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Webber SA, Chin H, Wilkinson JD, Armstrong BD, Canter CE, Dipchand AI, Dodd DA, Feingold B, Lamour JM, Mahle WT, Singh TP, Zuckerman WA, Rossano JW, Morrison Y, Diop H, Demetris AJ, Bentlejewski C, Mohanakumar T, Odim J, Zeevi A. Impact of donor-specific anti-HLA antibody on cardiac hemodynamics and graft function 3 years after pediatric heart transplantation: First results from the CTOTC-09 multi-institutional study. Am J Transplant 2023; 23:1893-1907. [PMID: 37579817 PMCID: PMC10841212 DOI: 10.1016/j.ajt.2023.08.006] [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: 12/22/2022] [Revised: 07/19/2023] [Accepted: 08/06/2023] [Indexed: 08/16/2023]
Abstract
The aim of this study (CTOTC-09) was to assess the impact of "preformed" (at transplant) donor-specific anti-HLA antibody (DSA) and first year newly detected DSA (ndDSA) on allograft function at 3 years after pediatric heart transplantation (PHTx). We enrolled children listed at 9 North American centers. The primary end point was pulmonary capillary wedge pressure (PCWP) at 3 years posttransplant. Of 407 enrolled subjects, 370 achieved PHTx (mean age, 7.7 years; 57% male). Pre-PHTx sensitization status was nonsensitized (n = 163, 44%), sensitized/no DSA (n = 115, 31%), sensitized/DSA (n = 87, 24%), and insufficient DSA data (n = 5, 1%); 131 (35%) subjects developed ndDSA. Subjects with any DSA had comparable PCWP at 3 years to those with no DSA. There were also no significant differences overall between the 2 groups for other invasive hemodynamic measurements, systolic graft function by echocardiography, and serum brain natriuretic peptide concentration. However, in the multivariable analysis, persistent first-year DSA was a risk factor for 3-year abnormal graft function. Graft and patient survival did not differ between groups. In summary, overall, DSA status was not associated with worse allograft function or inferior patient and graft survival at 3 years, but persistent first-year DSA was a risk factor for late graft dysfunction.
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Affiliation(s)
- Steven A Webber
- Department of Pediatrics, Vanderbilt University School of Medicine, Vanderbilt, Nashville, Tennessee, USA.
| | - Hyunsook Chin
- Rho Federal Systems Division, Durham, North Carolina, USA
| | - James D Wilkinson
- Department of Pediatrics, Vanderbilt University School of Medicine, Vanderbilt, Nashville, Tennessee, USA
| | | | - Charles E Canter
- Division of Pediatric Cardiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Anne I Dipchand
- Labatt Family Heart Center, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Debra A Dodd
- Department of Pediatrics, Vanderbilt University School of Medicine, Vanderbilt, Nashville, Tennessee, USA
| | - Brian Feingold
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jacqueline M Lamour
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Bronx, New York, USA
| | - William T Mahle
- Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Tajinder P Singh
- Department of Pediatric Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Warren A Zuckerman
- Division of Pediatric Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Joseph W Rossano
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yvonne Morrison
- Transplantation Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Helena Diop
- Transplantation Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Anthony J Demetris
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Carol Bentlejewski
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Jonah Odim
- Transplantation Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Webber S, Chin H, Wilkinson J, Armstrong B, Canter C, Dipchand A, Dodd D, Feingold B, Lamour J, Mahle W, Rossano J, Singh T, Zuckerman W, Morrison Y, Diop H, Bentlejewski C, Odim J, Zeevi A. No Association Between Early Donor Specific Antibody and Subsequent Allograft Function at 3 Years Post-Pediatric Heart Transplantation. First Results of a Prospective Multi-Institutional Study. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Mannon RB, Armstrong B, Stock PG, Mehta AK, Farris AB, Watson N, Morrison Y, Sarwal M, Sigdel T, Bridges N, Robien M, Newell KA, Larsen CP. Avoidance of CNI and steroids using belatacept-Results of the Clinical Trials in Organ Transplantation 16 trial. Am J Transplant 2020; 20:3599-3608. [PMID: 32558199 PMCID: PMC7710570 DOI: 10.1111/ajt.16152] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/09/2020] [Accepted: 06/11/2020] [Indexed: 01/25/2023]
Abstract
Immunosuppression devoid of corticosteroids has been investigated to avoid long-term comorbidities. Likewise, alternatives to calcineurin inhibitors have been investigated as a strategy to improve long-term kidney function following transplanion. Costimulatory blockade strategies that include corticosteroids have recently shown promise, despite their higher rates of early acute rejection. We designed a randomized clinical trial utilizing depletional induction therapy to mitigate early rejection risk while limiting calcineurin inhibitors and corticosteroids. This trial, Clinical Trials in Organ Transplantation 16 (CTOT-16), sought to evaluate novel belatacept-based strategies employing tacrolimus and corticosteroid avoidance. Sixty-nine kidney transplant recipients were randomized from 4 US transplant centers comparing a control group of with rabbit antithymocyte globulin (rATG) induction, rapid steroid taper, and maintenance mycophenolate and tacrolimus, to 2 arms using maintenance belatacept. There were no graft losses but there were 2 deaths in the control group. However, the trial was halted early because of rejection in the belatacept treatment groups. Serious adverse events were similar across groups. Although rejection was not uniform in the belatacept maintenance therapy groups, the frequency of rejection limits the practical implementation of this strategy to avoid both calcineurin inhibitors and corticosteroids at this time.
