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Lum EL, Zuckerman JE, Abdelnour L, Terenzini J, Singh G, Bunnapradist S. Pretransplant Treatment to Avoid Recurrent Membranous Nephropathy in a Kidney Transplant Recipient: A Case Report. Kidney Med 2024; 6:100822. [PMID: 38736639 PMCID: PMC11078694 DOI: 10.1016/j.xkme.2024.100822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
Kidney transplant candidates with high anti-M-type phospholipase A2 receptor antibody activity may be at increased risk for early postkidney transplant recurrence and allograft loss. Pretransplant treatment to induce serological remission may be warranted to improve allograft survival. In this case report, a patient seeking their third kidney transplant, who lost 2 prior living donor transplants from early recurrent membranous nephropathy, underwent pretransplant treatment for membranous nephropathy with serological remission and no evidence of recurrent disease.
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Affiliation(s)
- Erik L. Lum
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Jonathan E. Zuckerman
- Department of Pathology and Laboratory Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Lama Abdelnour
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Jennifer Terenzini
- Department of Transplant Services, Kidney and Pancreas Transplant, UCLA, Los Angeles, California
| | - Gurbir Singh
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Suphamai Bunnapradist
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
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Lum EL, Bunnapradist S, Wiseman AC, Gurakar A, Ferrey A, Reddy U, Al Ammary F. Novel indications for referral and care for simultaneous liver kidney transplant recipients. Curr Opin Nephrol Hypertens 2024; 33:354-360. [PMID: 38345405 PMCID: PMC10990015 DOI: 10.1097/mnh.0000000000000970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
PURPOSE OF REVIEW Kidney dysfunction is challenging in liver transplant candidates to determine whether it is reversible or not. This review focuses on the pertinent data on how to best approach liver transplant candidates with kidney dysfunction in the current era after implementing the simultaneous liver kidney (SLK) allocation policy and safety net. RECENT FINDINGS The implementation of the SLK policy inverted the steady rise in SLK transplants and improved the utilization of high-quality kidneys. Access to kidney transplantation following liver transplant alone (LTA) increased with favorable outcomes. Estimating GFR in liver transplant candidates remains challenging, and innovative methods are needed. SLK provided superior patient and graft survival compared to LTA only for patients with advanced CKD and dialysis at least 3 months. SLK can provide immunological protection against kidney rejection in highly sensitized candidates. Post-SLK transplant care is complex, with an increased risk of complications and hospitalization. SUMMARY The SLK policy improved kidney access and utilization. Transplant centers are encouraged, under the safety net, to reserve SLK for liver transplant candidates with advanced CKD or dialysis at least 3 months while allowing lower thresholds for highly sensitized patients. Herein, we propose a practical approach to liver transplant candidates with kidney dysfunction.
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Affiliation(s)
- Erik L. Lum
- Department of Medicine, University of California Los Angeles, Los Angeles, California
| | - Suphamai Bunnapradist
- Department of Medicine, University of California Los Angeles, Los Angeles, California
| | | | - Ahmet Gurakar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Antoney Ferrey
- Department of Medicine, University of California Irvine, Orange, California, USA
| | - Uttam Reddy
- Department of Medicine, University of California Irvine, Orange, California, USA
| | - Fawaz Al Ammary
- Department of Medicine, University of California Irvine, Orange, California, USA
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Bromberg JS, Bunnapradist S, Samaniego-Picota M, Anand S, Stites E, Gauthier P, Demko Z, Prewett A, Armer-Cabral M, Marshall K, Kaur N, Bloom MS, Tabriziani H, Bhorade S, Cooper M. Elevation of Donor-derived Cell-free DNA Before Biopsy-proven Rejection in Kidney Transplant. Transplantation 2024:00007890-990000000-00724. [PMID: 38595232 DOI: 10.1097/tp.0000000000005007] [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: 04/11/2024]
Abstract
BACKGROUND Standard-of-care biomarkers for renal allograft rejection are lagging indicators, signaling existing organ injury. This precludes early intervention, when immunological cascades leading to rejection are most susceptible. Donor-derived cell-free DNA (dd-cfDNA) shows promise as an early indicator of rejection, allowing earlier and possibly more effective treatment. This analysis was designed to assess this promise using real-world dd-cfDNA testing evidence. METHODS This retrospective analysis of the prospective, observational ProActive registry study (NCT04091984) assessed dd-cfDNA and serum creatinine levels before biopsy in 424 patients with ≥1 dd-cfDNA test (n = 1013) in the 6 mo before biopsy. RESULTS Of 4667 enrolled patients, 1631 patients had ≥18 mo of follow-up data, of which 424 had a biopsy and were included in this analysis. Twenty-six biopsies showed antibody-mediated rejection (ABMR), 62 showed T cell-mediated rejection, and 336 showed nonrejection; each from a unique patient. dd-cfDNA fractions were significantly elevated 5 mo before ABMR biopsies, and 2 mo before T cell-mediated rejection biopsies, compared with nonrejection biopsies. In contrast, serum creatinine did not discriminate between rejection and nonrejection in advance, or concurrent with biopsy. Among patients with nonrejection biopsies, estimated glomerular filtration rate was significantly lower in cases with ≥2 increased dd-cfDNA results (≥1%), compared with those with 0 or 1 increased dd-cfDNA result. CONCLUSIONS These data indicate that dd-cfDNA is an early indicator of biopsy-proven rejection, especially ABMR, suggesting a greater role for dd-cfDNA in surveillance to identify patients at high risk of ongoing or future rejection, thus requiring closer monitoring, biopsy, or other management changes.
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Affiliation(s)
- Jonathan S Bromberg
- Department of Surgery, University of Maryland, School of Medicine, Baltimore, MD
| | | | | | | | - Erik Stites
- School of Medicine, University of Colorado Anschutz Medical Campus, Denver, CO
| | | | | | | | | | | | | | | | | | | | - Matthew Cooper
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
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Wiseman A, Alhamad T, Alloway RR, Concepcion BP, Cooper M, Formica R, Klein CL, Kumar V, Leca N, Shihab F, Taber DJ, Mulnick S, Bushnell DM, Hadi M, Bunnapradist S. Use of LCP-Tacrolimus (LCPT) in Kidney Transplantation: A Delphi Consensus Survey of Expert Clinicians. Ann Transplant 2024; 29:e943498. [PMID: 38526543 PMCID: PMC10944009 DOI: 10.12659/aot.943498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/06/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND LCPT (Envarsus XR®) is a common once-daily, extended-release oral tacrolimus formulation used in kidney transplantation. However, there are minimal evidence-based recommendations regarding optimal dosing and treatment in the de novo and conversion settings. MATERIAL AND METHODS Using Delphi methodology, 12 kidney transplantation experts with LCPT experience reviewed available data to determine potential consensus topics. Key statements regarding LCPT use were generated and disseminated to the panel in an online Delphi survey. Statements were either accepted, revised, or rejected based on the level of consensus, perceived strength of evidence, and alignment with clinical practice. Consensus was defined a priori as ≥75% agreement. RESULTS Twenty-three statements were generated: 14 focused on de novo LCPT use and 9 on general administration or LCPT conversion use. After 2 rounds, consensus was achieved for 11/14 of the former and 7/9 of the latter statements. In a de novo setting, LCPT was recognized as a first-line option based on its safety and efficacy compared to immediate-release tacrolimus. In particular, African Americans and rapid metabolizer populations were identified as preferred for first-line LCPT therapy. In a conversion setting, full consensus was achieved for converting to LCPT to address neurological adverse effects related to immediate-release tacrolimus and for the time required (approximately 7 days) for steady-state LCPT trough levels to be reached. CONCLUSIONS When randomized clinical trials do not replicate current utilization patterns, the Delphi process can successfully generate consensus statements by expert clinicians to inform clinical decision-making for the use of LCPT in kidney transplant recipients.
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Affiliation(s)
- Alexander Wiseman
- AdventHealth Transplant Institute, Porter Adventist Hospital, Denver, CO, USA
| | - Tarek Alhamad
- Division of Nephrology, Washington University School of Medicine in St. Louis, Saint Louis, MO, USA
| | - Rita R. Alloway
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Matthew Cooper
- Transplant Center – Center for Advanced Care – Froedtert Hospital, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Richard Formica
- Yale New Haven Transplantation Center, Yale University School of Medicine, New Haven, CT, USA
| | - Christina L. Klein
- Department of Transplant Nephrology, Piedmont Transplant Institute, Atlanta, GA, USA
| | - Vineeta Kumar
- Renal Transplant Program, University of Alabama at Birmingham Hospital, Birmingham, AL, USA
| | - Nicolae Leca
- Kidney Care and Transplantation Services, University of Washington, Seattle, WA, USA
| | - Fuad Shihab
- Kidney and Liver Clinic, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - David J. Taber
- Transplant Immunobiology Laboratory, Medical University of South Carolina, Charleston, SC, USA
| | - Sarah Mulnick
- Patient-Centered Research, Evidera, Bethesda, MD, USA
| | | | - Monica Hadi
- Patient-Centered Research, Evidera, London, United Kingdom
| | - Suphamai Bunnapradist
- Division of Nephrology and Department of Medicine, David Geffen School of Medicine, Los Angeles, CA, USA
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Schaenman J, Ahn R, Lee C, Hale-Durbin B, Abdalla B, Danovitch G, Huynh A, Laviolette R, Shigri A, Bunnapradist S, Kendrick E, Lipshutz GS, Pham PT, Lum EL, Yabu JM, Seligman B, Goldwater D. Physical Frailty Predicts Outcomes in Patients Undergoing Evaluation for Kidney Transplantation. Transplant Proc 2023; 55:2372-2377. [PMID: 37985351 DOI: 10.1016/j.transproceed.2023.09.033] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 07/24/2023] [Accepted: 09/22/2023] [Indexed: 11/22/2023]
Abstract
INTRODUCTION An increasing number of older patients are undergoing evaluation for kidney transplantation; however, older patients experience increased rates of complications compared with younger patients, leading to the study of frailty assessments. Although many centers have evaluated the Fried Frailty Phenotype (FFP), less is known about the ability of the Short Performance Physical Battery (SPPB) to predict outcomes. METHODS Frailty assessment by FFP and SPPB was introduced into routine outpatient evaluation for patients aged 55 years and older referred for transplantation. Transplant rate, length of stay, readmission up to 3 months posttransplant, and death were reviewed. Patients were evaluated in an initial cohort followed by a validation cohort by FFP and SPPB. Multivariate analysis correcting for demographic characteristics was applied. RESULTS Patient cohorts reflected the racial and ethnic diversity of our population, including approximately 40% Hispanic patients. The first cohort of 514 patients demonstrated a significant association between frailty as measured by SPPB and transplantation (odds ratio [OR], 2.27; 95% CI, 1.38-3.83; p = .002). The second cohort of 1408 patients validated the association between frailty measured by SPPB and transplantation (OR, 2.81; 95% CI, 1.83-4.48; p < .001). In addition, there was a significant association between nonfrail status measured by SPPB and death (OR, 0.16; 95% CI, 0.04-0.62; p = .006). CONCLUSIONS Frailty assessment is a potentially useful approach for the assessment of transplant candidates. Our real-world study examined the performance of 2 methods of frailty evaluation methods in a diverse population, demonstrating that SPPB but not FFP was predictive of clinical outcomes. Incorporation of frailty assessments into transplant evaluation may improve risk stratification and optimize outcomes for older patients.
