A longitudinal exploration of perceptions of pharmacy practice preparedness among graduating pharmacy students and preceptors

Graduating student pharmacists who are practice-ready is an essential responsibility of pharmacy programs and heavily emphasized by Accreditation Council of Pharmacy Education (ACPE), pharmacy education's accrediting body. Although several studies have examined students' readiness to engage in advanced pharmacy practice experiences (APPE), few studies examine graduating students' readiness to practice. The objective of this study was to examine national trends in graduating pharmacy students' and preceptors' perceptions of students' pharmacy practice preparedness across a six-year time frame (2016-2021) and trends in graduating students' overall impressions of their program and the pharmacy profession across the same time period. A longitudinal descriptive study to examine trends in graduating student and preceptor perception was conducted utilizing data from the 2016-2021 American Association of Colleges of Pharmacy (AACP) Graduating Student Surveys (GSS) (n = 65,461) and Preceptor Surveys (PS) (n = 41,951). Over six years of survey data analyzed, a large percentage of students at both public and private institutions reported they felt prepared for practice (96.5% vs 95.5% respectively, p < 0.001). There was overall agreement (>90%) among preceptors that graduating students were prepared to enter pharmacy practice based on responses, although preceptors had lower levels of agreement compared to students on most statements. Based on the findings, both graduating pharmacy students and preceptors feel that graduates are prepared to practice pharmacy, with consistent trends in perceptions over the last six years. However, results also indicate that a consistent downward trend in students' willingness to pursue pharmacy again, indicating decreased optimism of graduating students for the profession.

Review of Objective Structured Clinical Examination Practices Within Pharmacy Programs Throughout the United States

OBJECTIVE

To update the description of current objective structured clinical examination (OSCE) practices within pharmacy schools in the United States and identify barriers to OSCE implementation and expansion.

METHODS

A survey was deployed to all accredited Doctor of Pharmacy programs within the United States. The survey was designed to collect information regarding the curricular mapping of OSCEs, OSCE design, OSCE delivery, assessment of OSCE performance, and barriers to OSCE implementation and expansion.

RESULTS

Of the 135 US-accredited programs identified, 109 (81%) programs completed the survey. In total, 93 (85%) programs reported using OSCEs to assess students; however, implementation throughout the curriculum and current practices varied by institution. Most programs place OSCEs within specific courses (96%), with the applied skills coursework being the most used (80%). The most common number of OSCEs that occur throughout a curriculum is 6 (18%), however, 20 (22%) programs execute 10 or more OSCEs throughout their curriculum. Forty (43%) programs use OSCEs as high-stakes assessments where poor performance could prevent a student from progressing to advanced pharmacy practice experiences. Of the responding programs, over half (56%) use teaching objective structured examinations to enhance learning. Common barriers to OSCE expansion exist and are related to resource utilization.

CONCLUSION

Significant expansion of OSCE development and implementation has occurred over the last decade. There is substantial variability in implementation and utilization among programs. Although standards of best practice for OSCEs exist for other health professions, best practices in pharmacy education have not been widely accepted or adopted.

Cytomegalovirus Treatment in Solid Organ Transplantation: An Update on Current Approaches

OBJECTIVE

The article reviews the safety and efficacy of treatments for cytomegalovirus (CMV) in solid organ transplantation.

DATA SOURCES

A literature review was conducted in PubMed, MEDLINE, and Clinicaltrials.gov from database inception through January 2024, using terms CMV, therapy, and solid organ transplantation.

STUDY SELECTION AND DATA EXTRACTION

Clinical trials, meta-analyses, cohort studies, case reports, and guidelines were included. Letters to the editor, reviews, and commentaries were excluded.

DATA SYNTHESIS

After abstract screening and full-text review of 728 citations for eligibility, 53 were included. Valganciclovir and intravenous ganciclovir are drugs of choice for CMV management and, until recently, the availability of alternative options has been restricted due to toxicity. For instance, foscarnet and cidofovir serve as second-line agents due to potential bone marrow and renal toxicity. In patients with refractory or resistant CMV, maribavir, a novel oral agent, has proven efficacy and a lower adverse effect profile. However, in refractory or resistant CMV, foscarnet and cidofovir are preferred in invasive disease (CMV gastritis, CMV retinitis, and CMV encephalitis), high viral loads, and inability to tolerate oral preparations.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Consensus guidelines have not been revised since approval of novel antivirals in solid organ transplantation. Valganciclovir and ganciclovir remain drugs of choice for initial CMV therapy. Foscarnet, cidofovir, and maribavir are treatments for refractory or resistant-CMV.

CONCLUSIONS

Selection of CMV antiviral treatment should be determined by patient-specific factors, including severity of illness, resistant or refractory disease, dose-limiting adverse effects, and the preferred route of administration.

Perceptions and Utility of Course Evaluations in US Pharmacy Schools

OBJECTIVE

This study aimed to describe the purpose, implementation, and perceived utility of course evaluations in pharmacy programs.

METHODS

After a literature review, a 34-item survey was developed, pretested, and sent to assessment administrators at accredited pharmacy programs (N = 139) with at least 3 follow-ups. Descriptive and inferential statistics were performed in IBM SPSS Statistics software.

RESULTS

A total of 90 programs responded (64.7% response rate). Most students (94%) were offered the opportunity to complete course evaluations. Some students completed evaluations during the course (47%), while others did so within 1 week of completion of the course (49%). Whether or not class time was given for students to complete the survey was often dependent on faculty choice (52.2%). Results were typically released after final grades were posted (92%), in time to use for the next semester of teaching (77%). Faculty were chosen to be evaluated by the number of teaching hours (50%) followed by all instructors (45.6%). Programs used the results for performance reviews by chairs (91%), course coordinator reviews (84%), and committee continuous quality improvement efforts (72%). Most programs did not provide faculty guidance on using evaluations (78%) nor development/mentoring (57%); only 22% of programs offered student development in completing evaluations.

CONCLUSION

While most programs invite feedback from all students via evaluations, most did not provide guidance to faculty on how to use this feedback for faculty or course development purposes. A more robust process to optimize the use of course evaluations should be developed.

Racial, Ethnic, and Sex Diversity Trends in Health Professions Programs From Applicants to Graduates

Importance

Diversity is an essential element of an effective health care system. A key to developing a diverse workforce is establishing a diverse student population in health professions programs.

Objective

To examine the diversity of students in Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), Doctor of Dental Surgery (DDS), Doctor of Dental Medicine (DMD), and Doctor of Pharmacy (PharmD) programs with emphasis on the trends of underrepresented minoritized groups (American Indian or Alaska Native, Black or African American, Hispanic or Latino, and Native Hawaiian or Other Pacific Islander) and sex relative to the overall age-adjusted US population.

Design, Setting, and Participants

This cross-sectional study used deidentified, self-reported data from 2003 to 2019 from the Association of American Medical Colleges, American Association of Colleges of Osteopathic Medicine, American Dental Education Association, American Dental Association, and American Association of Colleges of Pharmacy. Data analysis was performed from 2003 to 2004 and from 2018 to 2019.

Exposures

Data on the race, ethnicity, and sex of applicants, matriculants, and degrees conferred by health professions programs were collected and compared with the age-adjusted population in the US Census (aged 20-34 years) over time.

Main Outcomes and Measures

The main outcomes were trends in the proportions of underrepresented minoritized groups and sex diversity among applicants, matriculants, and degrees conferred relative to the overall age-adjusted US population. Trends were measured using the representation quotient, which is defined as the ratio of the proportion of each subgroup to the total population of applicants, matriculants, or graduates relative to the proportion for that subgroup within the US Census population of similar age. Regression analysis was used to evaluate the trend over time.

