1
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Pérez-Sáez MJ, Montero N, Oliveras L, Redondo-Pachón D, Martínez-Simón D, Abramovicz D, Maggiore U, Mariat C, Mjoen G, Oniscu GC, Peruzzi L, Sever MS, Watschinger B, Velioglu A, Demir E, Gandolfini I, Hellemans R, Hilbrands L, Pascual J, Crespo M. Immunosuppression of HLA identical living-donor kidney transplant recipients: A systematic review. Transplant Rev (Orlando) 2023; 37:100787. [PMID: 37657355 DOI: 10.1016/j.trre.2023.100787] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 07/29/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Kidney transplant (KT) recipients of HLA identical siblings (HLAid) have lower immunological risk, but there are no specific recommendations for immunosuppression. Our aim was to analyze evidence about results from HLAid living-donor recipients under different immunosuppression in the current era of immunological risk assessment. METHODS Systematic review of studies describing associations between outcomes of HLAid living-donor KT recipients according to their immunological risk and applied immunosuppression. RESULTS From 1351 studies, 16 (5636 KT recipients) were included in the analysis. All studies were retrospective, ten comparing immunosuppression strategies, and six immunological risk strata. Of those ten, six studies were published in 1990 or earlier and only three included tacrolimus. The evidence is poor, and the inclusion of calcineurin inhibitors does not demonstrate better results. Furthermore, only few studies describe different immunosuppression regimens according to the patient immunological risk and, in general, they do not include the assessment with new solid phase assays. CONCLUSIONS There are no studies analyzing the association of outcomes of HLAid KT recipients with current immunological risk tools. In the absence of evidence, no decision or proposal of immunosuppression adapted to modern immunological risk assessment can be made currently by the Descartes Working Group.
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Affiliation(s)
| | - Núria Montero
- Nephrology Department, Hospital de Bellvitge, Barcelona, Spain
| | - Laia Oliveras
- Nephrology Department, Hospital de Bellvitge, Barcelona, Spain
| | | | | | - Daniel Abramovicz
- Department of Nephrology, Antwerp University Hospital, Antwerp, Belgium
| | - Umberto Maggiore
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Christophe Mariat
- Nephrology Dialysis and Renal Transplantation Dpt, CHU de Saint-Etienne, Université Jean Monnet, Saint-Etienne, France
| | - Geir Mjoen
- Department of Transplant Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Licia Peruzzi
- Pediatric Nephrology Unit, Regina Margherita Children's Hospital, Turin, Italy
| | - Mehmet Sükrü Sever
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Bruno Watschinger
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Arzu Velioglu
- Marmara University, School of Medicine, Department of Nephrology, Istanbul, Turkey
| | - Erol Demir
- Transplant Immunology Research Centre of Excellence, Koç University Hospital, Istanbul, Turkey
| | - Ilaria Gandolfini
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Rachel Hellemans
- Department of Nephrology, Antwerp University Hospital, Antwerp, Belgium
| | - Luuk Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Julio Pascual
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Barcelona, Spain.
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2
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Hruba P, Klema J, Le AV, Girmanova E, Mrazova P, Massart A, Maixnerova D, Voska L, Piredda GB, Biancone L, Puga AR, Seyahi N, Sever MS, Weekers L, Muhfeld A, Budde K, Watschinger B, Miglinas M, Zahradka I, Abramowicz M, Abramowicz D, Viklicky O. Novel transcriptomic signatures associated with premature kidney allograft failure. EBioMedicine 2023; 96:104782. [PMID: 37660534 PMCID: PMC10480056 DOI: 10.1016/j.ebiom.2023.104782] [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: 04/25/2023] [Revised: 08/18/2023] [Accepted: 08/18/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND The power to predict kidney allograft outcomes based on non-invasive assays is limited. Assessment of operational tolerance (OT) patients allows us to identify transcriptomic signatures of true non-responders for construction of predictive models. METHODS In this observational retrospective study, RNA sequencing of peripheral blood was used in a derivation cohort to identify a protective set of transcripts by comparing 15 OT patients (40% females), from the TOMOGRAM Study (NCT05124444), 14 chronic active antibody-mediated rejection (CABMR) and 23 stable graft function patients ≥15 years (STA). The selected differentially expressed transcripts between OT and CABMR were used in a validation cohort (n = 396) to predict 3-year kidney allograft loss at 3 time-points using RT-qPCR. FINDINGS Archetypal analysis and classifier performance of RNA sequencing data showed that OT is clearly distinguishable from CABMR, but similar to STA. Based on significant transcripts from the validation cohort in univariable analysis, 2 multivariable Cox models were created. A 3-transcript (ADGRG3, ATG2A, and GNLY) model from POD 7 predicted graft loss with C-statistics (C) 0.727 (95% CI, 0.638-0.820). Another 3-transcript (IGHM, CD5, GNLY) model from M3 predicted graft loss with C 0.786 (95% CI, 0.785-0.865). Combining 3-transcripts models with eGFR at POD 7 and M3 improved C-statistics to 0.860 (95% CI, 0.778-0.944) and 0.868 (95% CI, 0.790-0.944), respectively. INTERPRETATION Identification of transcripts distinguishing OT from CABMR allowed us to construct models predicting premature graft loss. Identified transcripts reflect mechanisms of injury/repair and alloimmune response when assessed at day 7 or with a loss of protective phenotype when assessed at month 3. FUNDING Supported by the Ministry of Health of the Czech Republic under grant NV19-06-00031.
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Affiliation(s)
- Petra Hruba
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jiri Klema
- Department of Computer Science, Czech Technical University, Prague, Czech Republic
| | - Anh Vu Le
- Department of Computer Science, Czech Technical University, Prague, Czech Republic
| | - Eva Girmanova
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Petra Mrazova
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Annick Massart
- Antwerp University Hospital and Antwerp University, Antwerp, Belgium
| | - Dita Maixnerova
- Department of Nephrology, 1st Faculty of Medicine and General Faculty Hospital, Prague, Czech Republic
| | - Ludek Voska
- Department of Clinical and Transplant Pathology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Gian Benedetto Piredda
- Department of Kidney Disease Medicine of Renal Transplantation, G.Brotzu Hospital Cagliari, Italy
| | - Luigi Biancone
- Department of Medical Sciences, University of Torino, Torino, Italy
| | - Ana Ramirez Puga
- Hospital Universitario Insular de Gran Canaria, Servicio de nefrología, Spain
| | - Nurhan Seyahi
- Istanbul University, Cerrahpasa Medical Faculty, Nephrology, Istanbul, Turkey
| | - Mehmet Sukru Sever
- Istanbul University, Istanbul School of Medicine, Internal Medicine, Nephrology, Istanbul, Turkey
| | | | - Anja Muhfeld
- Department of Nephrology, Uniklinik RWTH Aachen, Aachen, Germany
| | - Klemens Budde
- Charité - Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivmedizin, Berlin, Germany
| | - Bruno Watschinger
- Department of Internal Medicine III, Nephrology, Medical University Vienna / AKH Wien, Vienna, Austria
| | - Marius Miglinas
- Faculty of Medicine, Nephrology Center, Vilnius University Hospital Santaros Klinikos, Vilnius University, Vilnius, Lithuania
| | - Ivan Zahradka
- Department of Nephrology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Marc Abramowicz
- Genetic Medicine and Development, Faculty of Medicine, University of Geneva, Rue Michel Servet 1, 1206 Geneva, Switzerland
| | - Daniel Abramowicz
- Antwerp University Hospital and Antwerp University, Antwerp, Belgium
| | - Ondrej Viklicky
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Department of Nephrology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
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3
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Sever MS, Vanholder R, Oniscu G, Abramowicz D, Van Biesen W, Maggiore U, Watschinger B, Mariat C, Buturovic-Ponikvar J, Crespo M, Mjoen G, Heering P, Peruzzi L, Gandolfini I, Hellemans R, Hilbrands L. Kidney transplantation during mass disasters - from COVID-19 to other catastrophes A Consensus Statement by the DESCARTES Working Group and Ethics Committee of the ERA. Nephrol Dial Transplant 2023; 38:300–308. [PMID: 36066915 PMCID: PMC9923698 DOI: 10.1093/ndt/gfac251] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Indexed: 07/23/2023] Open
Abstract
Mass disasters are characterized by a disparity between health care demand and supply, which hampers complex therapies like kidney transplantation. Considering scarcity of publications on previous disasters, we reviewed transplantation practice during the recent COVID-19 pandemic, and dwelled upon this experience for guiding transplantation strategies in the future pandemic and non-pandemic catastrophes. We strongly suggest continuing transplantation programs during mass disasters, if medical and logistic operational circumstances are appropriate. Postponing transplantations from living donors and referral of urgent cases to safe regions or hospitals are justified. Specific preventative measures in anticipated disasters (such as vaccination programs during pandemics or evacuation in case of hurricanes or wars) may be useful to minimize risks. Immunosuppressive therapies should consider stratifying risk status and avoiding heavy immune suppression in patients with a low probability of therapeutic success. Discharging patients at the earliest convenience is justified during pandemics, whereas delaying discharge is reasonable in other disasters, if infrastructural damage results in unhygienic living environments for the patients. In the outpatient setting, telemedicine is a useful approach to reduce the patient load to hospitals, to minimize the risk of nosocomial transmission in pandemics and the need for transport in destructive disasters. If it comes down to save as many lives as possible, some ethical principles may vary in function of disaster circumstances, but elementary ethical rules are non-negotiable. Patient education is essential to minimize disaster-related complications and to allow for an efficient use of health care resources.
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Affiliation(s)
| | - Raymond Vanholder
- European Kidney Health Alliance, Brussels, Belgium; Department of Internal Medicine and Pediatrics, Nephrology Section, Ghent University Hospital, Ghent, Belgium
| | | | | | - Wim Van Biesen
- Department of Internal Medicine and Pediatrics, Nephrology Section, Ghent University Hospital, Ghent, Belgium
| | - Umberto Maggiore
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Bruno Watschinger
- Medical University of Vienna, Department of Medicine III, Division of Nephrology and Dialysis, Vienna, Austria
| | - Christophe Mariat
- Service de Néphrologie, Dialyse et Transplantation rénale, Centre Hospitalier Universitaire de Saint Etienne, Hôpital NORD, Université de Lyon, Université Jean Monnet, Saint Etienne, France
| | | | - Marta Crespo
- Hospital del Mar, Department of Nephrology, Barcelona, Spain
| | - Geir Mjoen
- Section of Nephrology, Department of Transplant Medicine, Oslo University Hospital, Oslo, Norway
| | - Peter Heering
- Klinik für Nephrologie und Allgemeine Innere Medizin, Städtisches Klinikum Solingen, Solingen, Germany
| | | | | | - Rachel Hellemans
- Department of Nephrology and Hypertension, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Luuk Hilbrands
- Radboud university medical center, Department of Nephrology, Nijmegen, The Netherlands
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4
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Grossi AA, Sever MS, Hellemans R, Mariat C, Crespo M, Watschinger B, Peruzzi L, Demir E, Velioglu A, Gandolfini I, Oniscu GC, Hilbrands L, Mjoen G. The 3-Step Model of informed consent for living kidney donation: a proposal on behalf of the DESCaRTES Working Group of the European Renal Association. Nephrol Dial Transplant 2023:7005240. [PMID: 36702535 DOI: 10.1093/ndt/gfad022] [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] [Indexed: 01/28/2023] Open
Abstract
Living donation challenges the ethical principle of non-maleficence in that it exposes healthy persons to risks for the benefit of someone else. This makes safety, informed consent (IC) and education a priority. Living kidney donation has multiple benefits for the potential donor, but there are also several known short- and long-term risks. Although complete standardization of IC is likely to be unattainable, studies have emphasized the need for a standardized IC process to enable equitable educational and decision-making prospects for the prevention of inequities across transplant centers. Based on the Three-Talk Model of shared decision making by Elwyn et al., we propose a model, named 3-Step (S) Model, where each step coincides with the three ideal timings of the process leading the living donor to the decision to pursue living donation: prior to the need for kidney replacement therapy (team talk); at the local nephrology unit or transplant center, with transplant clinicians and surgeons prior to evaluations start (option talk); and throughout evaluation, after having learned about the different aspects of donation, especially if there are second thoughts or doubts (decision talk). Based on the 3-S Model, to deliver conceptual and practical guidance to nephrologists and transplant clinicians, we provide recommendations for standardization of the timing, content, modalities for communicating risks, and assessment of understanding prior to donation. The 3-S Model successfully allows an integration between standardization and individualization of IC, enabling a person-centered approach to potential donors. Studies will assess the effectiveness of the 3-S Model in kidney transplant clinical practice.