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Affiliation(s)
- Joanna Schaenman
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California.
| | - Richard Ahn
- Institute for Quantitative and Computational Biosciences, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Christine Lee
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Bethany Hale-Durbin
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Basmah Abdalla
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Gabriel Danovitch
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Alina Huynh
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Robert Laviolette
- UCLA Health Epic Applications, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ahson Shigri
- UCLA Health Epic Applications, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Suphamai Bunnapradist
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Elizabeth Kendrick
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Gerald S Lipshutz
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Phuong-Thu Pham
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Erik L Lum
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Julie M Yabu
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ben Seligman
- Division of Geriatrics, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Deena Goldwater
- Division of Geriatrics, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
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Kendrick E, Lum E, Bunnapradist S, Sisk A, Zuckerman J. 218.10: Deceased donor kidney biopsies may underrepresent extent of donor kidney disease. Transplantation 2023; 107:54. [PMID: 37845928 DOI: 10.1097/01.tp.0000993292.92200.1b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Affiliation(s)
- Elizabeth Kendrick
- Division of Nephrology, Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Erik Lum
- Division of Nephrology, Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Suphamai Bunnapradist
- Division of Nephrology, Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Anthony Sisk
- Department of Pathology, Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Jonathan Zuckerman
- Department of Pathology, Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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Bunnapradist S, Rosenthal JT, Huang E, Dafoe D, Seto T, Cohen A, Danovitch G. Deceased Donor Kidney Nonuse: A Systematic Approach to Improvement. Transplant Direct 2023; 9:e1491. [PMID: 37250491 PMCID: PMC10219747 DOI: 10.1097/txd.0000000000001491] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 03/09/2023] [Accepted: 03/14/2023] [Indexed: 05/31/2023] Open
Abstract
A large number of procured kidneys continue not to be transplanted, while the waiting list remains high. Methods We analyzed donor characteristics for unutilized kidneys in our large organ procurement organization (OPO) service area in a single year to determine the reasonableness of their nonuse and to identify how we might increase the transplant rate of these kidneys. Five experienced local transplant physicians independently reviewed unutilized kidneys to identify which kidneys they would consider transplanting in the future. Biopsy results, donor age, kidney donor profile index, positive serologies, diabetes, and hypertension were risk factors for nonuse. Results Two-thirds of nonused kidneys had biopsies with high degree of glomerulosclerosis and interstitial fibrosis. Reviewers identified 33 kidneys as potentially transplantable (12%). Conclusions Reducing the rate of unutilized kidneys in this OPO service area will be achieved by setting acceptable expanded donor characteristics, identifying suitable well-informed recipients, defining acceptable outcomes, and systematically evaluating the results of these transplants. Because the improvement opportunity will vary by region, to achieve a significant impact on improving the national nonuse rate, it would be useful for all OPOs, in collaboration with their transplant centers, to conduct a similar analysis.
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Affiliation(s)
- Suphamai Bunnapradist
- David Geffen School of Mesdicine, University of California Los Angeles, Los Angeles, CA
| | - J. Thomas Rosenthal
- David Geffen School of Mesdicine, University of California Los Angeles, Los Angeles, CA
| | - Edmund Huang
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA
| | - Donald Dafoe
- Department of Surgery, University of California Irvine, Irvine, CA
| | | | | | - Gabriel Danovitch
- David Geffen School of Mesdicine, University of California Los Angeles, Los Angeles, CA
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Lum EL, Zuckerman J, Gaynor P, Bunnapradist S. Adenovirus in a Kidney Transplant Recipient. Kidney Med 2023; 5:100605. [PMID: 36915369 PMCID: PMC10006501 DOI: 10.1016/j.xkme.2023.100605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Erik L Lum
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - Jonathan Zuckerman
- Department of Pathology, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - Pryce Gaynor
- Division of Infectious Disease, Department of Medicine, ULCA David Geffen School of Medicine, Los Angeles, CA
| | - Suphamai Bunnapradist
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA
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Hricik DE, Armstrong B, Alhamad T, Brennan DC, Bromberg JS, Bunnapradist S, Chandran S, Fairchild RL, Foley DP, Formica R, Gibson IW, Kesler K, Kim SJ, Mannon RB, Menon MC, Newell KA, Nickerson P, Odim J, Poggio ED, Sung R, Shapiro R, Tinckam K, Vincenti F, Heeger PS. Infliximab Induction Lacks Efficacy and Increases BK Virus Infection in Deceased Donor Kidney Transplant Recipients: Results of the CTOT-19 Trial. J Am Soc Nephrol 2023; 34:145-159. [PMID: 36195441 PMCID: PMC10101585 DOI: 10.1681/asn.2022040454] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 09/09/2022] [Accepted: 09/16/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Ischemia-reperfusion (IR) of a kidney transplant (KTx) upregulates TNF α production that amplifies allograft inflammation and may negatively affect transplant outcomes. METHODS We tested the effects of blocking TNF peri-KTx via a randomized, double-blind, placebo-controlled, 15-center, phase 2 clinical trial. A total of 225 primary transplant recipients of deceased-donor kidneys (KTx; 38.2% Black/African American, 44% White) were randomized to receive intravenous infliximab (IFX) 3 mg/kg or saline placebo (PLBO) initiated before kidney reperfusion. All patients received rabbit anti-thymocyte globulin induction and maintenance immunosuppression (IS) with tacrolimus, mycophenolate mofetil, and prednisone. The primary end point was the difference between groups in mean 24-month eGFR. RESULTS There was no difference in the primary end point of 24-month eGFR between IFX (52.45 ml/min per 1.73 m 2 ; 95% CI, 48.38 to 56.52) versus PLBO (57.35 ml/min per 1.73 m 2 ; 95% CI, 53.18 to 61.52; P =0.1). There were no significant differences between groups in rates of delayed graft function, biopsy-proven acute rejection (BPAR), development of de novo donor-specific antibodies, or graft loss/death. Immunosuppression did not differ, and day 7 post-KTx plasma analyses showed approximately ten-fold lower TNF ( P <0.001) in IFX versus PLBO. BK viremia requiring IS change occurred more frequently in IFX (28.9%) versus PLBO (13.4%; P =0.004), with a strong trend toward higher rates of BKV nephropathy in IFX (13.3%) versus PLBO (4.9%; P =0.06). CONCLUSIONS IFX induction therapy does not benefit recipients of kidney transplants from deceased donors on this IS regimen. Because the intervention unexpectedly increased rates of BK virus infections, our findings underscore the complexities of targeting peritransplant inflammation as a strategy to improve KTx outcomes.Clinical Trial registry name and registration number:clinicaltrials.gov (NCT02495077).
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Affiliation(s)
- Donald E Hricik
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - Tarek Alhamad
- Department of Medicine, Washington University, Saint Louis, Missouri
| | | | | | | | - Sindhu Chandran
- Departments of Medicine and Surgery, University of California, San Francisco, California
| | - Robert L Fairchild
- Glickman Urological and Kidney Institute and the Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - David P Foley
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Richard Formica
- Departments of Medicine and Surgery, Yale University, New Haven, Connecticut
| | - Ian W Gibson
- Departments of Medicine and Pathology, University of Manitoba, Winnipeg, Canada
| | | | - S Joseph Kim
- Department of Medicine, University Health Network, Toronto, Canada
| | - Roslyn B Mannon
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Madhav C Menon
- Departments of Medicine and Surgery, Yale University, New Haven, Connecticut
| | | | - Peter Nickerson
- Departments of Medicine and Pathology, University of Manitoba, Winnipeg, Canada
| | - Jonah Odim
- Transplant Branch, Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland
| | - Emilio D Poggio
- Glickman Urological and Kidney Institute and the Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Randall Sung
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Ron Shapiro
- Departments of Medicine, Icahn School of Medicine at Mount Sinai and Recanati Miller Transplant Institute, Mount Sinai Hospital, New York, New York
| | - Kathryn Tinckam
- Department of Medicine, University Health Network, Toronto, Canada
| | - Flavio Vincenti
- Departments of Medicine and Surgery, University of California, San Francisco, California
| | - Peter S Heeger
- Departments of Medicine, Icahn School of Medicine at Mount Sinai and Recanati Miller Transplant Institute, Mount Sinai Hospital, New York, New York
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Tang J, Woodruff K, Jang C, Charland N, Bass L, Vu P, Sotto C, Ahmed E, Van Hummelen P, Heilek G, Zimmermann B, Bunnapradist S, Tabriziani H, Afshar Y. Donor-derived cell free DNA (dd-cfDNA) in pregnant kidney transplant recipients. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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11
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Sigdel TK, Boada P, Kerwin M, Rashmi P, Gjertson D, Rossetti M, Sur S, Munar D, Cimino J, Ahn R, Pickering H, Sen S, Parmar R, Fatou B, Steen H, Schaenman J, Bunnapradist S, Reed EF, Sarwal MM. Plasma proteome perturbation for CMV DNAemia in kidney transplantation. PLoS One 2023; 18:e0285870. [PMID: 37205661 DOI: 10.1371/journal.pone.0285870] [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] [Received: 08/10/2022] [Accepted: 05/03/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) infection, either de novo or as reactivation after allotransplantation and chronic immunosuppression, is recognized to cause detrimental alloimmune effects, inclusive of higher susceptibility to graft rejection and substantive impact on chronic graft injury and reduced transplant survival. To obtain further insights into the evolution and pathogenesis of CMV infection in an immunocompromised host we evaluated changes in the circulating host proteome serially, before and after transplantation, and during and after CMV DNA replication (DNAemia), as measured by quantitative polymerase chain reaction (QPCR). METHODS LC-MS-based proteomics was conducted on 168 serially banked plasma samples, from 62 propensity score-matched kidney transplant recipients. Patients were stratified by CMV replication status into 31 with CMV DNAemia and 31 without CMV DNAemia. Patients had blood samples drawn at protocol times of 3- and 12-months post-transplant. Additionally, blood samples were also drawn before and 1 week and 1 month after detection of CMV DNAemia. Plasma proteins were analyzed using an LCMS 8060 triple quadrupole mass spectrometer. Further, public transcriptomic data on time matched PBMCs samples from the same patients was utilized to evaluate integrative pathways. Data analysis was conducted using R and Limma. RESULTS Samples were segregated based on their proteomic profiles with respect to their CMV Dnaemia status. A subset of 17 plasma proteins was observed to predict the onset of CMV at 3 months post-transplant enriching platelet degranulation (FDR, 4.83E-06), acute inflammatory response (FDR, 0.0018), blood coagulation (FDR, 0.0018) pathways. An increase in many immune complex proteins were observed at CMV infection. Prior to DNAemia the plasma proteome showed changes in the anti-inflammatory adipokine vaspin (SERPINA12), copper binding protein ceruloplasmin (CP), complement activation (FDR = 0.03), and proteins enriched in the humoral (FDR = 0.01) and innate immune responses (FDR = 0.01). CONCLUSION Plasma proteomic and transcriptional perturbations impacting humoral and innate immune pathways are observed during CMV infection and provide biomarkers for CMV disease prediction and resolution. Further studies to understand the clinical impact of these pathways can help in the formulation of different types and duration of anti-viral therapies for the management of CMV infection in the immunocompromised host.
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Affiliation(s)
- Tara K Sigdel
- Department of Surgery, University of California San Francisco, San Francisco, CA, United States of America
| | - Patrick Boada
- Department of Surgery, University of California San Francisco, San Francisco, CA, United States of America
| | - Maggie Kerwin
- Department of Surgery, University of California San Francisco, San Francisco, CA, United States of America
| | - Priyanka Rashmi
- Department of Surgery, University of California San Francisco, San Francisco, CA, United States of America
| | - David Gjertson
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Maura Rossetti
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Swastika Sur
- Department of Surgery, University of California San Francisco, San Francisco, CA, United States of America
| | - Dane Munar
- Department of Surgery, University of California San Francisco, San Francisco, CA, United States of America
| | - James Cimino
- Department of Surgery, University of California San Francisco, San Francisco, CA, United States of America
| | - Richard Ahn
- Department of Microbiology and Immunology, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Harry Pickering
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Subha Sen
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Rajesh Parmar
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Benoit Fatou
- Department of Pathology, Harvard Medical School, Boston, MA, United States of America
| | - Hanno Steen
- Department of Pathology, Harvard Medical School, Boston, MA, United States of America
| | - Joanna Schaenman
- Department of Medicine, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Suphamai Bunnapradist
- Department of Medicine, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Elaine F Reed
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Minnie M Sarwal
- Department of Surgery, University of California San Francisco, San Francisco, CA, United States of America
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12
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Al Ammary F, Muzaale AD, Tantisattamoa E, Hanna RM, Reddy UG, Bunnapradist S, Kalantar-Zadeh K. Changing landscape of living kidney donation and the role of telemedicine. Curr Opin Nephrol Hypertens 2023; 32:81-88. [PMID: 36444666 PMCID: PMC9713599 DOI: 10.1097/mnh.0000000000000848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW There has been a decline in living kidney donation over the last two decades. Donors from low-income families or racial/ethnic minorities face greater disproportionate geographic, financial, and logistical barriers to completing lengthy and complex evaluations. This has contributed to the decreased proportion of these subgroups. The authors view telemedicine as a potential solution to this problem. RECENT FINDINGS Since the initial decline of donors in 2005, biologically related donors have experienced a lack of growth across race/ethnicity. Conversely, unrelated donors have emerged as the majority of donors in recent years across race/ethnicity, except for unrelated black donors. Disparities in access to living kidney donation persist. Telemedicine using live-video visits can overcome barriers to access transplant centers and facilitate care coordination. In a U.S. survey, nephrologists, surgeons, coordinators, social workers, and psychologists/psychologists across transplant centers are favorably disposed to use telemedicine for donor evaluation/follow-up beyond the coronavirus disease 2019 pandemic. However, with the waning of relaxed telemedicine regulations under the Public Health Emergency, providers perceive payor policy and out-of-state licensing as major factors hindering telemedicine growth prospects. SUMMARY Permanent federal and state policies that support telemedicine services for living kidney donation can enhance access to transplant centers and help overcome barriers to donor evaluation.
