1
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Chan D, Karimi S, Follows G, Torpey N, Suchanek O. Use of rituximab in SARS-CoV-2-positive renal transplant recipient with EBV reactivation and probable haemophagocytic lymphohistiocytosis. CEN Case Rep 2023; 12:27-31. [PMID: 35729310 PMCID: PMC9213214 DOI: 10.1007/s13730-022-00711-4] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/24/2022] [Indexed: 02/04/2023] Open
Abstract
We present a case of a rapid clinical recovery in a critically ill kidney transplant recipient with SARS-CoV-2 positivity, Epstein-Barr virus (EBV) reactivation and probable secondary hemophagocytic lymphohistiocytosis (HLH) treated with etoposide-free regimen, based on dexamethasone and a single dose of rituximab. Although rituximab is often a part of EBV-HLH treatment strategy, its use in simultaneous Coronavirus 2019 disease (COVID-19) and solid-organ transplantation has not been reported yet. We review the current evidence for the potential of SARS-CoV-2 to trigger EBV reactivation, leading to a severe clinical illness. Finally, we compare the clinical features of hyper-inflammatory response typical for severe COVID-19 and classical secondary HLH and discuss the benefits of therapeutic B-cell depletion in both conditions.
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Affiliation(s)
- Derek Chan
- Department of Clinical Nephrology and Transplantation, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Haematology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Sabina Karimi
- Department of Clinical Nephrology and Transplantation, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - George Follows
- Department of Haematology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Nicholas Torpey
- Department of Clinical Nephrology and Transplantation, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ondrej Suchanek
- Department of Clinical Nephrology and Transplantation, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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2
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Martinelli AW, Dunn W, McClure ME, Walker I, Stewart A, Karia S, Preston SD, Thiru S, Torpey N, Ojha S, Symington E, Nathan JA. A Case of Thrombotic Microangiopathy and Acute Sarcoidosis. Chest 2022; 162:e245-e248. [PMID: 36344132 PMCID: PMC9752182 DOI: 10.1016/j.chest.2022.06.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/07/2022] [Accepted: 06/09/2022] [Indexed: 11/06/2022] Open
Abstract
Although sarcoidosis is an established cause of multiorgan dysfunction, acute presentation with thrombotic microangiopathy resulting in severe renal and hematological sequelae has not been reported. We describe the case of a patient presenting with hypercalcemia, pancreatitis, and acute renal failure, followed by microangiopathic hemolytic anemia. Although there were no significant respiratory symptoms, thoracic radiology and mediastinal lymph node biopsy results were in keeping with sarcoidosis as the underlying cause of this multisystem presentation. Corticosteroids were commenced with clinical and biochemical improvement. This novel case highlights the need to consider sarcoidosis as part of the differential diagnosis for unusual multiorgan presentations and for early multidisciplinary involvement in such cases to permit optimal treatment.
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Affiliation(s)
- Anthony W. Martinelli
- Department of Respiratory Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, England,Cambridge Institute of Therapeutic Immunology and Infectious Disease, Department of Medicine, University of Cambridge, Cambridge, England,CORRESPONDENCE TO: Anthony Martinelli, MB, BChir
| | - William Dunn
- Department of Haematology, Addenbrooke’s Hospital, Hills Road, Cambridge, England
| | - Mark E. McClure
- Department of Renal Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, England
| | - Ieuan Walker
- Department of Haematology, Addenbrooke’s Hospital, Hills Road, Cambridge, England
| | - Andrew Stewart
- Department of Renal Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, England
| | - Sumit Karia
- Department of Radiology, Addenbrooke’s Hospital, Hills Road, Cambridge, England
| | - Stephen D. Preston
- Department of Histopathology, Royal Papworth Hospital, Cambridge, England
| | - Sathia Thiru
- Department of Histopathology, Addenbrooke’s Hospital, Hills Road, Cambridge, England
| | - Nicholas Torpey
- Department of Renal Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, England
| | - Sanjay Ojha
- Department of Renal Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, England
| | - Emily Symington
- Department of Haematology, Addenbrooke’s Hospital, Hills Road, Cambridge, England
| | - James A. Nathan
- Department of Respiratory Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, England,Cambridge Institute of Therapeutic Immunology and Infectious Disease, Department of Medicine, University of Cambridge, Cambridge, England
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3
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Greenhall GHB, Ushiro-Lumb I, Pavord S, Hunt BJ, Sharma H, Mehra S, Calder F, Kessaris N, Kilbride H, Jones G, Motallebzadeh R, Arslan Z, Marks SD, Graetz K, Pettigrew GJ, Torpey N, Watson C, Roy D, Casey J, Oniscu GC, Currie I, Sutherland A, Clancy M, Dor F, Willicombe M, Sandhu B, Nath J, Weston C, van Dellen D, Roberts DJ, Madden S, Ravanan R, Forsythe J, Khurram MA, Mohamed I, Callaghan CJ. Kidney Transplantation From Deceased Donors With Vaccine-induced Immune Thrombocytopenia and Thrombosis: An Updated Analysis of the UK Experience. Transplantation 2022; 106:1824-1830. [PMID: 35821588 DOI: 10.1097/tp.0000000000004190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The emergence and attendant mortality of vaccine-induced immune thrombocytopenia and thrombosis (VITT) as a consequence of vaccination against severe acute respiratory syndrome coronavirus 2 have resulted in some patients with VITT being considered as deceased organ donors. Outcomes after kidney transplantation in this context are poorly described. Because the disease seems to be mediated by antiplatelet factor 4 antibodies, there is a theoretical risk of transmission via passenger leukocytes within the allograft. METHODS We analyzed the experience of kidney transplantation from donors with VITT in the United Kingdom between January and June 2021. We followed-up all recipients of kidney-only transplants from donors with VITT to detect major postoperative complications or features of disease transmission and assess graft survival and function. RESULTS There were 16 kidney donors and 30 single kidney transplant recipients in our study period. Of 11 preimplantation biopsies, 4 showed widespread glomerular microthrombi. After a median of 5 mo, patient and graft survival were 97% and 90%, respectively. The median 3-mo estimated glomerular filtration rate was 51 mL/min/1.73 m 2 . Two recipients had detectable antiplatelet factor 4 antibodies but no evidence of clinical disease after transplantation. Major hemorrhagic complications occurred in 3 recipients, all of whom had independent risk factors for bleeding, resulting in the loss of 2 grafts. The involvement of VITT could not be completely excluded in one of these cases. CONCLUSIONS The UK experience to date shows that favorable outcomes are possible after kidney transplantation from donors with VITT but highlights the need for ongoing vigilance for donor-related complications in these patients.