Results

A total of 594 352 applicants were analyzed across the examined programs. From 2003 to 2019, the proportions of individuals from underrepresented groups increased for DDS and DMD (applicants, from 1003 of 8176 to 1962 of 11 298 [5.1%]; matriculants, from 510 of 4528 to 966 of 6163 [4.2%]; degrees awarded, from 484 of 4350 to 878 of 6340 [2.7%]), PharmD (applicants, from 9045 of 71 966 to 11 653 of 50 482 [9.0%]; matriculants, from 5979 of 42 627 to 10 129 to 62 504 [6.3%]; degrees awarded, from 922 of 7770 to 2190 of 14 800 [3.0%]), and DO (applicants, from 740 of 6814 to 3478 of 21 090 [5.4%]; degrees awarded, 199 of 2713 to 582 of 6703 [1.4%]) programs, but decreased for MD programs (applicants, from 6066 of 34 791 to 7889 of 52 777 [-2.3%]; matriculants, 2506 of 16 541 to 2952 of 21 622 [-2.4%]; degrees awarded, from 2167 of 15 829 to 2349 of 19 937 [-0.1%]). Compared with age-adjusted US Census data, all programs had more Asian students and fewer male, American Indian or Alaska Native, Black or African American, Hispanic or Latino, and Native Hawaiian or Other Pacific Islander students (representation quotient <1).

Conclusions and Relevance

In this cross-sectional study, most of the health professions in the study saw increases in underrepresented minority applicants, matriculants, and degrees conferred from 2003 to 2019; however, all programs were below the age-adjusted US Census data. The increased racial, ethnic, and sex diversity in the programs illustrates progress, but additional strategies are needed to achieve a more representative health care workforce.

A critique of validity analysis from instruments assessing the affective domain

BACKGROUND

Schools and colleges of pharmacy need to show evidence that their students have internalized professional values, and many choose to do so through quantitative instruments. A review of the literature was completed to identify the evidence of validity of the scores from instruments designed to assess pharmacy students in the affective domain.

METHODS

Electronic databases were searched to identify instruments. Basic information regarding the instruments, the facets of validity assessed, and the evidence for validity were reviewed.

RESULTS

Of the studies identified, 25 focused on assessing the affective domain and reported evidence of at least one facet of validity. Most reported evidence of validity from two or more sources, and most reported evidence concerning test content and internal structure (i.e. internal consistency reliability or factor analysis). Other sources of validity were missing from most studies.

IMPLICATIONS

More research is needed to investigate the validity of the scores of instruments developed to assess pharmacy students within the affective domain, especially regarding relations to other variables, response processes, and consequences of use.

Belatacept for the prophylaxis of organ rejection in kidney transplant patients: an evidence-based review of its place in therapy

Background

Belatacept is a novel immunosuppressive therapy designed to improve clinical outcomes associated with kidney transplant recipients while minimizing use of calcineurin inhibitors (CNIs).

Methods

We searched for clinical trials related to administration of belatacept to kidney transplant patients compared to various immunosuppression regimens, as well as for studies that utilized data from belatacept trials to validate new surrogate measures. The purpose of this review is to consolidate the published evidence of belatacept’s effectiveness and safety in renal transplant recipients to better elucidate its place in clinical practice.

Results

Analysis of the results from the Belatacept Evaluation of Nephroprotection and Effi-cacy as First-Line Immunosuppressive Trial (BENEFIT) study, a de novo trial that compared cyclosporine (CsA)-based therapy to belatacept-based therapy in standard criteria donors, found a significant difference in mean estimated glomerular filtration rate (eGFR) of 13–15 mL/min/1.73 m² and 23–27 mL/min/1.73 m² at 1 year and 7 years, respectively. The BENEFIT-EXT study was similarly designed with the exception that it included extended criteria donors. Renal function improved significantly for the more intensive belatacept group in all years of the BENEFIT-EXT study; however, it was not significant in the less intensive group until 5 years after transplant. Belatacept regimens resulted in lower blood pressure, cholesterol levels, and incidence of new-onset diabetes after transplant compared to CsA-based regimens. Results from conversion of CNIs to belatacept therapy, dual therapy of belatacept with sirolimus, and belatacept with corticosteroid avoidance therapy are also included in this article.

Conclusion

The evidence reviewed in this article suggests that belatacept is an effective alternative in kidney transplant recipients. Compared to CNI-based therapy, belatacept-based therapy results in superior renal function and similar rates of allograft survival. In terms of safety, belatacept was shown to have lower incidence of hypertension, hyperlipidemia, and diabetes; however, incidence of posttransplantation lymphoproliferative disorder and the cost of belatacept may hinder use of this medication.

Hidden sources of grapefruit in beverages: potential interactions with immunosuppressant medications

PURPOSE

The interaction between grapefruit-containing beverages and immunosuppressants is not well defined in the literature. This study was conducted to investigate possible sources of grapefruit juice or grapefruit extract in common US-manufactured beverages. The goal was to identify those products that might serve as hidden sources of dietary grapefruit intake, increasing a transplant patient's risk for drug interactions.

METHODS

A careful review of the ingredients of the 3 largest US beverage manufacturer's product lines was conducted through manufacturer correspondence, product labeling examination, and online nutrition database research. Focus was placed on citrus-flavored soft drinks, teas, and juice products and their impact on a patient's immunosuppressant regimens.

RESULTS

Twenty-three beverages were identified that contained grapefruit. Five did not contain the word "grapefruit" in the product name. In addition to the confirmed grapefruit-containing products, 17 products were identified as possibly containing grapefruit juice or grapefruit extract.

CONCLUSION

A greater emphasis should be placed upon properly educating patients regarding hidden sources of grapefruit in popular US beverages and the potential for food-drug interactions.

Novel immunosuppressive agents in kidney transplantation

Excellent outcomes have been achieved in the field of renal transplantation. A significant reduction in acute rejection has been attained at many renal transplant centers using contemporary immunosuppressive, consisting of an induction agent, a calcineurin inhibitor, an antiproliferative agent plus or minus a corticosteroid. Despite improvements with these regimens, chronic allograft injury and adverse events still persist. The perfect immunosuppressive regimen would limit or eliminate calcineurin inhibitors and/or corticosteroid toxicity while providing enhanced allograft outcomes. Potential improvements to the calcineurin inhibitor class include a prolonged release tacrolimus formulation and voclosporin, a cyclosporine analog. Belatacept has shown promise as an agent to replace calcineurin inhibitors. A novel, fully-human anti-CD40 monoclonal antibody, ASKP1240, is currently enrolling patients in phase 2 trials with calcineurin minimization and avoidance regimens. Another future goal of transplant immunosuppression is effective and safe treatment of allograft rejection. Novel treatments for antibody mediated rejection include bortezomib and eculizumab. Several investigational agents are no longer being pursed in transplantation including the induction agents, efalizumab and alefacept, and maintenance agents, sotrastaurin and tofacitinib. The purpose of this review is to consolidate the published evidence of the effectiveness and safety of investigational immunosuppressive agents in renal transplant recipients.

Impact of participation on a solid organ transplant team on student pharmacists' perceptions of interprofessional roles

OBJECTIVE

To examine student pharmacists' perceptions of interprofessional roles before and after completing an advanced pharmacy practice experience on solid organ transplantation.

METHODS

Student pharmacists across the United States participating in an APPE on a solid organ transplant team completed an online pre- and post-APPE survey instrument examining perceptions of interprofessional roles, communication, and teamwork.

RESULTS

Student pharmacists' scores on interprofessionalism increased significantly on 17 of 22 items. Positive changes were seen in the interprofessional education core competency areas of roles and responsibilities, interprofessional communication, and teams and teamwork.

CONCLUSION

Student pharmacist participation in interprofessional clinical APPEs can positively influence their professional development as they prepare to become members of multi-disciplinary teams in the healthcare workforce.