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Affiliation(s)
- Alessandra Agnese Grossi
- Center for Clinical Ethics, Department of Biotechnologies and Life Sciences, University of Insubria, Varese, Italy.,Department of Human Sciences, Innovation, and Territory, University of Insubria, Como, Italy
| | | | - Rachel Hellemans
- Department of Nephrology-Hypertension, University Hospital, Edegem, Belgium.,Faculty of Medicine & Health Sciences, Laboratory of Experimental Medicine and Paediatrics (LEMP), University of Antwerp,Wilrijk, Belgium
| | - Christophe Mariat
- Nephrology Dialysis and Renal Transplantation Dpt, Chu de Saint-Etienne, Université Jean Monnet, Saint-Etienne, France
| | - Marta Crespo
- Department of Nephrology, Hospital del Mar Medical Research Institute (IMIM), Hospital del Mar, Barcelona, Spain. Partially supported by INT21/00003 (Spanish Ministry of Health ISCIII FIS-FEDER)
| | - Bruno Watschinger
- Medical University of Vienna, Department of Medicine III, Division of Nephrology and Dialysis, Vienna, Austria
| | - Licia Peruzzi
- Pediatric Nephrology Dialysis and Transplantation Unit, AOU Città della Salute e della Scienza, Turin, Italy
| | - Erol Demir
- Transplant Immunology Research Centre of Excellence, Koç University Hospital, Istanbul, Turkey
| | - Arzu Velioglu
- Marmara University, School of Medicine, Department of Nephrology, Istanbul, Turkey
| | | | - Gabriel C Oniscu
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, United Kingdom
| | - Luuk Hilbrands
- Department of Nephrology, Radboud university medical center, Nijmegen, The Netherlands
| | - Geir Mjoen
- Department of Transplant Medicine, Oslo University Hospital, Oslo, Norway
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5
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Boenink R, Kramer A, Vanholder RC, Mahillo B, Massy ZA, Bušić M, Ortiz A, Stel VS, Jager KJ, Idrizi A, Watschinger B, Neuwirt H, Eller K, Kalachik O, Leschuk S, Petkevich O, Abramowicz D, Hellemans R, Wissing KM, Colenbie L, Trnacevic S, Rebic D, Resic H, Filipov J, Megerov P, Bušić M, Žunec R, Markić D, Soloukides A, Savva I, Toumasi E, Viklicky O, Reischig T, Krejčí K, Sørensen SS, Bistrup C, Skov K, Lilienthal K, Ots-Rosenberg M, Helanterä I, Koivusalo A, Hourmant M, Essig M, Frimat L, Tomadze G, Banas B, Boletis I, Sándor M, Pálsson R, Plant W, Conlon P, Cooney A, Biancone L, Cardillo M, Ziedina I, Jusinskis J, Vaiciuniene R, Dalinkeviciene E, Delicata L, Farrugia E, Radunović D, Prelević V, Tomović F, Hilbrands L, Bemelman FJ, Schaefer B, Resisæter AV, Lien B, Skauby M, Dębska-Ślizień A, Durlik M, Wiecek A, Sampaio S, Romãozinho C, Jorge C, Rambabova-Bushljetikj I, Nikolov IG, Trajceska L, Tacu D, Elec A, Covic A, Zakharova E, Naumovic R, Lausevic M, Baltesová T, Žilinská Z, Dedinská I, Ponikvar JB, Arnol M, Valentín MO, Domínguez-Gil B, Crespo M, Mazuecos A, Wallquist C, Lundgren T, Dickenmann M, Toz H, Aki T, Keven K, Ravanan R, Geddes C. Factors influencing kidney transplantation rates: a study from the ERA Registry. Nephrol Dial Transplant 2023; 38:1540-1551. [PMID: 36626928 DOI: 10.1093/ndt/gfad001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Large international differences exist in kidney transplantation (KT) rates. We aimed to investigate which factors may explain the total, deceased donor, and living donor KT rates over the last decade. METHODS KT experts from 39 European countries completed the Kidney Transplantation Rate Survey on measures and barriers and their potential effect on the KT rate in their country. In the analyses, countries were divided into low, middle, and high KT rate countries based on the KT rate at the start of study period in 2010. RESULTS Experts from low KT rate countries reported more frequently to have taken measures regarding staff, equipment and facilities to increase total KT rate compared with middle and high KT rate countries. For donor type specific KT, the largest international differences in measures taken were reported for deceased donor KT, with middle and high KT rate countries taking more measures, such as the use of expanded criteria donor kidneys, the presence of transplantation coordinators, and (inter)national exchange of donor kidneys. Once a measure was taken, experts' opinion on its success was similar across the low, middle and high KT rate countries. Experts from low KT rate countries more often reported potential barriers, such as patients' lack of knowledge and distrust in the health care system. CONCLUSIONS In particular in low KT rate countries, KT rate might be stimulated by optimizing staff, equipment, and facilities. In addition, all countries may benefit from deceased and living donor specific measures.
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Affiliation(s)
- Rianne Boenink
- ERA Registry, Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands.,Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands
| | - Anneke Kramer
- ERA Registry, Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands.,Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands
| | - Raymond C Vanholder
- Nephrology Section, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, Belgium.,European Kidney Health Alliance, Brussels, Belgium
| | | | - Ziad A Massy
- Paris-Saclay University, UVSQ, Inserm, CESP, team 5, Clinical Epidemiology, Villejuif 94800, France.,Paris-Saclay University, AP-HP, Ambroise Paré Hospital, Nephrology department Boulogne-Billancourt 92100, France
| | | | - Alberto Ortiz
- Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Vianda S Stel
- ERA Registry, Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands.,Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands
| | - Kitty J Jager
- ERA Registry, Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands.,Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands
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6
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Daniel-Fischer L, Sobieszek IJ, Wagner A, Sacnun JM, Watschinger B, Aufricht C, Kratochwill K, Herzog R. In-Depth Analysis of the Extracorporeal Proteome Adsorbed to Dialysis Membranes during Hemodialysis. Membranes (Basel) 2022; 12:1120. [PMID: 36363675 PMCID: PMC9695746 DOI: 10.3390/membranes12111120] [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] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 10/31/2022] [Accepted: 11/03/2022] [Indexed: 06/16/2023]
Abstract
Used hemodialysis membranes (HD-M) are a valuable reservoir of biological information. Proteins bind to HD-M, but whether this process depends on the type of membrane or patient factors or selectively affects specific protein classes has not been adequately elucidated. State-of-the-art proteomics techniques are capable of identifying and quantifying this therapy-specific subproteome to enable the analysis of disease- or membrane-induced pathophysiologies. We demonstrate the feasibility of the deep proteomic characterization of the extracorporeal proteome adsorbed to HD-M. A shotgun proteomics approach using nano-flow liquid chromatography coupled to mass-spectrometry identified 1648 unique proteins eluted by a chaotropic buffer from the HD-M of eight patients. In total, 995 proteins were present in all eluates; a more stringent approach showed that a core proteome of 310 proteins could be identified independently in all samples. Stability of the dialyzer proteome was demonstrated by a >90% re-identification rate on longitudinal samples of a single patient. The core proteome showed an overrepresentation of pathways of hemostasis and the immune system, and showed differences in membrane materials (polysulfone vs. helixone). This study demonstrates that optimized conditions combined with high-performance proteomics enable the in-depth exploration of the subproteome bound to HD-M, yielding a stable core proteome that can be exploited to study patient-specific factors and improve hemodialysis therapy.
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Affiliation(s)
- Lisa Daniel-Fischer
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria
- Christian Doppler Laboratory for Molecular Stress Research in Peritoneal Dialysis, Medical University of Vienna, 1090 Vienna, Austria
| | - Isabel J. Sobieszek
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria
- Christian Doppler Laboratory for Molecular Stress Research in Peritoneal Dialysis, Medical University of Vienna, 1090 Vienna, Austria
| | - Anja Wagner
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria
- Christian Doppler Laboratory for Molecular Stress Research in Peritoneal Dialysis, Medical University of Vienna, 1090 Vienna, Austria
| | - Juan Manuel Sacnun
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria
- Christian Doppler Laboratory for Molecular Stress Research in Peritoneal Dialysis, Medical University of Vienna, 1090 Vienna, Austria
| | - Bruno Watschinger
- Division of Nephrology and Dialysis, Department of Inner Medicine III, Medical University of Vienna, 1090 Vienna, Austria
| | - Christoph Aufricht
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria
| | - Klaus Kratochwill
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria
- Christian Doppler Laboratory for Molecular Stress Research in Peritoneal Dialysis, Medical University of Vienna, 1090 Vienna, Austria
| | - Rebecca Herzog
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria
- Christian Doppler Laboratory for Molecular Stress Research in Peritoneal Dialysis, Medical University of Vienna, 1090 Vienna, Austria
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7
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Gandolfini I, Crespo M, Hellemans R, Maggiore U, Mariat C, Mjoen G, Oniscu GC, Peruzzi L, Sever MS, Watschinger B, Hilbrands L. Issues regarding COVID-19 in kidney transplantation in the era of the omicron variant: a commentary by the era descartes working group. Nephrol Dial Transplant 2022; 37:1824-1829. [PMID: 35746885 PMCID: PMC9278231 DOI: 10.1093/ndt/gfac203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Indexed: 11/20/2022] Open
Abstract
The Omicron variant, which has become the dominant strain of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) worldwide, brings new challenges to preventing and controlling the infection. Moreover, the widespread implementation of vaccination policies before and after transplantation, and the development of new prophylactic and treatment strategies for coronavirus disease 2019 (COVID-19) over the past 12–18 months, has raised several new issues concerning kidney transplant recipients. In this special report, the ERA DESCARTES (Developing Education Science and Care for Renal Transplantation in European States) Working Group addresses several questions related to everyday clinical practice concerning kidney transplant recipients and to the assessment of deceased and live kidney donors: what is the current risk of severe disease and of breakthrough infection, the optimal management of immunosuppression in kidney transplant recipients with COVID-19, the role of passive immunization and the efficacy of antiviral drugs in ambulatory patients, the management of drug-to-drug interactions, safety criteria for the use of SARS-CoV-2-positive donors, issues related to the use of T cell depleting agents as induction treatment, and current recommendations for shielding practices.
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Affiliation(s)
- Ilaria Gandolfini
- Dipartimento di Medicina e Chirurgia, Università di Parma, UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Marta Crespo
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Rachel Hellemans
- Laboratory of Experimental Medicine and Pediatrics, Department of Nephrology, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Umberto Maggiore
- Dipartimento di Medicina e Chirurgia, Università di Parma, UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Christophe Mariat
- Department of Nephrology, Dialysis and Renal transplantation, Centre Hospitalier Universitaire de Saint Etienne, Université Jean MONNET, Saint Etienne, France
| | - Geir Mjoen
- Department of Transplant Medicine, Oslo University Hospital, Oslo, Norway
| | - Gabriel C Oniscu
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Licia Peruzzi
- Pediatric Nephrology Unit, Regina Margherita Children's Hospital, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Mehmet Sükrü Sever
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Bruno Watschinger
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Luuk Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
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8
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Omić H, Kläger JP, Herkner H, Aberle SW, Regele H, Weseslindtner L, Schrag TA, Bond G, Hohenstein K, Watschinger B, Werzowa J, Strassl R, Eder M, Kikić Ž. Clinical Relevance of Absolute BK Polyoma Viral Load Kinetics in Patients With Biopsy Proven BK Polyomavirus Associated Nephropathy. Front Med (Lausanne) 2022; 8:791087. [PMID: 35071271 PMCID: PMC8770438 DOI: 10.3389/fmed.2021.791087] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: The absolute BK viral load is an important diagnostic surrogate for BK polyomavirus associated nephropathy (PyVAN) after renal transplant (KTX) and serial assessment of BK viremia is recommended. However, there is no data indicating which particular viral load change, i.e., absolute vs. relative viral load changes (copies/ml; percentage of the preceding viremia) is associated with worse renal graft outcomes. Materials and Methods: In this retrospective study of 91 biopsy proven PyVAN, we analyzed the interplay of exposure time, absolute and relative viral load kinetics, baseline risk, and treatment strategies as risk factors for graft loss after 2 years using a multivariable Poisson-model. Results: We compared two major treatment strategies: standardized immunosuppression (IS) reduction (n = 53) and leflunomide (n = 30). The median viral load at the index biopsy was 2.15E+04 copies/ml (interquartile range [IQR] 1.70E+03–1.77E+05) and median peak viremia was 3.6E+04 copies/ml (IQR 2.7E+03–3.3E+05). Treatment strategies and IS-levels were not related to graft loss. After correction for baseline viral load and estimated glomerular filtration rate (eGFR), absolute viral load decrease/unit remained an independent risk factor for graft loss [incidence rate ratios [IRR] = 0.77, (95% CI 0.61–0.96), p = 0.02]. Conclusion: This study provides evidence for the prognostic importance of absolute BK viremia kinetics as a dynamic parameter indicating short-term graft survival independently of other established risk factors.