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Affiliation(s)
- Fawaz Al Ammary
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Abimereki D. Muzaale
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Ramy M. Hanna
- Department of Medicine, University of California Irvine, Orange, California
| | - Uttam G. Reddy
- Department of Medicine, University of California Irvine, Orange, California
| | - Suphamai Bunnapradist
- Department of Medicine, University of California Los Angeles, Los Angeles, California
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13
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Lum EL, Towns A, Basuli D, Pham PT, Sarkar M, Bunnapradist S. Reduction in Maintenance Immunosuppression in Kidney Transplant Recipients With Stable Donor-Derived Cell-Free DNA Measurements: A Case Series. Transplant Proc 2023; 55:93-97. [PMID: 36586738 DOI: 10.1016/j.transproceed.2022.12.003] [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] [Received: 10/20/2022] [Accepted: 12/07/2022] [Indexed: 12/31/2022]
Abstract
Personalization of maintenance immunosuppression in kidney transplant recipients has long remained a goal in the transplant community. The recent addition of donor-derived cell-free DNA assays to detect allograft rejection and monitor allograft health may permit for reductions in maintenance immunosuppression in recipients with stable levels. Herein, we described 5 patients with stable donor-derived cell-free DNA levels who underwent reduction in maintenance immunosuppression without precipitation of clinical rejection, proteinuria, or de novo donor specific antibody formation.
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Affiliation(s)
- Erik L Lum
- Department of Medicine, Division of Nephrology, UCLA David Geffen School of Medicine, Los Angeles, California.
| | - Arta Towns
- UCLA Ronald Regan Medical Center Los Angeles, California
| | - Debargha Basuli
- Department of Nephrology and Hypertension, East Carolina University, Greenville, North Carolina
| | - Phuong-Thu Pham
- Department of Medicine, Division of Nephrology, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Mrinalini Sarkar
- Department of Medicine, Division of Nephrology, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Suphamai Bunnapradist
- Department of Medicine, Division of Nephrology, UCLA David Geffen School of Medicine, Los Angeles, California
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14
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Lum EL, Homkrailas P, Abdalla B, Danovitch GM, Bunnapradist S. Cold Ischemia Time, Kidney Donor Profile Index, and Kidney Transplant Outcomes: A Cohort Study. Kidney Med 2022; 5:100570. [PMID: 36632197 PMCID: PMC9827060 DOI: 10.1016/j.xkme.2022.100570] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Rationale & Objective An average of 3,280 recovered deceased donor kidneys are discarded annually in the United States. Increased cold ischemia time is associated with an increased rate of organ decline and subsequent discard. Here we examined the effect of prolonged cold ischemia time on kidney transplant outcomes. Study Design Retrospective observational study. Setting & Participants Recipients of deceased donor kidney transplants in the United States from 2000 to 2018. Exposure Recipients of deceased donor kidneys were divided based on documented cold ischemia time: ≤16, 16-24, 24-32, 32-40, and >40 hours. Outcomes The incidence of delayed graft function, primary nonfunction, and 10-year death-censored graft survival. Analytical Approach The Kaplan-Meier method was used to generate survival curves, and the log rank test was used to compare graft survival. Results The rate of observed delayed graft function increased with cold ischemia time (20.9%, 28.1%, 32.4%, 37.5%, and 35.8%). Primary nonfunction also showed a similar increase with cold ischemia time (0.6%, 0.9%, 1.3%, 2.1%, and 2.3%), During a median follow-up time of 4.6 years, 37,301 recipients experienced death-censored graft failure. Analysis based on kidney donor profile index (KDPI) demonstrated significant differences in 10-year death-censored graft survival, with a death-censored graft survival in recipients of a kidney with a KDPI <85% of 71.0% (95% CI, 70.5%-71.5%), 70.5% (95% CI, 69.9%-71.0%), 69.6% (95% CI, 68.7%-70.4%), 65.5% (95% CI, 63.7%-67.3%), and 67.2% (95% CI, 64.6%-69.6%), compared to 53.5% (95% CI, 51.1%-55.8%), 50.7% (95% CI, 48.3%-53.1%), 50.3% (95% CI, 46.6%-53.8%), 50.7% (95% CI, 45.1%-56.1%), and 48.3% (95% CI, 40.0%-56.1%), for recipients of a kidney with a KDPI >85%. Limitations Heterogeneity of acceptance patterns among transplant centers, presence of confounding variables leading to acceptance of kidneys with prolonged cold ischemia times. Conclusions Cold ischemia time was associated with an increased risk of delayed graft function and primary nonfunction. However, the effect of increased cold ischemia time is modest and has less impact than the KDPI. Transplant programs should not consider prolonged cold ischemia time alone as a predominant reason to decline an organ, especially with a KDPI <85%.
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Affiliation(s)
- Erik L. Lum
- Kidney and Pancreas Transplant Research Center, Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Piyavadee Homkrailas
- Kidney and Pancreas Transplant Research Center, Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California,Division of Nephrology, Department of Medicine, Bhumibol Adulyadej Hospital, Bangkok, Thailand
| | - Basmah Abdalla
- Kidney and Pancreas Transplant Research Center, Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Gabriel M. Danovitch
- Kidney and Pancreas Transplant Research Center, Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Suphamai Bunnapradist
- Kidney and Pancreas Transplant Research Center, Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California,Address for Correspondence: Suphamai Bunnapradist, MD, MS, Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, 10880 Wilshire Blvd, Ste 920, Los Angeles, CA 90024.
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15
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Schaenman J, Rossetti M, Pickering H, Sunga G, Wilhalme H, Elashoff D, Zhang Q, Hickey M, Reddy U, Danovitch G, Reed EF, Bunnapradist S. Preservation of Antiviral Immunologic Efficacy Without Alloimmunity After Switch to Belatacept in Calcineurin Inhibitor-Intolerant Patients. Kidney Int Rep 2022; 8:126-140. [PMID: 36644348 PMCID: PMC9832066 DOI: 10.1016/j.ekir.2022.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/18/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022] Open
Abstract
Introduction Belatacept has shown potential for prevention of rejection after kidney transplantation, given its demonstration of reduced nephrotoxicity in combination with absence of significant incidence of rejection. However, concerns have been raised regarding increased risk of viral infection. Methods We set out to explore the impact of the switch to belatacept on alloimmune and antiviral immunity through the study of patients switched from calcineurin inhibitor (CNI) to belatacept within 3 months of kidney transplantation compared with a matched cohort of control patients on a CNI-based regimen. Results After the switch to belatacept, immune phenotyping demonstrated a decrease in naive and an increase in terminally differentiated effector memory (TMRA) T cells, with no significant difference compared with control patients. Donor-specific immune response, measured by intracellular cytokine staining (ICS), did not change significantly either by single or double cytokine secretion, but it was associated with the appearance of donor-specific antibody (DSA) in the control but not the belatacept cohort (P = 0.039 for naive and P = 0.002 for TMRA subtypes). Increased incidence of de novo DSA development was observed in the control group (P = 0.035). Virus-specific immune response, as measured by ICS in response to cytomegalovirus (CMV) or Epstein-Barr virus (EBV), was similar in both groups and stable over time. Conclusion We found that belatacept use was associated with an absence of alloreactivity without impact on immune phenotype, while preserving the antiviral immune response, for patients switched from a CNI-based regimen. In parallel, the antiviral immune response against CMV and EBV was preserved after the belatacept switch (clinicaltrials.gov: NCT01953120).
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Affiliation(s)
- Joanna Schaenman
- Division of Infectious Disease, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Maura Rossetti
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Harry Pickering
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Gemalene Sunga
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Holly Wilhalme
- Department of Medicine Biostatistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - David Elashoff
- Department of Medicine Biostatistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Qiuheng Zhang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Michelle Hickey
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Uttam Reddy
- Division of Kidney Transplantation, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Gabriel Danovitch
- Division of Kidney Transplantation, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Elaine F. Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Suphamai Bunnapradist
- Division of Kidney Transplantation, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA,Correspondence: Suuphamai Bunnapradist, 200 UCLA Medical Plaza, Suite 565, Los Angeles, CA 90095, USA.
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16
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Pickering H, Schaenman J, Rossetti M, Ahn R, Sunga G, Liang EC, Bunnapradist S, Reed EF. Corrigendum to "T cell senescence and impaired CMV-specific response are associated with infection risk in kidney transplant recipients" [Hum. Immunol. 83(4) (2022) 273-280]. Hum Immunol 2022; 83:857. [PMID: 36192241 DOI: 10.1016/j.humimm.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | | | | | - Richard Ahn
- Quantitative and Computational Biosciences, USA
| | | | | | - Suphamai Bunnapradist
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Elaine F Reed
- Department of Pathology and Laboratory Medicine, USA
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17
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Lum EL, Lee S, Zuckerman J, Bunnapradist S. Subclinical non-HLA AMR detection and monitoring with surveillance dd-cfDNA in a kidney transplant recipient. Transplantation Reports 2022. [DOI: 10.1016/j.tpr.2022.100092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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18
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Pickering H, Schaenman J, Rossetti M, Ahn R, Sunga G, Liang EC, Bunnapradist S, Reed EF. T cell senescence and impaired CMV-specific response are associated with infection risk in kidney transplant recipients. Hum Immunol 2022; 83:273-280. [DOI: 10.1016/j.humimm.2022.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 01/30/2022] [Accepted: 01/31/2022] [Indexed: 02/04/2023]
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19
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Axelrod DA, Cheungpasitporn W, Bunnapradist S, Schnitzler MA, Xiao H, McAdams-DeMarco M, Caliskan Y, Bae S, Ahn JB, Segev DL, Lam NN, Hess GP, Lentine KL. Posttransplant Diabetes Mellitus and Immunosuppression Selection in Older and Obese Kidney Recipients. Kidney Med 2022; 4:100377. [PMID: 35072042 PMCID: PMC8767140 DOI: 10.1016/j.xkme.2021.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Rationale & Objective Posttransplant diabetes mellitus (DM) after kidney transplantation increases morbidity and mortality, particularly in older and obese recipients. We aimed to examine the impact of immunosuppression selection on the risk of posttransplant DM among both older and obese kidney transplant recipients. Study Design Retrospective database study. Setting & Participants Kidney-only transplant recipients aged ≥18 years from 2005 to 2016 in the United States from US Renal Data System records, which integrate Organ Procurement and Transplantation Network/United Network for Organ Sharing records with Medicare billing claims. Exposures Various immunosuppression regimens in the first 3 months after transplant. Outcomes Development of DM >3 months-to-1 year posttransplant. Analytical Approach We used multivariable Cox regression to compare the incidence of posttransplant DM by immunosuppression regimen with the reference regimen of thymoglobulin (TMG) or alemtuzumab (ALEM) with tacrolimus + mycophenolic acid + prednisone using inverse propensity weighting. Results 12.7% of kidney transplant recipients developed posttransplant DM with higher incidences in older (≥55 years vs <55 years: 16.7% vs 10.1%) and obese (body mass index [BMI] ≥ 30 kg/m2 vs BMI < 30 kg/m2: 17.1% vs 10.9%) patients. The incidence of posttransplant DM was lower with steroid avoidance [TMG/ALEM + no prednisone (8.4%) and IL2rAb + no prednisone (9.7%)] than TMG/ALEM with triple therapy (13.1%). After adjustment for donor and recipient characteristics, TMG/ALEM with steroid avoidance was beneficial for all groups [age < 55 years: adjusted HR (aHR), 0.63 (95% confidence interval [CI], 0.54-0.72); age ≥ 55 years: aHR, 0.69 (95% CI, 0.60-0.79); BMI < 30 kg/m2: aHR, 0.69 (95% CI, 0.60-0.78); BMI ≥ 30 kg/m2: aHR, 0.67 (95% CI, 0.57-0.79)]. However, IL2rAb with steroid avoidance was beneficial only for older patients (aHR, 0.76; 95% CI, 0.58-0.99) and for those with BMI < 30 kg/m2 (aHR, 0.63; 95% CI, 0.46-0.87). Limitations Retrospective study and lacked data on immunosuppression levels. Conclusions The beneficial impact of steroid avoidance using tacrolimus on posttransplant DM appears to differ by patient age and induction regimen.