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Affiliation(s)
- George H B Greenhall
- Organ and Tissue Donation and Transplantation Directorate, NHS Blood and Transplant, Bristol, United Kingdom
| | - Ines Ushiro-Lumb
- Department of Haematology, Oxford University Hospitals, Oxford, United Kingdom
| | - Sue Pavord
- Thrombosis and Haemophilia Centre, Guy's and St.Thomas' NHS Foundation Trust, London, United Kingdom
| | - Beverley J Hunt
- vDepartment of Nephrology and Transplantation, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Hemant Sharma
- Department of Transplant and Vascular Access Surgery, Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - Sanjay Mehra
- Department of Transplant and Vascular Access Surgery, Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - Francis Calder
- vDepartment of Nephrology and Transplantation, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Nicos Kessaris
- vDepartment of Nephrology and Transplantation, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Hannah Kilbride
- Kent Kidney Care Centre, East Kent Hospitals University NHS Foundation Trust, Canterbury, United Kingdom
| | - Gareth Jones
- UCL Department of Renal Medicine, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Reza Motallebzadeh
- UCL Department of Renal Medicine, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Zainab Arslan
- Department of Nephrology and Transplantation, Royal Free London NHS Foundation Trust London, United Kingdom
| | - Stephen D Marks
- Nephrology Department, Great Ormond Street Hospital, London, United Kingdom
| | - Keith Graetz
- NIHR Great Ormond Street Hospital Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Gavin J Pettigrew
- Wessex kidney centre, Queen Alexandra Hospital, Portsmouth, United Kingdom
| | - Nicholas Torpey
- Wessex kidney centre, Queen Alexandra Hospital, Portsmouth, United Kingdom
| | - Chris Watson
- University of Cambidge Department of Surgery, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Debabrata Roy
- University of Cambidge Department of Surgery, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - John Casey
- Department of Clinical Nephrology and Transplantation, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Gabriel C Oniscu
- Department of Clinical Nephrology and Transplantation, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Ian Currie
- Organ and Tissue Donation and Transplantation Directorate, NHS Blood and Transplant, Bristol, United Kingdom
| | - Andrew Sutherland
- Department of Clinical Nephrology and Transplantation, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Marc Clancy
- Renal transplant unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Frank Dor
- The Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Michelle Willicombe
- The Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Bynvant Sandhu
- The Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Jay Nath
- Renal transplant unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Charles Weston
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - David van Dellen
- Department of Renal Surgery, Southmead Hospital, Bristol, United Kingdom
| | - David J Roberts
- Renal unit, Dorset County Hospital NHS Foundation Trust, Dorchester, United Kingdom
| | - Susanna Madden
- Organ and Tissue Donation and Transplantation Directorate, NHS Blood and Transplant, Bristol, United Kingdom
| | - Rommel Ravanan
- Organ and Tissue Donation and Transplantation Directorate, NHS Blood and Transplant, Bristol, United Kingdom
| | - John Forsythe
- Organ and Tissue Donation and Transplantation Directorate, NHS Blood and Transplant, Bristol, United Kingdom
| | - Muhammad A Khurram
- Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Ismail Mohamed
- Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Chris J Callaghan
- Organ and Tissue Donation and Transplantation Directorate, NHS Blood and Transplant, Bristol, United Kingdom
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4
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Smith RM, Cooper DJ, Doffinger R, Stacey H, Al-Mohammad A, Goodfellow I, Baker S, Lear S, Hosmilo M, Pritchard N, Torpey N, Jayne D, Yiu V, Chalisey A, Lee J, Vilnar E, Cheung CK, Jones RB. SARS-COV-2 vaccine responses in renal patient populations. BMC Nephrol 2022; 23:199. [PMID: 35641961 PMCID: PMC9153874 DOI: 10.1186/s12882-022-02792-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 04/11/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Dialysis patients and immunosuppressed renal patients are at increased risk of COVID-19 and were excluded from vaccine trials. We conducted a prospective multicentre study to assess SARS-CoV-2 vaccine antibody responses in dialysis patients and renal transplant recipients, and patients receiving immunosuppression for autoimmune disease.
Methods
Patients were recruited from three UK centres (ethics:20/EM/0180) and compared to healthy controls (ethics:17/EE/0025). SARS-CoV-2 IgG antibodies to spike protein were measured using a multiplex Luminex assay, after first and second doses of Pfizer BioNTech BNT162b2(Pfizer) or Oxford-AstraZeneca ChAdOx1nCoV-19(AZ) vaccine.
Results
Six hundred ninety-two patients were included (260 dialysis, 209 transplant, 223 autoimmune disease (prior rituximab 128(57%)) and 144 healthy controls. 299(43%) patients received Pfizer vaccine and 379(55%) received AZ. Following two vaccine doses, positive responses occurred in 96% dialysis, 52% transplant, 70% autoimmune patients and 100% of healthy controls. In dialysis patients, higher antibody responses were observed with the Pfizer vaccination. Predictors of poor antibody response were triple immunosuppression (adjusted odds ratio [aOR]0.016;95%CI0.002–0.13;p < 0.001) and mycophenolate mofetil (MMF) (aOR0.2;95%CI 0.1–0.42;p < 0.001) in transplant patients; rituximab within 12 months in autoimmune patients (aOR0.29;95%CI 0.008–0.096;p < 0.001) and patients receiving immunosuppression with eGFR 15-29 ml/min (aOR0.031;95%CI 0.11–0.84;p = 0.021). Lower antibody responses were associated with a higher chance of a breakthrough infection.
Conclusions
Amongst dialysis, kidney transplant and autoimmune populations SARS-CoV-2 vaccine antibody responses are reduced compared to healthy controls. A reduced response to vaccination was associated with rituximab, MMF, triple immunosuppression CKD stage 4. Vaccine responses increased after the second dose, suggesting low-responder groups should be prioritised for repeated vaccination. Greater antibody responses were observed with the mRNA Pfizer vaccine compared to adenovirus AZ vaccine in dialysis patients suggesting that Pfizer SARS-CoV-2 vaccine should be the preferred vaccine choice in this sub-group.
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5
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Greenhall GHB, Ushiro‐Lumb I, Pavord S, Currie I, Perera MTPR, Hartog H, Hill QA, Mohamed I, Khurram MA, Motallebzadeh R, Jones G, Marshall A, Pollok J, Torpey N, Pettigrew GJ, Mehra S, Sharma H, Calder F, Kessaris N, Nath J, Roy D, Oniscu GC, Clancy M, Santhanakrishnan K, Mascaro J, Lim S, Berman M, Madden S, Mumford L, Mirza D, Watson C, McGowan O, Thorburn D, Ravanan R, Hunt BJ, Callaghan CJ, Roberts DJ, Forsythe J. Organ transplantation from deceased donors with vaccine-induced thrombosis and thrombocytopenia. Am J Transplant 2021; 21:4095-4097. [PMID: 34214257 PMCID: PMC8441635 DOI: 10.1111/ajt.16735] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 06/11/2021] [Accepted: 06/18/2021] [Indexed: 01/25/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Marc Clancy
- Queen Elizabeth University HospitalGlasgowUK
| | | | | | - Sern Lim
- Queen Elizabeth HospitalBirminghamUK
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6
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Georgiades F, Silva ANS, Purohit K, King S, Torpey N, Saeb-Parsy K, Pettigrew GJ, Rouhani FJ. Outpatient ureteric stent removal following kidney transplantation. Br J Surg 2021; 109:152-154. [PMID: 34435203 PMCID: PMC10364773 DOI: 10.1093/bjs/znab223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 05/18/2021] [Indexed: 11/13/2022]
Abstract
Lay Summary
During a kidney transplant, a plastic tube (stent) is placed in the ureter, connecting the new kidney to the bladder, in order to keep the new join open during the initial phase of transplantation. The stent is then removed after a few weeks via a camera procedure (cystoscopy), as it is no longer needed. The present study compared performing this in the operating theatre or in clinic for transplanted patients using a new single-use type of camera with an integrated grasper system. The results have shown that it is safe and cost-effective to do this in clinic, despite patients being susceptible to infection after transplantation.
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Affiliation(s)
- F Georgiades
- Department of Surgery, University of Cambridge, and Cambridge National Institute for Health Research Biomedical Research Centre, Cambridge, UK
| | - A N S Silva
- Department of Surgery, University of Cambridge, and Cambridge National Institute for Health Research Biomedical Research Centre, Cambridge, UK
| | - K Purohit
- Department of Surgery, University of Cambridge, and Cambridge National Institute for Health Research Biomedical Research Centre, Cambridge, UK
| | - S King
- Transplant Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - N Torpey
- Transplant Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - K Saeb-Parsy
- Department of Surgery, University of Cambridge, and Cambridge National Institute for Health Research Biomedical Research Centre, Cambridge, UK
| | - G J Pettigrew
- Department of Surgery, University of Cambridge, and Cambridge National Institute for Health Research Biomedical Research Centre, Cambridge, UK
| | - F J Rouhani
- Department of Surgery, University of Cambridge, and Cambridge National Institute for Health Research Biomedical Research Centre, Cambridge, UK
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7
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Undre N, Dawson I, Aluvihare V, Kamar N, Saliba F, Torpey N, Anaokar S, Kazeem G, Hussain I. Validation of a Capillary Dry Blood Sample MITRA-Based Assay for the Quantitative Determination of Systemic Tacrolimus Concentrations in Transplant Recipients. Ther Drug Monit 2021; 43:358-363. [PMID: 33278240 PMCID: PMC8115740 DOI: 10.1097/ftd.0000000000000847] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 11/06/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Tacrolimus is a narrow therapeutic index medication, which requires therapeutic drug monitoring to optimize dosing based on systemic exposure. MITRA microsampling offers a convenient, minimally invasive approach for the collection of capillary blood samples from a finger prick versus conventional venous blood sampling for quantitation of tacrolimus blood concentrations. However, the suitability of MITRA microsampling for the determination of tacrolimus concentrations requires assessment in clinical settings. METHODS Paired venous (2 mL) and capillary (10 μL) blood samples were collected pre-tacrolimus dose and 1 and 3 hours postdose during routine outpatient visits from stable adult liver or kidney transplant patients receiving prolonged-release tacrolimus. Tacrolimus concentrations were determined by liquid chromatography-tandem mass spectrometry, and the concentrations obtained by the 2 sampling methods were compared by linear regression and Bland-Altman agreement analyses. RESULTS Samples were available for 82 transplant recipients (kidney, n = 41; liver, n = 41). A high correlation was observed between tacrolimus concentrations in capillary and venous blood samples (Pearson correlation coefficient, 0.97; Lin concordance coefficient, 0.87; slope of the fitted line, >1.0). Tacrolimus concentrations in capillary samples were 22.5% higher on average than in the corresponding venous blood samples (95% limits of agreement, 0.5%-44.6%). Similar results were observed in both transplant subgroups. CONCLUSIONS MITRA finger prick sampling provides a convenient alternative to venipuncture for therapeutic drug monitoring in transplant recipients maintained on prolonged-release tacrolimus. When using the finger prick MITRA method, the positive bias in tacrolimus concentrations observed with this technique, when compared with venipuncture, needs to be taken into consideration.