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Affiliation(s)
- Roslyn B. Mannon
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Peter G. Stock
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, CA
| | - Aneesh K. Mehta
- Emory Transplant Center, Emory University School of Medicine, Atlanta GA,Department of Medicine, Emory University School of Medicine, Atlanta GA
| | - Alton B. Farris
- Emory Transplant Center, Emory University School of Medicine, Atlanta GA
| | - Natasha Watson
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Yvonne Morrison
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Minnie Sarwal
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, CA
| | - Tara Sigdel
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, CA
| | - Nancy Bridges
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Mark Robien
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Kenneth A. Newell
- Emory Transplant Center, Emory University School of Medicine, Atlanta GA
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Stock PG, Mannon RB, Armstrong B, Watson N, Ikle D, Robien M, Morrison Y, Odorico J, Fridell J, Mehta AK, Newell KA. Challenges of calcineurin inhibitor withdrawal following combined pancreas and kidney transplantation: Results of a prospective, randomized clinical trial. Am J Transplant 2020; 20:1668-1678. [PMID: 32039559 PMCID: PMC8982902 DOI: 10.1111/ajt.15817] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 08/30/2019] [Revised: 01/26/2020] [Accepted: 01/29/2020] [Indexed: 01/25/2023]
Abstract
In a phase 2 multicenter open-label randomized trial sponsored by the National Institutes of Health, simultaneous pancreas-kidney (SPK) recipients were randomized to a calcineurin inhibitor (CNI)-based immunosuppressive regimen (tacrolimus) (n = 21), or an investigational arm using low-dose CNI plus costimulation blockade (belatacept) with intended CNI withdrawal (n = 22). Both arms included induction therapy with rabbit ATG, mycophenolate sodium, or mycophenolate mofetil and rapid withdrawal of steroids. Enrollment and CNI withdrawal were stopped after 43/60 planned subjects had been enrolled. At that time, the rate of biopsy-proven acute rejection (BPAR) of the pancreas was low in both groups until CNI was withdrawn, with four of the five pancreas rejections occurring during or after CNI withdrawal. The rate of BPAR of kidney allografts was low in both control (9.5%) and investigational (9.1%) arms. Pancreas graft survival at 52 weeks, defined by insulin independence, was 21 (100%) in the control group and 19 (86%) in the investigational arm. One subject in the investigational arm died with functioning pancreas and kidney grafts. Renal function at week 52 was similar in both arms. Costimulation blockade with belatacept did not provide sufficient immunosuppression to reliably prevent pancreas rejection in SPK transplants undergoing CNI withdrawal.
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Affiliation(s)
| | | | | | - Natasha Watson
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | | | - Mark Robien
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Yvonne Morrison
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Jon Odorico
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Starling RC, Armstrong B, Bridges ND, Eisen H, Givertz MM, Kfoury AG, Kobashigawa J, Ikle D, Morrison Y, Pinney S, Stehlik J, Tripathi S, Sayegh MH, Chandraker A. Accelerated Allograft Vasculopathy With Rituximab After Cardiac Transplantation. J Am Coll Cardiol 2020; 74:36-51. [PMID: 31272550 DOI: 10.1016/j.jacc.2019.04.056] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 04/09/2019] [Accepted: 04/11/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The CTOT-11 (Prevention of Cardiac Allograft Vasculopathy Using Rituximab Therapy in Cardiac Transplantation [Clinical Trials in Organ Transplantation-11]) study was a randomized, placebo-controlled, multicenter, double-blinded clinical trial in nonsensitized primary heart transplant (HTX) recipients. OBJECTIVES The study sought to determine whether B cell depletion therapy would attenuate the development of cardiac allograft vasculopathy. METHODS A total of 163 HTX recipients were randomized to rituximab 1,000 mg intravenous or placebo on days 0 and 12 post-transplant. Primary outcome was change in percent atheroma volume (PAV) from baseline to 1 year measured by intravascular ultrasound. Secondary outcomes included treated episodes of acute rejection, de novo anti-HLA antibodies (including donor-specific antibodies), and phenotypic differentiation of B cells. RESULTS There were no significant differences at study entry between the rituximab and placebo groups. Paired intravascular ultrasound measures were available at baseline and 1 year in 86 subjects (49 rituximab, 37 placebo). The mean ± SD change in PAV at 12 months was +6.8 ± 8.2% rituximab versus +1.9 ± 4.4% placebo (p = 0.0019). Mortality at 12 months was 3.4% rituximab versus 6.8% placebo (p = 0.47); there were no retransplants or post-transplant lymphoproliferative disorder. The rate of treated rejection was 24.7% rituximab versus 32.4% placebo (p = 0.28). Rituximab therapy effectively eliminated CD20+/CD19+ B cells followed by a gradual expansion of a CD19- cell population in the rituximab-treated group. CONCLUSIONS A marked, unexpected increase in coronary artery PAV with rituximab was observed during the first year in HTX recipients. One-year mortality was not impacted; however, longer-term follow-up and mechanistic explanations are required. (Prevention of Cardiac Allograft Vasculopathy Using Rituximab [Rituxan] Therapy in Cardiac Transplantation; NCT01278745).