Admission variables predictive of academic struggle in a PharmD program

Objective. To characterize and describe admission variables predictive of poor grade attainment by students in 2 pathways to a doctor of pharmacy (PharmD) program.Methods. A retrospective analysis of course grades of PharmD students admitted from 2000 to 2009 (N= 1,019) in the traditional degree pathway ("1 plus 5" degree program) and the provisional pathway (admitted directly from high school) was performed.Results. Four hundred three grades of D or less were earned by 183 (18%) students. There were more grades of D or less in the first pharmacy year. Receipt of an unsatisfactory grade was associated with all Pharmacy College Admission Test (PCAT) subcategory scores, PCAT composite score, cumulative prepharmacy coursework hours, prepharmacy grade point average (GPA), prepharmacy science and math GPA, and interview score for accepted students in the traditional pathway. For students in the provisional pathway, PCAT-quantitative analysis, PCAT composite score, prepharmacy cumulative GPA, prepharmacy science and math GPA, English American College Testing (ACT) score, and composite ACT score predicted poor grades. Conclusion. Admissions committees should heed PCAT scores and GPAs, regardless of program pathway, while progression committees should focus on early program coursework when designing strategies to optimize retention.

Selection of induction therapy in kidney transplantation

Currently available immunosuppressive agents can be classified into three categories: induction agents, maintenance therapy, and treatment for rejection. This review article will focus on induction immunosuppression. There are three antibodies which are used for induction therapy: the lymphocyte-depleting agents - anti-thymocyte globulin and alemtuzumab, and basiliximab which is nondepleting. Historically, immunosuppressant selection was solely based on efficacy for prevention of rejection. In the current era of transplantation, it is now common practice in the transplant community to select induction therapy on the basis of risk-benefit considerations for each patient. This article will focus on the efficacy of available induction agents and the selection of induction agent based on donor and recipient risk factors.

Evaluation of a Pharmacist-Managed Anticoagulation Clinic

Background

Anticoagulation therapy is important in the prevention and treatment of cardioembolic events. Warfarin is frequently used but requires continual monitoring to ensure safety and efficacy. The target time in therapeutic range (TTR) is not always achieved.

Objectives

The objectives for this study were to determine the TTR for a pharmacist-managed anticoagulation clinic and identify reasons for sub- and supratherapeutic international normalized ratio (INR) values.

Methods

Medical records for subjects prescribed warfarin were reviewed. Demographic and relevant clinical information was assessed. INR measurements were extracted for subjects enrolled. The TTR was calculated, and the cause for sub- or supratherapeutic values was determined when possible.

Results

One hundred twenty-six subjects were included in this retrospective study. The calculated TTR was 51%. The cause for more than 65% of the sub- and supratherapeutic INR values could not be determined. One subject incurred a clot and 6 subjects suffered a bleed. No deaths occurred. Age was the only factor that correlated with a supratherapeutic INR value ( r = −0.179, P = .045).

Conclusion

Pharmacists in the anticoagulation clinic are effectively managing patients who are taking warfarin by frequently maintaining INR values near or within the recommended therapeutic range. Very few negative outcomes occurred during the time of study.

Current state of renal transplant immunosuppression: Present and future

For kidney transplant recipients, immunosuppression commonly consists of combination treatment with a calcineurin inhibitor, an antiproliferative agent and a corticosteroid. Many medical centers use a sequential immunosuppression regimen where an induction agent, either an anti-thymocyte globulin or interleukin-2 receptor antibody, is given at the time of transplantation to prevent early acute rejection which is then followed by a triple immunosuppressive maintenance regimen. Very low rejection rates have been achieved at many transplant centers using combinations of these agents in a variety of protocols. Yet, a large number of recipients suffer chronic allograft injury and adverse events associated with drug therapy. Regimens designed to limit or eliminate calcineurin inhibitors and/or corticosteroid use are actively being pursued. An ideal immunosuppressive regimen limits toxicity and prolongs the functional life of the graft. This article contains a critical analysis of clinical data on currently available immunosuppressive strategies and an overview of therapeutic moieties in development.

Inhibitory interactions between BK and JC virus among kidney transplant recipients

BK and JC polyomaviruses can reactivate after transplantation, causing renal dysfunction and graft loss. The incidence of JC reactivation after renal transplant is not well understood. Here, we characterized JC reactivation using samples collected during the first year after transplantation from 200 kidney recipients. We detected BK and JC viruses in the urine of 35 and 16% of transplant recipients, respectively. The median viral load in the urine was 400 times higher for BK virus than JC virus. The presence of BK viruria made concurrent JC viruria less likely: JC viruria was detected in 22% of non-BK viruric recipients compared with 4% of BK viruric recipients (P=0.001). The co-detection rate was 1.5%, which is less than the expected 5.6% if reactivation of each virus was independent (P=0.001). We did not observe JC viremia, JC nephropathy, or progressive multifocal leukoencephalopathy. The onset of JC viruria was associated with donor, but not recipient, JC-specific antibody in a titer-dependent fashion and inversely associated with donor and recipient BK-specific antibody. Donor and recipient JC seropositivity did not predict BK viruria or viremia. In conclusion, among renal transplant recipients, infection with one polyomavirus inversely associates with infection with the other.

The influence of bortezomib on donor specific antibody reduction in patients with antibody mediated rejection

Renal allograft biopsy is the gold standard for monitoring and diagnosing antibody mediated rejection (AMR), yet a biopsy is invasive, expensive, and may result in complications. Monitoring antibodies may aid in diagnosing and monitoring AMR, although many questions remain unanswered regarding the clinical utility of antibody monitoring. The purpose of this review is to examine the influence of bortezomib on reduction of donor specific antibody after AMR in renal transplant recipients. A retrospective review of patients was performed. Patients who received bortezomib after suffering AMR refractory to intravenous immunoglobulin and plasmapheresis from 2009 to 2011 were selected. Seven patients were identified. Three patients had antibodies tested after IVIG treatment with a mean antibody lowering of 29 percent from baseline. Five of the seven patients had antibodies tested after bortezomib treatment and the mean antibody reduction was 47 percent from baseline. Four patients were biopsied after treatment and all were C4d negative. The other three patients were not biopsied. Renal function improved in most patients. One patient returned to dialysis 16 months after transplant and treatment and another patient died with a functioning graft, due to pneumonia five months after transplant and treatment. In these seven cases, the use of intravenous immune globulin, plasmapheresis, and bortezomib appear to decrease antibodies, improve renal function, and reverse histological markers for rejection. Long-term, prospective follow-up is warranted to determine the influence of bortezomib on donor antibody removal, histological changes, and graft survival.

BK-virus and the impact of pre-emptive immunosuppression reduction: 5-year results

A 1-year, single-center, randomized trial demonstrated that the calcineurin inhibitor or adjuvant immunosuppression, independently, does not affect BK-viruria or viremia and that monitoring and pre-emptive withdrawal of immunosuppression was associated with resolution of BK-viremia and absence of clinical BK-nephropathy without acute rejection or graft loss. A retrospective 5-year review of this trial was conducted. In cases of BK viremia, the antimetabolite was withdrawn and for sustained viremia, the calcineurin inhibitor was minimized. Five-year follow-up was available on 97% of patients. Overall 5-year patient survival was 91% and graft survival was 84%. There were no differences in patient-survival by immunosuppressive regimen or presence of BK-viremia. Immunosuppression and viremia did not influence graft survival. Acute rejection occurred in 12% by 5-years after transplant, was less common with tacrolimus versus cyclosporine (9% vs. 18%; p = 0.082), and was lowest with the tacrolimus-azathioprine regimen (5%, p = 0.127). Tacrolimus was associated with better renal function at 5-years (eGFR 63 FK vs. 52 CsA mL/min, p = 0.001). Minimization of immunosuppression upon detection of BK-viremia was associated with excellent graft survival at 5-years, low rejection rates and excellent renal function. It is a safe, short and long-term strategy that resulted in freedom from clinically evident BK-virus nephropathy.