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Affiliation(s)
| | | | | | - Mark A. Schnitzler
- Saint Louis University Center for Abdominal Transplantation, Saint Louis, Missouri
| | - Huiling Xiao
- Saint Louis University Center for Abdominal Transplantation, Saint Louis, Missouri
| | | | - Yasar Caliskan
- Saint Louis University Center for Abdominal Transplantation, Saint Louis, Missouri
| | - Sunjae Bae
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | - JiYoon B. Ahn
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | | | | | - Krista L. Lentine
- University of Iowa, Iowa City, Iowa
- Address for Correspondence: Krista L. Lentine, MD, PhD, Saint Louis University Center for Abdominal Transplantation, 1402 S. Grand Blvd., St. Louis, MO, 63104.
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20
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Ahn R, Schaenman J, Qian Z, Pickering H, Groysberg V, Rossetti M, Llamas M, Hoffmann A, Gjertson D, Deng M, Bunnapradist S, Reed EF. Acute and Chronic Changes in Gene Expression After CMV DNAemia in Kidney Transplant Recipients. Front Immunol 2021; 12:750659. [PMID: 34867983 PMCID: PMC8634678 DOI: 10.3389/fimmu.2021.750659] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/20/2021] [Indexed: 12/13/2022] Open
Abstract
Cytomegalovirus (CMV) viremia continues to cause significant morbidity and mortality in kidney transplant patients with clinical complications including organ rejection and death. Whole blood gene expression dynamics in CMV viremic patients from onset of DNAemia through convalescence has not been well studied to date in humans. To evaluate how CMV infection impacts whole blood leukocyte gene expression over time, we evaluated a matched cohort of 62 kidney transplant recipients with and without CMV DNAemia using blood samples collected at multiple time points during the 12-month period after transplant. While transcriptomic differences were minimal at baseline between DNAemic and non-DNAemic patients, hundreds of genes were differentially expressed at the long-term timepoint, including genes enriching for pathways important for macrophages, interferon, and IL-8 signaling. Amongst patients with CMV DNAemia, the greatest amount of transcriptomic change occurred between baseline and 1-week post-DNAemia, with increase in pathways for interferon signaling and cytotoxic T cell function. Time-course gene set analysis of these differentially expressed genes revealed that most of the enriched pathways had a significant time-trend. While many pathways that were significantly down- or upregulated at 1 week returned to baseline-like levels, we noted that several pathways important in adaptive and innate cell function remained upregulated at the long-term timepoint after resolution of CMV DNAemia. Differential expression analysis and time-course gene set analysis revealed the dynamics of genes and pathways involved in the immune response to CMV DNAemia in kidney transplant patients. Understanding transcriptional changes caused by CMV DNAemia may identify the mechanism behind patient vulnerability to CMV reactivation and increased risk of rejection in transplant recipients and suggest protective strategies to counter the negative immunologic impact of CMV. These findings provide a framework to identify immune correlates for risk assessment and guiding need for extending antiviral prophylaxis.
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Affiliation(s)
- Richard Ahn
- Department of Microbiology, Immunology, and Molecular Genetics, University of California Los Angeles, Los Angeles, CA, United States.,Institute for Quantitative and Computational Biosciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Joanna Schaenman
- Department of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Zachary Qian
- Department of Microbiology, Immunology, and Molecular Genetics, University of California Los Angeles, Los Angeles, CA, United States.,Institute for Quantitative and Computational Biosciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Harry Pickering
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Victoria Groysberg
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Maura Rossetti
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Megan Llamas
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Alexander Hoffmann
- Department of Microbiology, Immunology, and Molecular Genetics, University of California Los Angeles, Los Angeles, CA, United States.,Institute for Quantitative and Computational Biosciences, University of California Los Angeles, Los Angeles, CA, United States
| | - David Gjertson
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, United States.,Department of Biostatistics, University of California Los Angeles, Los Angeles, CA, United States
| | - Mario Deng
- Department of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Suphamai Bunnapradist
- Department of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Elaine F Reed
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, United States
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21
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Pickering H, Sen S, Arakawa-Hoyt J, Ishiyama K, Sun Y, Parmar R, Ahn RS, Sunga G, Llamas M, Hoffmann A, Deng M, Bunnapradist S, Schaenman JM, Gjertson DW, Rossetti M, Lanier LL, Reed EF. NK and CD8+ T cell phenotypes predict onset and control of CMV viremia after kidney transplant. JCI Insight 2021; 6:153175. [PMID: 34609965 PMCID: PMC8663544 DOI: 10.1172/jci.insight.153175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/29/2021] [Indexed: 01/08/2023] Open
Abstract
CMV causes mostly asymptomatic but lifelong infection. Primary infection or reactivation in immunocompromised individuals can be life-threatening. CMV viremia often occurs in solid organ transplant recipients and associates with decreased graft survival and higher mortality. Furthering understanding of impaired immunity that allows CMV reactivation is critical to guiding antiviral therapy and examining the effect of CMV on solid organ transplant outcomes. This study characterized longitudinal immune responses to CMV in 31 kidney transplant recipients with CMV viremia and matched, nonviremic recipients. Recipients were sampled 3 and 12 months after transplant, with additional samples 1 week and 1 month after viremia. PBMCs were stained for NK and T cell markers. PBMC transcriptomes were characterized by RNA-Seq. Plasma proteins were quantified by Luminex. CD8+ T cell transcriptomes were characterized by single-cell RNA-Seq. Before viremia, patients had high levels of IL-15 with concurrent expansion of immature CD56bright NK cells. After viremia, mature CD56dim NK cells and CD28–CD8+ T cells upregulating inhibitory and NK-associated receptors were expanded. Memory NK cells and NK-like CD28–CD8+ T cells were associated with control of viremia. These findings suggest that signatures of innate activation may be prognostic for CMV reactivation after transplant, while CD8+ T cell functionality is critical for effective control of CMV.
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Affiliation(s)
- Harry Pickering
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Subha Sen
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Janice Arakawa-Hoyt
- Department of Microbiology and Immunology, Parker Institute for Cancer Immunotherapy, University of California, San Francisco, San Francisco, California, USA
| | - Kenichi Ishiyama
- Department of Microbiology and Immunology, Parker Institute for Cancer Immunotherapy, University of California, San Francisco, San Francisco, California, USA
| | - Yumeng Sun
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Rajesh Parmar
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Richard S Ahn
- Microbiology, Immunology, and Molecular Genetics.,Institute for Quantitative and Computational Biosciences, and
| | - Gemalene Sunga
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Megan Llamas
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Alexander Hoffmann
- Institute for Quantitative and Computational Biosciences, and.,Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Mario Deng
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Suphamai Bunnapradist
- Division of Nephrology, David Geffen School of Medicine, Los Angeles, California, USA
| | - Joanna M Schaenman
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - David W Gjertson
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, Los Angeles, California, USA.,Biostatistics, University of California, Los Angeles, Los Angeles, California, USA
| | - Maura Rossetti
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Lewis L Lanier
- Department of Microbiology and Immunology, Parker Institute for Cancer Immunotherapy, University of California, San Francisco, San Francisco, California, USA
| | - Elaine F Reed
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, Los Angeles, California, USA
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22
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Danovitch GM, Bunnapradist S, Cohen D, Hariharan S, McKay D, Ratner L, Stegall MD, Steiner RW, Stock PG, Vincenti F. Tests for the noninvasive diagnosis of kidney transplant rejection should be evaluated by kidney transplant programs. Am J Transplant 2021; 21:3811. [PMID: 34080294 DOI: 10.1111/ajt.16711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/26/2021] [Accepted: 06/01/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Gabriel M Danovitch
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Suphamai Bunnapradist
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - David Cohen
- Department of Surgery, Columbia University Medical School, New York, New York, USA
| | - Sundaram Hariharan
- Starzl Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dianne McKay
- Department of Immunology and Microbiology, Scripps Research, San Diego, California, USA
| | - Lloyd Ratner
- Department of Surgery, Columbia University Medical School, New York, New York, USA
| | - Mark D Stegall
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert W Steiner
- Department of Medicine, University of California at San Diego, San Diego, California, USA
| | - Peter G Stock
- Department of Surgery, University of California at San Francisco, San Francisco, California, USA
| | - Flavio Vincenti
- Department of Surgery, University of California at San Francisco, San Francisco, California, USA
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23
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Bunnapradist S, Tabriziani H. Authors' Reply. J Am Soc Nephrol 2021; 32:2973-2974. [PMID: 34716246 PMCID: PMC8806111 DOI: 10.1681/asn.2021081039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Suphamai Bunnapradist
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles at Los Angeles at California
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24
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Homkrailas P, Ayoub WS, Martin P, Bunnapradist S. Kidney utilization and outcomes of liver transplant recipients who were listed for kidney after liver transplant after the implementation of safety net policy. Clin Transplant 2021; 36:e14522. [PMID: 34716954 DOI: 10.1111/ctr.14522] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 09/28/2021] [Accepted: 10/16/2021] [Indexed: 01/07/2023]
Abstract
In 2017, United Network for Organ Sharing (UNOS) established the safety net policy with set criteria for offering kidney transplantation (KT) for patients who developed end-stage renal disease between 60 and 365 days after liver transplant (LT). We provide an update on the impact of the policy. We analyzed UNOS data of liver recipients transplanted between 1987 and 2020 who developed acute kidney injury requiring dialysis within 60 days before or after LT and subsequently listed for KT. We identified 407 patients who were listed for kidney after LT before policy and 248 patients after policy. Median waiting time to KT was shorter after policy (324 days vs. 2827 days). There was a higher proportion of candidates who were listed for subsequent KT within 1-year after policy (94.8% vs. 63.6%). KT rate was also higher after policy (87.7 vs. 30.7 per 100 patient-years at risk). Most importantly, we started to observe a net negative kidney utilization in end-stage liver disease setting (i.e., summation of simultaneous liver kidney and kidney after liver transplant in the first-year after LT has decreased from 1086 to 876 transplants in 2019). Such findings are consistent with a more efficient system and more appropriate allocation of organs.
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Affiliation(s)
- Piyavadee Homkrailas
- Department of Medicine, Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Department of Medicine, Division of Nephrology, Bhumibol Adulyadej Hospital, Bangkok, Thailand
| | - Walid S Ayoub
- Department of Medicine, Karsh Division of Gastroenterology and Hepatology, Comprehensive Transplant Center, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Paul Martin
- Division of Digestive Health and Liver Diseases, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Suphamai Bunnapradist
- Department of Medicine, Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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25
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Bunnapradist S, Homkrailas P, Ahmed E, Fehringer G, Billings PR, Tabriziani H. Using both the Fraction and Quantity of Donor-Derived Cell-Free DNA to Detect Kidney Allograft Rejection. J Am Soc Nephrol 2021; 32:2439-2441. [PMID: 34162734 PMCID: PMC8722815 DOI: 10.1681/asn.2021050645] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Suphamai Bunnapradist
- Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Piyavadee Homkrailas
- Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Ebad Ahmed
- R&D, Natera, Inc., San Carlos, California
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26
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Akalin E, Weir MR, Bunnapradist S, Brennan DC, Delos Santos R, Langone A, Djamali A, Xu H, Jin X, Dholakia S, Woodward RN, Bromberg JS. Clinical Validation of an Immune Quiescence Gene Expression Signature in Kidney Transplantation. Kidney360 2021; 2:1998-2009. [PMID: 35419538 PMCID: PMC8986041 DOI: 10.34067/kid.0005062021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/27/2021] [Indexed: 02/07/2023]
Abstract
Background Despite advances in immune suppression, kidney allograft rejection and other injuries remain a significant clinical concern, particularly with regards to long-term allograft survival. Evaluation of immune activity can provide information about rejection status and help guide interventions to extend allograft life. Here, we describe the validation of a blood gene expression classifier developed to differentiate immune quiescence from both T cell-mediated rejection (TCMR) and antibody-mediated rejection (ABMR). Methods A five-gene classifier (DCAF12, MARCH8, FLT3, IL1R2, and PDCD1) was developed on 56 peripheral blood samples and validated on two sample sets independent of the training cohort. The primary validation set comprised 98 quiescence samples and 18 rejection samples: seven TCMR, ten ABMR, and one mixed rejection. The second validation set included eight quiescence and 11 rejection samples: seven TCMR, two ABMR, and two mixed rejection. AlloSure donor-derived cell-free DNA (dd-cfDNA) was also evaluated. Results AlloMap Kidney classifier scores in the primary validation set differed significantly between quiescence (median, 9.49; IQR, 7.68-11.53) and rejection (median, 13.09; IQR, 11.25-15.28), with P<0.001. In the second validation set, the cohorts were statistically different (P=0.03) and the medians were similar to the primary validation set. The AUC for discriminating rejection from quiescence was 0.786 for the primary validation and 0.800 for the second validation. AlloMap Kidney results were not significantly correlated with AlloSure, although both were elevated in rejection. The ability to discriminate rejection from quiescence was improved when AlloSure and AlloMap Kidney were used together (AUC, 0.894). Conclusion Validation of AlloMap Kidney demonstrated the ability to differentiate between rejection and immune quiescence using a range of scores. The diagnostic performance suggests that assessment of the mechanisms of immunologic activity is complementary to allograft injury information derived from AlloSure dd-cfDNA. Together, these biomarkers offer a more comprehensive assessment of allograft health and immune quiescence.