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Affiliation(s)
- Randall C Starling
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, Ohio. https://twitter.com/rcstarling
| | | | - Nancy D Bridges
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Howard Eisen
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Michael M Givertz
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Jon Kobashigawa
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California
| | - David Ikle
- Rho Federal Systems Division, Chapel Hill, North Carolina
| | - Yvonne Morrison
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Sean Pinney
- Department of Medicine, Mount Sinai School of Medicine, New York, New York
| | - Josef Stehlik
- Department of Medicine, University of Utah, Salt Lake City, Utah
| | - Sudipta Tripathi
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mohamed H Sayegh
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Anil Chandraker
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Boston, Massachusetts.
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Lamour JM, Mason KL, Hsu DT, Feingold B, Blume ED, Canter CE, Dipchand AI, Shaddy RE, Mahle WT, Zuckerman WA, Bentlejewski C, Armstrong BD, Morrison Y, Diop H, Iklé DN, Odim J, Zeevi A, Webber SA. Early outcomes for low-risk pediatric heart transplant recipients and steroid avoidance: A multicenter cohort study (Clinical Trials in Organ Transplantation in Children - CTOTC-04). J Heart Lung Transplant 2019; 38:972-981. [PMID: 31324444 PMCID: PMC8359669 DOI: 10.1016/j.healun.2019.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 01/29/2019] [Revised: 06/12/2019] [Accepted: 06/16/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Immunosuppression strategies have changed over time in pediatric heart transplantation. Thus, comorbidity profiles may have evolved. Clinical Trials in Organ Transplantation in Children-04 is a multicenter, prospective, cohort study assessing the impact of pre-transplant sensitization on outcomes after pediatric heart transplantation. This sub-study reports 1-year outcomes among recipients without pre-transplant donor-specific antibodies (DSAs). METHODS We recruited consecutive candidates (<21 years) at 8 centers. Sensitization status was determined by a core laboratory. Immunosuppression was standardized as follows: Thymoglobulin induction with tacrolimus and/or mycophenolate mofetil maintenance. Steroids were not used beyond 1 week. Rejection surveillance was by serial biopsy. RESULTS There were 240 transplants. Subjects for this sub-study (n = 186) were non-sensitized (n = 108) or had no DSAs (n = 78). Median age was 6 years, 48.4% were male, and 38.2% had congenital heart disease. Patient survival was 94.5% (95% confidence interval, 90.1-97.0%). Freedom from any type of rejection was 67.5%. Risk factors for rejection were older age at transplant and presence of non-DSAs pre-transplant. Freedom from infection requiring hospitalization/intravenous anti-microbials was 75.4%. Freedom from rehospitalization was 40.3%. New-onset diabetes mellitus and post-transplant lymphoproliferative disorder (PTLD) occurred in 1.6% and 1.1% of subjects, respectively. There was no decline in renal function over the first year. Corticosteroids were used in 14.5% at 1 year. CONCLUSIONS Pediatric heart transplantation recipients without DSAs at transplant and managed with a steroid avoidance regimen have excellent short-term survival and a low risk of first-year diabetes mellitus and PTLD. Rehospitalization remains common. These contemporary observations allow for improved caregiver and/or patient counseling and provide the necessary outcomes data to help design future randomized controlled trials.
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Affiliation(s)
- Jacqueline M Lamour
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Bronx, New York, New York.
| | | | - Daphne T Hsu
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Bronx, New York, New York
| | - Brian Feingold
- Departments of Pediatrics and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Elizabeth D Blume
- Department of Pediatric Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Charles E Canter
- Division of Pediatric Cardiology, Washington University School of Medicine, St. Louis, Missouri
| | - Anne I Dipchand
- Department of Paediatrics, Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robert E Shaddy
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - William T Mahle
- Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Warren A Zuckerman
- Division of Pediatric Cardiology, Columbia University Medical Center, New York, New York
| | - Carol Bentlejewski
- Division of Pediatric Cardiology, Columbia University Medical Center, New York, New York
| | | | | | - Helena Diop
- Rho Federal Systems Division, Chapel Hill, North Carolina
| | - David N Iklé
- Rho Federal Systems Division, Chapel Hill, North Carolina
| | - Jonah Odim
- Transplantation Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Steven A Webber
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
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Stehlik J, Armstrong B, Baran DA, Bridges ND, Chandraker A, Gordon R, De Marco T, Givertz MM, Heroux A, Iklé D, Hunt J, Kfoury AG, Madsen JC, Morrison Y, Feller E, Pinney S, Tripathi S, Heeger PS, Starling RC. Early immune biomarkers and intermediate-term outcomes after heart transplantation: Results of Clinical Trials in Organ Transplantation-18. Am J Transplant 2019; 19:1518-1528. [PMID: 30549425 PMCID: PMC6482086 DOI: 10.1111/ajt.15218] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 08/03/2018] [Revised: 11/07/2018] [Accepted: 11/28/2018] [Indexed: 01/25/2023]
Abstract
Clinical Trials in Organ Transplantation-18 (CTOT-18) is a follow-up analysis of the 200-subject multicenter heart transplant CTOT-05 cohort. CTOT-18 aimed to identify clinical, epidemiologic, and biologic markers associated with adverse clinical events past 1 year posttransplantation. We examined various candidate biomarkers including serum antibodies, angiogenic proteins, blood gene expression profiles, and T cell alloreactivity. The composite endpoint (CE) included death, retransplantation, coronary stent, myocardial infarction, and cardiac allograft vasculopathy. The mean follow-up was 4.5 ± SD 1.1 years. Subjects with serum anti-cardiac myosin (CM) antibody detected at transplantation and at 12 months had a higher risk of meeting the CE compared to those without anti-CM antibody (hazard ratio [HR] = 2.9, P = .046). Plasma VEGF-A and VEGF-C levels pretransplant were associated with CE (odds ratio [OR] = 13.24, P = .029; and OR = 0.13, P = .037, respectively). Early intravascular ultrasound findings or other candidate biomarkers were not associated with the study outcomes. In conclusion, anti-CM antibody and plasma levels of VEGF-A and VEGF-C were associated with an increased risk of adverse events. Although this multicenter report supports further evaluation of the mechanisms through which anti-CM antibody and plasma angiogenesis proteins lead to allograft injury, we could not identify additional markers of adverse events or potential novel therapeutic targets.