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Affiliation(s)
- Haris Omić
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Stephan W Aberle
- Center for Virology, Medical University of Vienna, Vienna, Austria
| | - Heinz Regele
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | | | - Tarek Arno Schrag
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gregor Bond
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Katharina Hohenstein
- Department of Orthopedics and Trauma Surgery at the Medical University of Vienna in the General Hospital, Vienna, Austria
| | - Bruno Watschinger
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Johannes Werzowa
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Vienna, Austria
| | - Robert Strassl
- Division of Clinical Virology, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Eder
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Željko Kikić
- Department of Urology, Medical University of Vienna, Vienna, Austria
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9
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Goffin E, Candellier A, Vart P, Noordzij M, Arnol M, Covic A, Lentini P, Malik S, Reichert LJ, Sever MS, Watschinger B, Jager KJ, Gansevoort RT. COVID-19-related mortality in kidney transplant and haemodialysis patients: a comparative, prospective registry-based study. Nephrol Dial Transplant 2021; 36:2094-2105. [PMID: 34132811 PMCID: PMC8394823 DOI: 10.1093/ndt/gfab200] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [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] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) has exposed haemodialysis (HD) patients and kidney transplant (KT) recipients to an unprecedented life-threatening infectious disease, raising concerns about kidney replacement therapy (KRT) strategy during the pandemic. This study investigated the association of the type of KRT with COVID-19 severity, adjusting for differences in individual characteristics. METHODS Data on KT recipients and HD patients diagnosed with COVID-19 between 1 February 2020 and 1 December 2020 were retrieved from the European Renal Association COVID-19 Database. Cox regression models adjusted for age, sex, frailty and comorbidities were used to estimate hazard ratios (HRs) for 28-day mortality risk in all patients and in the subsets that were tested because of symptoms. RESULTS A total of 1670 patients (496 functional KT and 1174 HD) were included; 16.9% of KT and 23.9% of HD patients died within 28 days of presentation. The unadjusted 28-day mortality risk was 33% lower in KT recipients compared with HD patients {HR 0.67 [95% confidence interval (CI) 0.52-0.85]}. In a fully adjusted model, the risk was 78% higher in KT recipients [HR 1.78 (95% CI 1.22-2.61)] compared with HD patients. This association was similar in patients tested because of symptoms [fully adjusted model HR 2.00 (95% CI 1.31-3.06)]. This risk was dramatically increased during the first post-transplant year. Results were similar for other endpoints (e.g. hospitalization, intensive care unit admission and mortality >28 days) and across subgroups. CONCLUSIONS KT recipients had a greater risk of a more severe course of COVID-19 compared with HD patients, therefore they require specific infection mitigation strategies.
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Affiliation(s)
| | | | - Priya Vart
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marlies Noordzij
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Miha Arnol
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center, ‘C.I. PARHON’ University Hospital, ‘Grigore T. Popa’ University of Medicine, Iasi, Romania
| | - Paolo Lentini
- Nephrology and Dialysis Unit, San Bassiano Hospital, Vicenza, Italy
| | - Shafi Malik
- Department of Renal and Transplant, University Hospital of Coventry and Warwickshire and University of Leicester, Coventry, UK
| | - Louis J Reichert
- Department of Nephrology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Mehmet S Sever
- Department of Nephrology, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Bruno Watschinger
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Kitty J Jager
- Department of Medical Informatics, ERA-EDTA Registry, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Ron T Gansevoort
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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10
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Mariat C, Mjøen G, Watschinger B, Sever MS, Crespo M, Peruzzi L, Oniscu GC, Abramowicz D, Hilbrands L, Maggiore U. Assessment of Pre-Donation Glomerular Filtration Rate: Going Back To Basics A Position Paper from the DESCARTES Working Group of the ERA-EDTA. Nephrol Dial Transplant 2021; 37:430-437. [PMID: 34519827 DOI: 10.1093/ndt/gfab259] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 02/25/2021] [Indexed: 12/24/2022] Open
Abstract
The 2017 version of the KDIGO (Kidney Disease: Improving Global Outcomes) guidelines is the most recent international framework for the evaluation and care of living kidneys donors. Along with the call for an integrative approach evaluating the long-term end-stage kidney disease risk for the future potential donor, several recommendations are formulated regarding the predonation glomerular filtration rate (GFR) adequacy with no or little consideration for the donor candidate's age and for the importance of using reference methods of GFR measurements. Herein, we question the position of the KDIGO guidelines and discuss the rationale and modalities for a more basic, but not less demanding GFR evaluation susceptible to enable a more efficient selection of the potential kidney donor.
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Affiliation(s)
- Christophe Mariat
- Service de Néphrologie, Dialyse et Transplantation rénale, Centre Hospitalier Universitaire de Saint Etienne, Hôpital NORD, Université de LYON, Université Jean MONNET, Saint Etienne, France
| | | | - Bruno Watschinger
- Medical University of Vienna, Department of Medicine III, Division of Nephrology and Dialysis, Vienna, Austria
| | | | - Marta Crespo
- Hospital del Mar, Nephrology Department, Barcelona, Spain
| | | | | | | | - Luuk Hilbrands
- Radboud university medical center, Department of Nephrology, Nijmegen, The Netherlands
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11
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Candellier A, Goffin EJ, Vart P, Noordzij M, Arnol M, Covic A, Lentini P, Malik S, Reichert L, Sever MS, Watschinger B, Jager KJ, Gansevoort R. FC 028COVID-19 RELATED MORTALITY IN KIDNEY TRANSPLANT AND DIALYSIS PATIENTS: A COMPARATIVE, PROSPECTIVE REGISTRY BASED STUDY. Nephrol Dial Transplant 2021. [PMCID: PMC8195177 DOI: 10.1093/ndt/gfab145.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background and Aims Studies examining kidney failure patients with COVID-19 reported higher mortality in hemodialysis patients than in kidney transplant recipients. However, hemodialysis patients are often older and have more comorbidities. This study investigated the association of type of kidney replacement therapy with COVID-19 severity adjusting for differences in characteristics. Method Data were retrieved from the European Renal Association COVID-19 Database (ERACODA), which includes kidney replacement therapy patients diagnosed with COVID-19 from all over Europe. We included all kidney transplant recipients and hemodialysis patients who presented between February 1st and December 1st 2020 and had complete information reason for COVID-19 screening and vital status at day 28. The diagnosis of COVID-19 was made based on a PCR of a nasal or pharyngeal swab specimens and/or COVID-19 compatible findings on a lung CT scan. The association of kidney transplantation or hemodialysis with 28-day mortality was examined using Cox proportional-hazards regression models adjusted for age, sex, frailty and comorbidities. Additionally, this association was investigated in the subsets of patients that were screened because of symptoms or have had routine screening. Results A total of 1,670 patients (496 functional kidney transplant recipients and 1,174 hemodialysis patients) were examined. 16.9% of kidney transplant recipients and 23.9% of hemodialysis patients died within 28 days of presentation. In an unadjusted model, the risk of 28-day mortality was 33% lower in kidney transplant recipients compared with hemodialysis patients (hazard ratio (HR): 0.67, 95% CI: 0.52, 0.85). However, in an age, sex and frailty adjusted model, the risk of 28-day mortality was 29% higher in kidney transplant recipients (HR=1.29, 95% CI: 1.00, 1.68), whereas in a fully adjusted model the risk was even 43% higher (HR=1.43, 95% CI: 1.06, 1.93). This association in patients who were screened because of symptoms (n=1,145) was similar (fully adjusted model HR=1.46, 95% CI: 1.05, 2.04). Results were similar when other endpoints were studied (e.g. risk for hospitalization, ICU admission or mortality beyond 28 days) as well as across subgroups. Only age was found to interact significantly, suggesting that the increased mortality risk associated with kidney transplantation was especially present in elderly subjects. Conclusion In this study, kidney transplant recipients had a greater risk of a more severe course of COVID-19 compared with hemodialysis patients when adjusted for age, sex and comorbidities.
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Affiliation(s)
- Alexandre Candellier
- Cliniques Universitaires Saint-Luc, Institute of Experimental and Clinical Research, Université catholique de Louvain, Department of Nephrology, Brussels, Belgium
- Centre Hospitalier Universitaire Amiens-Picardie, Department of Nephrology, Amiens, France
| | - Eric Jean Goffin
- Cliniques Universitaires Saint-Luc, Institute of Experimental and Clinical Research, Université catholique de Louvain, Department of Nephrology, Brussels, Belgium
| | - Priya Vart
- University Medical Center Groningen, University of Groningen, Department of Internal Medicine, Groningen, Netherlands
- University Medical Center Groningen, University of Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, Netherlands
| | - Marlies Noordzij
- University Medical Center Groningen, University of Groningen, Department of Internal Medicine, Groningen, Netherlands
| | - Miha Arnol
- University Medical Centre Ljubljana, Department of Nephrology, Ljubljana, Slovenia
| | - Adrian Covic
- University Hospital, ‘Grigore T. Popa' University of Medicine, Nephrology Clinic, Dialysis and Renal Transplant Center, 'C.I. PARHON’ , Iasi, Romania
| | - Paolo Lentini
- San Bassiano Hospital, Bassano del Grappa, Nephrology and Dialysis Unit, Vicenza, Italy
| | - Shafi Malik
- University Hospital of Coventry and Warwickshire and University of Leicester., Department of Renal and Transplant, Leicester, United Kingdom
| | - Louis Reichert
- Rijnstate Hospital, Department of Nephrology, Arnhem, Netherlands
| | - Mehmet Sukru Sever
- Istanbul School of Medicine, Istanbul University, Department of Nephrology, Istanbul, Turkey
| | - Bruno Watschinger
- Medical University of Vienna, Department of Nephrology, Vienna, Austria
| | - Kitty J Jager
- Amsterdam University Medical Center, University of Amsterdam, Amsterdam Public Health research institute, ERA-EDTA Registry, Department of Medical Informatics, Amsterdam, Netherlands
| | - Ronald Gansevoort
- University Medical Center Groningen, University of Groningen, Department of Internal Medicine, Groningen, Netherlands
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12
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Mjøen G, Maggiore U, Kessaris N, Kimenai D, Watschinger B, Mariat C, Sever MS, Crespo M, Peruzzi L, Spasovski G, Sørensen SS, Heemann U, Pascual J, Viklicky O, Courtney AE, Hadaya K, Wagner L, Nistor I, Hadjianastassiou V, Durlik M, Helanterä I, Oberbauer R, Oniscu G, Hilbrands L, Abramowicz D. Long-term risks after kidney donation: how do we inform potential donors? A survey from DESCARTES and EKITA transplantation working groups. Nephrol Dial Transplant 2021; 36:1742-1753. [PMID: 33585931 PMCID: PMC8397510 DOI: 10.1093/ndt/gfab035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Indexed: 11/29/2022] Open
Abstract
Background Publications from the last decade have increased knowledge regarding long-term risks after kidney donation. We wanted to perform a survey to assess how transplant professionals in Europe inform potential kidney donors regarding long-term risks. The objectives of the survey were to determine how they inform donors and to what extent, and to evaluate the degree of variation. Methods All transplant professionals involved in the evaluation process were considered eligible, regardless of the type of profession. The survey was dispatched as a link to a web-based survey. The subjects included questions on demographics, the information policy of the respondent and the use of risk calculators, including the difference of relative and absolute risks and how the respondents themselves understood these risks. Results The main finding was a large variation in how often different long-term risks were discussed with the potential donors, i.e. from always to never. Eighty percent of respondents stated that they always discuss the risk of end-stage renal disease, while 56% of respondents stated that they always discuss the risk of preeclampsia. Twenty percent of respondents answered correctly regarding the relationship between absolute and relative risks for rare outcomes. Conclusions The use of written information and checklists should be encouraged. This may improve standardization regarding the information provided to potential living kidney donors in Europe. There is a need for information and education among European transplant professionals regarding long-term risks after kidney donation and how to interpret and present these risks.
