotherapy 2021; 41:132-143. [PMID: 33156560 DOI: 10.1002/phar.2484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 09/29/2020] [Accepted: 10/08/2020] [Indexed: 12/13/2022]
Abstract
Personalized medicine has been a mainstay and in practice in transplant pharmacotherapy since the advent of the field. Decisions pertaining to the diagnosis, selection, and monitoring of transplant pharmacotherapy are aimed toward the individual, the allograft, and the overall immunologic needs of the patient. Recent advances in pharmacogenomics, noninvasive biomarkers, and artificial intelligence (AI) technologies have the promise of transforming the way we individualize treatment and monitor allograft function. Pharmacogenomic testing can provide clinicians with additional data that can minimize toxicity and maximize therapeutic dosing in high-risk patients, leading to more informed decisions that may decrease the risk of rejection and adverse outcomes related to immunosuppressive therapies. Development of noninvasive strategies to monitor allograft function may offer safer and more convenient methods to detect allograft injury. Cell free DNA and gene expression profiling offer the potential to serve as "liquid biopsies" minimizing the risk to patients and providing clinicians with useful molecular data that may help individualize immunosuppression and rejection treatment. Use of big data in transplant and novel AI platforms, such as the iBox, hold tremendous promise in providing clinicians a "glimpse into the future" thereby allowing for a more individualized approach to immunosuppressive therapy that may minimize future adverse outcomes. Advances in diagnostics, laboratory science, and AI have made the application of personalized medicine even more tailored for solid organ transplant recipients. In this perspective, we summarize the current and emerging tools available, literature supporting use, and the horizon for future personalization of transplantation.
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Affiliation(s)
| | | | - Kayla Joyal
- Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
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8
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Woodle ES, Kaufman DB, Shields AR, Leone J, Matas A, Wiseman A, West-Thielke P, Sa T, King EC, Alloway RR. Belatacept-based immunosuppression with simultaneous calcineurin inhibitor avoidance and early corticosteroid withdrawal: A prospective, randomized multicenter trial. Am J Transplant 2020; 20:1039-1055. [PMID: 31680394 DOI: 10.1111/ajt.15688] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/18/2019] [Accepted: 10/23/2019] [Indexed: 01/25/2023]
Abstract
Simultaneous calcineurin inhibitor avoidance (CNIA) and early corticosteroid withdrawal (ESW) have not been achieved primarily due to excessive acute rejection. This trial compared 2 belatacept-based CNIA/ESW regimens with a tacrolimus-based ESW regimen. Kidney transplant recipients were randomized to receive alemtuzumab/belatacept, rabbit anti-thymocyte globulin (rATG)/belatacept, or rATG/tacrolimus. The combinatorial primary endpoint consisted of patient death, renal allograft loss, or a Modification of Diet in Renal Disease-calculated eGFR of <45 mL/min/1.73 m2 at 12 months. Results are reported by treatment group (alemtuzumab/belatacept, rATG/belatacept, and rATG/tacrolimus). Superiority was not observed at 1 year for the primary endpoint (9/107 [8.4%], 15/104 [14.4%], and 14/105 [13.3%], respectively; P = NS) for either belatacept-based regimen. Differences were not observed for secondary endpoints (death, death-censored graft loss, or estimated glomerular filtration rates < 45 mL/min/1.73 m2 ). Differences were observed in biopsy-proved acute cellular rejection (10.3%, 18.3%, and 1.9%, respectively) (P < .001), but not in antibody-mediated rejection, mixed acute rejection, or de novo donor-specific anti-HLA antibodies. Neurologic and electrolyte abnormality adverse events were less frequent under belatacept. Belatacept-based CNIA/ESW regimens did not prove to be superior for the primary or secondary endpoints. Belatacept-treated patients demonstrated an increase in biopsy-proved acute cellular rejection and reduced neurologic and metabolic adverse events. These results demonstrate that simultaneous CNIA/ESW is feasible without excessive acute rejection.