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Affiliation(s)
- Josef Stehlik
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | | | - Nancy D Bridges
- Transplantation Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | | | | | - Teresa De Marco
- University of California at San Francisco, San Francisco CA, USA
| | | | - Alain Heroux
- Loyola University Medical Center, Maywood, IL, USA
| | | | - Judson Hunt
- Medical City Dallas Hospital, Dallas TX, USA
| | | | | | - Yvonne Morrison
- Transplantation Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | | | - Sean Pinney
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Peter S Heeger
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Faddoul G, Nadkarni GN, Bridges ND, Goebel J, Hricik DE, Formica R, Menon MC, Morrison Y, Murphy B, Newell K, Nickerson P, Poggio ED, Rush D, Heeger PS. Analysis of Biomarkers Within the Initial 2 Years Posttransplant and 5-Year Kidney Transplant Outcomes: Results From Clinical Trials in Organ Transplantation-17. Transplantation 2018; 102:673-680. [PMID: 29189482 DOI: 10.1097/tp.0000000000002026] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND An early posttransplant biomarker/surrogate marker for kidney allograft loss has the potential to guide targeted interventions. Previously published findings, including results from the Clinical Trials in Organ Transplantation (CTOT)-01 study, showed that elevated urinary chemokine CXCL9 levels and elevated frequencies of donor-reactive interferon gamma (IFNγ)-producing T cells by enzyme-linked immunosorbent spot (ELISPOT) assay associated with acute cellular rejection within the first year and with lower 1-year posttransplant estimated glomerular filtration rate (eGFR). How well these biomarkers correlate with late outcomes, including graft loss, is unclear. METHODS In CTOT-17, we obtained 5-year outcomes in the CTOT-01 cohort and correlated them with (a) biomarker results and (b) changes in eGFR (Chronic Kidney Disease Epidemiology Collaboration formula) over the initial 2 years posttransplant using univariable analysis and multivariable logistic regression. RESULTS Graft loss occurred in 14 (7.6%) of 184 subjects 2 to 5 years posttransplant. Neither IFNγ ELISPOTs nor urinary CXCL9 were informative. In contrast, a 40% or greater decline in eGFR from 6 months to 2 years posttransplant independently correlated with 13-fold odds of 5-year graft loss (adjusted odds ratio, 13.1; 95% confidence interval, 3.0-56.6), a result that was validated in the independent Genomics of Chronic Allograft Rejection cohort (n = 165; adjusted odds ratio, 11.2). CONCLUSIONS We conclude that although pretransplant and early posttransplant ELISPOT and chemokine measurements associate with outcomes within 2 years posttransplant, changes in eGFR between 3 or 6 months and 24 months are better surrogates for 5-year outcomes, including graft loss.
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Affiliation(s)
- Geovani Faddoul
- Department of Medicine, Translational Transplant Research Center, Recanati Miller Transplant Institute, Immunology Institute Icahn School of Medicine at Mount Sinai, New York, NY
| | - Girish N Nadkarni
- Department of Medicine, Translational Transplant Research Center, Recanati Miller Transplant Institute, Immunology Institute Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nancy D Bridges
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Jens Goebel
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Donald E Hricik
- Department of Medicine, University Hospitals Case Medical Center, Cleveland, OH
| | - Richard Formica
- Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Madhav C Menon
- Department of Medicine, Translational Transplant Research Center, Recanati Miller Transplant Institute, Immunology Institute Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yvonne Morrison
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Barbara Murphy
- Department of Medicine, Translational Transplant Research Center, Recanati Miller Transplant Institute, Immunology Institute Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kenneth Newell
- Department of Surgery, Emory University Medical Center, Atlanta, GA
| | - Peter Nickerson
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Emilio D Poggio
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, OH
| | - David Rush
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Peter S Heeger
- Department of Medicine, Translational Transplant Research Center, Recanati Miller Transplant Institute, Immunology Institute Icahn School of Medicine at Mount Sinai, New York, NY
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Dipchand AI, Webber S, Mason K, Feingold B, Bentlejewski C, Mahle WT, Shaddy R, Canter C, Blume ED, Lamour J, Zuckerman W, Diop H, Morrison Y, Armstrong B, Ikle D, Odim J, Zeevi A. Incidence, characterization, and impact of newly detected donor-specific anti-HLA antibody in the first year after pediatric heart transplantation: A report from the CTOTC-04 study. Am J Transplant 2018; 18:2163-2174. [PMID: 29442424 PMCID: PMC6092243 DOI: 10.1111/ajt.14691] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 01/30/2018] [Accepted: 02/04/2018] [Indexed: 01/25/2023]
Abstract
Data on the clinical importance of newly detected donor-specific anti-HLA antibodies (ndDSAs) after pediatric heart transplantation are lacking despite mounting evidence of the detrimental effect of de novo DSAs in solid organ transplantation. We prospectively tested 237 pediatric heart transplant recipients for ndDSAs in the first year posttransplantation to determine their incidence, pattern, and clinical impact. One-third of patients developed ndDSAs; when present, these were mostly detected within the first 6 weeks after transplantation, suggesting that memory responses may predominate over true de novo DSA production in this population. In the absence of preexisting DSAs, patients with ndDSAs had significantly more acute cellular rejection but not antibody-mediated rejection, and there was no impact on graft and patient survival in the first year posttransplantation. Risk factors for ndDSAs included common sensitizing events. Given the early detection of the antibody response, memory responses may be more important in the first year after pediatric heart transplantation and patients with a history of a sensitizing event may be at risk even with a negative pretransplantation antibody screen. The impact on late graft and patient outcomes of first-year ndDSAs is being assessed in an extended cohort of patients.