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Affiliation(s)
- Enver Akalin
- Division of Nephrology, Kidney Transplant Program, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Matthew R. Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Suphamai Bunnapradist
- Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Daniel C. Brennan
- Comprehensive Transplant Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rowena Delos Santos
- Division of Nephrology, Washington University School of Medicine, St. Louis, Missouri
| | - Anthony Langone
- Vanderbilt University Medical Center, Medical Specialties Clinic, Veteran Affairs Hospital Renal Transplant Program, Nashville, Tennessee
| | - Arjang Djamali
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Hua Xu
- Research and Development, CareDx, Brisbane, California
| | - Xia Jin
- Research and Development, CareDx, Brisbane, California
| | - Sham Dholakia
- Medical Affairs, CareDx, South San Francisco, California
| | | | - Jonathan S. Bromberg
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
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27
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Lum EL, Nieves-Borrero K, Homkrailas P, Lee S, Danovitch G, Bunnapradist S. Title: Single center experience comparing two clinically available donor derived cell free DNA tests and review of literature. Transplantation Reports 2021. [DOI: 10.1016/j.tpr.2021.100079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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28
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Tan T, Bunnapradist S. Comparing the pharmacokinetics of extended-release tacrolimus (LCP-TAC) to immediate-release formulations in kidney transplant patients. Expert Opin Drug Metab Toxicol 2021; 17:1175-1186. [PMID: 34459696 DOI: 10.1080/17425255.2021.1974399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION One of the most commonly used immunosuppressants in organ transplant, tacrolimus exhibits wide interpatient and intrapatient variability and narrow therapeutic index that necessitates routine concentration monitoring and dosage adjustments. Availability of modified -release tacrolimus products offer once-daily dosing options. The objective of this review is to highlight and compare available pharmacokinetic (PK) data of extended-release tacrolimus tablets (LCP-TAC) to immediate-release tacrolimus (IR-TAC) in kidney transplant recipients. AREAS COVERED A review of the literature was performed using PubMed and Embase search to identify relevant articles evaluating PK data for LCP-TAC compared to IR-TAC in kidney transplant patients including special populations. EXPERT OPINION LCP-TAC's unique PK profile may be more favorable than IR-TAC. While the clinical impact of these PK differences have not been established, several outcomes are being evaluated in ongoing studies. Results of these studies will add information incrementally to care for kidney transplant patients. Larger prospective studies evaluating kidney and patient survival differences are needed but it is unlikely that they will be conducted. Given that the patent exclusivity of LCP-TAC for the next several years and imminent loss of exclusivity of PR-TAC, our opinion is the use of LCP-TAC will be increasing, especially in Europe.
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Affiliation(s)
- Teresa Tan
- Department of Pharmaceutical Services, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | - Suphamai Bunnapradist
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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29
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Sampaio MS, Lum EL, Homkrailas P, Gritsch HA, Bunnapradist S. Outcomes of small pediatric donor kidney transplants according to donor weight. Transpl Int 2021; 34:2403-2412. [PMID: 34431138 DOI: 10.1111/tri.14026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 08/05/2021] [Accepted: 08/13/2021] [Indexed: 11/27/2022]
Abstract
A small pediatric deceased donor (SPD) weight cutoff whether to transplant as en bloc (EB) or single pediatric (SP) kidney is uncertain. Using UNOS/OPTN data (2000-2019), 27 875 SPDs were divided by (i) EB (11.4%) or SP (88.6%) and (ii) donor weight [≤10 (5.4%), >10-15 (8.3%), >15-18 (3.7%), >18-20 (2.9%), and >20 kg (79.7%)]. SP >20 kg and adult deceased donors (grouped by Kidney Donor Profile Index, KDPI, <30, 30-85, and >85) were used as references. The primary outcome was 10-year graft failure. In SP <10 kg, the hazard ratio (HR) for overall graft failure was 1.64 (1.38-2.20) compared with EB <10 kg, and 1.45 (1.18-1.80) compared with SP >20 kg. In SP >10-15 kg, HR was 1.31 (1.12-1.54) compared with EB >10-15 kg, and 1.04 (0.91-1.18) compared with SP >20 kg. In SP >15 kg, the risk was the same as SP >20 kg. Ten-year overall graft survival of SP 12 kg was comparable to SP >20 kg (62% vs. 57%). Ten-year death censored graft failure of SP >10-15 kg (70%) and SP >15-18 kg (70%) was like the adult donors with KDPI 30-85 (67%). In conclusion, we recommend single kidney transplants from SPDs with weight >12 kg to adult recipients in centers with experience in SPD transplants to optimize organ utilization.
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Affiliation(s)
- Marcelo Santos Sampaio
- Department of Nephrology and Kidney Transplant, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.,Department of Nephrology, Veterans Affairs Greater Los Angeles Medical Center, Los Angeles, CA, USA
| | - Erik Lawrence Lum
- Department of Nephrology and Kidney Transplant, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Piyavadee Homkrailas
- Department of Nephrology and Kidney Transplant, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Hans Albin Gritsch
- Department of Urology and Kidney Transplant, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Suphamai Bunnapradist
- Department of Nephrology and Kidney Transplant, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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30
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Homkrailas P, Bunnapradist S. Association between ethnicity and kidney transplant waitlist outcomes beyond estimated post-transplant survival score. Transpl Int 2021; 34:1837-1844. [PMID: 34192375 DOI: 10.1111/tri.13965] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 11/28/2022]
Abstract
White kidney transplant candidates have the highest pre-transplant mortality rate compared to other ethnicities. The reason for a higher mortality rate is not well-understood. Estimated post-transplant survival (EPTS) score has been used to predict patient survival after transplant and may be associated with pre-transplant survival. First-time kidney transplant candidates listed between 2015 and 2018 were identified from the Organ Procurement Transplantation Network database. Individuals listed for multiple organs, at multiple centers, and age <18 years were excluded. We examined the impact of ethnicity on waitlist mortality and delisting. A total of 114 806 candidates were included. The study population was categorized into four groups which were 43% white, 28% Black, 19.2% Hispanic, and 9.8% "other ethnicities." At 5.2 years, the cumulative incidences of death and delist were 32%, 31%, 29%, and 26%, respectively. Compared to whites, adjusted subdistribution hazard ratio (aSHR) for death and delist among Black, Hispanics, and "other ethnicities" were 0.92 (95% CI 0.89-0.95), 0.89 (95% CI 0.85-0.91), and 0.76 (95% CI 0.72-0.80) after adjustment by EPTS along with other factors, respectively. After adjusting for EPTS score along with additional confounding factors and functional status at initial listing, white ethnicity was independently associated with an increased risk for death and delist.
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Affiliation(s)
- Piyavadee Homkrailas
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Division of Nephrology, Department of Medicine, Bhumibol Adulyadej Hospital, Bangkok, Thailand
| | - Suphamai Bunnapradist
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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31
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Cheungpasitporn W, Lentine KL, Tan JC, Kaufmann M, Caliskan Y, Bunnapradist S, Lam NN, Schnitzler M, Axelrod DA. Immunosuppression Considerations for Older Kidney Transplant Recipients. Curr Transplant Rep 2021; 8:100-110. [PMID: 34211822 PMCID: PMC8244945 DOI: 10.1007/s40472-021-00321-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW While kidney transplantation improves the long-term survival of the majority of patients with end-stage kidney disease (ESKD), age-related immune dysfunction and associated comorbidities make older transplant recipients more susceptible to complications related to immunosuppression. In this review, we discuss appropriate management of immunosuppressive agents in older adults to minimize adverse events, avoid acute rejection, and maximize patient and graft survival. RECENT FINDINGS Physiological changes associated with senescence can impact drug metabolism and increase the risk of posttransplant infection and malignancy. Clinical trials assessing the safety and efficacy of immunosuppressive agents in older adults are lacking. Recent findings from U.S. transplant registry-based studies suggest that risk-adjusted death-censored graft failure is higher among older patients who received antimetabolite avoidance, mammalian target of rapamycin inhibitor (mTORi)-based, and cyclosporine-based regimens. Observational data suggest that risk-adjusted mortality may be increased in older patients who receive mTORi-based and cyclosporine-based regimens but lower in those managed with T-cell induction and maintenance steroid avoidance/withdrawal. SUMMARY Tailored immunosuppression management to improve patient and graft survival in older transplant recipients is an important goal of personalized medicine. Lower intensity immunosuppression, such as steroid-sparing regimens, appear beneficial whereas mTORi- and cyclosporine-based maintenance are associated with greater potential for adverse effects. Prospective clinical trials to assess the safety and efficacy of immunosuppression agents in older recipients are urgently needed.
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32
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Faravardeh A, Akkina S, Villicana R, Guerra G, Moten MA, Meier-Kriesche U, Stevens DR, Patel SJ, Bunnapradist S. Efficacy and Safety of Once-Daily LCP-Tacrolimus Versus Twice-Daily Immediate-Release Tacrolimus in Adult Hispanic Stable Kidney Transplant Recipients: Sub-Group Analysis from a Phase 3 Trial. Ann Transplant 2021; 26:e929535. [PMID: 33859155 PMCID: PMC8056872 DOI: 10.12659/aot.929535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The pharmacokinetics and metabolism of tacrolimus, an immunosuppressant commonly used to prevent transplant rejection, can differ in specific subpopulations. This analysis examined treatment outcomes and safety of immediate-release tacrolimus (IR-Tac) and LCP-tacrolimus (LCPT) in stable Hispanic kidney transplant recipients. MATERIAL AND METHODS This was a post hoc analysis of clinical trial data from Hispanic adult stable kidney transplant recipients randomized to remain on IR-Tac or convert from IR-Tac to a reduced dose of LCPT (NCT00817206). Composite treatment failure was evaluated at 12 months. Estimated glomerular filtration rate and tacrolimus trough concentrations were evaluated over 12 months. RESULTS Fifty-five stable (LCPT n=26, IR-Tac n=29) kidney transplant recipients who self-identified as Hispanic or Latino were included in this analysis. Composite treatment failure occurred in 1 patient (4%) who converted to LCPT and 1 (3%) who remained on IR-Tac. The estimated glomerular filtration rate was stable over time and similar in the 2 treatment groups (P=0.08). Tacrolimus trough levels for both groups were similar over time in the 2 treatment groups (P=0.98). Treatment-emergent adverse events were similar in patients who converted to LCPT and in those who remained on IR-Tac. CONCLUSIONS Efficacy and safety were similar in Hispanic kidney transplant recipients who converted from IR-Tac to LCPT and in those remaining on IR-Tac.