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Affiliation(s)
- E Steve Woodle
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Adele R Shields
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | | | | | | | - Ting Sa
- Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
| | - Eileen C King
- University of Cincinnati College of Medicine, Cincinnati, Ohio.,Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
| | - Rita R Alloway
- University of Cincinnati College of Medicine, Cincinnati, Ohio
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9
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Mansell H, Rosaasen N, West-Thielke P, Wichart J, Daley C, Mainra R, Shoker A, Liu J, Blackburn D. Randomised controlled trial of a video intervention and behaviour contract to improve medication adherence after renal transplantation: the VECTOR study protocol. BMJ Open 2019; 9:e025495. [PMID: 30872550 PMCID: PMC6429879 DOI: 10.1136/bmjopen-2018-025495] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Non-adherence after kidney transplantation contributes to increased rejections, hospitalisations and healthcare expenditures. Although effective adherence interventions are sorely needed, increasing education and support to transplant recipients demands greater use of care providers' time and resources in a healthcare system that is stretched. The objective of this clinical trial is to determine the effectiveness of an electronically delivered video series and adherence behaviour contract on improving medication adherence to immunosuppressant medications. METHODS AND ANALYSIS A multicentre, parallel arm, randomised controlled trial will be conducted with four sites across North America (Saskatoon, Calgary, Halifax, Chicago). Adult patients will be randomised (1:1) to either the intervention (ie, home-based video education +behaviour contract plus usual care) or usual care alone. De novo transplant recipients will be enrolled prior to their hospital discharge and will be provided with electronic access to the video intervention (immediately) and adherence contract (1 month post-transplant). Follow-up electronic surveys will be provided at 3 and 12 months postenrolment. The primary outcome will be adherence at 12 months post-transplant, as measured by self-report Basel Assessment of Adherence to Immunosuppressive medications and immunosuppressant levels. Secondary outcomes include the difference in knowledge score between the intervention and control in groups (measured by the Kidney Transplant Understanding Tool); differences in self-efficacy (Generalised Self-efficacy Scale), Beliefs of Medicine Questionnaire (BMQ), quality of life (Short Form-12), patient satisfaction and cost utilisation. The study aims to recruit at least 200 participants across participating sites. ETHICS AND DISSEMINATION Ethical approval was obtained from the University of Saskatchewan Behavioural Ethics Committee (Beh 18-63), and all patients provide informed consent prior to participating. This educational intervention aims to improve information retention and self-efficacy, leading to improved medication adherence after kidney transplantation, at low cost, with little impact to existing healthcare personnel. If proven beneficial, delivery can be easily implemented into standard of care. TRIAL REGISTRATION NUMBER NCT03540121; Pre-results.
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Affiliation(s)
- Holly Mansell
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Nicola Rosaasen
- Saskatchewan Transplant Program, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Patricia West-Thielke
- Department of Surgery, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
| | - Jenny Wichart
- Southern Alberta Transplant Program, Alberta Health Services, Calgary, Alberta, Canada
| | - Christopher Daley
- Multi-organ Transplant Program of Atlantic Canada, Halifax, Nova Scotia, Canada
| | - Rahul Mainra
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Ahmed Shoker
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Juxin Liu
- College of Arts and Science, University of Saskatchewan, Saskatoon, SK, Canada
| | - David Blackburn
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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10
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Maldonado AQ, West-Thielke P, Dew MA, Peipert JD, Heldenbrand S, Kaiser TE, Chisholm-Burns M, Potter LM. Meeting report: Consensus recommendations for a research agenda to address immunosuppressant nonadherence in organ transplantation. Clin Transplant 2018; 32:e13362. [DOI: 10.1111/ctr.13362] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 07/13/2018] [Accepted: 07/24/2018] [Indexed: 11/26/2022]
Affiliation(s)
| | | | - Mary Amanda Dew
- University of Pittsburgh; School of Medicine and Medical Center; Pittsburgh Pennsylvania
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11
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West-Thielke P, Progar K, Campara M, Jasiak N, Gallon L, Tang I, Spaggiari M, Tzvetanov I, Benedetti E. Eculizumab for Prevention of Antibody-Mediated Rejection in Blood Group-Incompatible Renal Transplantation. Transplant Proc 2018; 50:66-69. [PMID: 29407333 DOI: 10.1016/j.transproceed.2017.12.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 12/09/2017] [Indexed: 12/28/2022]
Abstract
Antibody-mediated rejection (AMR) is one of the leading causes of allograft failure especially in patients undergoing ABO-incompatible (ABOi) renal transplantation. We hypothesized that complement inhibition with eculizumab, a C5 inhibitor, would protect against AMR and maintain graft function in ABOi renal transplant recipients. Four patients undergoing living donor kidney transplant from ABOi donors were treated with a 9-week eculizumab course without therapeutic plasma exchange, intravenous immunoglobulin, or splenectomy. All patients had successful transplants and have normal graft function at the time of last follow-up. There were no cases of AMR or acute cellular rejection. Of note, 2 patients were transplanted despite persistent ABO antibody titers of 1:32, conventionally considered a contraindication to proceed in standard protocols. Eculizumab is a promising option to prevent AMR with ABOi renal transplantation without the need for splenectomy, post-transplant therapeutic plasma exchange, and intravenous immunoglobulin. Future multicenter studies are needed to determine long-term efficacy and safety.