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Affiliation(s)
- A. I. Dipchand
- Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - S. Webber
- Vanderbilt University Medical Center, Nashville, TN
| | | | - B. Feingold
- Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | | | - W. T. Mahle
- Children’s Healthcare of Atlanta, Atlanta, GA
| | - R. Shaddy
- Children’s Hospital of Philadelphia, Philadelphia, PA
| | - C. Canter
- St Louis Children’s Hospital, St Louis, MO
| | | | - J. Lamour
- Montefiore Children’s Hospital, New York, NY
| | | | - H. Diop
- National Institutes of Health, Bethesda, MD
| | | | | | | | - J. Odim
- National Institutes of Health, Bethesda, MD
| | - A. Zeevi
- Department of Pathology, UPMC, Pittsburgh, PA
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Zuckerman WA, Zeevi A, Mason KL, Feingold B, Bentlejewski C, Addonizio LJ, Blume ED, Canter CE, Dipchand AI, Hsu DT, Shaddy RE, Mahle WT, Demetris AJ, Briscoe DM, Mohanakumar T, Ahearn JM, Iklé DN, Armstrong BD, Morrison Y, Diop H, Odim J, Webber SA. Study rationale, design, and pretransplantation alloantibody status: A first report of Clinical Trials in Organ Transplantation in Children-04 (CTOTC-04) in pediatric heart transplantation. Am J Transplant 2018; 18:2135-2147. [PMID: 29446208 PMCID: PMC6093810 DOI: 10.1111/ajt.14695] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 08/30/2017] [Revised: 02/05/2018] [Accepted: 02/07/2018] [Indexed: 01/25/2023]
Abstract
Anti-HLA donor-specific antibodies are associated with worse outcomes after organ transplantation. Among sensitized pediatric heart candidates, requirement for negative donor-specific cytotoxicity crossmatch increases wait times and mortality. However, transplantation with positive crossmatch may increase posttransplantation morbidity and mortality. We address this clinical challenge in a prospective, multicenter, observational cohort study of children listed for heart transplantation (Clinical Trials in Organ Transplantation in Children-04 [CTOTC-04]). Outcomes were compared among sensitized recipients who underwent transplantation with positive crossmatch, nonsensitized recipients, and sensitized recipients without positive crossmatch. Positive crossmatch recipients received antibody removal and augmented immunosuppression, while other recipients received standard immunosuppression with corticosteroid avoidance. This first CTOTC-04 report summarizes study rationale and design and relates pretransplantation sensitization status using solid-phase technology. Risk factors for sensitization were explored. Of 317 screened patients, 290 were enrolled and 240 underwent transplantation. Core laboratory evaluation demonstrated that more than half of patients were anti-HLA sensitized. Greater than 80% of sensitized patients had class I (with or without class II) HLA antibodies, and one-third of sensitized patients had at least 1 HLA antibody with median fluorescence intensity of ≥8000. Logistic regression models demonstrated male sex, weight, congenital heart disease history, prior allograft, and ventricular assist device are independent risk factors for sensitization.