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Affiliation(s)
- Geir Mjøen
- Section of Nephrology, Department of Transplant Medicine, Oslo University Hospital, Oslo, Norway
| | - Umberto Maggiore
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | | | - Diederik Kimenai
- Erasmus University Hospital Rotterdam, Rotterdam, The Netherlands
| | - Bruno Watschinger
- Medical University of Vienna, Department of Medicine III, Division of Nephrology and Dialysis, Vienna, Austria
| | - Cristophe Mariat
- Centre Hospitalier Universitaire de Saint Etienne, Saint Etienne, France
| | | | - Marta Crespo
- Hospital del Mar, Department of Nephrology, Barcelona, Spain
| | | | - Goce Spasovski
- University Clinic of Nephrology, Skopje, North Macedonia
| | | | - Uwe Heemann
- Technische Universität München, München, Germany
| | - Julio Pascual
- Hospital del Mar, Department of Nephrology, Barcelona, Spain
| | - Ondrej Viklicky
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | | | | | | | - Ionut Nistor
- Methodological Center for Medical Research and Evidence-Based Medicine, University of Medicine and Pharmacy "Grigore T. Popa", Iasi, Romania
| | - Vassilis Hadjianastassiou
- Renal Unit, Royal London Hospital, Whitechapel, Bart's Health, NHS Trust, London, UK.,University of Nicosia, Nicosia, Cyprus
| | | | | | - Rainer Oberbauer
- Medical University of Vienna, Department of Medicine III, Division of Nephrology and Dialysis, Vienna, Austria
| | | | - Luuk Hilbrands
- Radboud University Medical Center, Nijmegen, The Netherlands
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13
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Watschinger B, Watschinger C, Reindl-Schwaighofer R, Meyer EL, Deak AT, Hammer T, Eigner M, Sprenger-Mähr H, Schneeberger S, Cejka D, Mayer G, Oberbauer R, Rosenkranz AR, Kerschbaum J. Impact of Timely Public Health Measures on Kidney Transplantation in Austria during the SARS-CoV-2 Outbreak-A Nationwide Analysis. J Clin Med 2020; 9:jcm9113465. [PMID: 33126481 PMCID: PMC7693584 DOI: 10.3390/jcm9113465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 09/16/2020] [Revised: 10/21/2020] [Accepted: 10/24/2020] [Indexed: 02/06/2023] Open
Abstract
SARS-CoV-2 led to considerable morbidity/mortality worldwide and tremendously impacted on daily life. Strict lockdown measures were implemented early to contain the viral outbreak in Austria. Massive changes in organizational structures of healthcare facilities followed with unclear implications on the care of non-COVID-19-affected patients. We studied the nationwide impact of COVID-19 on kidney transplantation in Austria during the first six months of 2020. Concurrent with general lockdown measures, all kidney transplant activity was suspended from 13 March to 9 April. Nevertheless, between January and June, total transplant (p = 0.48) and procured donor organ numbers (p = 0.6) did not differ significantly from earlier years. Ten (0.18%) of 5512 prevalent Austrian kidney transplant recipients were diagnosed with SARS-CoV-2. The case fatality rate (one death; 10%) in renal transplant patients was less than in other countries but higher than in Austria's general population (2.4%). We conclude that early and strict general lockdown measures imposed by the government allowed an early, however cautious, re-opening of Austrian transplant programs and played a crucial role for the favorable outcomes of SARS-CoV-2 in Austrian kidney transplant patients. Even though it may be uncertain whether similar results may be obtainable in other countries, the findings may support early intervention strategies during similar episodes in the future.
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Affiliation(s)
- Bruno Watschinger
- Department of Nephrology, Medical University of Vienna, 1090 Vienna, Austria; (C.W.); (R.R.-S.); (R.O.)
- Correspondence: ; Tel.: +43-1-40400-43910
| | - Clara Watschinger
- Department of Nephrology, Medical University of Vienna, 1090 Vienna, Austria; (C.W.); (R.R.-S.); (R.O.)
| | - Roman Reindl-Schwaighofer
- Department of Nephrology, Medical University of Vienna, 1090 Vienna, Austria; (C.W.); (R.R.-S.); (R.O.)
| | - Elias L. Meyer
- Section for Medical Statistics, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, 1090 Vienna, Austria;
| | - Andras T. Deak
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (A.T.D.); (A.R.R.)
| | - Tamara Hammer
- Department of Medicine III: Nephrology, Transplantation Medicine, Rheumatology, Geriatrics, Ordensklinikum Linz Elisabethinen, 4010 Linz, Austria; (T.H.); (D.C.)
| | - Manfred Eigner
- Department of Medicine I, Klinik Favoriten, 1100 Vienna, Austria;
| | - Hannelore Sprenger-Mähr
- Landeskrankenhaus Feldkirch Abteilung für Innere Medizin III, Nephrologie und Dialyse, 6807 Feldkirch, Austria;
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Daniel Cejka
- Department of Medicine III: Nephrology, Transplantation Medicine, Rheumatology, Geriatrics, Ordensklinikum Linz Elisabethinen, 4010 Linz, Austria; (T.H.); (D.C.)
| | - Gert Mayer
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, 6020 Innsbruck, Austria; (G.M.); (J.K.)
- Austrian Dialysis and Transplant Registry, Department of Internal Medicine IV, Nephrology and Hypertension, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Rainer Oberbauer
- Department of Nephrology, Medical University of Vienna, 1090 Vienna, Austria; (C.W.); (R.R.-S.); (R.O.)
| | - Alexander R. Rosenkranz
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (A.T.D.); (A.R.R.)
| | - Julia Kerschbaum
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, 6020 Innsbruck, Austria; (G.M.); (J.K.)
- Austrian Dialysis and Transplant Registry, Department of Internal Medicine IV, Nephrology and Hypertension, Medical University of Innsbruck, 6020 Innsbruck, Austria
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14
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Maggiore U, Abramowicz D, Crespo M, Mariat C, Mjoen G, Peruzzi L, Sever MS, Oniscu GC, Hilbrands L, Watschinger B. How should I manage immunosuppression in a kidney transplant patient with COVID-19? An ERA-EDTA DESCARTES expert opinion. Nephrol Dial Transplant 2020; 35:899-904. [PMID: 32441741 PMCID: PMC7313836 DOI: 10.1093/ndt/gfaa130] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/04/2020] [Indexed: 12/15/2022] Open
Affiliation(s)
- Umberto Maggiore
- Dipartimento di Medicina e Chrurgia, Università d Parma, UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Daniel Abramowicz
- Department of Nephrology, Antwerp University Hospital, Antwerp University, Antwerp, Belgium
| | - Marta Crespo
- Department of Nephrology, Hospital del Mar Barcelona, Barcelona, Spain
| | - Christophe Mariat
- Department of Nephrology, Dialysis, and Renal Transplantation, University North Hospital, Saint Etienne, France
| | - Geir Mjoen
- Department of Transplant Medicine, Oslo University Hospital, Oslo, Norway
| | - Licia Peruzzi
- Pediatric Nephrology Unit, Regina Margherita Children’s Hospital, Turin, Italy
| | - Mehmet Sükrü Sever
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | - Luuk Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bruno Watschinger
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
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15
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Watschinger B, Budde K, Crespo M, Heemann U, Hilbrands L, Maggiore U, Mariat C, Oberbauer R, Oniscu GC, Peruzzi L, Sorensen SS, Viklicky O, Abramowicz D. Pre-existing malignancies in renal transplant candidates-time to reconsider waiting times. Nephrol Dial Transplant 2020; 34:1292-1300. [PMID: 30830155 DOI: 10.1093/ndt/gfz026] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 12/24/2018] [Indexed: 12/12/2022] Open
Abstract
Current proposals for waiting times for a renal transplant after malignant disease may not be appropriate. New data on malignancies in end-stage renal disease and recent diagnostic and therapeutic options should lead us to reconsider our current practice.
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Affiliation(s)
- Bruno Watschinger
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Klemens Budde
- Department of Nephrology, Charité Medical University Berlin, Berlin, Germany
| | - Marta Crespo
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Institute Mar for Medical Research, Parc de Salut Mar, Barcelona, Spain
| | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Luuk Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Umberto Maggiore
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Christophe Mariat
- Department of Nephrology, Dialysis, and Renal Transplantation, University North Hospital, Saint Etienne, France
| | - Rainer Oberbauer
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
| | | | - Licia Peruzzi
- Pediatric Nephrology Unit, Regina Margherita Children's Hospital, Turin, Italy
| | - Søren S Sorensen
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ondrej Viklicky
- Department of Nephrology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Daniel Abramowicz
- Department of Nephrology, Antwerp University Hospital, Antwerp University, Antwerp, Belgium
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16
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Maggiore U, Abramowicz D, Budde K, Crespo M, Mariat C, Oberbauer R, Pascual J, Peruzzi L, Schwartz Sorensen S, Viklicky O, Watschinger B, Oniscu GC, Heemann U, Hilbrands LB. Standard work-up of the low-risk kidney transplant candidate: a European expert survey of the ERA-EDTA Developing Education Science and Care for Renal Transplantation in European States Working Group. Nephrol Dial Transplant 2020; 34:1605-1611. [PMID: 30629182 DOI: 10.1093/ndt/gfy391] [Citation(s) in RCA: 11] [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: 08/19/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Existing guidelines on the evaluation and preparation of recipients for kidney transplantation target the entire spectrum of patients with end-stage renal disease. Within the ERA-EDTA Developing Education Science and Care for Renal Transplantation in European States (DESCARTES) Working Group, it was proposed that in a subset of relatively young patients (<40 years) without significant comorbidities (such as diabetes or cardiovascular disease), the work-up for transplantation could be restricted to a small set of tests. METHODS Aiming for agreement between transplant centres across Europe, we surveyed the opinion of 80 transplant professionals from 11 European states on the composition of a minimal work-up. RESULTS We show that there is a wide agreement among European experts that the work-up for kidney transplantation of the low-risk candidate, as opposed to the standard risk candidate, could include a limited number of investigations. However, there is some disagreement regarding the small number of diagnostic procedures, which is related to geographical location within Europe and the professional background of respondents. CONCLUSIONS Based on the results of the survey, published guidelines and expert meetings by the DESCARTES Working Group, we have formulated a proposal for the work-up of low-risk kidney transplant candidates.
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Affiliation(s)
- Umberto Maggiore
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Daniel Abramowicz
- Department of Nephrology, Antwerp University Hospital, Antwerp University, Antwerp, Belgium
| | - Klemens Budde
- Department of Nephrology, Charité Medical University Berlin, Berlin, Germany
| | - Marta Crespo
- Department of Nephrology, Hospital del Mar Barcelona, Barcelona, Spain
| | - Christophe Mariat
- Department of Nephrology, Dialysis, and Renal Transplantation, University North Hospital, Saint Etienne, France
| | - Rainer Oberbauer
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar Barcelona, Barcelona, Spain
| | - Licia Peruzzi
- Pediatric Nephrology Unit, Regina Margherita Children's Hospital, Turin, Italy
| | - Soren Schwartz Sorensen
- Department of Nephrology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ondrej Viklicky
- Department of Nephrology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Bruno Watschinger
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
| | | | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Luuk B Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
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17
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Schernthaner G, Saely CH, Schernthaner GH, Watschinger B, Drexel H. [Individualising antihypertensive therapy in patients with diabetes. A guideline by the Austrian Diabetes Association (Update 2019)]. Wien Klin Wochenschr 2019; 131:124-135. [PMID: 30980142 DOI: 10.1007/s00508-019-1460-2] [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] [Indexed: 10/27/2022]
Abstract
Hypertension is one of the most important comorbidities of diabetes, contributing significantly to death and leads to macrovascular and microvascular complications. When assessing the medical priorities for patients with diabetes, treating hypertension should be a primary consideration. In the present review practical approaches to hypertension in diabetes, including individualized targets for preventing specific complications are discussed according to current studies and guidelines. According to recent studies, blood pressure values of about 130/80 mm Hg are associated with the best outcome. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers are the most effective drugs for treating hypertension in diabetes. Calcium antagonists or diuretics are acceptable as second-line agents. Once the target is achieved, antihypertensive drugs should be continued. Newer antidiabetic medications such as SGLT-2-inhibitors or GLP1-receptor agonists have also antihypertensive effects.