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Affiliation(s)
| | | | | | | | - Faouzi Saliba
- AP-HP Hôpital Paul-Brousse, INSERM Unit 1193, Villejuif, France; and
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8
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Georgiades F, Summers DM, Butler AJ, Russell NKI, Clatworthy MR, Torpey N. Renal transplantation during the SARS-CoV-2 pandemic in the UK: Experience from a large-volume center. Clin Transplant 2020; 35:e14150. [PMID: 33170982 DOI: 10.1111/ctr.14150] [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: 09/02/2020] [Revised: 11/01/2020] [Accepted: 11/03/2020] [Indexed: 12/22/2022]
Abstract
There is uncertainty about the safety of kidney transplantation during the SARS-CoV-2 pandemic due to the risk of donor transmission, nosocomial infection and immunosuppression use. We describe organ donation and transplant practice in the UK and assess whether kidney transplantation conferred a substantial risk of harm. Data from the UK transplant registry were used to describe kidney donation and transplant activity in the UK, and a detailed analysis of short-term, single-center, patient results in two periods: during the pre-pandemic era from 30th December 2019 to 8th March 2020 ("Pre-COVID era") and the 9th March 2020 to 19th May 2020 ("COVID era"). Donor and recipient numbers fell by more than half in the COVID compared to the pre-COVID era in the UK, but there were more kidney transplants performed in our center (42 vs. 29 COVID vs. pre-COVID respectively). Overall outcomes, including re-operation, delayed graft function, primary non-function, acute rejection, length of stay and graft survival were similar between COVID and pre-COVID era. 6/71 patients became infected with SARS-CoV-2 but all were discharged without critical care requirement. Transplant outcomes have remained similar within the COVID period and no serious sequelae of SARS-CoV-2 infection were observed in the peri-transplant period.
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Affiliation(s)
| | | | - Andrew J Butler
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Neil K I Russell
- Department of Transplantation, Cambridge University Hospitals, Cambridge, UK
| | | | - Nicholas Torpey
- Department of Transplantation, Cambridge University Hospitals, Cambridge, UK
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9
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Foukaneli T, Kerr P, Bolton‐Maggs PH, Cardigan R, Coles A, Gennery A, Jane D, Kumararatne D, Manson A, New HV, Torpey N. Guidelines on the use of irradiated blood components. Br J Haematol 2020; 191:704-724. [DOI: 10.1111/bjh.17015] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Theodora Foukaneli
- NHS Blood and Transplant Cambridge Cambridge UK
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Paul Kerr
- Department of Haematology Royal Devon & Exeter NHS Foundation Trust Exeter UK
| | - Paula H.B. Bolton‐Maggs
- Faculty of Biology, Medicine and Health University of Manchester Manchester UK
- Serious Hazards of Transfusion Office Manchester Blood Centre Manchester UK
| | - Rebecca Cardigan
- Haematology University of Cambridge Cambridge Biomedical Campus Cambridge UK
| | - Alasdair Coles
- Clinical Neuroscience University of Cambridge Cambridge Biomedical Campus Cambridge UK
| | - Andrew Gennery
- Department of Paediatric Immunology Institute of Cellular Medicine Newcastle University Cambridge Newcastle upon Tyne UK
| | - David Jane
- Department of Medicine University of Cambridge Cambridge Biomedical Campus Cambridge Cambridge UK
| | - Dinakantha Kumararatne
- Department of Clinical Immunology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Ania Manson
- Department of Clinical Immunology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Helen V. New
- NHS Blood and Transplant London UK
- Department of Haematology Imperial College London London UK
| | - Nicholas Torpey
- Department of Clinical Nephrology and Transplantation Cambridge University Hospitals NHS Foundation Trust Cambridge UK
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10
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Abstract
Abstract
Background and Aims
Hyperkalaemia is a common and life-threatening medical emergency present in up to 10% of acute hospital admissions. End-stage Kidney Disease (ESKD) patients undergoing transplantation are at increased risk of hyperkalaemia, a potentially life-threatening medical emergency. Although the prevalence of hyperkalaemia in ESKD is well described, few studies have assessed the incidence and associations of hyperkalaemia in kidney transplant recipients. We evaluated post-transplant hyperkalaemia in a single centre using a large electronic health record dataset of emergency admissions.
Methods
Prevalent kidney transplant recipients were identified using ICD-10 codes from a complete Electronic Health Records database of all emergency admissions to Addenbrooke’s Hospital, Cambridge between April 2015 and August 2018. We abstracted demographics, comorbidities, concomitant medications, biochemistry results including all blood potassium values, in-hospital prescribing and admission and discharge dates.
Data were summarised as frequency (%), mean± standard deviation (SD) or median with interquartile range (IQR) as appropriate. Categorical variables were compared by Chi-squared test and continuous variables by Student's t-test or Mann–Whitney U-test based on their distribution. Factors associated with developing hyperkalaemia were explored using mixed-effects logistic regression and odds ratios (OR) are reported.
Results
421 prevalent kidney transplant recipients were admitted a total of 1,065 times via the Emergency Department and a further 475 times direct to the Transplant ward. 324 (77%) were deceased-donor recipients with 83 (20%) living-donor recipients and 14 (3%) simultaneous pancreas kidney (SPK) recipients.
Median age of admitted recipients was 56 (IQR 44-65) years and 87% were of white ethnic origin. Mean serum potassium was 4.56±0.72 mmol/L compared to 4.21±0.61 mmol/L amongst the 170,913 non-kidney transplant patients admitted over the same time period (p<0.001). 376 (89%) recipients were prescribed a calcineurin inhibitor.
Hyperkalaemia >5.5mmol/L occurred in 282 (67%) of 421 prevalent kidney transplant recipients with 203 (48%) patients including all SPK recipients experiencing moderate-severe hyperkalaemia (K >=6.0mmol/L). Of these, 110 (39%) received emergency treatment with insulin/dextrose. Potassium concentration immediately (≤ 60 min) pre-treatment was 6.26±0.76 mmol/L. The mean reduction in potassium at 4-hours post treatment was 0.89±0.90 mmol/L. Twenty-five of 110 (23%) patients developed hypoglycaemia (glucose <4mmol/L) within 6 hours of treatment and 37/110 (34%) required retreatment with insulin/dextrose within 24 hours.
Kidney transplant recipients were at significantly increased risk of developing hyperkalaemia (OR 19.8, 95% Confidence Interval (CI) 16.2-24.4, p<0.001) compared with all admitted patients and this risk persisted after adjustment for age, sex and co-morbidity (OR 3.6, 2.9-4.5, p<0.001). Associations with hyperkalaemia amongst transplant recipients included receiving a deceased-donor kidney (OR 1.96, 1.13-3.40, p=0.017) and exposure to beta-blockers (OR 2.26, 1.36-3.59, p=0.001) and calcineurin inhibitors (OR 6.39, 2.81-14.5, p<0.001).
Conclusion
Kidney transplant recipients are at greatly increased risk of developing hyperkalaemia. Recipients who become hyperkalaemic are more likely to have received a deceased-donor transplant and be prescribed beta-blockers and calcineurin inhibitors than those who do not. Insulin/dextrose for hyperkalaemia is associated with hypoglycaemia in almost 1 in 4 recipients treated and re-treatment is required in one third of recipients.