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Affiliation(s)
- Warren A. Zuckerman
- Division of Pediatric Cardiology, Columbia University Medical
Center, New York, NY
| | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh Medical Center,
Pittsburgh, PA
| | | | - Brian Feingold
- Department of Pediatrics and Clinical and Translational Science,
University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Carol Bentlejewski
- Department of Pathology, University of Pittsburgh Medical Center,
Pittsburgh, PA
| | - Linda J. Addonizio
- Division of Pediatric Cardiology, Columbia University Medical
Center, New York, NY
| | - Elizabeth D. Blume
- Department of Pediatric Cardiology, Boston Children’s
Hospital, Boston, MA
| | - Charles E. Canter
- Division of Pediatric Cardiology, Washington University School of
Medicine, St. Louis, MO
| | - Anne I. Dipchand
- Labatt Family Heart Center, Department of Paediatrics, Hospital for
Sick Children, Toronto, ON, Canada
| | - Daphne T. Hsu
- Division of Pediatric Cardiology, Children’s Hospital at
Montefiore, Bronx, NY
| | - Robert E. Shaddy
- Division of Pediatric Cardiology, Children’s Hospital of
Philadelphia, Philadelphia, PA
| | - William T. Mahle
- Division of Pediatric Cardiology, Children’s Healthcare of
Atlanta, Atlanta, GA
| | - Anthony J. Demetris
- Department of Pathology, University of Pittsburgh Medical Center,
Pittsburgh, PA
| | - David M. Briscoe
- Transplant Research Program, Division of Pediatric Nephrology,
Harvard Medical School, Boston, MA
| | | | - Joseph M. Ahearn
- Department of Medicine, Allegheny Health Network, Pittsburgh,
PA
| | - David N. Iklé
- Rho Federal Systems Division, Chapel Hill, North Carolina
| | | | - Yvonne Morrison
- Transplantation Branch, National Institute of Allergy and Infectious
Diseases, National Institutes of Health, Bethesda, MD
| | - Helena Diop
- Transplantation Branch, National Institute of Allergy and Infectious
Diseases, National Institutes of Health, Bethesda, MD
| | - Jonah Odim
- Transplantation Branch, National Institute of Allergy and Infectious
Diseases, National Institutes of Health, Bethesda, MD
| | - Steven A. Webber
- Division of Pediatric Cardiology, Monroe Carrell Jr.
Children’s Hospital at Vanderbilt, Nashville, TN
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11
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Webber S, Zeevi A, Mason K, Addonizio L, Blume E, Dipchand A, Shaddy R, Feingold B, Canter C, Hsu D, Mahle W, Armstrong B, Morrison Y, Ikle D, Diop H, Odim J. Pediatric heart transplantation across a positive crossmatch: First year results from the CTOTC-04 multi-institutional study. Am J Transplant 2018; 18:2148-2162. [PMID: 29673058 DOI: 10.1111/ajt.14876] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [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: 09/15/2017] [Revised: 04/01/2018] [Accepted: 04/03/2018] [Indexed: 01/25/2023]
Abstract
Sensitization is common in pediatric heart transplant candidates and waitlist mortality is high. Transplantation across a positive crossmatch may reduce wait time, but is considered high risk. We prospectively recruited consecutive candidates at eight North American centers. At transplantation, subjects were categorized as nonsensitized or sensitized (presence of ≥1 HLA antibody with MFI ≥1000 using single antigen beads). Sensitized subjects were further classified as complement-dependent cytotoxicity crossmatch (CDC-crossmatch) positive or negative and as donor-specific antibodies (DSA) positive or negative. Immunosuppression was standardized. CDC-crossmatch-positive subjects also received perioperative antibody removal, maintenance corticosteroids, and intravenous immunoglobulin. The primary endpoint was the 1 year incidence rate of a composite of death, retransplantation, or rejection with hemodynamic compromise. 317 subjects were screened, 290 enrolled and 240 transplanted (51 with pretransplant DSA, 11 with positive CDC-crossmatch). The incidence rates of the primary endpoint did not differ statistically between groups; nonsensitized 6.7% (CI: 2.7%, 13.3%), sensitized crossmatch positive 18.2% (CI: 2.3%, 51.8%), sensitized crossmatch negative 10.7% (CI: 5.7%, 18.0%), P = .2354. The primary endpoint also did not differ by DSA status. Freedom from antibody-mediated and cellular rejection was lower in the crossmatch positive group and/or in the presence of DSA. Follow-up will determine if acceptable outcomes can be achieved long-term.
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Affiliation(s)
- S Webber
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - A Zeevi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - K Mason
- Rho Federal Systems Division, Chapel Hill, NC, USA
| | - L Addonizio
- Division of Pediatric Cardiology, Columbia University Medical Center, New York, NY, USA
| | - E Blume
- Department of Pediatric Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - A Dipchand
- Department of Paediatrics, Hospital for Sick Children, Labatt Family Heart Center, Toronto, Ontario, Canada
| | - R Shaddy
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - B Feingold
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - C Canter
- Division of Pediatric Cardiology, Washington University School of Medicine, St. Louis, MO, USA
| | - D Hsu
- Division of Pediatric Cardiology, Albert Einstein College of Medicine/Children's Hospital at Montefiore, Bronx, NY, USA
| | - W Mahle
- Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - B Armstrong
- Rho Federal Systems Division, Chapel Hill, NC, USA
| | - Y Morrison
- Transplantation Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - D Ikle
- Rho Federal Systems Division, Chapel Hill, NC, USA
| | - H Diop
- Transplantation Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - J Odim
- Transplantation Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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Asare A, Kanaparthi S, Lim N, Phippard D, Vincenti F, Friedewald J, Pavlakis M, Poggio E, Heeger P, Mannon R, Burrell BE, Morrison Y, Bridges N, Sanz I, Chandraker A, Newell KA, Turka LA. B Cell Receptor Genes Associated With Tolerance Identify a Cohort of Immunosuppressed Patients With Improved Renal Allograft Graft Function. Am J Transplant 2017; 17:2627-2639. [PMID: 28371372 PMCID: PMC5620117 DOI: 10.1111/ajt.14283] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 02/16/2017] [Accepted: 03/15/2017] [Indexed: 01/25/2023]
Abstract
We previously reported that two B cell receptor genes, IGKV1D-13 and IGKV4-1, were associated with tolerance following kidney transplantation. To assess the potential utility of this "signature," we conducted a prospective, multicenter study to determine the frequency of patients predicted tolerant within a cohort of patients deemed to be candidates for immunosuppressive minimization. At any single time point, 25-30% of patients were predicted to be tolerant, while 13.7% consistently displayed the tolerance "signature" over the 2-year study. We also examined the relationship of the presence of the tolerance "signature" on drug use and graft function. Contrary to expectations, the frequency of predicted tolerance was increased in patients receiving tacrolimus and reduced in those receiving corticosteroids, mycophenolate mofetil, or Thymoglobulin as induction. Surprisingly, patients consistently predicted to be tolerant displayed a statistically and clinically significant improvement in estimated glomerular filtration rate that increased over time following transplantation. These findings indicate that the frequency of patients consistently predicted to be tolerant is sufficiently high to be clinically relevant and confirm recent findings by others that immunosuppressive agents impact putative biomarkers of tolerance. The association of a B cell-based "signature" with graft function suggests that B cells may contribute to the function/survival of transplanted kidneys.