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Affiliation(s)
- Guntram Schernthaner
- 1. Medizinische Abteilung, Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030, Wien, Österreich. .,Universität Wien, Wien, Österreich.
| | - Christoph H Saely
- Abteilung für Innere Medizin I, Akademisches Lehrkrankenhaus Feldkirch, Feldkirch, Österreich
| | - Gerit-Holger Schernthaner
- Klinische Abteilung für Angiologie, Universitätsklinik für Innere Medizin II, Medizinische Universität Wien, Wien, Österreich
| | - Bruno Watschinger
- Klinische Abteilung für Nephrologie und Dialyse, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Heinz Drexel
- VIVIT Institut, Landeskrankenhaus Feldkirch, Feldkirch, Österreich.,Private Universität im Fürstentum Liechtenstein, Liechtenstein, Liechtenstein.,Drexel University College of Medicine, Philadelphia, PA, USA.,Abteilung für Angiologie, Universitätsspital Bern, Bern, Schweiz.,ESC-Working Group "Cardiovascular Pharmacotherapy", Sophia Antipolis, Frankreich
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18
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Pisano A, Bolignano D, Mallamaci F, Graziella D, Halimi JM, Persu A, Wuerzner G, Sarafidis P, Watschinger B, Burnier M, Zoccali C. FP760COMPARATIVE EFFECTIVENESS OF DIFFERENT ANTIHYPERTENSIVE AGENTS IN KIDNEY TRANSPLANTATION: A SYSTEMATIC REVIEW AND META-ANALYSIS. Nephrol Dial Transplant 2019. [DOI: 10.1093/ndt/gfz106.fp760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | | | | | | | - Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain; Brussels, Belgium
| | | | - Pantelis Sarafidis
- Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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19
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Pisano A, Bolignano D, Mallamaci F, D’Arrigo G, Halimi JM, Persu A, Wuerzner G, Sarafidis P, Watschinger B, Burnier M, Zoccali C. Comparative effectiveness of different antihypertensive agents in kidney transplantation: a systematic review and meta-analysis. Nephrol Dial Transplant 2019; 35:878-887. [DOI: 10.1093/ndt/gfz092] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/11/2019] [Indexed: 12/19/2022] Open
Abstract
Abstract
Background
We conducted a systematic review and meta-analysis to compare benefits and harms of different antihypertensive drug classes in kidney transplant recipients, as post-transplant hypertension (HTN) associates with increased cardiovascular (CV) morbidity and mortality.
Methods
The Ovid-MEDLINE, PubMed and CENTRAL databases were searched for randomized controlled trials (RCTs) comparing all main antihypertensive agents versus placebo/no treatment, routine treatment.
Results
The search identified 71 RCTs. Calcium channel blockers (CCBs) (26 trials) reduced the risk for graft loss {risk ratio [RR] 0.58 [95% confidence interval (CI) 0.38–0.89]}, increased glomerular filtration rate (GFR) [mean difference (MD) 3.08 mL/min (95% CI 0.38–5.78)] and reduced blood pressure (BP). Angiotensin-converting enzyme inhibitors (ACEIs) (13 trials) reduced the risk for graft loss [RR 0.62 (95% CI 0.40–0.96)] but decreased renal function and increased the risk for hyperkalaemia. Angiotensin receptor blockers (ARBs) (10 trials) did not modify the risk of death, graft loss and non-fatal CV events and increased the risk for hyperkalaemia. When pooling ACEI and ARB data, the risk for graft failure was lower in renin–angiotensin system (RAS) blockade as compared with control treatments. In direct comparison with ACEIs or ARBs (11 trials), CCBs increased GFR [MD 11.07 mL/min (95% CI 6.04–16.09)] and reduced potassium levels but were not more effective in reducing BP. There are few available data on mortality, graft loss and rejection. Very few studies performed comparisons with other active drugs.
Conclusions
CCBs could be the preferred first-step antihypertensive agents in kidney transplant patients, as they improve graft function and reduce graft loss. No definite patient or graft survival benefits were associated with RAS inhibitor use over conventional treatment.
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Affiliation(s)
- Anna Pisano
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Davide Bolignano
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Francesca Mallamaci
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Graziella D’Arrigo
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Jean-Michel Halimi
- Service de Néphrologie et Immunologie clinique, CHRU de Tours—Hôpital Bretonneau, Tours, France
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, University Hospital, Lausanne, Switzerland
| | | | - Bruno Watschinger
- Department of Internal Medicine III, Division of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Michel Burnier
- Service of Nephrology and Hypertension, University Hospital, Lausanne, Switzerland
| | - Carmine Zoccali
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
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20
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Samaha E, Schwameis M, Schranz S, Watschinger B, Buchmüller A, Jilma B. Acetylsalicylic acid decreases clotting in combination with enoxaparin during haemodialysis in vitro. Nephrol Dial Transplant 2019; 34:509-515. [PMID: 30053218 DOI: 10.1093/ndt/gfy229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 06/16/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Anticoagulation is a cornerstone in haemodialysis (HD) therapy to avoid clotting of blood when it comes into contact with the dialysis membrane. Although heparins are usually administered as anticoagulants, they are not always sufficient to maintain adequate HD. We investigated the additional effect of acetylsalicylic acid compared with standard anticoagulation on maintaining adequate flow properties during HD in vitro. METHODS We collected blood from 42 healthy volunteers, between 18 and 60 years of age, into bags filled with 1, 1.5 or 2 mg enoxaparin, with (treatment group) or without (control group) 100 mg of aspirin. Blood was evaluated before, during and at the end of each experiment to determine coagulation parameters, whole blood aggregation and thromboelastogram measurements. Transmembrane pressure was recorded as indirect estimate of dialysis patency. The primary endpoint was time to filter clotting. RESULTS Addition of acetylsalicylic acid significantly prolonged the time to circuit clotting from 120 (105-150) min to >180 min (120-180) min (P = 0.047) and allowed lowering the enoxaparin concentration from 2 mg per circuit to 1 mg without an increase in clotting. Furthermore, it reduced the transmembrane pressure from 46 to 4 mmHg (P < 0.001) after 4 h of dialysis. Acetylsalicylic acid better preserved the platelet count (128 versus 116 × 10E9/L, P = 0.01) and improved platelet aggregation at the end of the dialysis procedure. CONCLUSION Adding acetylsalicylic acid to HD circuits lowered the transmembrane pressure, better preserved platelet function and prolonged the time to circuit clotting, which in sum increases haemodialyser performance and may facilitate a more effective HD.
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Affiliation(s)
- Eslam Samaha
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria.,Department of Internal Medicine II, Division of Pulmonology, Medical University of Vienna, Vienna, Austria
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Sabine Schranz
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Bruno Watschinger
- Department of Internal Medicine III, Division of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Anja Buchmüller
- Bayer Healthcare AG, Nordrhein-Westfalen, Wuppertal, Germany
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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21
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Halimi JM, Persu A, Sarafidis PA, Burnier M, Abramowicz D, Sautenet B, Oberbauer R, Mallamaci F, London G, Rossignol P, Wuerzner G, Watschinger B, Zoccali C. Optimizing hypertension management in renal transplantation: a call to action. Nephrol Dial Transplant 2017; 32:1959-1962. [PMID: 29099945 DOI: 10.1093/ndt/gfx283] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/14/2017] [Indexed: 12/19/2022] Open
Affiliation(s)
- Jean-Michel Halimi
- Service de Néphrologie-Immunologie Clinique, CHU Tours, Tours, France.,FCRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, François-Rabelais University, Tours, France
| | - Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.,Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Pantelis A Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Greece
| | - Michel Burnier
- Service of Nephrology and Hypertension, University Hospital (CHUV), Lausanne, Switzerland
| | - Daniel Abramowicz
- Antwerp University Hospital, Department of Nephrology, and Antwerp University, Belgium
| | - Bénédicte Sautenet
- Service de Néphrologie-Immunologie Clinique, CHU Tours, Tours, France.,FCRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, François-Rabelais University, Tours, France
| | - Rainer Oberbauer
- Departement of Nephrology, Medical University of Vienna, Austria
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy
| | - Gérard London
- FCRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, Manhes Hospital and FCRIN INI-CRCTC, Manhes, France
| | - Patrick Rossignol
- INSERM, Centre, d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHU de Nancy, and FCRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, Vandoeuvre-lès-Nancy, France
| | - Grégoire Wuerzner
- Service of Nephrology and Hypertension, University Hospital (CHUV), Lausanne, Switzerland
| | | | - Carmine Zoccali
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy
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22
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Toplak H, Ludvik B, Lechleitner M, Dieplinger H, Föger B, Paulweber B, Weber T, Watschinger B, Horn S, Wascher TC, Drexel H, Brodmann M, Pilger E, Rosenkranz A, Pohanka E, Oberbauer R, Traindl O, Roithinger FX, Metzler B, Haring HP, Kiechl S. Austrian Lipid Consensus on the management of metabolic lipid disorders to prevent vascular complications: A joint position statement issued by eight medical societies. 2016 update. Wien Klin Wochenschr 2017; 128 Suppl 2:S216-28. [PMID: 27052248 PMCID: PMC4839054 DOI: 10.1007/s00508-016-0993-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 01/09/2023]
Abstract
In 2010, eight Austrian medical societies proposed a joint position statement on the management of metabolic lipid disorders for the prevention of vascular complications. An updated and extended version of these recommendations according to the current literature is presented, referring to the primary and secondary prevention of vascular complications in adults, taking into consideration the guidelines of other societies. The "Austrian Lipid Consensus - 2016 update" provides guidance for individualized risk stratification and respective therapeutic targets, and discusses the evidence for reducing vascular endpoints with available lipid-lowering therapies. Furthermore, specific management in key patient groups is outlined, including subjects presenting with coronary, cerebrovascular, and/or peripheral atherosclerosis; diabetes mellitus and/or metabolic syndrome; nephropathy; and familial hypercholesterolemia.
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Affiliation(s)
- Hermann Toplak
- Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
| | - Bernhard Ludvik
- First Medical Department, Rudolfstiftung Hospital, Vienna, Austria
| | | | - Hans Dieplinger
- Department of Medical Genetics, Clinical and Molecular Pharmacology, Medical University of Innsbruck, Innsbruck, Austria
| | - Bernhard Föger
- Department of Internal Medicine, Bregenz Hospital, Bregenz, Austria
| | - Bernhard Paulweber
- First Medical Department, Paracelsus Medical University, Salzburg, Austria
| | - Thomas Weber
- Department of Cardiology, Wels Hospital, Wels, Austria
| | - Bruno Watschinger
- Third Medical Department, Medical University of Vienna, Vienna, Austria
| | - Sabine Horn
- Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | | | - Heinz Drexel
- Department of Internal Medicine and Cardiology, Feldkirch Hospital, Feldkirch, Austria
| | - Marianne Brodmann
- Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Ernst Pilger
- Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Alexander Rosenkranz
- Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Erich Pohanka
- Medical Department, Linz General Hospital, Linz, Austria
| | | | - Otto Traindl
- First Medical Department, Mistelbach Hospital, Mistelbach, Austria
| | | | - Bernhard Metzler
- Third Medical Department, Medical University of Innsbruck, Innsbruck, Austria
| | - Hans-Peter Haring
- First Department of Neurology, Kepler University Clinic, Linz, Austria
| | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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23
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Schernthaner G, Drexel H, Rosenkranz A, Schernthaner GH, Watschinger B. [Antihypertensive therapy in diabetes mellitus: Guidelines of the Austrian Diabetes Association 2016]. Wien Klin Wochenschr 2017; 128 Suppl 2:S62-7. [PMID: 27052224 DOI: 10.1007/s00508-015-0924-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Blood pressure lowering is one of the most important interventions for reducing the vascular complications and mortality in patients with diabetes mellitus. Recent studies indicate that the optimal blood pressure level might be in the range between 130-140 mmHg systolic and 80‒90 mmHg diastolic. Lower blood pressure levels (e.g. 120/80 mmHg) can further reduce the risk for stroke and diabetic nephropathy, but are associated with increased cardiovascular mortality. In particular, very low blood pressure levels (< 120 mmHg) should be avoided in patients with coronary heart disease or peripheral arterial disease. Most patients with diabetes mellitus need antihypertensive combination therapies, whereby ACE-inhibitors or Angiotensin-II receptor antagonists should be first line drugs.