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Affiliation(s)
- P West-Thielke
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA.
| | - K Progar
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - M Campara
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - N Jasiak
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - L Gallon
- Department of Nephrology, Northwestern University, Chicago, Illinois, USA
| | - I Tang
- Department of Nephrology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - M Spaggiari
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - I Tzvetanov
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - E Benedetti
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
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12
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Trofe-Clark J, Brennan DC, West-Thielke P, Milone MC, Lim MA, Neubauer R, Nigro V, Bloom RD. Results of ASERTAA, a Randomized Prospective Crossover Pharmacogenetic Study of Immediate-Release Versus Extended-Release Tacrolimus in African American Kidney Transplant Recipients. Am J Kidney Dis 2017; 71:315-326. [PMID: 29162334 DOI: 10.1053/j.ajkd.2017.07.018] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [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: 01/23/2017] [Accepted: 07/20/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Differences in tacrolimus dosing across ancestries is partly attributable to polymorphisms in CYP3A5 genes that encode tacrolimus-metabolizing cytochrome P450 3A5 enzymes. The CYP3A5*1 allele, preponderant in African Americans, is associated with rapid metabolism, subtherapeutic concentrations, and higher dose requirements for tacrolimus, all contributing to worse outcomes. Little is known about the relationship between CYP3A5 genotype and the tacrolimus pharmacokinetic area under the curve (AUC) profile in African Americans or whether pharmacogenetic differences exist between conventional twice-daily, rapidly absorbed, immediate-release tacrolimus (IR-Tac) and once-daily extended-release tacrolimus (LifeCycle Pharma Tac [LCPT]) with a delayed absorption profile. STUDY DESIGN Randomized prospective crossover study. SETTING & PARTICIPANTS 50 African American maintenance kidney recipients on stable IR-Tac dosing. INTERVENTION Recipients were randomly assigned to continue IR-Tac on days 1 to 7 and then switch to LCPT on day 8 or receive LCPT on days 1 to 7 and then switch to IR-Tac on day 8. The LCPT dose was 85% of the IR-Tac total daily dose. OUTCOMES Tacrolimus 24-hour AUC (AUC0-24), peak and trough concentrations (Cmax and Cmin), time to peak concentration, and bioavailability of LCPT versus IR-Tac, according to CYP3A5 genotype. MEASUREMENTS CYP3A5 genotype, 24-hour tacrolimus pharmacokinetic profiles. RESULTS ∼80% of participants carried the CYP3A5*1 allele (CYP3A5 expressers). There were no significant differences in AUC0-24 or Cmin between CYP3A5 expressers and nonexpressers during administration of either IR-Tac or LCPT. With IR-Tac, tacrolimus Cmax was 33% higher in CYP3A5 expressers compared with nonexpressers (P=0.04): With LCPT, this difference was 11% (P=0.4). LIMITATIONS This was primarily a pharmacogenetic study rather than an efficacy study; the follow-up period was too short to capture clinical outcomes. CONCLUSIONS Achieving therapeutic tacrolimus trough concentrations with IR-Tac in most African Americans results in significantly higher peak concentrations, potentially magnifying the risk for toxicity and adverse outcomes. This pharmacogenetic effect is attenuated by delayed tacrolimus absorption with LCPT. TRIAL REGISTRATION Registered at ClinicalTrials.gov, with study number NCT01962922.