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Affiliation(s)
- Adam Asare
- Immune Tolerance Network, Massachusetts General Hospital, Bethesda, MD 20814
| | - Sai Kanaparthi
- Immune Tolerance Network, Massachusetts General Hospital, Bethesda, MD 20814
| | - Noha Lim
- Immune Tolerance Network, Massachusetts General Hospital, Bethesda, MD 20814
| | - Deborah Phippard
- Immune Tolerance Network, Massachusetts General Hospital, Bethesda, MD 20814
| | - Flavio Vincenti
- Departments of Medicine and Surgery, University of California - San Francisco, CA 94143
| | - John Friedewald
- Northwestern Memorial Hospital, Northwestern University, Chicago, IL 60611
| | | | | | - Peter Heeger
- Recanati Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Roslyn Mannon
- University of Alabama School of Medicine, Birmingham, AL 35233
| | - Bryna E. Burrell
- Immune Tolerance Network, Massachusetts General Hospital, Bethesda, MD 20814
| | - Yvonne Morrison
- Division of Allergy, Immunology, and Transplantation (DAIT), NIAID, Rockville, MD 20852
| | - Nancy Bridges
- Division of Allergy, Immunology, and Transplantation (DAIT), NIAID, Rockville, MD 20852
| | - Inaki Sanz
- Department of Surgery, Emory University School of Medicine, Emory University, Atlanta, GA 30322
| | | | - Kenneth A. Newell
- Department of Surgery, Emory University School of Medicine, Emory University, Atlanta, GA 30322
| | - Laurence A. Turka
- Center for Transplantation Sciences and Immune Tolerance Network, Massachusetts General Hospital, Boston, MA 02129
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Newell KA, Mehta AK, Larsen CP, Stock PG, Farris AB, Mehta SG, Ikle D, Armstrong B, Morrison Y, Bridges N, Robien M, Mannon RB. Lessons Learned: Early Termination of a Randomized Trial of Calcineurin Inhibitor and Corticosteroid Avoidance Using Belatacept. Am J Transplant 2017; 17:2712-2719. [PMID: 28556519 PMCID: PMC5623170 DOI: 10.1111/ajt.14377] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 04/26/2017] [Accepted: 05/21/2017] [Indexed: 01/25/2023]
Abstract
The intent of this National Institutes of Health-sponsored study was to compare a belatacept-based immunosuppressive regimen with a maintenance regimen of tacrolimus and mycophenolate. Nineteen primary, Epstein-Barr virus-immune renal transplant recipients with a negative cross-match were randomized to one of three groups. All patient groups received perioperative steroids and maintenance mycophenolate mofetil. Patients in groups 1 and 2 were induced with alemtuzumab and maintained on tacrolimus or belatacept, respectively. Patients in group 3 were induced with basiliximab, received 3 mo of tacrolimus, and maintained on belatacept. There was one death with a functioning allograft due to endocarditis (group 1). There were three graft losses due to vascular thrombosis (all group 2) and one graft loss due to glomerular disease (group 1). Biopsy-proven acute cellular rejection was more frequent in the belatacept-treated groups, with 10 treated episodes in seven participants compared with one episode in group 1; however, estimated GFR was similar between groups at week 52. There were no episodes of posttransplant lymphoproliferative disorder or opportunistic infections in any group. Protocol enrollment was halted prematurely because of a high rate of serious adverse events. Such negative outcomes pose challenges to clinical investigators, who ultimately must weigh the risks and benefits in randomized trials.