Bortezomib as rescue therapy for antibody mediated rejection: a single-center experience

Case series have reported the use of bortezomib for treatment of primary and refractory treatment of cell-mediated acute rejection. The purpose of this article is to review a single-center experience with bortezomib used to treat humoral rejection in four transplant recipients. All patients received bortezomib after suffering antibody-mediated rejection refractory to intravenous immunoglobulin and plasmapheresis. Each patient had improved renal function after bortezomib treatment, biopsies became c4d negative in three of the four patients and the level of donor specific antibody reduction was mixed. Adverse drug events were not encountered, although two patients suffered infections, H1N1 pneumonia and cytomegalovirus colitis. In conclusion, these four cases demonstrate the promising use of bortezomib as rescue therapy for antibody mediated rejection. Future research is needed to explore the impact of bortezomib on HLA removal, histological reversal of rejection, and long-term graft function after transplantation.

Serum sickness after treatment with rabbit antithymocyte globulin in kidney transplant recipients with previous rabbit exposure

Serum sickness after rabbit antithymocyte globulin administration has a reported incidence of 7% to 27% in kidney transplant recipients. We describe 4 patients with previous exposure to rabbits who developed serum sickness after primary rabbit antithymocyte globulin induction. All patients presented with jaw pain. Three of 4 patients treated with plasmapheresis and steroids had prompt recovery, and 1 patient treated with steroids had slower recovery. We performed a telephone interview of 214 patients who contemporaneously underwent transplantation between November 2006 and July 2008 regarding rabbit exposure. More than half the patients had some type of previous rabbit exposure. There was a suggestion that patients with serum sickness were exposed more frequently to rabbits than those without. Jaw pain appears to be a hallmark symptom, and treatment with plasmapheresis and steroids relieves symptoms more rapidly than steroids alone.

Bortezomib for acute humoral rejection in two repeat transplant recipients

Case series have reported the use of bortezomib to remove antibodies in live-donor transplant recipients with HLA alloantibodies and to treat antibody and cell-mediated acute rejection. The purpose of this article is to review a single-center experience with bortezomib used to treat humoral rejection in two sensitized, repeat transplant recipients. Both patients received bortezomib after suffering antibody-mediated rejection refractory to intravenous immunoglobulin and plasmapheresis. Short-term follow-up of the case reports presented here demonstrated that renal function has improved after bortezomib treatment while the immunological outcomes were mixed. In the first case the donor specific antibodies initially decreased, but then rebounded and in the second case the DR antibodies decreased while the DQ antibodies increased slightly. In conclusion, these two cases demonstrate the promising use of bortezomib in antibody mediated rejection. Future research is needed to explore the impact of bortezomib on HLA removal, histological reversal of rejection, and long-term graft function after transplantation.

Adverse drug reaction driven immunosuppressive drug manipulations: a single-center comparison of enteric-coated mycophenolate sodium vs. mycophenolate mofetil

Enteric-coated mycophenolate sodium (MPS) has been developed to help circumvent the upper gastrointestinal side-effects of mycophenolic acid by facilitating drug release in the small intestine. Many questions regarding the side-effect profile of MPS remain. Therefore, the purpose of this study is to review a single-center's experience with mycophenolate mofetil (MMF) and MPS.

METHODS

This retrospective, sequential cohort analysis of de novo renal and pancreas transplants (n = 198) compared MMF 500 mg b.i.d. to MPS 360 mg b.i.d. in conjunction with antibody induction, tacrolimus, and steroids.

RESULTS

There were fewer adverse event driven drug manipulations in the MPS group at 90 d (4% MPS vs. 17% MMF) and 180 d (10% MPS vs. 24% MMF, p = 0.006, log-rank) after transplantation. There was a trend toward fewer GI-related hospital admissions in the MPS arm (7% MPS vs. 13% MMF, p = 0.18). Allograft outcomes including patient survival, graft survival, acute rejection, serum creatinine, and infection were similar.

CONCLUSION

This single-center, sequential cohort study demonstrates that MPS is associated with fewer adverse event driven drug manipulations while maintaining similar safety and allograft outcomes.

A randomized, prospective, pharmacoeconomic trial of neoral 2-hour postdose concentration monitoring versus tacrolimus trough concentration monitoring in de novo liver transplant recipients

Two-hour postdose cyclosporine (C2) monitoring is becoming an accepted method of therapeutic drug monitoring, although it is not known whether C2 monitoring is superior to tacrolimus (FK)-based immunosuppression. The purpose of this trial was to compare the safety, efficacy, and pharmacoeconomics of cyclosporine A (CsA) monitored by C2 levels versus FK monitored by trough levels in de novo liver transplant recipients. After informed consent, 60 de novo liver transplant recipients were randomized in a 1:1 fashion to receive either FK (trough, 6-10 ng/mL) or CsA (C2, 600-1200 ng/mL) and corticosteroids. The 2 groups were similar for gender, race, indication for liver disease, and age. At 1 year, patient survival was similar (93% for FK versus 90% for C2). One patient in the FK arm was retransplanted because of recurrent hepatitis C virus (HCV). Early acute rejection occurred in 27% of FK-treated patients and 23% of CsA-treated recipients [P = not significant (NS)]. Recurrent HCV occurred in 21% of FK-treated patients and 61% of CsA-treated patient (P = 0.04). The incidence of other infections, new onset diabetes mellitus, requirement for antihypertensives, and requirement for cholesterol medications were similar between the groups. Annual calcineurin inhibitor costs were lower in the C2 arm ($5432 +/- 2091 for C2 versus $8291 +/- 3948 for FK, P = 0.001). Annual pretransplant drug costs ($2292 +/- 2331 for C2 versus $2831 +/- 2358 for FK, P = NS) and 1-year posttransplant drug costs ($17,214 +/- 16,600 for C2 versus $15,151 +/- 11,699 for FK, P = NS) were similar. In conclusion, immunosuppression with CsA, monitored by C2 levels, is safe, effective, and economical in liver transplant recipients and provides immunosuppression at least equivalent to that of FK.

Sirolimus conversion in liver transplant recipients with renal dysfunction: a prospective, randomized, single-center trial

This pilot trial was designed to assess the safety and efficacy of SRL in liver transplant recipients with renal dysfunction. Forty patients with renal dysfunction (24-hr CrCl 40-80 mL/min) were randomized to be withdrawn from the calcineurin inhibitor (CNI) and receive sirolimus (SRL) or to continue CNI (control arm). Improvement in 24-hour CrCl was seen in the SRL arm at 3 months (75 mL/min SRL vs. 56 mL/min control, P=0.012), whereas at 12 months there was a trend toward improvement in the SRL arm (72 mL/min SRL vs. 58 mL/min control, P=0.09). Two patients, one in each arm, developed steroid-sensitive rejection. Side effects of SRL were limited and included hyperlipidemia requiring treatment (15%), pruritus (5%), and mouth sores (25%). In this trial, SRL-based immunosuppression was a safe alternative to CNI. Although early improvements were observed, withdrawing CNI and replacing it with SRL did not result in a statistically significant improvement in renal function at 12 months of follow-up.

Health insurance considerations for adolescent transplant recipients as they transition to adulthood

The advent of improved immunosuppression and enhanced allograft outcomes has resulted in a growing number of patients taking expensive immunosuppression medications for the rest of their lives. Healthcare costs for the majority of transplantation procedures in the USA currently are covered by Medicare, but coverage ends for outpatient immunosuppression medications 36-44 months after transplantation. Two or three immunosuppressive agents typically are included in post-transplant regimens with a total annual cost that can exceed 13,000 dollars. This represents a significant financial burden for families no matter if they have adequate health insurance coverage because of co-payment obligations. Evidence suggests that some patients have reduced immunosuppression doses because of an inability to afford their medication, increasing the risk of graft failure. The purpose of this article was to review these and other issues pertaining to medical insurance coverage and transplantation, particularly for adolescent recipients as they transition to adulthood.