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Affiliation(s)
| | - Heinz Drexel
- Abteilung für Innere Medizin und Kardiologie, Landeskrankenhaus Feldkirch, Feldkirch, Österreich
| | - Alexander Rosenkranz
- Klinische Abteilung für Nephrologie, Medizinische Universitätsklinik Graz, Graz, Österreich
| | - Gerit-Holger Schernthaner
- Klinische Abteilung für Angiologie, Universitätsklinik für Innere Medizin II, Medizinische Universität Wien, Wien, Österreich
| | - Bruno Watschinger
- Klinische Abteilung für Nephrologie und Dialyse, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
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24
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Beinhardt S, Al Zoairy R, Ferenci P, Kozbial K, Freissmuth C, Stern R, Stättermayer AF, Stauber R, Strasser M, Zoller H, Watschinger B, Schmidt A, Trauner M, Hofer H, Maieron A. DAA-based antiviral treatment of patients with chronic hepatitis C in the pre- and postkidney transplantation setting. Transpl Int 2016; 29:999-1007. [DOI: 10.1111/tri.12799] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 02/29/2016] [Accepted: 05/15/2016] [Indexed: 02/06/2023]
Affiliation(s)
- Sandra Beinhardt
- Division of Gastroenterology and Hepatology; Department of Internal Medicine III; Medical University of Vienna; Vienna Austria
| | - Ramona Al Zoairy
- Division of Gastroenterology and Hepatology; Department of Medicine II; Medical University of Innsbruck; Innsbruck Tirol Austria
| | - Peter Ferenci
- Division of Gastroenterology and Hepatology; Department of Internal Medicine III; Medical University of Vienna; Vienna Austria
| | - Karin Kozbial
- Division of Gastroenterology and Hepatology; Department of Internal Medicine III; Medical University of Vienna; Vienna Austria
| | - Clarissa Freissmuth
- Division of Gastroenterology and Hepatology; Department of Internal Medicine III; Medical University of Vienna; Vienna Austria
| | - Rafael Stern
- Division of Gastroenterology and Hepatology; Department of Internal Medicine III; Medical University of Vienna; Vienna Austria
| | - Albert Friedrich Stättermayer
- Division of Gastroenterology and Hepatology; Department of Internal Medicine III; Medical University of Vienna; Vienna Austria
| | - Rudolf Stauber
- Division of Gastroenterology and Hepatology; Department of Internal Medicine; Medical University of Graz; Graz Austria
| | - Michael Strasser
- Department of Gastroenterology and Hepatology; Paracelsus Medical University Salzburg; Salzburg Austria
| | - Heinz Zoller
- Division of Gastroenterology and Hepatology; Department of Medicine II; Medical University of Innsbruck; Innsbruck Tirol Austria
| | - Bruno Watschinger
- Division of Nephrology; Department of Internal Medicine III; Medical University of Vienna; Vienna Austria
| | - Alice Schmidt
- Division of Nephrology; Department of Internal Medicine III; Medical University of Vienna; Vienna Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology; Department of Internal Medicine III; Medical University of Vienna; Vienna Austria
| | - Harald Hofer
- Division of Gastroenterology and Hepatology; Department of Internal Medicine III; Medical University of Vienna; Vienna Austria
| | - Andreas Maieron
- Department of Gastroenterology; Elisabethinen Hospital; Linz Austria
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25
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Weber T, Lang I, Zweiker R, Horn S, Wenzel RR, Watschinger B, Slany J, Eber B, Roithinger FX, Metzler B. Hypertension and coronary artery disease: epidemiology, physiology, effects of treatment, and recommendations : A joint scientific statement from the Austrian Society of Cardiology and the Austrian Society of Hypertension. Wien Klin Wochenschr 2016; 128:467-79. [PMID: 27278135 DOI: 10.1007/s00508-016-0998-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 03/15/2016] [Indexed: 01/13/2023]
Abstract
High blood pressure is a major modifiable risk factor for all clinical manifestations of coronary artery disease (CAD). In people without known cardiovascular disease, the lowest systolic (down to 90-114 mmHg) and the lowest diastolic (down to 60-74 mmHg) pressures are associated with the lowest risk for developing CAD. Although diastolic blood pressure is the strongest predictor of CAD in younger and middle-aged people, this relationship becomes inverted and pulse pressure shows the strongest direct relationship with CAD in people above 60 years of age.Pathophysiological mechanisms of blood pressure as a risk factor for CAD are complex and include the influence of blood pressure as a physical force on the development of the atherosclerotic plaque, and the relationship between pulsatile hemodynamics/arterial stiffness and coronary perfusion. Treatment of arterial hypertension has been proven to prevent coronary events in patients without clinical CAD. In patients with established CAD, the effect of blood pressure lowering per se is beneficial, probably more than specific drugs or drug classes. The important exceptions are beta blockers (BBs), which are superior to all other drug classes for use after a recent myocardial infarction. Blood pressure targets in patients with established CAD have created controversy in the light of the so-called J-curve phenomenon, which describes an increase in coronary events at lower diastolic blood pressures. One explanation for this observation is that perfusion of the left ventricle occurs predominantly during diastole, and that coronary autoregulation may be exhausted with low diastolic blood pressure in the setting of left ventricular hypertrophy and atherosclerotic narrowing of the epicardial coronaries. The worst situation is a high systolic blood pressure in the presence of a low diastolic blood pressure, both a hallmark of increased aortic stiffness. However, the lowering of systolic blood pressure is clearly beneficial in this setting, even at the price of further lowering diastolic pressure. Primary blood pressure goal in patients with established CAD is below 140/90 mmHg. Recent studies suggest that a lower systolic blood pressure may be appropriate, whereas caution is advised with diastolic blood pressure below 60 mmHg.
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Affiliation(s)
- Thomas Weber
- Cardiology Department, Klinikum Wels-Grieskirchen, Grieskirchnerstraße 42, 4600, Wels, Austria.
| | - Irene Lang
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Robert Zweiker
- Division of Cardiology, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Sabine Horn
- Division of Nephrology, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Rene R Wenzel
- Department of Internal Medicine, Krankenhaus Tauernkliniken, Zell am See, Austria
| | - Bruno Watschinger
- Division of Nephrology, Department of Internal Medicine III, Medical University Vienna, Vienna, Austria
| | | | - Bernd Eber
- Cardiology Department, Klinikum Wels-Grieskirchen, Grieskirchnerstraße 42, 4600, Wels, Austria
| | - Franz Xaver Roithinger
- Second Department of Internal Medicine, Landesklinikum Wiener Neustadt, Vienna, Austria
- Internal Department, Landesklinikum Mödling, Mödling, Austria
| | - Bernhard Metzler
- Department of Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
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Schwarz C, Mayerhoffer S, Berlakovich GA, Steininger R, Soliman T, Watschinger B, Böhmig GA, Eskandary F, König F, Mühlbacher F, Wekerle T. Long-term outcome of belatacept therapy in de novo kidney transplant recipients - a case-match analysis. Transpl Int 2015; 28:820-7. [PMID: 25703346 DOI: 10.1111/tri.12544] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [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: 09/01/2014] [Revised: 10/17/2014] [Accepted: 02/16/2015] [Indexed: 01/06/2023]
Abstract
While belatacept has shown favorable short- and midterm results in kidney transplant recipients, only projections exist regarding its potential impact on long-term outcome. Therefore, we performed a retrospective case-match analysis of the 14 belatacept patients originally enrolled in the phase II multicenter trial at our center. Fifty six cyclosporine (CyA)-treated patients were matched according to age at transplantation, first/retransplant, and donor type. Ten years after kidney transplantation, kidney function remained superior in belatacept-treated patients compared with the CyA control group. Moreover, none of the belatacept-treated patients had donor-specific antibodies ≥10 years post-transplantation compared with 38.5% of tested CyA-treated subject (0/10 vs. 5/13; P = 0.045). Notably, however, patient and graft survival was virtually identical in both groups (71.4% vs. 71.3%; P = 0.976). In the present single-center study population, patients treated with belatacept demonstrated a patient and graft survival at 10 years post-transplant which was comparable to that of similarly selected CNI-treated patients. Larger studies with sufficient statistical power are necessary to definitively determine long-term graft survival with belatacept.
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Affiliation(s)
- Christoph Schwarz
- Division of Transplantation/Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Sophie Mayerhoffer
- Division of Transplantation/Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Gabriela A Berlakovich
- Division of Transplantation/Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Rudolf Steininger
- Division of Transplantation/Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Soliman
- Division of Transplantation/Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Bruno Watschinger
- Division of Nephrology and Dialysis/Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - Georg A Böhmig
- Division of Nephrology and Dialysis/Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - Farsad Eskandary
- Division of Nephrology and Dialysis/Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - Franz König
- Section for Medical Statistics, Medical University of Vienna, Vienna, Austria
| | - Ferdinand Mühlbacher
- Division of Transplantation/Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Wekerle
- Division of Transplantation/Department of Surgery, Medical University of Vienna, Vienna, Austria
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Weber T, Zweiker R, Watschinger B, Grüner P, Koppelstätter C, Brandt MC, Horina J, Brussee H, Hohenstein K, Lambert T, Auer J, Hoppe UC. Clinical application of interventional renal sympathetic denervation: recommendations of the Austrian Society of Hypertension 2012. Wien Klin Wochenschr 2012. [DOI: 10.1007/s00508-012-0257-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
Anemia is a highly prevalent disorder in recipients of renal allografts. Despite its frequent occurrence, there is still uncertainty with regard to treatment targets and treatment options. This includes questions on appropriate iron management, the choice and dosage of erythropoietin stimulating agents, criteria for the timing of treatment initiation and the targeted hemoglobin values. The review summarizes available data on recent therapeutic strategies for post transplant anemia, as well as for post transplant erythrocytosis, another hematological disorder, that has decreased in recent years.
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Affiliation(s)
- Jolanta Malyszko
- Department of Nephrology and Transplantology, Medical University, Bialystok, Poland.
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Gremmel T, Pfaffenberger S, Binder T, Kocher A, Watschinger B. Recurrent circumflex artery embolization due to a free-floating fibroelastoma at the aortic valve. Ann Thorac Surg 2011; 91:1626. [PMID: 21524483 DOI: 10.1016/j.athoracsur.2010.09.062] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 08/24/2010] [Accepted: 09/24/2010] [Indexed: 11/25/2022]
Affiliation(s)
- Thomas Gremmel
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.
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Zitt E, Jäger C, Rosenkranz AR, Eigner M, Kodras K, Kovarik J, Graf H, Pétavy F, Horn S, Watschinger B. Effective use of cinacalcet for the treatment of secondary hyperparathyroidism in Austrian dialysis patients--results of the Austrian cohort of the ECHO study. Wien Klin Wochenschr 2011; 123:45-52. [PMID: 21253777 DOI: 10.1007/s00508-010-1515-x] [Citation(s) in RCA: 9] [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] [Received: 08/11/2010] [Accepted: 11/18/2010] [Indexed: 01/27/2023]
Abstract
BACKGROUND Despite extensive use of standard therapy for secondary hyperparathyroidism (sHPT) in dialysis patients, still most patients do not achieve the recommended treatment targets. In a pan-European observational study (ECHO), the effectiveness of the calcimimetic cinacalcet for the treatment of sHPT was evaluated in real-world clinical practice. A sub-analysis of the entire Austrian study cohort is presented. METHODS Adult dialysis patients who had initiated cinacalcet therapy were included. Data on biochemical parameters of bone and mineral metabolism (intact parathyroid hormone [iPTH], calcium [Ca] and phosphorus [P]) and concurrent medication were collected 6 months prior to the initiation of cinacalcet, at initiation (baseline) and after up to 12 months of active treatment. RESULTS A total of 320 patients (mean age (±SD): 56 (±14) years) from 34 Austrian dialysis centres were enrolled. At baseline, patients presented with elevated serum iPTH (median 605 pg/ml) and hyperphosphataemia (median 2.1 mmol/l). After 12 months of cinacalcet treatment, serum iPTH (median percentage change -48%), calcium (-2%) and phosphorus (-6%) decreased. The greatest iPTH reduction (-66%) was found in patients with most severe sHPT (>800 pg/ml at baseline). The proportion of patients achieving the recommended NKF/K-DOQI(™) treatment targets increased from baseline to month 12 for iPTH (3-36%) and phosphorus (24 to 39%) and remained stable for calcium (51 to 50%), respectively. No patient had all 3 parameters simultaneously within NKF/K-DOQI(™) treatment targets at baseline, while 7% of patients achieved this treatment goal after 12 months. During the study the use of the phosphate binder sevelamer remained fairly stable, while the relative percentage use of calcium-based phosphate binders increased and the usage of aluminium-containing binders decreased; vitamin D analogue use remained stable. CONCLUSION Additional use of cinacalcet improved biochemical parameters of bone and mineral metabolism and enabled more patients to achieve and maintain the KDOQI(™) treatment targets for serum iPTH, calcium and phosphorus.
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Affiliation(s)
- Emanuel Zitt
- Department of Nephrology and Dialysis, LKH Feldkirch, Feldkirch, Austria.
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Abstract
Hypertension and proteinuria are common risk factors for cardiovascular morbidity and mortality, as well as for the progression of renal disease. Renal functional impairment represents an independent cardiovascular risk factor by itself. Strict antihypertensive therapy and measures to maximally reduce proteinuria can substantially improve the prognosis of renal patients. This review summarizes current evidence for the role of hypertension and proteinuria with regard to renal and cardiovascular outcomes and for the importance of intensive antihypertensive and anti-proteinuric measures.