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Affiliation(s)
- Jennifer Trofe-Clark
- Department of Pharmacy Services, Hospital of the University of Pennsylvania, Philadelphia, PA; Renal Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Michael C Milone
- Perelman School of Medicine, University of Pennsylvania, Penn Institute for Immunology, Philadelphia, PA
| | - Mary Ann Lim
- Renal Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Robin Neubauer
- Renal Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Roy D Bloom
- Renal Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Ayloo SM, D'Amico G, West-Thielke P, Bejarano-Pineda L, Tzvetanov I, Giulianotti PC, Benedetti E, Oberholzer J. Combined Robot-assisted Kidney Transplantation and Sleeve Gastrectomy in a Morbidly Obese Recipient. Transplantation 2016; 99:1495-8. [PMID: 25675197 DOI: 10.1097/tp.0000000000000541] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Kidney transplantation confers a well-documented survival advantage for patients with end-stage renal disease (ESRD) over dialysis, regardless of body mass index (BMI). However, obese patients with ESRD have limited access to kidney transplantation. In most transplant centers, a patient with a BMI above 35 to 40 kg/m is either completely excluded from transplantation or is required to lose weight before being considered for transplantation. MATERIALS AND METHODS Herein, we present the first case of a 35-year-old woman with a BMI of 42 kg/m (96.8 kg) and ESRD, who underwent combined robot-assisted kidney transplant and sleeve gastrectomy. RESULTS The total operative time was 318 minutes with an estimated blood loss of 125 mL. At 24 months after transplantation, the patient's weight, BMI, creatinine, and estimated glomerular filtration rate were 81.9 kg, 35.1 kg/m, 0.79 mg/dL, and 81.2 mL/min per 1.73 m, respectively. CONCLUSIONS Combined robot-assisted kidney transplant and sleeve gastrectomy is feasible in morbidly obese patients and adds little additional operative time.
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Affiliation(s)
- Subhashini M Ayloo
- 1 Division of Transplantation, University of Illinois Hospital & Health Sciences System, Chicago, IL
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14
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Bunnapradist S, Rostaing L, Alloway RR, West-Thielke P, Denny J, Mulgaonkar S, Budde K. LCPT once-daily extended-release tacrolimus tablets versus twice-daily capsules: a pooled analysis of two phase 3 trials in important de novo and stable kidney transplant recipient subgroups. Transpl Int 2016; 29:603-11. [PMID: 26953629 DOI: 10.1111/tri.12770] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 11/07/2015] [Accepted: 02/26/2016] [Indexed: 11/29/2022]
Abstract
African-American and elderly kidney transplant recipients (KTR) have increased risk for poor clinical outcomes post-transplant. Management of immunosuppression may be challenging in these patients and contribute to worse outcomes. A novel once-daily formulation of tacrolimus (LCPT) has demonstrated noninferiority, similar safety, improved bioavailability, a consistent concentration time profile, and less peak and peak-trough fluctuations vs. tacrolimus twice-daily (Tac BID). This pooled analysis of two phase 3 randomized, controlled trials, including 861 (LCPT N = 428; Tac BID N = 433; 38% of patients were stable KTR, and 62% were de novo KTR) patients, examined the efficacy of LCPT in KTR subgroups (blacks, females, and age ≥65). Overall, treatment failure [death, graft failure, centrally read biopsy-proven acute rejection (BPAR), or lost to follow-up] at 12 months was as follows: LCPT: 11.9%, BID Tac: 13.4% [-1.48% (-5.95%, 2.99%)]. BPAR rates were as follows: LCPT: 8.2%, Tac BID: 9.5% [-1.29% (-5.14%, 2.55%)]. Numerically, fewer treatment failure events with LCPT were found in the majority of subgroups, with significantly less treatment failure associated with LCPT among black KTR [-13.82% (-27.22%, -0.31%)] and KTR ≥65 [-13.46% (-25.27%, -0.78%)]. This pooled analysis suggests numerically lower efficacy failure rates associated with LCPT among high-risk subgroups, in particular black KTR and KTR ≥65 years old.
