Başkent Üniversitesi Yayınları
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Item Treatment of Antibody-Mediated Rejection in Kidney Transplant Recipients: A Single-Center Experience With a Bortezomib-Based Regimen(Başkent Üniversitesi, 2012-12) Nigos, Janice G.; Sureshkumar, Kalathil K.; Ko, Tina Y.; Marcus, Richard J.; Hussain, Sabiha M.; Nath, Parineesha; Arora, SwatiObjectives: Antibody-mediated rejection after kidney transplant is less responsive to conventional antirejection therapies. The proteasome inhibitor bortezomib has activity against mature plasma cells that produce damaging donor-specific antibodies. We present our experience of using a bortezomib-based regimen in patients with severe antibody-mediated rejection. Materials and Methods: A retrospective chart review was performed on patients with biopsy-proven antibody-mediated rejection after kidney transplant at our institution over 12 months. Diagnosis of antibody-mediated rejection was made on the basis of positive peritubular capillary C4d staining along with either histologic evidence of acute rejection or positive donor-specific antibody titers. Treatment for antibody-mediated rejection included plasmapheresis, intravenous immunoglobulin, steroids, single-dose rituximab (375 mg/m2) along with bortezomib (1.3 mg/m2) on days 1, 4, 8, and 11. Antibody-mediated rejection was diagnosed in 6 patients. Patients received induction with either alemtuzumab (n=4) or rabbit-antithymocyte globulin (n=2) and were maintained on a tacrolimus/mycophenolate mofetil/early steroid withdrawal protocol. Results: Four of 6 patients responded to treatment. Patients had stable kidney function during follow-up (median 14 months) after bortezomib therapy. Conclusions: In this series, we demonstrated the effectiveness of a bortezomib-based treatment regimen in achieving reduction of donor-specific antibody titers and stable renal function in patients experiencing severe antibody-mediated rejection.Item Impact of the Addition of Maintenance Steroids to a Rapid Steroid Discontinuation Immunosuppressive Protocol Following Acute Renal Transplant Rejection(Başkent Üniversitesi, 2009-12) Arora, Swati; Sureshkumar, Kalathil K.; Dikkala, Sudharani; Marcus, Richard J.Objectives: Rapid steroid discontinuation immunosuppressive protocols are increasingly used in renal transplant. The optimal immunosuppressive regimen in patients who develop acute rejection while on a rapid steroid discontinuation protocol is less clear. We examined our experience of adding maintenance steroid therapy in renal transplant recipients who developed 1 or more acute rejection episode while on a rapid steroid discontinuation protocol. Materials and Methods: The outcome of 145 patients who underwent renal transplant from 2002 to 2007 and initiated a rapid steroid discontinuation protocol was analyzed. Patients were divided into the following 5 groups: (i): acute rejection × 1 and no maintenance steroids, (ii): acute rejection × 1 and started on maintenance steroids, (iii): acute rejection × 2 and no maintenance steroids (iv): acute rejection × 2 and started on maintenance steroids, and (v): no acute rejection Results: Compared with patients with no acute rejection, graft survival was significantly inferior in patients who experienced 2 or more acute rejection episodes—whether they were started on maintenance steroids (P = .003) or not (P = .006)—but was similar in patients who experienced only 1 episode of acute rejection, and were started either on maintenance steroids (P = .87) or were continued on the rapid steroid discontinuation protocol (P = .69). In patients who sustained 2 episodes of acute rejection, addition of maintenance steroids had no impact on graft survival (P = .97). Conclusions: More than 1 episode of acute rejection in renal transplant recipients on rapid steroid discontinuation protocol is associated with poor, long-term, graft survival, which remains unchanged despite starting maintenance steroids. The use of maintenance steroids may not have a positive impact on graft survival after acute rejection.Item Steroid Avoidance in Renal Transplant Patients Maintained on a Cyclosporine-based Protocol(2007-12) Ko, Tina Y; Julie A Haddy,; Sureshkumar, Kalathil K.; Breckenridge, Molly; Patel, Satish; Marcus, Richard J.; Sandroni, Stephen E.; McGill, Rita L.; Carpenter, Barbara J.; Nghiem, Dai D.Objective: The aim of this study was to analyze the effect of steroid avoidance, as compared with our pre-existing protocol that contained steroids, on renal allograft and patient survival. Secondary outcomes included body weight, diabetes, hyperlipidemia, and infection. Materials and Methods: This retrospective chart review of the results of steroid avoidance was performed in 169 patients who had undergone renal transplant between January 2000 and March 2002 and had received an immunosuppression regimen of cyclosporine, mycophenolate mofetil, and prednisone; and 148 patients who had undergone transplant between November 2002 and November 2004 who had received induction immunosuppression with a steroid taper by postoperative day 4 and were maintained on cyclosporine and mycophenolate mofetil. Results: One-year allograft survival rates, rejection-free graft survival rates, and patient survival rates were 88%, 76%, and 97%, respectively, in the steroid-maintenance group compared with 90%, 74%, and 96%, respectively, in the steroid-avoidance group (P = NS). No differences were detected in multiple secondary variables related to the metabolic effects of steroid therapy. Conclusions: These data suggest that steroid avoidance can be performed safely and effectively in patients on a cyclosporine-based protocol of immunosuppression. Longer follow-ups are suggested to determine the effects of limited steroid exposure on the metabolic profiles of patients.