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Affiliation(s)
- Katharina Hohenstein
- Klinische Abteilung für Nephrologie und Dialyse, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Austria
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Watschinger B. Laudatio auf Prof. Dr. Gerhard Giebisch anlässlich der Verleihung der Ehrenmitgliedschaft der ÖGIM. Wien Klin Wochenschr 2008; 120:514-7. [DOI: 10.1007/s00508-008-1041-2] [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: 10/21/2022]
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33
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Hecking M, Kainz A, Schillinger M, Posch C, Birsan T, Rasoul-Rockenschaub S, Böhmig GA, Schmaldienst S, Watschinger B, Hörl WH, Mühlbacher F, Säemann MD. Analysis of liver function in renal transplant recipients undergoing C2-monitoring for cyclosporine. Transpl Int 2007; 21:223-33. [PMID: 17903183 DOI: 10.1111/j.1432-2277.2007.00563.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
There exists no systematic evaluation of liver function in renal allograft recipients undergoing C2-monitoring with Neoral [cyclosporine A (CsA)-microemulsion]. In the present cohort analysis, we compared the hepatic profiles of C2-monitored (n = 80), C0-monitored (n = 81), and non-CsA-treated renal allograft recipients (n = 29), transplanted between 1/1999 and 2/2004 in our institution. While the C2-targets were set in accordance with (n = 72) or below (n = 8) the consensus on Neoral (1500 +/- 200 ng/ml), non-CsA-patients received FK506 (n = 29), partially in combination with rapamycin (n = 13) as primary immunosuppression. Analysis of maximum hepatic laboratory parameters and also repeated measures by anova within 30 days post-transplant revealed highly significant elevations of direct, indirect and total bilirubin, glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, and lactate dehydrogenase (P < 0.001) in the C2-group, in comparison with the C0- and the non-CsA-group. Bilirubin-levels were by far the most affected of all hepatic parameters, and correlated with C2-levels (r2 = 0.62). Seventeen CsA-patients had excessive bilirubin-elevations (>4 mg/dl) and were therefore considered to be 'CsA-sensitive' [14 C2-patients (17% of all C2-patients), 3 C0-patients (4% of all C0-patients)]. Bilirubin- and the other parameter elevations in these patients were reversible upon withdrawal or lowering of CsA. Most 'CsA-sensitive' patients (n = 12, 70%) displayed pre-transplant hepatic impairment, indicating a pre-existing liver instability. Collectively, our data emphasize the need for increased awareness toward individual predispositions for CsA-sensitivity.
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Affiliation(s)
- Manfred Hecking
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria.
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Abstract
The introduction of both complement 4d (C4d) staining in renal allograft biopsies and sensitive methods to detect anti-human leukocyte antigen antibodies, such as single antigen bead flow assays, into tissue-typing techniques have shown the importance of antibody-mediated alloimmune response in kidney transplantation. The use of these sensitive methods, combined with the increased number of transplants in highly sensitized patients with donor-specific antibodies, or patients receiving desensitization protocols, have increased the awareness and thus the incidence of acute antibody-mediated rejection. Chronic rejection also can be mediated through alloantibodies, and the term chronic antibody-mediated rejection recently was proposed. In this review article we summarize the current knowledge of the role of alloantibodies in transplantation, the diagnosis and treatment of acute and chronic antibody-mediated rejection, and their effect on graft function and outcome.
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Affiliation(s)
- Enver Akalin
- Renal Division and Recanati/Miller Transplantation Institute, Mount Sinai School of Medicine, New York, NY 10029, USA.
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35
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Aull-Watschinger S, Konstantin H, Demetriou D, Schillinger M, Habicht A, Horl WH, Watschinger B. Pre-transplant predictors of cerebrovascular events after kidney transplantation. Nephrol Dial Transplant 2007; 23:1429-35. [DOI: 10.1093/ndt/gfm766] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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36
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Zeyda M, Geyeregger R, Poglitsch M, Weichhart T, Zlabinger GJ, Koyasu S, Hörl WH, Stulnig TM, Watschinger B, Saemann MD. Impairment of T cell interactions with antigen-presenting cells by immunosuppressive drugs reveals involvement of calcineurin and NF-κB in immunological synapse formation. J Leukoc Biol 2006; 81:319-27. [PMID: 17038582 DOI: 10.1189/jlb.0606378] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
A stable supramolecular cluster in T cells at the contact site of APCs, the immunological synapse (IS), is essential for full T cell activation. Failure of IS maturation, as determined by defective relocalization of the TCR/CD3 complex at the T cell/APC contact site, is linked with T cell hyporesponsiveness. The effects of clinically used immunosuppressants on these critical events, however, are undefined. Here, we show that treatment of T cells with cyclosporin A, FK506, and dexamethasone, which are known to inhibit calcineurin and NF-kappaB, respectively, but not rapamycin, the inhibitor of mammalian target of rapamycin, selectively prevented TCR/CD3 relocalization into the IS, while relocalization of adhesion and cytoskeletal proteins as well as T cell/APC conjugate formation remained unaltered. The involvement of calcineurin and NF-kappaB in IS maturation was confirmed by using specific inhibitors of these molecules (FR901725, gossypol, SN50). FK778, as an inhibitor of DNA replication and also TCR/CD3-activated tyrosine kinases, globally abrogated cytoskeletal, adhesion, and signaling molecule relocalization, thereby preventing formation of an IS at an earlier, immature stage along with impaired, antigen-specific T cell/APC conjugate formation. Collectively, blocking IS formation at distinct stages may mediate effects on T cell activation of currently used immunosuppressants, apart from their capacity to block gene transcription, cytokine signaling, and DNA replication. Furthermore, these data imply novel functions of calcineurin and NF-kappaB for successful IS maturation.
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Affiliation(s)
- Maximilian Zeyda
- Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
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37
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Kirsch BM, Haidinger M, Zeyda M, Böhmig GA, Tombinsky J, Mühlbacher F, Watschinger B, Hörl WH, Säemann MD. Alemtuzumab (Campath-1H) induction therapy and dendritic cells: Impact on peripheral dendritic cell repertoire in renal allograft recipients. Transpl Immunol 2006; 16:254-7. [PMID: 17138063 DOI: 10.1016/j.trim.2006.09.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2006] [Revised: 08/10/2006] [Accepted: 09/08/2006] [Indexed: 11/18/2022]
Abstract
Dendritic cells (DC) are the most potent antigen-presenting cells (APC) and are pivotal for initiating allograft immunity. Recently, particular DC subsets have been implicated also in allogeneic T cell hyporesponsiveness. Alemtuzumab (anti-CD52, Campath-1H) is a novel T cell depleting antibody that is currently under investigation for the use in allogeneic organ transplantation. While recent studies demonstrated a conspicuous effect of alemtuzumab on peripheral DC in clinical graft-versus-host disease, its efficiency in patients receiving allogeneic organ transplants is still undefined. In the present study we assessed the peripheral DC repertoire in kidney transplant recipients after either alemtuzumab induction therapy followed by FK506 monotherapy or after conventional immunosuppression (FK506, mycophenolate mofetil and steroids) without any induction agent. Induction with alemtuzumab caused a strong and sustained reduction of the total number of peripheral DC and a significant shift from myeloid to plasmacytoid DC subsets (mDC/pDC ratio) as early as 1 month post-transplantation. These data show that alemtuzumab induction targets the peripheral DC repertoire, which might add another mechanism allowing immunosuppressive drug minimization. Further studies are warranted to further elucidate the functional significance of these finding in the setting of allogeneic organ transplantation.
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Affiliation(s)
- Bernhard M Kirsch
- Department of Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Austria
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38
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Steiner S, Winkelmayer WC, Kleinert J, Grisar J, Seidinger D, Kopp CW, Watschinger B, Minar E, Hörl WH, Födinger M, Sunder-Plassmann G. Endothelial Progenitor Cells in Kidney Transplant Recipients. Transplantation 2006; 81:599-606. [PMID: 16495809 DOI: 10.1097/01.tp.0000198418.06383.e8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lower concentrations of endothelial progenitor cells (EPCs) may be associated with increased cardiovascular risk. EPC counts and their correlates have not yet been studied in kidney transplant recipients (KTR). METHODS We cross-sectionally studied EPC counts in 105 middle-aged KTR (mean estimated glomerular filtration rate 45.2 ml/min/1.73 m; range: 5.4 to 117.5). Using univariate and multivariate linear regression assuming a gamma distribution of the outcome, we examined the associations between counts of cultured EPCs and traditional cardiovascular disease risk factors (hypertension, diabetes, hyperlipidemia, smoking), kidney function, and immunosuppressive agents, amongst others. RESULTS The median count of cultured EPCs was 34 cells per high-power field (interquartile range: 19 to 64), comparable to healthy individuals. From multivariate analyses, we found independent inverse associations between counts of cultured EPCs and body mass index, mean arterial pressure, and history of cardiovascular disease. Statin use was associated with greater EPC counts, whereas patients receiving azathioprine or angiotensin II receptor treatment had lower EPC counts (all P<0.01). CONCLUSIONS This study suggests negative associations in KTR between EPC counts and body mass index, and blood pressure, whereas statin use was associated with greater EPC counts. These findings raise the hypothesis whether EPCs are responsible, at least in part, for the well established associations between these factors and cardiovascular outcomes in KTR.
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Affiliation(s)
- Sabine Steiner
- Division of Angiology, Department of Medicine II, Medical University Vienna, Vienna, Austria
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39
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Zeyda M, Stuhlmeier KM, Kirsch B, Watschinger B, Hörl WH, Stulnig TM, Säemann MD. The malononitrilamide FK778 inhibits activation of NF-kappaB in human dendritic cells. Transplant Proc 2005; 37:1968-9. [PMID: 15919520 DOI: 10.1016/j.transproceed.2005.03.079] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
FK778, a derivative of the active leflunomide-metabolite, A77 1726, has been shown to be a powerful immunosuppressant in several transplantation models, particularly efficient in prevention of chronic allograft rejection. However, the cellular and molecular mechanisms underlying these effects of FK778 have not been investigated yet in detail. Because dendritic cells (DCs) are a crucial cell type in initiation of immune responses including chronic allograft rejection, we investigated whether FK778 affects this peculiar cell population. NF-kappaB is the essential transcription factor involved in DC activation and function. We found that lipopolysaccharide (LPS)-induced activation of NF-kappaB, as assessed using electromobility shift assay, is markedly inhibited by FK778 in human monocyte-derived DCs. Hence, FK778 could exert its immunosuppressive effects via inhibition of activation and thus function of the central antigen-presenting cell, ie, DC.
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Affiliation(s)
- M Zeyda
- Clinical Division of Nephrology and Dialysis, Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
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40
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Zeyda M, Geyeregger R, Poglitsch M, Watschinger B, Hörl WH, Stulnig TM, Säemann MD. The Novel Immunosuppressant FK778 Inhibits Formation of the Immunologic Synapse. Transplant Proc 2005; 37:1970-1. [PMID: 15919521 DOI: 10.1016/j.transproceed.2005.03.083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The malononitrilamide FK778 is a derivative of A77 1726, the active metabolite of the antirheumatic drug leflunomide. A77 1726 inhibits de novo pyrimidine synthesis and activity of Src-family kinases; thus, it may interfere with T-cell proliferation as well as with early T-cell signaling. Formation of a stable interaction between T cells and antigen-presenting cells (APC)--the immunologic synapse--has emerged to be of crucial importance for T-cell activation. Here in we show that FK778 inhibits formation of the immunologic synapse by blocking superantigen-stimulated relocalization of adhesion (LFA-1), and signaling molecules (CD3) to the T-cell/APC contact site. These data show that FK778 affects T-cell/APC interactions, particularly events crucial for T-cell adhesion and formation of stable conjugates underlying sustained and effective T-cell activation. Thus, in this model system close to physiologic T-cell stimulation, FK778 affects critical events in the course of T-cell-mediated immune responses earlier than T-cell proliferation, which may contribute to its immunosuppressive potential.
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Affiliation(s)
- M Zeyda
- Clinical Division of Nephrology and Dialysis, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
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41
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Kirsch BM, Zeyda M, Stuhlmeier K, Grisar J, Smolen JS, Watschinger B, Stulnig TM, Hörl WH, Zlabinger GJ, Säemann MD. The active metabolite of leflunomide, A77 1726, interferes with dendritic cell function. Arthritis Res Ther 2005; 7:R694-703. [PMID: 15899055 PMCID: PMC1174963 DOI: 10.1186/ar1727] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2004] [Revised: 02/23/2005] [Accepted: 03/01/2005] [Indexed: 01/11/2023] Open
Abstract
Leflunomide, a potent disease-modifying antirheumatic drug used in the treatment of rheumatoid arthritis (RA), exhibits anti-inflammatory, antiproliferative and immunosuppressive effects. Although most of the beneficial effects of leflunomide have been attributed to its antimetabolite activity, mainly in T cells, other targets accounting for its potency might still exist. Because of mounting evidence for a prominent role of dendritic cells (DCs) in the initiation and maintenance of the immune response in RA, we analyzed the effect of the active metabolite of leflunomide (A77 1726; LEF-M) on phenotype and function of human myleloid DCs at several stages in their life cycle. Importantly, DCs differentiated in the presence of LEF-M exhibited an altered phenotype, with largely reduced surface expression of the critical co-stimulatory molecules CD40 and CD80. Furthermore, treatment of DCs during the differentiation or maturation phase with LEF-M aborted successful DC maturation. Exogenous addition of uridine revealed that DC modulation by LEF-M was independent of its proposed ability as an antimetabolite. In addition, the ability of DCs to initiate T-cell proliferation and to produce the proinflammatory cytokines IL-12 and tumour necrosis factor-α was markedly impaired by LEF-M treatment. As a molecular mechanism, transactivation of nuclear factor-κB, an transcription factor essential for proper DC function, was completely suppressed in DCs treated with LEF-M. These data indicate that interference with several aspects of DC function could significantly contribute to the beneficial effects of leflunomide in inflammatory diseases, including RA.