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Affiliation(s)
- Toby Humphrey
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Nephrology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Nicholas Torpey
- Department of Nephrology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Thomas Hiemstra
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Nephrology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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11
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Humphrey T, Torpey N, Hiemstra T. P1721PERI-OPERATIVE HYPERKALAEMIA IN DECEASED-DONOR KIDNEY TRANSPLANT RECIPIENTS. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p1721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Hyperkalaemia is a common and life-threatening medical emergency present in up to 10% of acute hospital admissions. End-stage Kidney Disease (ESKD) patients undergoing transplantation are at increased risk of hyperkalaemia and although the prevalence of hyperkalaemia in ESKD is well described, few studies have assessed the incidence and treatment of hyperkalaemia in kidney transplant recipients. Here, we describe the results from a retrospective review of peri-operative hyperkalaemia in incident deceased-donor kidney transplant recipients.
Methods
We conducted a retrospective electronic health record review of 172 consecutive deceased-donor kidney recipients at Addenbrooke’s Hospital, Cambridge between November 2018 and November 2019. Patients receiving simultaneous pancreas/kidney transplants, simultaneous liver/kidney or multi-visceral transplants were excluded as were living-donor kidney recipients. Variables abstracted included demographics, the type of organ received, pre-transplant renal replacement modality, treatments received for hyperkalaemia, serum potassium values and admission and discharge dates.
Data were summarised as frequency (%), mean ± standard deviation (SD) or median with interquartile range (IQR) as appropriate. Categorical variables were compared by Chi-squared test and continuous variables by Student's t-test or Mann–Whitney U-test based on their distribution.
Results
172 patients received a deceased-donor kidney during the study period and the median age of all recipients was 56 (IQR 46-64.5) years. 110 (64%) patients received a DCD (donation after circulatory death) kidney with the remaining 62 (36%) receiving DBD (donation after brainstem death) kidneys. 110 (64%) of recipients received haemodialysis prior to transplant. Mean serum potassium prior to transplant was 4.22±0.61 mmol/L and immediately post-operatively was 4.69±0.61 mmol/L.
85 (49%) recipients required emergency treatment for hyperkalaemia post-operatively. The median serum potassium prior to treatment was 5.98mmol/L (IQR 5.7-6.2) with median time to treatment of 6.8 hours (IQR 2.4-9.6) after kidney reperfusion. Of these patients 64% underwent emergency haemodialysis as the first line treatment for hyperkalaemia, whilst 24 of the 31 patients treated with insulin/dextrose for hyperkalaemia went on to receive haemodialysis for hyperkalaemia. Median length of stay was longer in those receiving treatment for hyperkalaemia (9 days (7-13) vs 7 days (6-10), p=0.005). Additional data is described in the figure below.
Conclusion
Hyperkalaemia amongst kidney transplant recipients is common, particularly in the peri-operative period. Current management strategies contribute to morbidity, with haemodialysis in the first week also independently associated with increased healthcare costs per patient in the first year following transplantation. New oral potassium binders may offer an alternative or adjunct to current management but there is a lack of data for their use in transplant patients. Clinical trials in the transplant peri-operative setting are warranted.
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Affiliation(s)
- Toby Humphrey
- Department of Medicine, University of Cambridge
- Department of Nephrology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Nicholas Torpey
- Department of Nephrology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Thomas Hiemstra
- Department of Medicine, University of Cambridge
- Department of Nephrology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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12
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Broecker V, Bardsley V, Torpey N, Perera R, Montero R, Dorling A, Bentall A, Neil D, Willicombe M, Berry M, Roufosse C. Clinical-pathological correlations in post-transplant thrombotic microangiopathy. Histopathology 2020; 75:88-103. [PMID: 30851188 DOI: 10.1111/his.13855] [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: 11/20/2018] [Accepted: 03/06/2019] [Indexed: 12/25/2022]
Abstract
AIMS Post-transplant thrombotic microangiopathy (TMA) is a rare and clinically challenging finding in renal transplant biopsies. In addition to recurrent atypical haemolytic uraemic syndrome, TMA in renal transplants is associated with various conditions, such as calcineurin inhibitor (CNI) treatment, antibody-mediated rejection (ABMR), viral infections, sepsis, pregnancy, malignancies, and surgery. The therapeutic implications of this diagnosis are considerable. In order to better understand post-transplant TMA and to identify histological or clinical differences between associated causes, we conducted a multicentre retrospective study. METHODS AND RESULTS Clinical parameters and transplant renal biopsy findings from 81 patients with TMA were analysed. Biopsies from 38 patients were also analysed with electron microscopy. On the basis of clinical-pathological correlation, TMA was attributed to a main aetiology, whenever possible. TMA occurred at a median of 30 days post-transplantation. Systemic features of TMA were present in only 18% of cases. Twenty-two per cent of cases were attributed to CNI and 11% to ABMR. Although other potentially contributing factors were found in 56% of patients, in most cases (63%) no clearly attributable cause of TMA was identified. Histological differences between groups were minimal. The detection of ultrastructural features that are usually associated with ABMR may help to establish ABMR as the cause of TMA. CONCLUSIONS Although CNI and ABMR appear to be the main contributors to post-transplant TMA, the aetiology of most cases is probably multifactorial, and TMA cannot be unequivocally attributed to a single underlying aetiology. Morphological features of TMA are not discriminating, but electron microscopy may help to identify ABMR-associated TMA.
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Affiliation(s)
- Verena Broecker
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Histopathology, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Victoria Bardsley
- Department of Histopathology, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Nicholas Torpey
- Department of Clinical Nephrology and Transplantation, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ranmith Perera
- Department of Cellular Pathology, St Thomas' Hospital, London, UK
| | - Rosa Montero
- Department of Nephrology, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Anthony Dorling
- MRC Centre for Transplantation, King's College London, London, UK
| | - Andrew Bentall
- Department of Nephrology and Transplantation, University Hospital Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Desley Neil
- Department of Histopathology, University Hospital Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Michelle Willicombe
- Department of Medicine, Hammersmith Hospital, Imperial College Health Care NHS Trust, London, UK
| | - Miriam Berry
- Department of Clinical Nephrology and Transplantation, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Candice Roufosse
- Faculty of Medicine, Imperial College, London, UK.,Department of Cellular Pathology, North West London Pathology, London, UK
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13
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Banham GD, Flint SM, Torpey N, Lyons PA, Shanahan DN, Gibson A, Watson CJE, O'Sullivan AM, Chadwick JA, Foster KE, Jones RB, Devey LR, Richards A, Erwig LP, Savage CO, Smith KGC, Henderson RB, Clatworthy MR. Belimumab in kidney transplantation: an experimental medicine, randomised, placebo-controlled phase 2 trial. Lancet 2018; 391:2619-2630. [PMID: 29910042 DOI: 10.1016/s0140-6736(18)30984-x] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/17/2018] [Accepted: 04/20/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND B cells produce alloantibodies and activate alloreactive T cells, negatively affecting kidney transplant survival. By contrast, regulatory B cells are associated with transplant tolerance. Immunotherapies are needed that inhibit B-cell effector function, including antibody secretion, while sparing regulators and minimising infection risk. B lymphocyte stimulator (BLyS) is a cytokine that promotes B-cell activation and has not previously been targeted in kidney transplant recipients. We aimed to determine the safety and activity of an anti-BLyS antibody, belimumab, in addition to standard-of-care immunosuppression in adult kidney transplant recipients. We used an experimental medicine study design with multiple secondary and exploratory endpoints to gain further insight into the effect of belimumab on the generation of de-novo IgG and on the regulatory B-cell compartment. METHODS We undertook a double-blind, randomised, placebo-controlled phase 2 trial of belimumab, in addition to standard-of-care immunosuppression (basiliximab, mycophenolate mofetil, tacrolimus, and prednisolone) at two centres, Addenbrooke's Hospital, Cambridge, UK, and Guy's and St Thomas' Hospital, London, UK. Participants were eligible if they were aged 18-75 years and receiving a kidney transplant and were planned to receive standard-of-care immunosuppression. Participants were randomly assigned (1:1) to receive either intravenous belimumab 10 mg per kg bodyweight or placebo, given at day 0, 14, and 28, and then every 4 weeks for a total of seven infusions. The co-primary endpoints were safety and change in the concentration of naive B cells from baseline to week 24, both of which were analysed in all patients who received a transplant and at least one dose of drug or placebo (the modified intention-to-treat [mITT] population). This trial has been completed and is registered with ClinicalTrials.gov, NCT01536379, and EudraCT, 2011-006215-56. FINDINGS Between Sept 13, 2013, and Feb 8, 2015, of 303 patients assessed for eligibility, 28 kidney transplant recipients were randomly assigned to receive belimumab (n=14) or placebo (n=14). 25 patients (12 [86%] patients assigned to the belimumab group and 13 [93%] patients assigned to the placebo group) received a transplant and were included in the mITT population. We observed similar proportions of adverse events in the belimumab and placebo groups, including serious infections (one [8%] of 12 in the belimumab group and five [38%] of 13 in the placebo group during the 6-month on-treatment phase; and none in the belimumab group and two [15%] in the placebo group during the 6-month follow-up). In the on-treatment phase, one patient in the placebo group died because of fatal myocardial infarction and acute cardiac failure. The co-primary endpoint of a reduction in naive B cells from baseline to week 24 was not met. Treatment with belimumab did not significantly reduce the number of naive B cells from baseline to week 24 (adjusted mean difference between the belimumab and placebo treatment groups -34·4 cells per μL, 95% CI -109·5 to 40·7). INTERPRETATION Belimumab might be a useful adjunct to standard-of-care immunosuppression in renal transplantation, with no major increased risk of infection and potential beneficial effects on humoral alloimmunity. FUNDING GlaxoSmithKline.