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Affiliation(s)
- Kenneth A. Newell
- Department of Surgery, Emory University School of Medicine, Atlanta GA
| | - Aneesh K. Mehta
- Department of Surgery, Emory University School of Medicine, Atlanta GA,Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta GA
| | | | - Peter G. Stock
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, CA
| | - A. Bradley Farris
- Department of Surgery, Emory University School of Medicine, Atlanta GA
| | - Shikha G. Mehta
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
| | | | | | - Yvonne Morrison
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Nancy Bridges
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Mark Robien
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Roslyn B. Mannon
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
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Dipchand A, Webber S, Much K, Feingold B, Bentlejewski C, Blume E, Shaddy R, Canter C, Lamour J, Mahle W, Zuckerman W, Diop H, Morrison Y, Armstrong B, Ikle D, Odim J, Zeevi A. Impact of Newly Detected Donor Specific Anti-HLA Antibody in the First Year After Pediatric Heart Transplantation. J Heart Lung Transplant 2017. [DOI: 10.1016/j.healun.2017.01.193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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15
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Starling RC, Stehlik J, Baran DA, Armstrong B, Stone JR, Ikle D, Morrison Y, Bridges ND, Putheti P, Strom TB, Bhasin M, Guleria I, Chandraker A, Sayegh M, Daly KP, Briscoe DM, Heeger PS. Multicenter Analysis of Immune Biomarkers and Heart Transplant Outcomes: Results of the Clinical Trials in Organ Transplantation-05 Study. Am J Transplant 2016; 16:121-36. [PMID: 26260101 PMCID: PMC4948061 DOI: 10.1111/ajt.13422] [Citation(s) in RCA: 48] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 05/20/2015] [Accepted: 06/14/2015] [Indexed: 01/25/2023]
Abstract
Identification of biomarkers that assess posttransplant risk is needed to improve long-term outcomes following heart transplantation. The Clinical Trials in Organ Transplantation (CTOT)-05 protocol was an observational, multicenter, cohort study of 200 heart transplant recipients followed for the first posttransplant year. The primary endpoint was a composite of death, graft loss/retransplantation, biopsy-proven acute rejection (BPAR), and cardiac allograft vasculopathy (CAV) as defined by intravascular ultrasound (IVUS). We serially measured anti-HLA- and auto-antibodies, angiogenic proteins, peripheral blood allo-reactivity, and peripheral blood gene expression patterns. We correlated assay results and clinical characteristics with the composite endpoint and its components. The composite endpoint was associated with older donor allografts (p < 0.03) and with recipient anti-HLA antibody (p < 0.04). Recipient CMV-negativity (regardless of donor status) was associated with BPAR (p < 0.001), and increases in plasma vascular endothelial growth factor-C (OR 20; 95%CI:1.9-218) combined with decreases in endothelin-1 (OR 0.14; 95%CI:0.02-0.97) associated with CAV. The remaining biomarkers showed no relationships with the study endpoints. While suboptimal endpoint definitions and lower than anticipated event rates were identified as potential study limitations, the results of this multicenter study do not yet support routine use of the selected assays as noninvasive approaches to detect BPAR and/or CAV following heart transplantation.
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Affiliation(s)
| | - Josef Stehlik
- University of Utah Health Sciences Center, Salt Lake City UT
| | | | | | | | | | - Yvonne Morrison
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville MD
| | - Nancy D. Bridges
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville MD
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16
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Morrison Y, Wilson L, Kelly F, Bennett C, Duffy F, McGoldrick S, Reynish E. Assessment of outcome in clinical trials in mild Alzheimer�s disease: Urgent time for a rethink? ACTA ACUST UNITED AC 2013. [DOI: 10.13172/2054-734x-1-1-921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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17
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Benfield MR, Bartosh S, Ikle D, Warshaw B, Bridges N, Morrison Y, Harmon W. A randomized double-blind, placebo controlled trial of steroid withdrawal after pediatric renal transplantation. Am J Transplant 2010; 10:81-8. [PMID: 19663893 DOI: 10.1111/j.1600-6143.2009.02767.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [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
In an effort to reduce rejection, extend allograft survival and minimize complications, we hypothesized that robust immunosuppression during the first 6 months after transplantation would allow for the safe withdrawal of steroids. A total of 274 pediatric subjects were enrolled and received an anti-CD25 antibody, sirolimus, calcineurin inhibitor and steroids. At 6 months after transplantation, subjects were randomized to steroid withdrawal (n=73) versus continued low-dose steroids (n=59). This study was stopped prior to target enrollment because of the incidence of post-transplant lymphoproliferative disorder. At the time of study termination, 132 subjects had been randomized and were available for analysis. At 18 months after transplantation, there was no difference in the standardized height z score; however, the standardized height velocity was greater in the steroid withdrawal group compared to the control group (p=0.033). There were no differences in acute rejection episodes between treatment groups. The 3-year allograft survival rate was 84.5% in the control group and 98.6% in the steroid withdrawal group (p=0.002). The immunosuppressive protocol utilized in this study allowed for the withdrawal of steroids without an increased risk of rejection or allograft loss. However, the complications associated with the use of this immunosuppressive protocol were too high to recommend its routine use in pediatric patients.
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Affiliation(s)
- M R Benfield
- Division of Pediatric Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA.
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18
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Das S, Morrison Y. Preformed laryngeal masks. Anaesthesia 2000. [DOI: 10.1046/j.1365-2044.2000.01557-13.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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19
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Das S, Morrison Y. Preformed laryngeal masks. Anaesthesia 2000; 55:701-2. [PMID: 10919440 DOI: 10.1046/j.1365-2044.2000.01557-13x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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21
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Morrison Y. Major redevelopment for Dr Gray's hospital. Health Estate J 1993; 47:4-6. [PMID: 10125454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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22
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Affiliation(s)
- Y Morrison
- College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City
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