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Affiliation(s)
- Bernhard M Kirsch
- Department of Internal Medicine III/Clinical Divisions of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Maximilian Zeyda
- Department of Internal Medicine III/Clinical Divisions of Endocrinology and Metabolism, Medical University of Vienna, Vienna, Austria
| | | | - Johannes Grisar
- Department of Internal Medicine III/Clinical Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Josef S Smolen
- Department of Internal Medicine III/Clinical Division of Rheumatology, Medical University of Vienna, Vienna, Austria
- CeMM – Center of Molecular Medicine, Austrian Academy of Sciences, Vienna, Austria
| | - Bruno Watschinger
- Department of Internal Medicine III/Clinical Divisions of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Thomas M Stulnig
- Department of Internal Medicine III/Clinical Divisions of Endocrinology and Metabolism, Medical University of Vienna, Vienna, Austria
- CeMM – Center of Molecular Medicine, Austrian Academy of Sciences, Vienna, Austria
| | - Walter H Hörl
- Department of Internal Medicine III/Clinical Divisions of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | | | - Marcus D Säemann
- Department of Internal Medicine III/Clinical Divisions of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
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Kerjaschki D, Regele HM, Moosberger I, Nagy-Bojarski K, Watschinger B, Soleiman A, Birner P, Krieger S, Hovorka A, Silberhumer G, Laakkonen P, Petrova T, Langer B, Raab I. Lymphatic Neoangiogenesis in Human Kidney Transplants Is Associated with Immunologically Active Lymphocytic Infiltrates. J Am Soc Nephrol 2004; 15:603-12. [PMID: 14978162 DOI: 10.1097/01.asn.0000113316.52371.2e] [Citation(s) in RCA: 360] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Renal transplant rejection is caused by a lymphocyte-rich inflammatory infiltrate that attacks cortical tubules and endothelial cells. Immunosuppressive therapy reduces the number of infiltrating cells; however, their exit routes are not known. Here a >50-fold increase of lymphatic vessel density over normal kidneys in grafts with nodular mononuclear infiltrates is demonstrated by immunohistochemistry on human renal transplant biopsies using antibodies to the lymphatic endothelial marker protein podoplanin. Nodular infiltrates are constantly associated with newly formed, Ki-67-expressing lymphatic vessels and contain the entire repertoire of T and B lymphocytes to provide specific cellular and humoral alloantigenic immune responses, including Ki-67(+) CD4(+) and CD8(+) T lymphocytes, S100(+) dendritic cells, and Ki-67(+)CD20(+) B lymphocytes and lambda- and kappa-chain-expressing plasmacytoid cells. Numerous chemokine receptor CCR7(+) cells within the nodular infiltrates seemed to be attracted by secondary lymphatic chemokine (SLC/CCL21) that is produced and released by lymphatic endothelial cells in a complex with podoplanin. From these results, it is speculated that lymphatic neoangiogenesis not only contributes to the export of the rejection infiltrate but also is involved in the maintenance of a potentially detrimental alloreactive immune response in renal transplants and provides a novel therapeutic target.
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Affiliation(s)
- Dontscho Kerjaschki
- Department of Pathology, Medical University of Vienna, Allgemeines Krankenhaus, Vienna, Austria.
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Exner M, Böhmig GA, Schillinger M, Regele H, Watschinger B, Hörl WH, Raith M, Mannhalter C, Wagner OF. Donor heme oxygenase-1 genotype is associated with renal allograft function1. Transplantation 2004; 77:538-42. [PMID: 15084931 DOI: 10.1097/01.tp.0000113467.36269.f8] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The heme oxygenase (HO) isoenzyme HO-1 has recently been suggested to protect transplants from ischemia/reperfusion and immunologic injury. Inducibility of this enzyme is modulated by a (GT)n dinucleotide length polymorphism in the HO-1 gene promoter. Short (class S) repeats are associated with greater up-regulation of HO-1 than are long repeats. In the present study we investigated the impact of the promoter polymorphism of kidney allograft donors on clinical outcomes after transplantation. METHODS We enrolled 101 recipients of cadaveric donor kidney allografts (who underwent transplantation between June 1998 and September 1999) in this retrospective study. The HO-1 genotype was assessed using genomic DNA isolated from cryopreserved donor splenocytes. RESULTS Fifty patients (49.5%) had received a kidney from a donor with at least one class S allele. Recipients of allografts from a class S allele carrier had significantly lower 1-year serum creatinine levels (median 1.46 mg/dL, interquartile range 1.17-1.68 mg/dL) compared with recipients of a non-class S allele donor kidney (median 1.61 mg/dL, interquartile range 1.38-2.22 mg/dL, P =0.01). After adjustment for cold ischemia time, retransplantation, donor age, delayed graft function, and HLA mismatch, recipients of a class S allele transplant had serum creatinine levels 0.81 times (95% confidence interval: 0.70-0.95, P =0.01) those of recipients of a non-class S allele transplant. The two patient groups did not differ significantly with respect to the incidence of delayed graft function, allograft rejection, or immunologic graft loss. CONCLUSION Our data suggest an influence of the HO-1 gene promoter polymorphism on kidney allograft function and thus support previous studies indicating a protective effect of HO-1 induction in organ transplantation.
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Affiliation(s)
- Markus Exner
- Department of Medical and Chemical Laboratory Diagnostics, University of Vienna, Vienna, Austria
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Abstract
Hypertension is present in the majority of patients with chronic renal failure and constitutes a major risk factor for the very high cardiovascular morbidity and mortality in this patient population. Furthermore hypertension is known to be a substantial progression factor in renal disease. In the past, it had been presumed that hypertension in chronic renal failure is due to enhanced sodium retention, chronic hypervolemia and increased activity of the renin-angiotensin-aldosterone-system. Recent studies now provide evidence that sympathetic overactivity plays an additional important role and also promotes progression of renal failure. The treatment goal in renal patients is to delay or even prevent progression of renal failure and to reduce the cardiovascular risk. Recent studies have investigated the respective impact of sympatholytic drugs, e.g. inhibitors of the renin-angiotensin-aldosterone-system, beta-blockers or I1-Imidazolin-receptor-agonists in fulfilling these aims. The present report will review experimental and clinical studies on the role of sympathetic overactivity in hypertension and chronic renal failure and possible new therapeutic options.
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Affiliation(s)
- Antje Habicht
- Klinische Abteilung für Nephrologie und Dialyse, Universitätsklinik für Innere Medizin III, Wien, Osterreich
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Watschinger B, Habicht A. [Renal sequelae of sympathetic hyperactivity]. Wien Med Wochenschr 2004; 154 Spec No 1:7-9. [PMID: 15346546] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Affiliation(s)
- Bruno Watschinger
- Klinische Abteilung für Nephrologie und Dialyse der Universitätsklinik für Innere Medizin III, Wien, Osterreich
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Abstract
PURPOSE OF REVIEW Hypertension is very common in renal transplant recipients and is a significant risk factor for mortality from cardiovascular diseases and for development of graft dysfunction. RECENT FINDINGS Recent guidelines for the treatment of hypertension (Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure VI Report and World Health Organization Guidelines) do not directly address post-transplant hypertension. Specific recommendations for the drug treatment of hypertension in renal allograft recipients have not been given in the Clinical Practice Guidelines of the American Society of Transplantation or those of the European Renal Association. SUMMARY The present paper summarizes some important aspects of post-transplant hypertension and discusses potential treatment strategies aimed at reducing blood pressure and thus improving patient and allograft survival.
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Affiliation(s)
- Leszek Tylicki
- Department of Internal Medicine, Nephrology and Transplantology, Medical University of Gdansk, Gdansk, Poland.
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Habicht A, Regele H, Exner M, Soleiman A, Hörl WH, Watschinger B, Derfler K, Böhmig GA. A case of severe C4d-positive kidney allograft dysfunction in the absence of histomorphologic features of rejection. Wien Klin Wochenschr 2002; 114:945-8. [PMID: 12528329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
Acute antibody-mediated (humoral) renal allograft rejection has emerged as a clinicopathological entity that carries a poor prognosis. Its diagnosis is based on typical pathohistologic features, serologic detection of donor-specific alloantibodies and the immunohistochemical finding of endothelial deposits of the complement split product C4d. We herein report a case of severe antibody-mediated graft injury after spousal-donor kidney transplantation. Despite an increased risk for humoral presensitization in the female recipient (three previous pregnancies), donor-specific alloantibodies were not detectable before transplantation. After initial graft function, severe graft dysfunction occurred one week after transplantation. A renal biopsy revealed no histomorphologic features of rejection. However, immunohistochemical detection of diffuse C4d deposits along peritubular capillaries suggested acute humoral rejection. The diagnosis of antibody-mediated rejection was confirmed by the detection of de-novo production of anti-donor alloantibodies. Graft dysfunction was resistant to high dose steroids or antilymphocyte antibody therapy. However, a recovery of graft function could be achieved by antibody elimination using immunoadsorption therapy. This case reinforces the high diagnostic value of C4d staining. In severe graft dysfunction humoral immune mechanisms should be considered, even when histopathologic features of humoral rejection are completely absent.
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Affiliation(s)
- Antje Habicht
- Department of Internal Medicine III, University of Vienna, Vienna, Austria
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Krebs M, Watschinger B, Brunner C, Hassl A, Base W. Pneumocystis carinii in a patient with hypercalcemia and renal failure secondary to sarcoidosis. Wien Klin Wochenschr 2002; 114:785-8. [PMID: 12416284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
A case of severe dyspnea, hypercalcemia and renal failure secondary to sarcoidosis is reported. The clinical diagnosis of sarcoidosis in a 48-year-old man was confirmed by histology and cytology. Transiently decreased numbers of CD4+ T cells (282/microliter) indicated impaired immunity in the absence of HIV-infection during the acute phase of the disease. Surprisingly, numerous "trophozoites" of Pneumocystis carinii were detected by immunofluorescence staining and PCR in the bronchoalveolar fluid indicating infection or colonization of the lungs. Corticosteroid therapy was administered together with trimethoprim-sulfamethoxazole and rapidly reduced elevated serum calcium and creatinine concentrations. Since airborne person-to-person transmission of P. carinii to susceptible individuals might be possible, patients with sarcoidosis could be a previously unrecognized reservoir for P. carinii distribution in hospitals and in the community at large.
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Affiliation(s)
- Michael Krebs
- Department of Internal Medicine III, University of Vienna, Vienna, Austria.
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Regele H, Böhmig GA, Habicht A, Gollowitzer D, Schillinger M, Rockenschaub S, Watschinger B, Kerjaschki D, Exner M. Capillary deposition of complement split product C4d in renal allografts is associated with basement membrane injury in peritubular and glomerular capillaries: a contribution of humoral immunity to chronic allograft rejection. J Am Soc Nephrol 2002; 13:2371-80. [PMID: 12191982 DOI: 10.1097/01.asn.0000025780.03790.0f] [Citation(s) in RCA: 359] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Endothelial deposition of the complement split product C4d is an established marker of antibody-mediated acute renal allograft rejection. A contribution of alloantibody-dependent immune reactions to chronic rejection is under discussion. In this study, the association of immunohistochemically detected endothelial C4d deposition in peritubular capillaries (PTC) with morphologic features of chronic renal allograft injury was investigated in a large study cohort. C4d deposits in PTC were detected in 73 (34%) of 213 late allograft biopsies performed in 213 patients more than 12 mo after transplantation (median, 4.9 yr) because of chronic allograft dysfunction. Endothelial C4d deposition was found to be associated with chronic transplant glomerulopathy (CG) (P < 0.0001), with basement membrane multilayering in PTC (P = 0.01), and with an accumulation of mononuclear inflammatory cells in PTC (P < 0,001). Furthermore, C4d deposits in PTC (in biopsies with normal glomerular morphology) were associated with development of CG in follow-up biopsies. Other morphologic features of chronic allograft nephropathy (with exception of tubular atrophy) were not associated with C4d deposits in PTC. Analyses of previous and follow-up biopsies revealed that C4d deposits may occur de novo and may also disappear at any time after transplantation. In conclusion, the data suggest that complement activation in renal microvasculature, indicating humoral alloreactivity, contributes to chronic rejection characterized by chronic transplant glomerulopathy and basement membrane multilayering in PTC.
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Affiliation(s)
- Heinz Regele
- Clinical Institute of Pathology, University of Vienna, Vienna, Austria.
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