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Affiliation(s)
- Gemma D Banham
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Shaun M Flint
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Nicholas Torpey
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Paul A Lyons
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Don N Shanahan
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Adele Gibson
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Christopher J E Watson
- Department of Surgery, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Ann-Marie O'Sullivan
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Joseph A Chadwick
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Katie E Foster
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Rachel B Jones
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Luke R Devey
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Anna Richards
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Lars-Peter Erwig
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Caroline O Savage
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Kenneth G C Smith
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | | | - Menna R Clatworthy
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK.
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14
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Pankhurst L, Hudson A, Mumford L, Willicombe M, Galliford J, Shaw O, Thuraisingham R, Puliatti C, Talbot D, Griffin S, Torpey N, Ball S, Clark B, Briggs D, Fuggle SV, Higgins RM. The UK National Registry of ABO and HLA Antibody Incompatible Renal Transplantation: Pretransplant Factors Associated With Outcome in 879 Transplants. Transplant Direct 2017; 3:e181. [PMID: 28706984 PMCID: PMC5498022 DOI: 10.1097/txd.0000000000000695] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 04/18/2017] [Accepted: 05/03/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND ABO and HLA antibody incompatible (HLAi) renal transplants (AIT) now comprise around 10% of living donor kidney transplants. However, the relationship between pretransplant factors and medium-term outcomes are not fully understood, especially in relation to factors that may vary between centers. METHODS The comprehensive national registry of AIT in the United Kingdom was investigated to describe the donor, recipient and transplant characteristics of AIT. Kaplan-Meier analysis was used to compare survival of AIT to all other compatible kidney transplants performed in the United Kingdom. Cox proportional hazards regression modeling was used to determine which pretransplant factors were associated with transplant survival in HLAi and ABOi separately. The primary outcome was transplant survival, taking account of death and graft failure. RESULTS For 522 HLAi and 357 ABO incompatible (ABOi) transplants, 5-year transplant survival rates were 71% (95% confidence interval [CI], 66-75%) for HLAi and 83% (95% CI, 78-87%) for ABOi, compared with 88% (95% CI, 87-89%) for 7290 standard living donor transplants, and 78% (95% CI, 77-79%) for 15 322 standard deceased donor transplants (P < 0.0001). Increased chance of transplant loss in HLAi was associated with increasing number of donor specific HLA antibodies, center performing the transplant, antibody level at the time of transplant, and an interaction between donor age and dialysis status. In ABOi, transplant loss was associated with no use of IVIg, cytomegalovirus seronegative recipient, 000 HLA donor-recipient mismatch; and increasing recipient age. CONCLUSIONS Results of AIT were acceptable, certainly in the context of a choice between living donor AIT and an antibody compatible deceased donor transplant. Several factors were associated with increased chance of transplant loss, and these can lead to testable hypotheses for further improving therapy.
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Affiliation(s)
| | - Alex Hudson
- NHS Blood and Transplant, Bristol, United Kingdom
| | - Lisa Mumford
- NHS Blood and Transplant, Bristol, United Kingdom
| | | | - Jack Galliford
- Renal and Transplant Unit, Hammersmith Hospital, London, United Kingdom
| | - Olivia Shaw
- Clinical Transplantation Laboratory, Guy's Hospital, London, United Kingdom
| | - Raj Thuraisingham
- Renal and Transplant Unit, Royal London Hospital, London, United Kingdom
| | - Carmelo Puliatti
- Renal and Transplant Unit, Royal London Hospital, London, United Kingdom
| | - David Talbot
- Transplant Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Sian Griffin
- Renal and Transplant Unit, University Hospital of Wales, Cardiff, United Kingdom
| | - Nicholas Torpey
- Renal and Transplant Unit, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Simon Ball
- Renal and Transplant Unit, University Hospital Birmingham, Birmingham, United Kingdom
| | - Brendan Clark
- Transplant Immunology, Leeds General Infirmary, Leeds, United Kingdom
| | - David Briggs
- Dept Histocompatibility and Immunobiology, NHSBT, Birmingham, United Kingdom
| | | | - Robert M. Higgins
- Renal and Transplant Unit, University Hospitals Coventry and Warwickshire, Coventry, United Kingdom
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15
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Mirshekar-Syahkal B, Summers D, Bradbury LL, Aly M, Bardsley V, Berry M, Norris JM, Torpey N, Clatworthy MR, Bradley JA, Pettigrew GJ. Local Expansion of Donation After Circulatory Death Kidney Transplant Activity Improves Waitlisted Outcomes and Addresses Inequities of Access to Transplantation. Am J Transplant 2017; 17:390-400. [PMID: 27428662 DOI: 10.1111/ajt.13968] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 06/24/2016] [Accepted: 07/12/2016] [Indexed: 01/25/2023]
Abstract
In the United Kingdom, donation after circulatory death (DCD) kidney transplant activity has increased rapidly, but marked regional variation persists. We report how increased DCD kidney transplant activity influenced waitlisted outcomes for a single center. Between 2002-2003 and 2011-2012, 430 (54%) DCD and 361 (46%) donation after brain death (DBD) kidney-only transplants were performed at the Cambridge Transplant Centre, with a higher proportion of DCD donors fulfilling expanded criteria status (41% DCD vs. 32% DBD; p = 0.01). Compared with U.K. outcomes, for which the proportion of DCD:DBD kidney transplants performed is lower (25%; p < 0.0001), listed patients at our center waited less time for transplantation (645 vs. 1045 days; p < 0.0001), and our center had higher transplantation rates and lower numbers of waiting list deaths. This was most apparent for older patients (aged >65 years; waiting time 730 vs. 1357 days nationally; p < 0.001), who received predominantly DCD kidneys from older donors (mean donor age 64 years), whereas younger recipients received equal proportions of living donor, DBD and DCD kidney transplants. Death-censored kidney graft survival was nevertheless comparable for younger and older recipients, although transplantation conferred a survival benefit from listing for only younger recipients. Local expansion in DCD kidney transplant activity improves survival outcomes for younger patients and addresses inequity of access to transplantation for older recipients.