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Affiliation(s)
| | - Sanjeev Akkina
- Loyola Outpatient Center, Loyola University Medical Center, Maywood, IL, USA
| | - Rafael Villicana
- Loma Linda University Transplant Institute, Loma Linda University Health, Loma Linda, CA, USA
| | - Giselle Guerra
- Miami Transplant Institute, University of Miami Health System, Miami, FL, USA
| | - Misbah A Moten
- Department of Medical Affairs, Veloxis Pharmaceuticals, Cary, NC, USA
| | | | - Daniel R Stevens
- Department of Medical Affairs, Veloxis Pharmaceuticals, Cary, NC, USA
| | - Samir J Patel
- Department of Medical Affairs, Veloxis Pharmaceuticals, Cary, NC, USA
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33
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Homkrailas P, Sampaio M, Datta N, Danovitch GM, Bunnapradist S. Impact of donor obesity on allograft outcomes after kidney transplantation adjusted for kidney donor profile index - a national cohort study. Transpl Int 2021; 34:681-688. [PMID: 33475204 DOI: 10.1111/tri.13826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/06/2020] [Accepted: 01/18/2021] [Indexed: 11/29/2022]
Abstract
Obesity in deceased kidney donors is a known risk factor for poor allograft outcomes. The Kidney Donor Profile Index (KDPI) has been introduced to predict graft survival in deceased donor kidney transplantation (DDKT). Obesity, however, is not included in KDPI. We study the impact of donor obesity on DDKT outcomes after adjusting for organ quality by KDPI. The Organ Procurement Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) data of DDKT from 2005 to 2017, with donor BMI ≥ 18.5 kg/m2 and weight >80 kg were included. There was a total of 66 382 DDKTs with 10 917 death-censored graft failures. For KDPI ≤ 30%, the 10-year death-censored graft survival (DCGS) rates among donor BMI < 30, 30-35, 35-40, 40-45 and ≥45 kg/m2 groups were 75.9%, 75.4%, 76.1%, 74.9% and 79.6%, respectively. For KDPI > 30%, 10-year DCGS rates were 67.5%, 66.1%, 65.9%, 62.6% and 63.2%, respectively. After adjusting for known confounding factors including KDPI, donor obesity was not independently associated with an increased risk for graft failure. In DDKT with donor weight >80 kg, donor obesity was not associated with a lower long term DCGS compared to non-obesity when KDPI ≤ 30%.
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Affiliation(s)
- Piyavadee Homkrailas
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Division of Nephrology, Department of Medicine, Bhumibol Adulyadej Hospital, Bangkok, Thailand
| | - Marcelo Sampaio
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Nakul Datta
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Gabriel M Danovitch
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Suphamai Bunnapradist
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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34
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Schaenman JM, Rossetti M, Liang EC, Lum E, Abdalla B, Bunnapradist S, Pham PT, Danovitch G, Reed EF, Cole SW. Leukocyte transcriptome indicators of development of infection in kidney transplant recipients. Clin Transplant 2021; 35:e14252. [PMID: 33570750 DOI: 10.1111/ctr.14252] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 01/18/2021] [Accepted: 01/31/2021] [Indexed: 12/01/2022]
Abstract
After kidney transplantation, infection and death are important clinical complications, especially for the growing numbers of older patients with limited resilience to withstand adverse events. Evaluation of changes in gene expression in immune cells can reveal the underlying mechanisms behind vulnerability to infection. A cohort of 60 kidney transplant recipients was evaluated. Gene expression in peripheral blood mononuclear cells 3 months after kidney transplantation was analyzed to compare differences between patients with infection and those who were infection-free in the first-year post-transplant. Pro-inflammatory genes such as IL1B, CCL4, and TNF were found to be downregulated in post-transplant PBMC from patients who developed infection. In contrast, genes involved in metabolism, HLA genes, and transcripts involved in type I interferon innate antiviral responses were found to be upregulated. Promoter-based bioinformatic analyses implicated increased activity of interferon regulatory factors, erythroid nuclear factor (E2), and CCAAT-enhancer-binding protein (C/EBP) in patients who developed infections. Differential patterns of gene expression were observed in patients who developed infection after kidney transplantation, with patterns distinct from changes associated with patient age, suggesting possible mechanisms behind vulnerability to infection. Assessment of gene expression in blood may offer an approach for patient risk stratification and monitoring after transplantation.
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Affiliation(s)
- Joanna M Schaenman
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Maura Rossetti
- Department of Pathology and Laboratory Medicine, UCLA Immunogenetics Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Emily C Liang
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Erik Lum
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Basmah Abdalla
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Suphamai Bunnapradist
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Phuong Thu Pham
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Gabriel Danovitch
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Elaine F Reed
- Department of Pathology and Laboratory Medicine, UCLA Immunogenetics Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Steve W Cole
- Department of Medicine, Division of Hematology-Oncology, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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35
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Schaenman J, Phonphok K, Spanuchart I, Duong T, Sievers TM, Lum E, Reed EF, Bunnapradist S. Early cytomegalovirus DNAemia and antiviral dose adjustment in high vs intermediate risk kidney transplant recipients. Transpl Infect Dis 2021; 23:e13457. [PMID: 32892447 PMCID: PMC7962879 DOI: 10.1111/tid.13457] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 06/24/2020] [Accepted: 08/11/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection continues to negatively affect outcomes for solid organ transplant recipients, despite the advent of strategies for preemptive surveillance and prophylaxis. The impact is especially great for CMV seronegative recipients of donor seropositive organs, who typically lack the ability to control CMV infection at the time of transplantation. METHODS We reviewed episodes of CMV DNAemia in a modern cohort of kidney transplant recipients over a 3-year period at a high-volume transplant center to investigate the frequency of DNAemia during antiviral prophylaxis. RESULTS Despite receipt of antiviral prophylaxis per current guidelines, 75 cases of CMV DNAemia were observed in the first 100 days after transplantation. For high risk patients, median time to DNAemia was 75 days after transplantation, and the majority of patients had experienced dose-reduction of valganciclovir due to renal insufficiency. Review of CMV seropositive intermediate risk patients demonstrated DNAemia occurring earlier after transplantation compared with high risk patients with a median time of 64 days (P = .029). The impact of valganciclovir dose adjustment was less notable in the intermediate risk group. CONCLUSIONS Guidelines recommend beginning routine surveillance for CMV after the completion of antiviral prophylaxis. Our findings suggest that closer monitoring may be beneficial, especially for high risk patients at risk for DNAemia. Patients requiring dose adjustment of valganciclovir due to renal insufficiency may be at increased risk for CMV DNAemia. Improved methods for CMV prophylaxis and evaluation of immunologic risk for CMV DNAemia and disease are needed to improve patient outcomes after kidney transplantation.
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Affiliation(s)
- Joanna Schaenman
- Division of Infectious Diseases, David Geffen School of Medicine, Los Angeles, CA 90095
| | - Korntip Phonphok
- Division of Nephrology, David Geffen School of Medicine, Los Angeles, CA 90095
| | - Ittikorn Spanuchart
- Division of Nephrology, David Geffen School of Medicine, Los Angeles, CA 90095
| | - Tin Duong
- Division of Nephrology, David Geffen School of Medicine, Los Angeles, CA 90095
| | - Theodore M. Sievers
- Division of Nephrology, David Geffen School of Medicine, Los Angeles, CA 90095
| | - Erik Lum
- Division of Nephrology, David Geffen School of Medicine, Los Angeles, CA 90095
| | - Elaine F. Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, Los Angeles, CA 90095
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Qaqish S, Datta N, Bunnapradist S, Lum EL. Listing Malignant Melanoma Patients for Renal Transplantation. Transplant Proc 2020; 52:3033-3037. [PMID: 32654800 DOI: 10.1016/j.transproceed.2020.04.1823] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 03/04/2020] [Accepted: 04/25/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Melanoma is an immune responsive malignancy and the need for immunosuppression for successful transplantation may lead to recurrent disease. The recommended waiting time is unknown with various groups recommending anywhere from no wait to 5 years. METHODS In this single-center, retrospective observational study all kidney transplant recipients' charts from 1991 to 2015 were reviewed for a diagnosis of melanoma before transplantation. The charts were reviewed for the clinical characteristics of melanoma pre transplantation, induction immunosuppression, maintenance immunosuppression, graft function, death, and recurrence of melanoma. RESULTS Thirteen patients with a history of melanoma underwent kidney transplantation during this period. Recipients had been in remission for an average of 7.0 years (range, 10 months to 20 years, median 6 years). Approximately 61.5% received a living donor transplant, antithymocyte globulin was administered in 23.1% of recipients, and the remaining 76.9% received basiliximab. Melanoma recurred in 1 patient (7.7%). Maintenance immunosuppression varied, but only 2 patients remained on standard triple therapy with prednisone, calcineurin inhibitor, and antimetabolite therapy. Average follow-up time since transplant was 7.5 years, with 1 patient death 9 years post transplant from sepsis. CONCLUSION In conclusion, with our center demonstrates safety of kidney transplantation in patients with a prior history of localized melanoma and shorter waiting time. In malignant melanoma stage 0 and 1, waiting the recommended 5 years from the time of remission to kidney transplantation should be reconsidered.
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Affiliation(s)
- Shaker Qaqish
- Department of Medicine, Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, California.
| | - Nakul Datta
- Department of Medicine, Division of Nephrology, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Suphamai Bunnapradist
- Department of Medicine, Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Erik L Lum
- Department of Medicine, Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, California
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Lum E, Bunnapradist S, Multani A, Beaird OE, Carlson M, Gaynor P, Kotton C, Abdalla B, Danovitch G, Kendrick E, Nieves-Borrero K, Pham PT, Yabu J, Schaenman J. Spectrum of Coronavirus Disease 2019 Outcomes in Kidney Transplant Recipients: A Single-Center Experience. Transplant Proc 2020; 52:2654-2658. [PMID: 33041077 PMCID: PMC7832798 DOI: 10.1016/j.transproceed.2020.09.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 09/08/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE We reviewed the clinical experience of kidney transplant recipients diagnosed with severe acute respiratory syndrome coronavirus 2 infection in order to understand the impact of the current coronavirus disease 2019 (COVID-19) pandemic infection on transplant recipients. Given that early reports from heavily affected areas demonstrated a very high mortality rate amongst kidney transplant recipients, ranging between 30% and 40%, we sought to evaluate outcomes at a center with a high burden of cases but not experiencing acute crisis due to COVID-19. PROCEDURES In this single center retrospective observational study, medical records of all kidney transplant recipients at the UCLA Medical Center were reviewed for a diagnosis of COVID-19 by polymerase chain reaction, followed by chart review to determine kidney transplant characteristics and clinical course. MAIN FINDINGS A total of 41 kidney transplant recipients were identified with COVID-19 positive polymerase chain reaction. Recipients had been transplanted for a median of 47 months before diagnosis. The large proportion of infected individuals were minorities (Hispanic 65.9%, black 14.6%), on prednisone, tacrolimus, and mycophenolate mofetil (95.1%, 87.8%, and 87.8%, respectively), and had excellent allograft function (median 1.25 mg/dL). The most common presenting symptoms were fever, dyspnea, or cough. Most patients were hospitalized (63.4%); mortality was 9.8% and occurred only in patients in the intensive care unit. The most common treatment was reduction or removal of antimetabolite (77.8%). Approximately 26.9% presented with AKI. CONCLUSIONS COVID-19 infection in kidney transplant recipients results in a higher rate of hospitalization and mortality than in the general population. In an area with a high number of infections, the mortality rate was lower compared with earlier reports from areas experiencing early surge and strain on the medical system. Minorities were disproportionately affected. Future studies are needed to determine optimal approach to treatment and management of immunosuppression in kidney transplant recipients with COVID-19 infection.
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Affiliation(s)
- Erik Lum
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Suphamai Bunnapradist
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Ashrit Multani
- Division of Infectious Diseases, UCLA David Geffen School of Medicine, University of California, Los Angeles, California
| | - Omer E Beaird
- Division of Infectious Diseases, UCLA David Geffen School of Medicine, University of California, Los Angeles, California
| | - Margrit Carlson
- Division of Infectious Diseases, UCLA David Geffen School of Medicine, University of California, Los Angeles, California
| | - Pryce Gaynor
- Division of Infectious Diseases, UCLA David Geffen School of Medicine, University of California, Los Angeles, California
| | - Camille Kotton
- Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Basmah Abdalla
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Gabriel Danovitch
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Elizabeth Kendrick
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Karid Nieves-Borrero
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Phuong T Pham
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Julie Yabu
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Joanna Schaenman
- Division of Infectious Diseases, UCLA David Geffen School of Medicine, University of California, Los Angeles, California.