Rabbit antithymocyte globulin induction therapy in adult renal transplantation

Rabbit antithymocyte globulin (rATG) and horse antithymocyte globulin (horse ATG) are the polyclonal antithymocyte agents available for use in solid organ transplantation in the United States. Horse ATG is indicated for induction immunosuppression and for treatment of acute rejection episodes after kidney transplantation; rATG is indicated for treatment of acute rejection only. However, rATG is commonly used in clinical practice as an induction immunosuppressive agent, instigating many questions regarding appropriate dosing, tolerability, safety, and efficacy. Available evidence supports the use of rATG as an induction agent in adult renal transplant recipients. The use of this product for induction therapy has been studied in conjunction with a full-dose, triple-therapy maintenance regimen (sequential quadruple immunosuppression) consisting of a calcineurin inhibitor, an antimetabolite, and corticosteroids. Rabbit ATG has a proven safety and efficacy profile both as treatment of acute rejection and as induction therapy in patients undergoing kidney transplantation. The most common adverse events associated with rATG are cytokine release syndrome, thrombocytopenia, and lymphopenia. Results of early studies showed an increased rate of cytomegalovirus disease associated with rATG treatment, but recent studies indicate that routine administration of modern antiviral prophylaxis can reduce this risk. Current practice with rATG is evolving to minimize lifelong exposure to calcineurin inhibitors and corticosteroids.

Prophylactic versus preemptive oral valganciclovir for the management of cytomegalovirus infection in adult renal transplant recipients

Prophylaxis reduces cytomegalovirus (CMV) disease, but is associated with increased costs and risks for side effects, viral resistance and late onset CMV disease. Preemptive therapy avoids drug costs but requires frequent monitoring and may not prevent complications of asymptomatic CMV replication. Kidney transplant recipients at risk for CMV (D+/R-, D+/R+, D-/R+) were randomized to prophylaxis (valganciclovir 900 mg q.d. for 100 days, n=49) or preemptive therapy (900 mg b.i.d. for 21 days, n=49) for CMV DNAemia (CMV DNA level>2000 copies/mL in >or=1 whole blood specimens by quantitative PCR) assessed weekly for 16 weeks and at 5, 6, 9 and 12 months. More patients in the preemptive group, 29 (59%) than in the prophylaxis group, 14 (29%) developed CMV DNAemia, p=0.004. Late onset of CMV DNAemia (>100 days after transplant) occurred in 11 (24%) randomized to prophylaxis, and none randomized to preemptive therapy. Symptomatic infection occurred in five patients, four (3 D+/R- and 1 D+/R+) in the prophylactic group and one (D+/R-) in the preemptive group. Peak CMV levels were highest in the D+/R- patients. Both strategies were effective in preventing symptomatic CMV. Overall costs were similar and insensitive to wide fluctuations in costs of either monitoring or drug.

Mycophenolate mofetil dose reductions and discontinuations after gastrointestinal complications are associated with renal transplant graft failure

BACKGROUND

Mycophenolate mofetil (MMF) use in renal transplantation has steadily increased since 1995 because of its ability to lower the risks of rejection and chronic allograft nephropathy. However, significant gastrointestinal (GI) complications may lead to MMF dose reductions and discontinuations. Little is known of the association between MMF dose reductions and discontinuations following GI complications and graft survival.

METHODS

Using the United States Renal Data System, we identified 3,675 adult recipients (age >or=18) with a diagnosed GI complication who were prescribed MMF at the time of first GI diagnosis and had Medicare as their primary insurer. MMF doses were ascertained from Medicare payment records. We estimated risk of graft loss associated with MMF dose adjustments after GI diagnosis: dosage unchanged (reference), reduced <50%, reduced >or=50%, and MMF discontinued. Patients were followed until graft loss, death, last recorded immunosuppression prescription, or 3 years posttransplant.

RESULTS

Compared to those with no MMF dose reductions or discontinuations, the risk of graft failure increased with MMF doses reduction >or=50% (HR=2.36, 95% CI 1.23-4.54) and those with MMF discontinuation (2.72, CI 1.60-4.64).

CONCLUSION

Renal transplant recipients who underwent MMF dose reduction or withdrawal following GI diagnosis are associated with increased risk of graft failure.

Thymoglobulin induction is safe and effective in live-donor renal transplantation: a single center experience

BACKGROUND

The relative benefit versus safety of induction therapy in live-donor renal transplant recipients is controversial. This paper presents observational data of live-donor recipients who received Thymoglobulin induction and standard maintenance immunosuppressive therapy.

METHODS

Review and analysis of clinic records and electronic databases of live-donor renal transplants that received Thymoglobulin induction from May 1996 through 2003.

RESULTS

Data analysis included 214 live-donor recipients (146 related, 68 unrelated) with a mean follow-up of 3.0+/-1.9 years. The average age of recipients was 44+/-13 years, with a majority being Caucasian (86%) and male (64%). Nineteen (9%) received previous transplants. No patients experienced delayed graft function and 10 (5%) developed acute rejection. Overall, predicted five-year patient survival was 96% and graft survival was 82%. The rates of CMV infection (5%), malignancy (3%), and lymphoproliferative disorder (0.5%) were low. When compared to live-donor kidney transplant recipients nationwide, the center cohort demonstrated improved five year patient (96% center versus 90% national, P=0.0326) and graft survival (82% center versus 79% national, P=0.0901), and a lower one-year acute rejection rate (2% center versus 21 % national, P<0.001).

CONCLUSIONS

In this analysis, the use of Thymoglobulin in live-donor renal transplantation was associated with an absence of delayed graft function, low acute rejection rates, and high patient and graft survival without increasing the risk of infection or lymphoproliferative disorder.

A Randomized, Prospective, Pharmacoeconomic Trial of Tacrolimus versus Cyclosporine in Combination with Thymoglobulin in Renal Transplant Recipients

BACKGROUND

To date, the clinical trials of tacrolimus (TAC) versus cyclosporine modified (CsA), have not defined which agent is more cost-effective for immunosuppression in renal transplant recipients especially in a quadruple immunosuppressive regimen.

METHODS

The objective of this randomized, prospective study was to compare the clinical and economic outcomes of TAC versus CsA, in a regimen that consisted of Thymoglobulin induction, an antimetabolite, and prednisone. Between December 2000 and October 2002, 200 patients were enrolled and randomized in a 2:1 fashion (TAC n=134, CsA n=66).

RESULTS

At 1 year, acute rejection (4% TAC vs. 6% CsA), patient survival (TAC 99% vs. CsA 100%), and graft survival (95% TAC versus 100% CsA, P=0.059) were similar. Serum creatinine levels were lower in the TAC group compared with the CsA group (1.3+/-0.3 vs. 1.6+/-0.7 mg/dL, P=0.03). The incidence of CMV infection was similar between the groups and two patients, both in the TAC arm, developed malignancy. Anti-hypertensive requirement (32% TAC vs. 32% CsA) and the incidence of posttransplant diabetes mellitus (4% TAC vs. 2% CsA) were similar. Pretransplant, fewer TAC patients received dyslipidemia treatment (40% TAC vs. 67% CsA, P=0.0005), while more CsA patients were able to discontinue these medications posttransplant (absolute change 25% TAC vs. 47% CsA). Total 12-month medication costs were similar (17,723 +/- 11,647 dollars TAC vs. 16,515 +/- 10,189 dollars CsA).

CONCLUSIONS

When combined with Thymoglobulin induction, an antimetabolite, and corticosteroids, TAC and CsA are comparable in safety, efficacy, and cost in renal transplantation.