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Affiliation(s)
| | - D Summers
- University Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
| | | | - M Aly
- University Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - V Bardsley
- Department of Histopathology, Addenbrooke's Hospital, Cambridge, UK
| | - M Berry
- Department of Renal Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - J M Norris
- University Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - N Torpey
- Department of Renal Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - M R Clatworthy
- Department of Renal Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - J A Bradley
- University Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - G J Pettigrew
- University Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
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16
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Mallon DH, Riddiough GE, Summers DM, Butler AJ, Callaghan CJ, Bradbury LL, Bardsley V, Broecker V, Saeb-Parsy K, Torpey N, Bradley JA, Pettigrew GJ. Successful transplantation of kidneys from elderly circulatory death donors by using microscopic and macroscopic characteristics to guide single or dual implantation. Am J Transplant 2015; 15:2931-9. [PMID: 26108421 DOI: 10.1111/ajt.13349] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 03/26/2015] [Accepted: 04/10/2015] [Indexed: 01/25/2023]
Abstract
Most kidneys from potential elderly circulatory death (DCD) donors are declined. We report single center outcomes for kidneys transplanted from DCD donors over 70 years old, using preimplantation biopsy Remuzzi grading to inform implantation as single or dual transplants. Between 2009 and 2012, 43 single transplants and 12 dual transplants were performed from elderly DCD donors. Remuzzi scores were higher for dual than single implants (4.4 vs. 3.4, p < 0.001), indicating more severe baseline injury. Donor and recipient characteristics for both groups were otherwise similar. Early graft loss from renal vein thrombosis occurred in two singly implanted kidneys, and in one dual-implanted kidney; its pair continued to function satisfactorily. Death-censored graft survival at 3 years was comparable for the two groups (single 94%; dual 100%), as was 1 year eGFR. Delayed graft function occurred less frequently in the dual-implant group (25% vs. 65%, p = 0.010). Using this approach, we performed proportionally more kidney transplants from elderly DCD donors (23.4%) than the rest of the United Kingdom (7.3%, p < 0.001), with graft outcomes comparable to those achieved nationally for all deceased-donor kidney transplants. Preimplantation biopsy analysis is associated with acceptable transplant outcomes for elderly DCD kidneys and may increase transplant numbers from an underutilized donor pool.
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Affiliation(s)
- D H Mallon
- University Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - G E Riddiough
- University Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - D M Summers
- University Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - A J Butler
- University Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - C J Callaghan
- University Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
| | | | - V Bardsley
- Department of Histopathology, Addenbrooke's Hospital, Cambridge, UK
| | - V Broecker
- Department of Histopathology, Addenbrooke's Hospital, Cambridge, UK
| | - K Saeb-Parsy
- University Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - N Torpey
- Department of Renal Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - J A Bradley
- University Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - G J Pettigrew
- University Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
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17
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Hamed MO, Chen Y, Pasea L, Watson CJ, Torpey N, Bradley JA, Pettigrew G, Saeb-Parsy K. Early graft loss after kidney transplantation: risk factors and consequences. Am J Transplant 2015; 15:1632-43. [PMID: 25707303 DOI: 10.1111/ajt.13162] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [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: 09/26/2014] [Revised: 12/12/2014] [Accepted: 12/14/2014] [Indexed: 01/25/2023]
Abstract
Early graft loss (EGL) after kidney transplantation is a catastrophic outcome that is assumed to be more likely after the use of kidneys from suboptimal donors. We therefore examined its incidence, risk factors and consequences in our center in relation to different donor types. Of 801 recipients who received a kidney-only transplant from deceased donors, 50 (6.2%) suffered EGL within 30 days of transplantation. Significant risks factors for EGL were donation after circulatory death (DCD) (odds ratio [OR] 2.88; p = 0.006), expanded criteria donor (ECD) transplantation (OR 4.22; p = 0.010), donor age (OR 1.03; p = 0.044) and recipient past history of thrombosis (OR 4.91; p = 0.001). Recipients with EGL had 12.28 times increased risk of death within the first year, but long-term survival was worse for patients remaining on the waiting list. In comparison with patients on the waiting list but not transplanted, and with all patients on the waiting list, the risk of death after EGL decreased to baseline 4 and 23 months after transplantation, respectively. Our findings suggest that DCD and ECD transplantation are significant risk factors for EGL, which is a major risk factor for recipient death. However, long-term mortality is even greater for those remaining on the waiting list.
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Affiliation(s)
- M O Hamed
- Department of Surgery, University of Cambridge, and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Y Chen
- Department of Pure Mathematics and Mathematical Statistics, Cambridge, UK
| | - L Pasea
- Centre for Applied Medical Statistics, University of Cambridge, Cambridge, UK
| | - C J Watson
- Department of Surgery, University of Cambridge, and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - N Torpey
- Department of Renal Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - J A Bradley
- Department of Surgery, University of Cambridge, and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - G Pettigrew
- Department of Surgery, University of Cambridge, and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - K Saeb-Parsy
- Department of Surgery, University of Cambridge, and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
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18
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Kosmoliaptsis V, Salji M, Bardsley V, Chen Y, Thiru S, Griffiths MH, Copley HC, Saeb-Parsy K, Bradley JA, Torpey N, Pettigrew GJ. Baseline donor chronic renal injury confers the same transplant survival disadvantage for DCD and DBD kidneys. Am J Transplant 2015; 15:754-63. [PMID: 25639995 DOI: 10.1111/ajt.13009] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 08/06/2014] [Accepted: 08/28/2014] [Indexed: 01/25/2023]
Abstract
Histological assessment of baseline chronic kidney injury may discriminate kidneys that are suitable for transplantation, but has not been validated for appraisal of donation after circulatory death (DCD) kidneys. 'Time-zero' biopsies for 371 consecutive, solitary, deceased-donor kidneys transplanted at our center between 2006 and 2010 (65.5% DCD, 34.5% donation after brain death [DBD]) were reviewed and baseline chronic degenerative injury scored using Remuzzi's classification. High scores correlated with donor age and extended criteria donors (42% of donors), but the spectrum of scores was similar for DCD and DBD kidneys. Transplant outcomes for kidneys scoring from 0 to 4 were comparable (1 and 3 year graft survival 95% and 92%), but were much poorer for kidneys scoring ≥5, with 1 year graft survival only 73%, and 12.5% suffering primary nonfunction. Critically, high Remuzzi scores conferred the same survival disadvantage for DCD and DBD kidneys. On multi-variable regression analysis, time-zero biopsy score was the only independent predictor for graft survival, whereas one-year graft estimated glomerular filtration rate (eGFR) correlated with donor age and biopsy score. In conclusion, the relationship between severity of chronic kidney injury and transplant outcome is similar for DCD and DBD kidneys. Kidneys with Remuzzi scores of ≤4 can be implanted singly with acceptable results.
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Affiliation(s)
- V Kosmoliaptsis
- Department of Surgery, University of Cambridge, and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
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19
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Asher J, Vasdev N, Wyrley-Birch H, Wilson C, Soomro N, Rix D, Jaques B, Manas D, Torpey N, Talbot D. A Prospective Randomised Paired Trial of Sirolimus versus Tacrolimus as Primary Immunosuppression following Non-Heart Beating Donor Kidney Transplantation. Curr Urol 2014. [PMID: 26195946 DOI: 10.1159/000365671] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION With calcineurin inhibitors potentiating damage from ischaemia-reperfusion injury in kidneys from donors after cardiac death we wanted to investigate the role of substituting sirolimus for tacrolimus in the delayed introduction of calcineurin inhibitor regime used in our centre. METHOD A prospective randomised paired open-label study was performed taking pairs of kidneys from each donor and randomising one to a tacrolimus-based regime and the other to a similar regime based on sirolimus. Graft function at one year was the primary endpoint. RESULTS Total 31 pairs of kidneys were randomised to each group, with 19 pairs of recipients available for analysis after post-randomisation study exclusions. Despite a higher incidence of biopsy proven acute rejection in the sirolimus group, renal allograft function was similar in both groups at three-monthly intervals up to one year post-transplant. All episodes of acute rejection in the sirolimus group occurred in the first three months. Graft and patient survival at one year was 100% in the tacrolimus group, with one death with functioning graft in the sirolimus group (95% survival). Unfortunately, 10 of the 19 patients in the sirolimus arm required switch of medication to tacrolimus due to acute rejection or intolerable drug side effects. CONCLUSIONS Graft survival and function were very similar in the two groups despite the higher rate of acute rejection in the sirolimus arm, raising the possibility that the damage done by acute rejection was adequately offset by the nephron-sparing effect of sirolimus compared to tacrolimus. Sirolimus may have a role as a longer-term maintenance immunosuppressant after initial treatment with a different agent such as tacrolimus or belatacept.