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Phonphok K, Homkrailas P, Duong T, Panombualert S, Cho YW, Sampaio M, Lum EL, Bunnapradist S. Time to second kidney transplantation in young adults after failed pediatric kidney transplant. Pediatr Transplant 2020; 24:e13800. [PMID: 32722896 DOI: 10.1111/petr.13800] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/16/2020] [Accepted: 06/30/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Under the current kidney allocation system, pediatric candidates listed prior to age 18 receive priority for high-quality deceased donor organs. This has resulted in a decline in living donor transplantation in pediatrics, despite superior outcomes of living donor transplantation. Due to a young age at transplantation, most pediatric kidney transplant recipients require re-transplantation. The effects of a previously failed deceased donor vs a previously failed living donor on re-transplant candidates are unknown. METHODS Using the United Network for Organ Sharing database, we examined 2772 re-transplant recipients aged 18-30 years at time of relisting for second KT from 2000 to 2018 with history of prior pediatric KT (age ≤ 18 years). RESULTS PFLDKT recipients compared to those with PFDDKT had shorter median waiting times and dialysis time regardless of their second donor type (14.0 vs 20.3 months, and 19.1 vs 34.5 months, respectively). PFLDKT recipients had higher re-transplant rates (adjusted HR 1.17, 95% CI 1.09-1.27, and adjusted HR 1.05, 95% CI 0.95-1.15 when calculating from time of relisting and time of returning to dialysis, respectively). PFDDKT recipients were more likely to have higher median PRA levels (90% vs 73%). CONCLUSIONS Re-transplant candidates who received a previous deceased donor as a child had a higher level of sensitization, longer waiting time, and dialysis exposure compared to those with PFLDKT. Among primary pediatric kidney transplant candidates, consideration should be considered for living donor transplantation, despite the priority for deceased donor organs, to avoid increased sensitization and longer waiting times for with re-transplantation.
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Affiliation(s)
- Korntip Phonphok
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Division of Nephrology, Department of Medicine, Rajavithi Hospital, Bangkok, Thailand
| | - Piyavadee Homkrailas
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Division of Nephrology, Department of Medicine, Bhumibol Adulyadej Hospital, Bangkok, Thailand
| | - Tin Duong
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sunee Panombualert
- Division of Pediatric Nephrology, Department of Pediatrics, Khon Kaen University, Khon Kaen, Thailand
| | - Yong W Cho
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Marcelo Sampaio
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Erik L Lum
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Suphamai Bunnapradist
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Suwelack B, Bunnapradist S, Meier-Kriesche U, Stevens DR, Procaccianti C, Morganti R, Budde K. Effect of Concentration/Dose Ratio in De Novo Kidney Transplant Recipients Receiving LCP-Tacrolimus or Immediate-Release Tacrolimus: Post Hoc Analysis of a Phase 3 Clinical Trial. Ann Transplant 2020; 25:e923278. [PMID: 32719307 PMCID: PMC7412936 DOI: 10.12659/aot.923278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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] [Indexed: 11/24/2022] Open
Abstract
Background A previous phase 3 clinical trial in de novo adult kidney transplant recipients (NCT01187953) compared the efficacy and safety of once-daily LCP-tacrolimus (LCPT) and twice-daily immediate-release tacrolimus (IR-Tac). However, whether the rate of tacrolimus metabolism affects outcomes between LCPT and IR-Tac was not examined. Material/Methods Patients were initiated on 0.17 mg/kg/day LCPT or 0.1 mg/kg/day IR-Tac, with doses adjusted over time to maintain target therapeutic trough concentrations. This post hoc analysis examined dosing trends, relative efficacy, and safety of LCPT (n=247) and IR-Tac (n=249) in slow, intermediate, and rapid metabolizers as defined by concentration/dose ratios at day 30. Results For all metabolizer subgroups, minimum target tacrolimus trough concentrations were obtained more rapidly with LCPT than with IR-Tac. Slow metabolizers were more likely to exceed target trough concentrations with LCPT, while rapid metabolizers were more likely to fall below target trough concentrations with IR-Tac. Regardless of metabolizer status, significant differences were not detected between LCPT and IR-Tac for treatment failure, death, graft failure, biopsy-proven acute rejection, estimated glomerular filtration rate, or other clinical outcomes. Conclusions Although within metabolizer subgroups, attainment of target trough concentrations in the first week differed between LCPT and IR-Tac, these results suggest that, regardless of metabolizer phenotype, clinical outcomes do not differ between these formulations when dose adjustments are made. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT01187953
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Affiliation(s)
- Barbara Suwelack
- Department of Internal Medicine, Transplant Nephrology, University Hospital Münster, Westfalian Wilhelms University, Münster, Germany
| | - Suphamai Bunnapradist
- Division of Nephrology, University of California Los Angeles (UCLA) Medical Center, Los Angeles, CA, USA
| | | | | | | | | | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité - University Medicine Berlin, Berlin, Germany
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Korayem IM, Agopian VG, Lunsford KE, Gritsch HA, Veale JL, Lipshutz GS, Yersiz H, Serrone CL, Kaldas FM, Farmer DG, Bunnapradist S, Danovitch GM, Busuttil RW, Zarrinpar A. Factors predicting kidney delayed graft function among recipients of simultaneous liver-kidney transplantation: A single-center experience. Clin Transplant 2019; 33:e13569. [PMID: 31006141 DOI: 10.1111/ctr.13569] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 03/26/2019] [Accepted: 04/09/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Kidney delayed graft function (kDGF) remains a challenging problem following simultaneous liver and kidney transplantation (SLKT) with a reported incidence up to 40%. Given the scarcity of renal allografts, it is crucial to minimize the development of kDGF among SLKT recipients to improve patient and graft outcomes. We sought to assess the role of preoperative recipient and donor/graft factors on developing kDGF among recipients of SLKT. METHODS A retrospective review of 194 patients who received SLKT in the period from January 2004 to March 2017 in a single center was performed to assess the effect of preoperative factors on the development of kDGF. RESULTS Kidney delayed graft function was observed in 95 patients (49%). Multivariate analysis revealed that donor history of hypertension, cold static preservation of kidney grafts [versus using hypothermic pulsatile machine perfusion (HPMP)], donor final creatinine, physiologic MELD, and duration of delay of kidney transplantation after liver transplantation were significant independent predictors for kDGF. kDGF is associated with worse graft function and patient and graft survival. CONCLUSIONS Kidney delayed graft function has detrimental effects on graft function and graft survival. Understanding the risks and combining careful perioperative patient management, proper recipient selection and donor matching, and graft preservation using HPMP would decrease kDGF among SLKT recipients.
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Affiliation(s)
- Islam M Korayem
- Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California.,Department of Surgery, Hepato-Pancreato-Biliary and Liver Transplantation Surgery Unit, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Vatche G Agopian
- Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Keri E Lunsford
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, J.C. Walter Jr Transplant Center, Weill Cornell Medical College, Houston Methodist Hospital, Houston, Texas
| | - Hans A Gritsch
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Jeffrey L Veale
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Gerald S Lipshutz
- Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California.,Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Hasan Yersiz
- Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Coney L Serrone
- Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Fady M Kaldas
- Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Douglas G Farmer
- Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Suphamai Bunnapradist
- Division of Nephrology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Gabriel M Danovitch
- Division of Nephrology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Ronald W Busuttil
- Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Ali Zarrinpar
- Division of Transplantation and Hepatobiliary Surgery, University of Florida, Gainesville, Florida
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41
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Sethi S, Najjar R, Peng A, Mirocha J, Vo A, Bunnapradist S, Jordan SC, Huang E. Allocation of the Highest Quality Kidneys and Transplant Outcomes Under the New Kidney Allocation System. Am J Kidney Dis 2019; 73:605-614. [DOI: 10.1053/j.ajkd.2018.12.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 12/19/2018] [Indexed: 11/11/2022]
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Lum EL, Cárdenas A, Martin P, Bunnapradist S. Current Status of Simultaneous Liver-Kidney Transplantation in the United States. Liver Transpl 2019; 25:797-806. [PMID: 30861294 DOI: 10.1002/lt.25444] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 03/01/2019] [Indexed: 02/07/2023]
Abstract
On August 10, 2017, a formal policy was enacted in the United States that defined listing criteria for simultaneous liver-kidney transplantation and priority for patients who received a liver transplantation (LT) and subsequently developed significant kidney disease after LT. This article reviews and summarizes the rationale for such policies, the policies themselves, and the potential impact on LT candidates.
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Affiliation(s)
- Erik L Lum
- Division of Nephrology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA
| | - Andrés Cárdenas
- Institute of Digestive Diseases and Metabolism, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Paul Martin
- Division of Gastroenterology and Hepatology, Miller School of Medicine, University of Miami, Miami, FL
| | - Suphamai Bunnapradist
- Division of Nephrology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA
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Schaenman JM, Rossetti M, Lum E, Abdalla B, Bunnapradist S, Pham TP, Danovitch G, Reed EF, Cole S. Differences in Gene Expression in Older Compared With Younger Kidney Transplant Recipients. Transplant Direct 2019; 5:e436. [PMID: 30993190 PMCID: PMC6445656 DOI: 10.1097/txd.0000000000000870] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 01/16/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND For the growing numbers of older transplant patients, increased incidence of infection and death compared with younger patients may limit the many benefits provided by transplantation. However, little is known about age-associated immune dysfunction in the older transplant recipient. METHODS A cohort of 60 kidney transplant recipients, 23 older (≥ 60y) and 37 younger (30-59y), matched on antithymocyte induction and donor type (living vs deceased) was evaluated. Gene expression in peripheral blood mononuclear cells 3 months after kidney transplantation was analyzed to compare differences between older and younger patients. RESULTS Proinflammatory genes were upregulated in older kidney transplant patients, including cytokines IL1-β and IL-6. Downregulated genes were associated with B-cell and T-cell function, including CCR7 and CD27. Analysis of predicted transcription factor binding suggested an increase in proinflammatory transcription factor CCAAT/enhancer binding protein β-binding sites in older patients, whereas interferon regulatory factor 2 transcription factor binding sites were less prevalent. CONCLUSIONS Older kidney transplant recipients exhibited multiple differences in gene expression compared with younger patients, with upregulation of proinflammatory genes and downregulation of adaptive immune response genes. These findings may explain the mechanism of increased vulnerability to infection and malignancy observed in older transplant patients.
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Affiliation(s)
- Joanna M Schaenman
- Division of Infectious Diseases, Department of Medicine, UCLA Immunogenetics Center, Los Angeles, CA
| | - Maura Rossetti
- Department of Pathology and Laboratory Medicine, UCLA Immunogenetics Center, Los Angeles, CA
| | - Erik Lum
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Basmah Abdalla
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Suphamai Bunnapradist
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Thu-Phuong Pham
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Gabriel Danovitch
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Elaine F Reed
- Department of Pathology and Laboratory Medicine, UCLA Immunogenetics Center, Los Angeles, CA
| | - Steve Cole
- Division of Hematology-Oncology, Department of Medicine, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Schaenman J, Liao D, Phonphok K, Bunnapradist S, Karlamangla A. Predictors of Early and Late Mortality in Older Kidney Transplant Recipients. Transplant Proc 2019; 51:684-691. [PMID: 30979451 DOI: 10.1016/j.transproceed.2019.01.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 01/02/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Older kidney patients with chronic kidney disease benefit significantly from kidney transplantation. However, these older transplant recipients have greater mortality after transplantation than younger transplant recipients. Understanding the impact of comorbidities on post-transplant mortality can improve risk stratification and patient selection. METHODS A single-center analysis of 3105 kidney transplant recipients was performed over a 12-year period. Comorbidities associated with death were evaluated in older and younger transplant recipients. RESULTS The 2 most important factors associated with increased mortality in the first 100 days after transplant were recipient age ≥60 and receipt of deceased donor organs (adjusted odds ratios, 3.29 and 5.80, respectively), with no statistically significant impact of recipient comorbidities. In the later post-transplant period (after the first 100 days), recipient age ≥60 and receipt of deceased donor organs (adjusted hazard ratios [HR] of 2.14 and 2.29, respectively) remained predictors of mortality. We also found that donor age ≥60 and the recipient having cardiovascular disease and diabetes were independent predictors of increased mortality. There was a statistically significant interaction between diabetes and heart disease and recipient age ≥60, with a lesser impact on late mortality in older patients compared to younger patients. CONCLUSIONS This analysis suggests that comorbidities have a larger impact later after transplantation, with less effect on older recipients. These observations suggest that certain comorbid conditions should be evaluated differently in older patients compared to younger ones.