Incidence of BK with tacrolimus versus cyclosporine and impact of preemptive immunosuppression reduction

Our purposes were to determine the incidence of BK viruria, viremia or nephropathy with tacrolimus (FK506) versus cyclosporine (CyA) and whether intensive monitoring and discontinuation of mycophenolate (MMF) or azathioprine (AZA), upon detection of BK viremia, could prevent BK nephropathy. We randomized 200 adult renal transplant recipients to FK506 (n = 134) or CyA (n = 66). Urine and blood were collected weekly for 16 weeks and at months 5, 6, 9 and 12 and analyzed for BK by polymerase chain reaction (PCR). By 1 year, 70 patients (35%) developed viruria and 23 (11.5%) viremia; neither were affected independently by FK506, CyA, MMF or AZA. Viruria was highest with FK506-MMF (46%) and lowest with CyA-MMF (13%), p = 0.005. Viruria >/= 9.5 log(10) copies/mL was associated with a 3-fold increased risk of viremia and a 13-fold increased risk of sustained viremia. After reduction of immunosuppression, viremia resolved in 95%, without increased acute rejection, allograft dysfunction or graft loss. No BK nephropathy was observed. Choice of calcineurin inhibitor or adjuvant immunosuppression, independently, did not affect BK viruria or viremia. Viruria was highest with FK506-MMF and lowest with CyA-MMF. Monitoring and preemptive withdrawal of immunosuppression were associated with resolution of viremia and absence of BK nephropathy without acute rejection or graft loss.

Current and future immunosuppressive strategies in renal transplantation

The past decade has witnessed the introduction of several new immunosuppressive agents. The availability of these new pharmacologic offerings has not diminished the challenge of achieving a balance of adequate graft protection while minimizing the consequences of excessive immunosuppression. For renal transplant recipients, maintenance immunosuppression generally consists of a calcineurin inhibitor in combination with an antiproliferative agent and a corticosteroid; more recently, mammalian target of rapamycin inhibitors have been used. Excellent results have been achieved at many transplant centers with combinations of these agents in a variety of protocols. Regimens designed to limit or eliminate calcineurin inhibitor and/or corticosteroid therapy are actively being pursued in the transplant community. Allograft tolerance and xenotransplantation are being studied, and the knowledge gained from the effort may help in the development of innovative strategies and new immunosuppressive agents.

Long-term outcome of gastrointestinal complications in renal transplant patients treated with mycophenolate mofetil

This study examined consequences of gastrointestinal (GI) complications and mycophenolate mofetil (MMF) discontinuation on long-term outcomes in patients who received MMF at transplantation and had graft function 12 months post-transplantation. Data were obtained from the United States Renal Data System for cadaveric renal transplant recipients between 1995 and 1998. GI complications or MMF discontinuation occurred in 27.4% and 17.5% of patients, respectively. MMF was discontinued in 21.3% of patients with GI complications and 16.0% of patients without (P<0.00001). Four-year graft survival was reduced from 87.1% to 82.3% (P=0.091) with MMF discontinuation, to 83.0% (P=0.001) with GI complications, and to 70.2% (P<0.0001) with GI complications and MMF discontinuation. While the retrospective nature of this work cannot prove causality, which will require future prospective studies, both GI complications and MMF withdrawal are associated with increased risk of graft loss and may warrant further study in the management of transplant recipients.

Cyclosporine Minimization and Cost Reduction in Renal Transplant Recipients Receiving a C2-Monitored, Cyclosporine-Based Quadruple Immunosuppressive Regimen

BACKGROUND

Targeting 2-hr postdose cyclosporine (C2) levels to 1,000 to 1,700 mg/dL during the first 6 months after renal transplantation is recommended for triple immunosuppressive regimens. This trial determines whether lower C2 levels could be targeted safely in de novo kidney transplant recipients under a quadruple regimen compared with a similar cohort monitored with trough (C0) levels.

METHODS

This single-center, sequential, cohort-designed trial included patients who received Thymoglobulin, corticosteroids, an antimetabolite, and cyclosporine monitored by C2 (n=50) or C0 (n=50). Cyclosporine was tapered to maintain the C2 between 1,000 and 1,200 ng/mL months 0 to 3 and between 600 and 1,000 ng/mL thereafter and C0 between 250 and 350 ng/mL months 0 to 3 and between 100 and 250 ng/mL thereafter.

RESULTS

Baseline patient and donor characteristics were similar. There were no differences in graft survival (100% C2 vs. 100% C0), acute rejection (4% C2 vs. 6% C0), allograft function, or adverse events at 6 months. C2 levels were lower than the suggested guidelines throughout the study (33% lower at 1 month and 48% lower at 6 months). Lower cyclosporine doses were achieved in the C2 arm compared with the C0 arm by 1 month and were sustained throughout the trial, which translated into an average cyclosporine cost savings of USD $773 in the C2 arm during the 6-month period (P<0.001).

CONCLUSION

With a quadruple immunosuppressive regimen and lower C2 targets than recommended for triple therapy, safe and effective cyclosporine minimization was achieved. Lower cyclosporine doses were achieved in C2-monitored patients compared with C0-monitored patients, translating into lower immunosuppressive costs.

Five-year follow up of thymoglobulin versus ATGAM induction in adult renal transplantation

BACKGROUND

One-year results of a randomized, double-blinded trial of Thymoglobulin versus Atgam for induction therapy in renal transplantation revealed that Thymoglobulin was associated with higher event-free survival (94% vs. 63%), less acute rejection (4% vs. 25%), and better graft survival. This article compares the safety and efficacy of Thymoglobulin versus Atgam induction through 5 years.

METHODS

Review and analysis of clinic records and electronic databases.

RESULTS

At 5 years, event-free survival (73% vs. 33%, P<0.001), graft survival (77% vs. 55%, P=0.047), and freedom from rejection (92% vs. 66%, P=0.007) were higher with Thymoglobulin versus Atgam. No additional cytomegalovirus (CMV) disease occurred after the first year with Thymoglobulin or Atgam (13% vs. 33%, P=0.056). There were two cases of posttransplant lymphoproliferative disorder (PTLD) with the Atgam arm and none with Thymoglobulin. Thymoglobulin was associated with profound lymphopenia at 2 years after transplantation.

CONCLUSIONS

Thymoglobulin was associated with higher event-free survival, graft survival, and freedom from rejection without increased PTLD or CMV disease at 5 years compared with Atgam. The prolonged and profound lymphopenia may contribute to the long-term results associated with Thymoglobulin.

Pharmacokinetics of tacrolimus in kidney transplant recipients: twice daily versus once daily dosing

Tacrolimus a macrolide immunosuppressant that is routinely given in two equally divided doses every 12 h. However, the time-dependent pharmacokinetics of tacrolimus suggest that once daily morning administration of tacrolimus may produce appropriate drug exposure. The purpose of this pilot study was to compare the pharmacokinetics and safety of twice vs. once daily administration of tacrolimus in stable kidney transplant recipients. Steady-state tacrolimus pharmacokinetic parameters were estimated on two occasions in an open-label, three-arm, two-period sequential study: twice daily dosing (Phase I) and once daily dosing (Phase II). In phase II, 18 patients were assigned to one of three arms: those taking 67%, 85% and 100% of their total twice daily dose once in the morning. In phase I, the mean area under the blood concentration-time curve (AUC) was higher after the morning dose, AUC(0-12) 117 +/- 40 vs. AUC(12-24) 97 +/- 30 ng/h/mL, p=0.012. In the 85% Group, the mean AUC ratio between twice and once daily was 1.0 (95% CI, 0.9-1.1) which predicted the best conversion ratio. Tacrolimus given once daily in the morning, at 85% of the twice daily dose, provides safe and equivalent drug exposure to twice daily dosing. This convenient dosing schedule may help to increase compliance and lower costs.