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Affiliation(s)
- John Asher
- Renal Transplant Unit, Western Infirmary, Glasgow
| | - Nikhil Vasdev
- Department of Hepatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Hugh Wyrley-Birch
- Department of Hepatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Colin Wilson
- Department of Hepatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Naeem Soomro
- Department of Hepatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - David Rix
- Department of Hepatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Bryon Jaques
- Department of Hepatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Derek Manas
- Department of Hepatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Nicholas Torpey
- Department of Hepatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - David Talbot
- Department of Hepatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
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20
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Kosmoliaptsis V, Gjorgjimajkoska O, Sharples LD, Chaudhry AN, Chatzizacharias N, Peacock S, Torpey N, Bolton EM, Taylor CJ, Bradley JA. Impact of donor mismatches at individual HLA-A, -B, -C, -DR, and -DQ loci on the development of HLA-specific antibodies in patients listed for repeat renal transplantation. Kidney Int 2014; 86:1039-48. [PMID: 24717292 DOI: 10.1038/ki.2014.106] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 01/31/2014] [Accepted: 02/13/2014] [Indexed: 12/22/2022]
Abstract
We have analyzed the relationship between donor mismatches at each HLA locus and development of HLA locus-specific antibodies in patients listed for repeat transplantation. HLA antibody screening was undertaken using single-antigen beads in 131 kidney transplant recipients returning to the transplant waiting list following first graft failure. The number of HLA mismatches and the calculated reaction frequency of antibody reactivity against 10,000 consecutive deceased organ donors were determined for each HLA locus. Two-thirds of patients awaiting repeat transplantation were sensitized (calculated reaction frequency over 15%) and half were highly sensitized (calculated reaction frequency of 85% and greater). Antibody levels peaked after re-listing for repeat transplantation, were independent of graft nephrectomy and were associated with length of time on the waiting list (odds ratio 8.4) and with maintenance on dual immunosuppression (odds ratio 0.2). Sensitization was independently associated with increasing number of donor HLA mismatches (odds ratio 1.4). All mismatched HLA loci contributed to the development of HLA locus-specific antibodies (HLA-A: odds ratio 3.2, HLA-B: odds ratio 3.4, HLA-C: odds ratio 2.5, HLA-DRB1: odds ratio 3.5, HLA-DRB3/4/5: odds ratio 3.9, and HLA-DQ: odds ratio 3.0 (all significant)). Thus, the risk of allosensitization following failure of a first renal transplant increases incrementally with the number of mismatches at all HLA loci assessed. Maintenance of re-listed patients on dual immunosuppression was associated with a reduced risk of sensitization.
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Affiliation(s)
- Vasilios Kosmoliaptsis
- Department of Surgery, University of Cambridge, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Olivera Gjorgjimajkoska
- Department of Surgery, University of Cambridge, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Linda D Sharples
- MRC Biostatistics Unit, Institute of Public Health, Cambridge, UK
| | - Afzal N Chaudhry
- Department of Renal Medicine, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Nikolaos Chatzizacharias
- Department of Surgery, University of Cambridge, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Sarah Peacock
- Histocompatibility and Immunogenetics Laboratory, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Nicholas Torpey
- Department of Renal Medicine, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Eleanor M Bolton
- Department of Surgery, University of Cambridge, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Craig J Taylor
- Histocompatibility and Immunogenetics Laboratory, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - J Andrew Bradley
- Department of Surgery, University of Cambridge, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
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21
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Abstract
Donor-specific alloantibodies (DSA) mediate hyperacute and acute antibody-mediated rejection (AMR), which can lead to early graft damage and loss, and are also associated with chronic AMR and reduced long-term graft survival. Such alloantibodies can be generated by previous exposure to major histocompatibility (MHC) antigens (usually via blood transfusions, previous allografts or pregnancy) or can occur de novo after transplantation. Recent studies also suggest that non-MHC antibodies, including those recognising major histocompatibility complex class I-related chain A (MICA), MICB, vimentin, angiotensin II type I receptor may also have an adverse impact on allograft outcomes. In this review, we consider how the dose, route and context of antigen exposure influences DSA induction and describe factors which control the generation, maintenance and survival of alloantibody-producing plasma cells. Finally, we discuss the implications of these variables on therapeutic approaches to DSA.
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Affiliation(s)
- M R Clatworthy
- Cambridge Institute for Medical Research, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, CB2 0XY, Cambridge, UK
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22
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Tan S, Lawler J, Foster K, Hall L, Talbot D, Torpey N, Raza M, Gould F. Nosocomial transmission of Salmonella typhimurium in renal transplant recipients. J Hosp Infect 2010; 75:241-2. [DOI: 10.1016/j.jhin.2009.11.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2009] [Accepted: 11/19/2009] [Indexed: 10/19/2022]
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23
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Simms R, Torpey N, Kanagasundaram NS, Baines L, Sayer JA. Emphysematous pyelonephritis leading to end-stage renal failure. Clin Kidney J 2008; 1:264-5. [PMID: 25983899 PMCID: PMC4421217 DOI: 10.1093/ndtplus/sfn002] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Accepted: 12/31/2007] [Indexed: 11/17/2022] Open
Affiliation(s)
- Roslyn Simms
- Nephrology Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, NE7 7DN
| | - Nicholas Torpey
- Nephrology Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, NE7 7DN
| | - Nigel S. Kanagasundaram
- Nephrology Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, NE7 7DN
| | - Laura Baines
- Nephrology Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, NE7 7DN
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24
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Abstract
As demand for donor pancreases increases, attempts are being made to utilize even marginal grafts for transplantation. Injury during pancreas recovery can predispose to posttransplant complications and graft loss. Early recognition and correction can salvage these grafts. The authors report an instance of poor segmental perfusion of the pancreas graft that was salvaged by pancreas head resection and enteric drainage through a Roux-en-Y pancreatico-jejunostomy.
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Affiliation(s)
- M S Reddy
- Department of Hepatobiliary and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
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25
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Mohiuddin MK, El-Asir L, Gupta A, Brown A, Torpey N, Ward M, Talbot D, Ahmed S. Perioperative Erythropoietin Efficacy in Renal Transplantation. Transplant Proc 2007; 39:132-4. [PMID: 17275489 DOI: 10.1016/j.transproceed.2006.10.217] [Citation(s) in RCA: 6] [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] [Received: 03/20/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is no consensus on the usage of erythropoietin in the immediate postoperative period to prevent anemia and delayed graft function. METHODS A retrospective case note audit of renal transplants included hemoglobin (Hb) and serum creatinine (Scr) values preoperatively as well as at days 7, 14, 30, 60, and 90. Patients were categorized as those receiving erythropoietin during the first 6 months posttransplant (Epo+ve) and those not receiving any erythropoietin (Epo-ve). RESULTS Hb decreased from 12.4 +/- 1.6 g/L preoperatively to 9.5 +/- 1.5 g/L at day 14 and then rose to 10.5 +/- 1.6 g/L at 1 month and 12.4 +/- 1.7 g/L at 3 months. There was no difference in absolute Hb values in three transplant groups. Scr decreased from 597.0 +/- 200.1 mmol/L preoperatively to 254.1 +/- 196.9 mmol/L at day 14 and continued to fall to 163.8 +/- 98.9 mmol/L at 1 month and 147.8 +/- 66.9 mmol/L at 3 months. There was no difference in absolute Hb values and delayed graft function in the three transplant groups. CONCLUSION With respect to anemia and delayed graft function, the use of erythropoietin in the first 3 months had little impact. We suggest that such an expensive medication may be safely omitted in the immediate postoperative period.
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Affiliation(s)
- M K Mohiuddin
- Freeman Hospital, Department of Renal Transplantation, Newcastle Upon Tyne, UK.