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Affiliation(s)
- J Schaenman
- Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - D Liao
- Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - K Phonphok
- Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, CA; Division of Nephrology, Department of Medicine, Rajavithi Hospital, Bangkok, Thailand
| | - S Bunnapradist
- Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - A Karlamangla
- Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA
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45
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Schaenman J, Rossetti M, Bunnapradist S, Liang E, Beaird O, Reed E, Cole S. 629. Blood Transcriptome Variations Predict Infection and Rejection in the Older Kidney Transplant Recipient. Open Forum Infect Dis 2018. [PMCID: PMC6253193 DOI: 10.1093/ofid/ofy210.636] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Compared with younger patients on similar immunosuppression regimens, older solid-organ transplant recipients experience increased rates of infection and death, but decreased rates of rejection. Our previous findings demonstrated increased T-cell immunosenescence and pro-inflammatory monocytes in older patients. This study sought to define the implications of transcriptome alterations for clinical outcomes. The objective of this abstract is to evaluate older vs. younger solid-organ transplant recipients for differential patterns of gene expression associated with infection and rejection. Methods Peripheral blood mononuclear cells were isolated from 23 older (≥age 60) and 37 matched younger (ages 30–59) kidney transplant recipients at 3 months after transplantation. RNA extraction was performed on banked PBMCs. Isolated RNA was converted to fluorescent cRNA and hybridized to Illumina Human HT-12 v4 BeadArrays. Gene expression values were quantile-normalized and log2-transformed for mixed effect linear model analyses to identify differential expression as a function of age, adjusted for induction type, donor type, and sex. Statistical analysis was performed using R software. Results Genes differentially expressed in older patients revealed an over-representation of pro-inflammatory genes and a down regulation of genes associated with the CD8 immune response. Patients who went on to develop infection demonstrated an increase in IRF transcription factor activation and plasmacytoid dendritic cell activity. Patients who developed rejection demonstrated an increase in myeloid lineage immune cell activity. Conclusion Differential patterns of gene expression were observed in patients who developed infection in the first year after kidney transplantation. These findings were distinct from the gene expression changes associated with development of rejection. These findings may explain the mechanism behind vulnerability to infection in older transplant patients. In addition, monitoring of changes in gene expression may provide an avenue for patient monitoring after transplantation as well as individualization of immune suppression after solid-organ transplantation. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Joanna Schaenman
- Division of Infectious Diseases, University of California, Los Angeles, Los Angeles, California
| | - Maura Rossetti
- David Geffen School of Medicine at UCLA, Department of Pathology, Los Angeles, California
| | | | - Emily Liang
- David Geffen School of Medicine, Los Angeles, California
| | - Omer Beaird
- Medicine – Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Elaine Reed
- David Geffen School of Medicine at UCLA, Department of Pathology, Los Angeles, California
| | - Steve Cole
- David Geffen School of Medicine, Division of Geriatrics, Los Angeles, California
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Shekhtman G, Huang E, Danovitch GM, Martin P, Bunnapradist S. Combined Dual-Kidney Liver Transplantation in the United States: A Review of United Network for Organ Sharing/Organ Procurement and Transplantation Network Data Between 2002 and 2012. Liver Transpl 2018; 24:1570-1577. [PMID: 29493877 DOI: 10.1002/lt.25045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 08/22/2016] [Accepted: 01/31/2018] [Indexed: 02/07/2023]
Abstract
In kidney-alone recipients, dual-kidney transplantation using "higher-risk" donor organs has shown outcomes comparable to those of single-kidney transplantation using extended criteria donor (ECD) organs. To investigate the feasibility of a similar approach with combined kidney-liver transplantation, we identified 22 dual-kidney liver transplantations (DKLTs) and 3044 single-kidney liver transplantations (SKLTs) performed in the United States between 2002 and 2012 using United Network for Organ Sharing/Organ Procurement and Transplantation Network registry data. We compared donor/recipient characteristics as well as graft/recipient survival between DKLT recipients and SKLT recipients of "higher-risk" kidneys (ECD and high kidney donor profile index [KDPI; >85%] donors). Despite having overall similar donor and recipient characteristics compared with both "higher-risk" donor groups, recipient survival in the DKLT group at 36 months was markedly inferior at 40.9% (compared with 67.5% for ECD SKLT recipients and 64.5% for high-KDPI SKLT recipients); nondeath-censored graft survival did not differ. Death was the most common cause of graft loss in all groups. Contrary to dual-kidney transplantation data in kidney-alone recipients, DKLT recipients in our study had inferior survival when compared with SKLT recipients of "higher-risk" donor kidneys. These findings would suggest that dual kidney-liver transplantation has an uncertain role as a strategy to expand the existing kidney donor pool in combined transplantation.
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Affiliation(s)
- Grigoriy Shekhtman
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | | | - Gabriel M Danovitch
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Paul Martin
- Department of Medicine, University of Miami Miller School of Medicine and the Miami Veterans Administration Hospital, Miami, FL
| | - Suphamai Bunnapradist
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
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Jordan SC, Bunnapradist S, Bromberg JS, Langone AJ, Hiller D, Yee JP, Sninsky JJ, Woodward RN, Matas AJ. Donor-derived Cell-free DNA Identifies Antibody-mediated Rejection in Donor Specific Antibody Positive Kidney Transplant Recipients. Transplant Direct 2018; 4:e379. [PMID: 30234148 PMCID: PMC6133406 DOI: 10.1097/txd.0000000000000821] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [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: 03/23/2018] [Accepted: 06/22/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Elevated levels of donor-derived cell-free DNA (dd-cfDNA) in the plasma of renal allograft recipients indicates organ injury and an increased probability of active rejection. Donor-specific antibodies (DSA) to HLA antigens are associated with risk of antibody-mediated rejection (ABMR). This study assessed the combined use of dd-cfDNA and DSA testing to diagnose active ABMR. METHODS Donor-derived cell-free DNA was assayed in 90 blood samples with paired DSA and clinically indicated biopsies from 87 kidney transplant patients. Sixteen cases met criteria for active ABMR. Performance characteristics of dd-cfDNA for diagnosis of active ABMR were determined for samples with prior or current positive DSA (DSA+, n = 33). RESULTS The median level of dd-cfDNA (2.9%) in DSA+ patients with active ABMR was significantly higher than the median level (0.34%) in DSA+ patients without ABMR (P < 0.001). The median level of dd-cfDNA in DSA- patients was 0.29%. The positive predictive value of dd-cfDNA (at 1%) to detect active ABMR in DSA+ patients was 81%, whereas the negative predictive value was 83%. The positive predictive value for DSA+ alone was 48%. CONCLUSIONS The combined use of dd-cfDNA and DSA testing may improve the noninvasive diagnosis of active ABMR in kidney transplant patients. Patients with dd-cfDNA+/ DSA+ results have a high probability of active ABMR.
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Affiliation(s)
- Stanley C Jordan
- Division of Nephrology, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Suphamai Bunnapradist
- Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
| | - Jonathan S Bromberg
- Departments of Surgery and Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD
| | - Anthony J Langone
- Department of Medicine, Vanderbilt University Medical Center, and Medical Specialties Clinic, Veteran Affairs Hospital Renal Transplant Program, Nashville, TN
| | | | - James P Yee
- Clinical Research, CareDx, Inc, Brisbane, CA
| | | | | | - Arthur J Matas
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN
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Affiliation(s)
- Larry A Weinrauch
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass; Kidney and Hypertension Section, Joslin Diabetes Center, Boston, Mass; Departments of Medicine andSurgery,Beth Israel Deaconess Medical Center, Boston, Mass; Harvard Medical School, Boston, Mass
| | - John A D'Elia
- Kidney and Hypertension Section, Joslin Diabetes Center, Boston, Mass; Departments of Medicine andSurgery,Beth Israel Deaconess Medical Center, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Matthew R Weir
- Division of Nephrology, Departmentof Medicine, University of Maryland School of Medicine, Baltimore
| | - Suphamai Bunnapradist
- Division of Nephrology, Departmentof Medicine, University of Californiaat Los Angeles, Los Angeles
| | - Peter V Finn
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass
| | - Jiankang Liu
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass
| | - Anthony P Monaco
- Departments of Medicine andSurgery,Beth Israel Deaconess Medical Center, Boston, Mass; Harvard Medical School, Boston, Mass; Division of Nephrology, New EnglandMedical Center, Tufts UniversitySchool of Medicine, Boston,Mass
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Hanna RM, Lopez EA, Hasnain H, Selamet U, Wilson J, Youssef PN, Akladeous N, Bunnapradist S, Gorin MB. Three patients with injection of intravitreal vascular endothelial growth factor inhibitors and subsequent exacerbation of chronic proteinuria and hypertension. Clin Kidney J 2018; 12:92-100. [PMID: 30746134 PMCID: PMC6366143 DOI: 10.1093/ckj/sfy060] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 05/28/2018] [Indexed: 12/31/2022] Open
Abstract
Vascular endothelial growth factor (VEGF) receptor inhibition is a commonly used tool to prevent vascular proliferation in tumors and retinal diseases. The antiangiogenic effects of these drugs have made them potent adjunct therapies when given systemically for malignancies. They are also useful tools to ameliorate diminishing eyesight in retinopathy. Hypertension and proteinuria have been observed in systemic VEGF inhibitor therapy, with rarer presentations involving nephrotic-range proteinuria due to glomerulopathies. Pharmacokinetic studies have shown detectable blood levels of anti-VEGF inhibitors up to 30 days postintravitreal injection. Animal studies have also demonstrated binding of VEGF inhibitors in simian glomeruli 1 week after a single intravitreal injection. We report three patients who received intravitreal bevacizumab and/or aflibercept with worsening hypertension, proteinuria and renal injury. Data regarding emerging evidence of VEGF inhibitor nephrotoxicity after intravitreal injections are also presented. The clinical data and the existing literature are reviewed to support the hypothesis that intravitreal anti-VEGF agents may be unrecognized nephrotoxins. These agents are given to vulnerable patients with diabetes, hypertension and preexisting nephropathy and proteinuria. This case series is reported to spur further study of the systemic effects of intravitreal VEGF inhibitors.
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Affiliation(s)
- Ramy M Hanna
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Eduardo A Lopez
- Division of Nephrology, Department of Medicine, Kaiser Permanente Panorama City, Panorama City, CA, USA
| | - Huma Hasnain
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Umut Selamet
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - James Wilson
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Peter N Youssef
- Division of Transplant Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Nermeen Akladeous
- Department of Preventative Medicine, Loma Linda University School of Medicine, Los Angeles, CA, USA
| | - Suphamai Bunnapradist
- Division of Ophthalmology, Department of Surgery, Kaiser Permanente La Palma, La Palma, CA, USA
| | - Michael B Gorin
- Retinal Disorders and Ophthalmic Genetics, Department of Ophthalmology, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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Phonphok K, Beaird O, Duong T, Datta N, Schaenman J, Bunnapradist S. Screening Coccidioides serology in kidney transplant recipients: A 10-year cross-sectional analysis. Transpl Infect Dis 2018; 20:e12932. [PMID: 29809303 DOI: 10.1111/tid.12932] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/28/2018] [Accepted: 05/17/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Kidney transplant recipients (KTRs) are at risk for reactivation and complicated infection due to Coccidioides. Pre-transplant serological screening should provide benefit for patients from endemic areas. We evaluated Coccidioides seroprevalence by area of residence in KTRs at a major transplant program in Los Angeles. METHODS We performed cross-sectional analyses of adult KTRs who underwent transplantation at UCLA between 2007-2016. Patients with Coccidioides serology by enzyme immunoassay (EIA) before or within 14 days from transplantation were included. Patients were classified as living in highly, established, suspected, or not endemic areas by their residential zip code. RESULTS Overall prevalence of Coccidioides IgG and IgM were 1.4% and 2.8%, respectively. Of patients with positive serology, 31.4% had isolated IgG and 66.3% isolated IgM. Patients from established and highly endemic areas had IgG seropositivity of 3.7% versus 1.3% for patients living in suspected endemic areas(P < .01). Rates of IgM seropositivity were 3.7% compared to 2.8% respectively (P = .28). No patients from non-endemic areas had positive screening serology. CONCLUSIONS Pre-transplant serological screening for Coccidioides is recommended in kidney transplant candidates from endemic areas. We observed high seroprevalence among patients from highly and established endemic areas, for whom universal prophylaxis is recommended. For residents from less well-established areas of endemicity, serological screening showed benefit in identifying patients at risk. In patients with isolated EIA IgM, performing repeat and confirmatory tests is recommended. Patients from non-endemic areas had low risk of infection, however, a thorough social history is necessary to evaluate risk.
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Affiliation(s)
- Korntip Phonphok
- Department of Medicine, Division of Nephrology, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Medicine, Division of Nephrology, Rajavithi Hospital, Bangkok, Thailand
| | - Omer Beaird
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Tin Duong
- Department of Medicine, Division of Nephrology, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Nakul Datta
- Department of Medicine, Division of Nephrology, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Joanna Schaenman
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Suphamai Bunnapradist
- Department of Medicine, Division of Nephrology, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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