West Nile virus-associated meningoencephalitis in two chronically immunosuppressed renal transplant recipients

West Nile virus is a mosquito-borne, single-stranded RNA virus of the Flaviviridae family. Approximately 1 in 150 patients who have serologic evidence of West Nile virus infection develop encephalitis or meningitis. We report two chronically immunosuppressed renal transplant recipients with confirmed West Nile virus meningoencephalitis acquired through community exposure. Both patients presented with fever and neurological changes in the autumn of 2002. Flavivirus-specific immunoglobulin M in antibodies in the cerebral spinal fluid and serum were detected by antibody-capture enzyme immunoassay, and antibodies for West Nile virus were confirmed by the plaque neutralization reduction assay. Reduction in immunosuppression and supportive care were successful in treating both patients. West Nile meningoencephalitis should be considered in transplant recipients that present with signs and symptoms of meningoencephalitis.

Serial measurements of bone density at the lumbar spine do not predict fracture risk after liver transplantation

Bone disease has emerged as a serious and complex complication after liver transplantation. The purpose of this study is to determine risk factors for fracture and bone loss after liver transplantation. Dual-energy x-ray absorptiometry (DEXA) of the lumbar spine was performed routinely pretransplantation, 6 months posttransplantation, and at yearly intervals thereafter at our center. We followed up patients who underwent transplantation in the past 10 years and compared bone mineral density (BMD) and fracture rate with known risk factors for bone loss in primary transplant recipients who met the inclusion criteria of a pretransplantation DEXA and at least one follow-up DEXA scan postoperatively (n = 153). We observed a 15% (n = 23) prevalence of symptomatic fractures at a mean of 2.2 +/- 1.8 years after transplantation. Change in BMD was greatest from pretransplantation to 6 months posttransplantation (-4.2%; P =.006), then increased at a rate of 1.4% per year. Logistic regression analysis showed an association of fracture risk with several factors, including number of acute rejection episodes (P =.045), smoking (P =.02), and female sex (P =.02). Stepwise logistic regression analysis reported female sex (P =.004) as the only factor associated with fracture after transplantation. Age, time listed for transplantation, race, menopause, chronic renal insufficiency, loss of height, family history of osteoporosis, BMD, and T score did not predict fracture or bone loss after transplantation. In conclusion, serial measurements of BMD at the lumbar spine do not appear to predict fracture risk; however, data suggest that female sex is the strongest predictor of fracture after liver transplantation.

The expanded criteria donor dilemma in cadaveric renal transplantation

BACKGROUND

Outcomes of expanded criteria donor (ECD) kidney transplants are known to be superior to dialysis but inferior to transplant with a standard donor. Because of recent policy changes, ECD kidneys will be offered only to patients who have agreed to consider such an organ in advance. There is wide variation in opinion concerning the composition of ECD wait lists. However, the relative benefits of accepting an ECD versus waiting for a standard donor have not been quantified.

METHODS

A Markov model was developed to determine when an individual patient should accept or reject an offer of an ECD kidney to optimize their personal expected quality-adjusted life years (QALY). Input variables were estimated from the United States Renal Data System (USRDS) database using a sample of 35,030 recipients.

RESULTS

Recipients of ECD kidneys waited 77 days longer for transplant than recipients of standard donors. The average patient could wait 3.2 years longer, in addition to the time they have already waited, for a standard donor than an ECD and expect equivalent QALYs. Selected subsets revealed differences in wait times that equated QALYs for ECD and standard donors: African American, 4.4 years; age under 30, 4.0 years; age over 60, 11 months.

CONCLUSIONS

Existing policy is likely to be in the best interests of only certain sets of patients awaiting cadaveric kidney transplantation unless ECDs dramatically reduce expected waiting for transplantation. This is most possible in elderly patients because of the short wait-time reduction required to make ECDs beneficial. Data reported here have been supplied by the USRDS. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the US Government. The data and analyses reported in the 2001 Annual Report of the United States Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients have been supplied by the United Network for Organ Sharing and University Renal Research and Education Association under contract with Health and Human Services. The authors alone are responsible for reporting and interpreting of these data.

The association of cytomegalovirus sero-pairing with outcomes and costs following cadaveric renal transplantation prior to the introduction of oral ganciclovir CMV prophylaxis

Cytomegalovirus (CMV) is an important cause of morbidity, mortality and cost in cadaveric renal transplantation. This study was designed to document the clinical and economic outcomes associated with donor and recipient CMV sero-pairing. Data were drawn from the United States Renal Data System (USRDS) on 17 001 cadaveric renal transplant recipients transplanted between 1995 and 1997 with recorded donor and recipient CMV sero-status. In multivariate analysis, CMV-seropositive recipients were associated with a significantly higher incidence of delayed graft function, a lower incidence of graft loss, and lower costs than CMV-seronegative recipients. CMV-seropositive compared to seronegative donors were associated with significantly higher incidence of CMV disease, graft loss, and higher costs when transplanted into CMV-seronegative recipients. However, CMV-seronegative donors into seropositive recipients had no significant association with outcome beyond a higher incidence of CMV disease compared to CMV-seronegative donor and recipient pairs. The outcomes associated with CMV-seropositive donors and seronegative recipients call for tailored management strategies which may include avoidance of such mismatching, antiviral therapy, immunization, or modified immunosuppression.

Cytomegalovirus disease after prophylaxis with oral ganciclovir in renal transplantation: the importance of HLA-DR matching

This study assessed the incidence of cytomegalovirus (CMV) disease and associated outcomes after oral ganciclovir prophylaxis in renal transplantation. A retrospective analysis was performed of all adult renal transplant recipients at a single transplant center transplanted between August 16, 1996, and December 31, 2000. CMV disease prophylaxis included ganciclovir 1000 mg orally thrice daily prescribed for 90 d in D-/R+ cases and 180 d in D+/R- and D+/R+ cases. Forty (9.1%) of 470 patients studied were diagnosed with CMV disease, which varied significantly by CMV serostatus and number of HLA-DR matches. The highest incidence of disease, 26.2%, was in D+/R- patients with zero HLA-DR matches. Five-year graft survival was 56.8% with CMV disease compared with 79.1% without (P < 0.001). Five-year graft survival with CMV disease was 75.9% with one or two HLA-DR matches versus 16.2% with zero HLA-DR matches (P < 0.001). CMV remains an important factor in long-term graft survival after oral ganciclovir prophylaxis. However, we have observed that the adverse impact of CMV disease on graft survival is apparent only in patients with zero HLA-DR matches. These results call for the development of new CMV disease prophylaxis and treatment strategies in patients with zero HLA-DR matches. In addition, organ allocation policies discouraging combining CMV-seropositive donors and zero HLA-DR matches may be worth consideration.

Prospective, pilot, open-label, short-term study of conversion to leflunomide reverses chronic renal allograft dysfunction

Leflunomide (LEF) is a synthetic isoxazole derivative with anti-inflammatory and antiviral properties, which has been reported to prevent acute rejection and delay progression of chronic allograft nephropathy (CAN) in animal models. We performed a pilot, crossover trial in 22 renal transplant recipients who were converted from azathioprine (AZA) or mycophenolate mofetil (MMF) to LEF in an effort to slow progression of renal dysfunction [deteriorating renal function (n = 5), cyclosporine (CyA) nephrotoxicity (n = 4) or biopsy-proven CAN (n = 13)]. Baseline maintenance immunosuppression consisted of CyA, AZA or MMF and prednisone. Six-month postconversion patient and graft survival was 100% and 91%, respectively. Mean serum creatinine 6months preconversion was 2.2 +/- 0.6mg/dL, at initiation was 3.0 +/- 1.1 mg/dL, and 6 months postconversion was 2.8 +/- 1.3 mg/dL. The rate of change in serum creatinine was 35 +/- 39%/6 months preconversion and -5 +/- 21%/6 months postconversion to LEF (p = 0.003). Two patients discontinued LEF for diarrhea and myalgia. No readmissions, increase in liver function tests, infections or acute rejection episodes occurred. Mean CyA levels did not change, 146 +/- 72 ng/ mL pre-LEF vs. 132 +/- 51 ng/mL post-LEF, p = NS. Conversion to LEF reversed progression of chronic renal allograft dysfunction with minimal toxicity.