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26
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Choi J, Walker J, Boichuk S, Kirkiles-Smith N, Torpey N, Pober JS, Alexander L. Human endothelial cells enhance human immunodeficiency virus type 1 replication in CD4+ T cells in a Nef-dependent manner in vitro and in vivo. J Virol 2005; 79:264-76. [PMID: 15596822 PMCID: PMC538695 DOI: 10.1128/jvi.79.1.264-276.2005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Infected CD4+ T cells are the primary sites of human immunodeficiency virus type 1 (HIV-1) replication in vivo. However, signals from professional antigen-presenting cells (APCs), such as dendritic cells and macrophages, greatly enhance HIV-1 replication in T cells. Here, we report that in cocultures, vascular endothelial cells (ECs), which in humans can also serve as APCs, can enhance HIV-1 production of both CCR5- and CXCR4-utilizing strains approximately 50,000-fold. The observed HIV-1 replication enhancement conferred by ECs occurred only in memory CD4+ T cells, required expression of major histocompatibility complex class II (MHC-II) molecules by the ECs, and could not be conferred by fixed ECs, all of which are consistent with a requirement for EC-mediated T-cell activation via T-cell receptor (TCR) signaling. Deletion of nef (Nef-) decreased HIV-1 production by approximately 100-fold in T cells cocultured with ECs but had no effect on virus production in T cells cocultured with professional APCs or fibroblasts induced to express MHC-II. Human ECs do not express B7 costimulators, but Nef- replication in CD4(+)-T-cell and EC cocultures could not be rescued by anti-CD28 antibody. ECs act in trans to enhance wild-type but not Nef- replication and facilitate enhanced wild-type replication in naive T cells when added to T-cell or B-lymphoblastoid cell cocultures, suggesting that ECs also provide a TCR-independent signal to infected T cells. Consistent with these in vitro observations, wild-type HIV-1 replicated 30- to 50-fold more than Nef- in human T cells infiltrating allogeneic human skin grafts on human huPBL-SCID/bg mice, an in vivo model of T-cell activation by ECs. Our studies suggest that ECs, which line the entire cardiovascular system and are, per force, in frequent contact with memory CD4+ T cells, provide signals to HIV-1-infected CD4+ T cells to greatly enhance HIV-1 production in a Nef-dependent manner, a mechanism that could contribute to the development of AIDS.
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Affiliation(s)
- Jaehyuk Choi
- Section of Immunobiology, Yale University School of Medicine, New Haven, Connecticut 06520, USA
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27
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Torpey N, Maher SE, Bothwell ALM, Pober JS. Interferon α but Not Interleukin 12 Activates STAT4 Signaling in Human Vascular Endothelial Cells. J Biol Chem 2004; 279:26789-96. [PMID: 15087447 DOI: 10.1074/jbc.m401517200] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
STAT4 signaling, activated by either interleukin 12 (IL12) or interferon alpha (IFNalpha), promotes T(H)1 responses in CD4(+) T cells. Vascular endothelial cells (EC) may also become polarized in response to various cytokines, favoring recruitment and activation of T(H)1 or T(H)2 effector cells. Here we have investigated the role of the STAT4 pathway in EC. Cultured human umbilical vein EC (HUVEC) express low levels of STAT4, which may be tyrosine-phosphorylated by treatment with IFNalpha but not IL12. This is because HUVEC lack both subunits of the IL12 receptor (IL12Rbeta1 and IL12Rbeta2), even following treatment with various cytokines. IL12 phosphorylation of STAT4 can be observed in HUVEC that have been transduced to express the IL12R. To identify STAT4-induced genes we pursued three approaches: analysis by DNA microarray and quantitative RT-PCR (Q-PCR) of the IL12 responses in IL12R-transduced EC; analysis by Q-PCR of IFNalpha responses in STAT4-overexpressing EC; and analysis of IFNalpha responses in U3A neuroblastoma cell lines that express either STAT1 or STAT4, but not both. In all three instances we observe STAT4-mediated induction of the chemokine monocyte chemoattractant protein 1 (MCP1) and suppressor of cytokine signaling 3 (SOCS3) mRNA, and we confirm the production of each protein in both IL12R-transduced EC and STAT4-transduced U3A cells. These observations reveal that there is a STAT4 response of EC, activated by IFNalpha but not IL12, and that it may modulate the pro-inflammatory behavior of EC.
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Affiliation(s)
- Nicholas Torpey
- Interdepartmental Program in Vascular Biology and Transplantation, Boyer Center for Molecular Medicine, Yale University School of Medicine, New Haven, Connecticut 06510, USA
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28
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Torpey N, Pober J. THE STAT4 RESPONSE OF HUMAN ENDOTHELIAL CELLS. Cardiovasc Pathol 2004. [DOI: 10.1016/j.carpath.2004.03.174] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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29
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Torpey N, Barker T, Ross C. Drug-induced tubulo-interstitial nephritis secondary to proton pump inhibitors: experience from a single UK renal unit. Nephrol Dial Transplant 2004; 19:1441-6. [PMID: 15004262 DOI: 10.1093/ndt/gfh137] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [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: 11/13/2022] Open
Abstract
BACKGROUND Acute tubulo-interstitial nephritis (TIN) is an important cause of acute renal failure, and is often caused by hypersensitivity to drugs. The aim of this study was to determine the aetiology of interstitial nephritis among an unselected cohort of patients, and to identify those drugs commonly implicated. METHODS A single-centre retrospective analysis was carried out of renal biopsy results from 296 consecutive patients between 1995 and 1999. RESULTS Acute TIN was identified in 24 (8.1%) biopsies. Eight out of 14 cases with presumed drug-related TIN could be attributed to the proton pump inhibitors omeprazole and lansoprazole. The two cases of lansoprazole-associated TIN are the first to be reported with this drug. The presentation and favourable response to treatment of these patients are described. CONCLUSION Drugs are the most common cause of interstitial nephritis in the population studied. Those drugs most commonly associated with interstitial nephritis were the proton pump inhibitors omeprazole and lansoprazole.
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Affiliation(s)
- Nicholas Torpey
- Renal Unit, Norfolk and Norwich University Hospital, Norwich, UK.
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30
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Gutowski NJ, Gómez-Ansón B, Torpey N, Revesz T, Miller D, Rudge P. Oligodendroglial gliomatosis cerebri: (1)H-MRS suggests elevated glycine/inositol levels. Neuroradiology 1999; 41:650-3. [PMID: 10525765 DOI: 10.1007/s002340050818] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [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: 10/28/2022]
Abstract
Oligodendroglial gliomatosis cerebri is very rare. We describe 42-year-old woman who had low-grade oligodendroglial gliomatosis cerebri confirmed on stereotactic biopsy. The diffuse nature of the tumour was apparent clinically, neurophysiologically, on MRI and on proton magnetic resonance spectroscopy (MRS). She also had an isolated, false-localising partial seventh nerve palsy. MRS, of which there are no previous reports, suggested elevated glycine/inositol levels. This might be explained by the cell lineage from which the tumour arose.
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Affiliation(s)
- N J Gutowski
- The National Hospital for Neurology and Neurosurgery and The Institute of Neurology, London, UK
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31
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Abstract
Intermediate filaments are ubiquitous in eukaryotic cells, but their functions are poorly understood. The Xenopus oocyte contains both messenger RNA and protein products of cytokeratin and vimentin genes in non-overlapping arrays. The cytokeratin filaments contain dimers of the type I (acidic) subunit XLK3a(19), and the type II (basic) subunit XCK1(8), polymerized to form a cortical network. These are homologues of the human simple epithelial keratins 19 and 8, respectively. After the first few cell cycles following fertilization these filaments become restricted to the superficial cells of the blastula. We have depleted the oocyte's store of the type II cytokeratin mRNA by injecting antisense oligodeoxynucleotides (oligos) and studied the effect on embryonic development. As zygotic transcription does not commence until the late blastula stage, there are at least 9 hours in which to see the effect of loss of function of this mRNA. We report here that the cytokeratin filaments become depleted in the cortical cells of the embryo. As a result, there is a loss of the 'compacted' epithelial surface of the blastula, an inability to close a wounded surface and defective gastrulation.
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Affiliation(s)
- N Torpey
- Wellcome/Cancer Research Campaign Institute of Cancer, Cambridge, UK
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32
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Abstract
The effects of depleting a maternal cytokeratin mRNA on the developing embryo are described. Cytokeratins are members of the intermediate filament family of cytoskeletal proteins, and are expressed in a cortical network of the superficial cytoplasm of the oocyte. After fertilisation, a new cortical network is built up, which comes to occupy only the most superficial cells of the blastula. The maternal cytokeratin mRNA is abundantly translated, both during oogenesis, and during oocyte maturation and after fertilisation. Depletion of the mRNA results in depletion of the cortical filaments at the blastula stage and leads to gastrulation abnormalities. We discuss the various possible control experiments required for antisense oligo depletion studies and the implications of these results for cytokeratin function.
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Affiliation(s)
- Janet Heasman
- Wellcome/CRC Institute, University of Cambridge, Tennis Court Road, CAMBRIDGE CB2 1QR, UK
| | - Nicholas Torpey
- Wellcome/CRC Institute, University of Cambridge, Tennis Court Road, CAMBRIDGE CB2 1QR, UK
| | - Chris Wylie
- Wellcome/CRC Institute, University of Cambridge, Tennis Court Road, CAMBRIDGE CB2 1QR, UK
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