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Affiliation(s)
| | | | - Rita R Alloway
- University of Cincinnati Medical Center & The Christ Hospital, Cincinnati, OH, USA
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15
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Bunnapradist S, Ciechanowski K, West-Thielke P, Mulgaonkar S, Rostaing L, Vasudev B, Budde K. Conversion from twice-daily tacrolimus to once-daily extended release tacrolimus (LCPT): the phase III randomized MELT trial. Am J Transplant 2013; 13:760-9. [PMID: 23279614 PMCID: PMC3613750 DOI: 10.1111/ajt.12035] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 10/12/2012] [Accepted: 10/13/2012] [Indexed: 01/25/2023]
Abstract
Phase III noninferiority trial examining efficacy and safety of converting stable renal transplant recipients from twice-daily tacrolimus to a novel extended-release once-daily tacrolimus formulation (LCPT) with a controlled agglomeration technology. Controls maintained tacrolimus twice daily. The primary efficacy endpoint was proportion of patients with efficacy failures (death, graft failure, locally read biopsy-proven acute rejection [BPAR], or loss to follow-up) within 12 months. Starting LCPT dose was 30% lower (15% for blacks) than preconversion tacrolimus dose; target trough levels were 4-15 ng/mL. A total of 326 patients were randomized; the mITT population (n = 162 each group) was similar demographically in the two groups. Mean daily dose of LCPT was significantly (p < 0.0001) lower than preconversion tacrolimus dose at each visit; mean trough levels between groups were similar. There were four efficacy failures in each group; safety outcomes were similar between groups. Frequency of premature study drug discontinuation was LCPT: 12% versus tacrolimus twice daily: 5% (p = 0.028). LCPT demonstrated noninferiority to tacrolimus twice daily in efficacy failure rates. LCPT may offer a safe and effective alternative for converting patients to a once-daily formulation. Compared to currently available tacrolimus formulation, LCPT requires lower doses to achieve target trough levels.
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Affiliation(s)
- S Bunnapradist
- David Geffen School of Medicine at UCLALos Angeles, CA,*Corresponding author: Suphamai Bunnapradist
| | - K Ciechanowski
- Department of Nephrology, Pomeranian Medical UniversitySzczecin, Poland
| | - P West-Thielke
- University of Illinois Hospital and Health Science SystemChicago, IL
| | | | - L Rostaing
- University Hospital Toulouse-RangueilToulouse, France
| | - B Vasudev
- Medical College of WisconsinMilwaukee, WI
| | - K Budde
- Department of Nephrology, Charité UniversitätsmedizinBerlin, Germany
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16
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West-Thielke P, Herren H, Thielke J, Oberholzer J, Sankary H, Raofi V, Benedetti E, Kaplan B. Results of positive cross-match transplantation in African American renal transplant recipients. Am J Transplant 2008; 8:348-54. [PMID: 18190659 DOI: 10.1111/j.1600-6143.2007.02085.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Positive cross-match (PXM) renal transplantation has been utilized to address the issue of the increasing demand for transplantation with the shortage of suitable organs. Our primary objective was to analyze the outcomes of African American (AA) PXM renal transplant recipients utilizing AA negative cross-match (NXM) renal transplant recipients as a comparator group. This was a retrospective study consisting of all PXM patients who underwent a desensitization protocol and all AA NXM transplant recipients at the University of Illinois at Chicago from July 2001 to March 2007. We found that AA PXM recipients had significantly lower estimated glomerular filtration rate (eGFR) at 1 year than AA NXM (46.2 vs. 60.6, p = 0.007). AA PXM who experienced acute rejection within the first year were more likely to have an eGFR less than 30 mL/min/1.73 m(2) at 1 year compared to their NXM counterparts (45.5% vs. 12.5%, p = 0.034). Positive cross-match renal transplantation in AA seems to be associated with a high degree of AR and severe renal compromise at 1 year. Larger studies are needed to determine if protocols that are associated with good short-term outcomes in non-AA need to be modified for the AA population.
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Affiliation(s)
- P West-Thielke
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
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