Sirolimus-induced leukocytoclastic vasculitis

A 41-year-old white woman with cystic fibrosis underwent lung transplantion that was complicated by cyclosporine-induced nephrotoxicity, which required kidney transplantation. Three years after the renal transplant, sirolimus was substituted for mycophenolate mofetil in a maintenance immunosuppressive regimen that consisted of cyclosporine and prednisone, with the hope of lowering cyclosporine concentrations and avoiding the nephrotoxic effects. Three weeks after the initiation of sirolimus, the patient developed palpable purpura on the bilateral lower extremities that resolved after discontinuation of sirolimus and reappeared with rechallenge. Punch biopsy of the initial eruption revealed leukocytoclastic vasculitis with focal fibrinoid necrosis. Sirolimus should be considered as a causative agent of cutaneous leukocytoclastic vasculitis.

Evolving experience of hepatitis B virus prophylaxis in liver transplantation

Passive immunoprophylaxis with hepatitis B immunoglobulin (HBIG) is important to prevent recurrence of hepatitis B virus (HBV) after orthotopic liver transplantation (OLT) for chronic HBV cirrhosis. With availability of lamivudine (3TC), the use of combination prophylaxis with long-term HBIG/3TC has been shown to prevent short-term HBV recurrence. This report compares HBV recurrence rates between groups receiving no/short-term HBIG, long-term HBIG alone, or HBIG/3TC prophylaxis, and describes HBIG requirements during the first 6 and 12 months in the latter two groups. This study involved patients undergoing OLT at the University of Tennessee-Memphis between May 1990 and July 2001. During this period, 388 liver transplants were performed at our center. All hepatitis B surface antigen (HBsAg)-positive recipients (n = 27) were included in this retrospective analysis. The groups were similar with regard to pre-transplant demographic characteristics such as age, gender, weight, and pre-transplant diagnosis. Owing to the retrospective study design, median follow-up was longer for the no-prophylaxis (5.6 years) and the HBIG-alone (6.0 years) groups compared to the HBIG/3TC group (4.2 years). Patient survival was 50% in the no-prophylaxis and 71% in the HBIG-alone groups compared to 100% in the HBIG/3TC group (P = 0.09). When censored for death with a functioning graft, graft survival was 50% in the no-prophylaxis and 86% in the HBIG-alone group compared to 100% in the HBIG/3TC group (P = 0.07). The overall incidence of HBV recurrence in the no-prophylaxis era was 100% and 21% in the HBIG-alone era compared to 0% in the HBIG/3TC era (P < 0.001), despite similar mean and median HBIG trough titers in the HBIG-alone and HBIG/3TC groups. The incidence of HBV recurrence in HBV DNA-positive recipients was 100% in the no-prophylaxis era, 30% in the HBIG-alone era, and 0% in the HBIG/3TC era (P < 0.001). Recipients in the HBIG-alone group had a nearly two-fold increase in HBIG requirement at 6 and 12 months in order to maintain similar HBIG trough titers post-transplant compared to recipients in the HBIG/3TC group despite similar pre-transplant HBV serology. This increased HBIG requirement in the HBIG-alone group resulted in a marked increase in the mean overall cost of HBV prophylaxis in this group ($47,367 US dollars at 6 months; $84,280 US dollars at 12 months) compared to the HBIG/3TC group ($25,931 US dollars at 6 months; $49,599 US dollars at 12 months). These data demonstrate an improvement in patient and graft survival rates in the group receiving combination HBIG/3TC prophylaxis compared to the HBIG-alone and no-prophylaxis groups. There was a significant reduction in HBV recurrence in the group receiving combination HBIG/3TC when compared to the groups receiving HBIG alone or no prophylaxis. Furthermore, we demonstrated that the addition of 3TC to the long-term HBIG regimen led to elimination of the disparity previously described in HBV recurrence rates between HBV DNA-positive and HBV DNA-negative recipients. Importantly, our data demonstrates a complete lack of HBV recurrence in the HBIG/3TC group at a median follow-up of 4.2 years. Additionally, the data show that the addition of 3TC to the post-operative prophylaxis regimen resulted in a reduction in the requirement of HBIG at 6 and 12 months, which markedly reduced the overall cost of post-transplant HBV prophylaxis.

Impact of hepatitis C virus status in pancreas transplantation: a case controlled study

Available data suggest that hepatitis C virus positive (HCV+) renal transplant patients may be at an increased risk of morbidity and mortality compared with HCV- patients. Limited data are available regarding the impact of HCV status in pancreas transplant patients. We compared the outcomes of 10 HCV+ patients undergoing pancreas transplantation (seven simultaneous kidney-pancreas, one pancreas after kidney, two pancreas alone) between 1/96 and 10/99 with 20 HCV- recipients that were matched for age, race, gender, timing of transplant, type of pancreas transplant, and surgical technique. Length of follow-up was not significantly different between the HCV+ group compared with the HCV- group (24 +/- 14 vs. 20 +/- 13 months; p=0.45). There was a trend toward a higher incidence of all cause mortality in HCV+ recipients compared with HCV- recipients, 30 vs. 10%, respectively (p=0.17). Additionally, the HCV+ recipients had a trend toward a higher incidence of sepsis-related mortality compared with HCV- recipients, 20 vs. 5%, respectively (p=0.19). Renal allograft survival was 50% in the HCV+ group compared with 94% in the HCV- group (p=0.02). Pancreas allograft survival was not significantly different between the groups, 60 vs. 80%, respectively (p=0.24). At 3, 6, 12 months, and end of follow-up, there were no differences in serum creatinine, amylase, C-peptide, or fasting glucose levels. However, there was a significantly higher incidence of proteinuria at last follow-up in the HCV+ recipients with a renal allograft when compared with HCV- recipients, 50 vs. 12.5%, respectively (p=0.05). In order to maintain comparable glycemic control between the groups, there was a significant increase in oral hypoglycemic requirement in HCV+ recipients compared with HCV- recipients, 33 vs. 0%, respectively (p=0.01). These data suggest that HCV+ pancreas transplant patients may be at an increased risk of graft dysfunction and morbidity. Further studies with more patients and longer follow-up are needed to fully define the impact of HCV status on pancreas graft survival and function.

Renal allograft outcomes in African American versus Caucasian transplant recipients in the tacrolimus era

METHODS

Between January 1995 and December 1999, 185 kidney transplants were performed with tacrolimus (TAC)-based immunosuppression including 120 African American (AA, 65%) and 65 Caucasian recipients (C, 35%). Mean follow-up was 34 months. The AA group was characterized by a higher incidence of renal disease due to hypertension (72% AA vs 37% C, P <.001), pretransplant dialysis (95% AA vs 82% C, P =.003), waiting time (1.9 years AA vs 1.1 years C, P =.02), cadaveric donation (88% AA vs 68% C, P =.01), HLA mismatching (mean 3.5 AA vs 2.4 C, P <.001), and delayed graft function (DGF; 50% AA vs 22% C, P =.001).

RESULTS

The 5-year actuarial patient and graft survival rates were 96% AA versus 83% C (P = NS) and 83% AA versus 75% C, (P = NS), respectively. The incidence of acute rejection (21% AA vs 12% C, P = NS) and mean time to acute rejection (12 months AA vs 11 months C) were similar. Although the incidence of chronic allograft nephropathy (CAN) was comparable (7% AA vs 5% C), the mean time to CAN was shorter in AA recipients (18 months AA vs 37 months C, P =.03).

CONCLUSIONS

These results suggest marked improvement in post-transplant outcomes in the TAC era in patients with multiple immunologic risk factors including AA ethnicity, cadaveric donor source, DGF, and HLA mismatching.