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Comparison of cyclosporine and tacrolimus after liver transplantation for primary biliary cholangitis: A propensity-score matched intention-to-treat registry study. 原发性胆汁性胆管炎肝移植后环孢素与他克莫司的比较:倾向分数匹配的意向治疗登记研究。
IF 8.8 2区 医学 Q1 SURGERY Pub Date : 2024-10-12 DOI: 10.1016/j.ajt.2024.10.010
Fredrik Åberg,Ville Sallinen,Samuli Tuominen,Ilkka Helanterä,Arno Nordin
The optimal calcineurin inhibitor after liver transplantation (LT) for primary biliary cholangitis (PBC) remains debated. We compared tacrolimus with cyclosporine in a propensity score-matched intention-to-treat analysis from the Scientific Registry of Transplant Recipients. We included adults with PBC who underwent primary LT 1995-2022. Patients with initial cyclosporine treatment were 1:3 matched with those with initial tacrolimus treatment, ensuring exact calendar-period match. Primary outcomes were patient and graft survival. After matching, 579 patients with PBC and initial cyclosporine and 1348 with tacrolimus were well balanced for baseline characteristics. During a median follow-up of 11.1 years, 1044 (54%) deaths and 124 (6%) re-LTs occurred. In the overall matched sample, no significant survival difference emerged between cyclosporine and tacrolimus. However, tacrolimus conferred a survival advantage in some secondary analysis such as LT after year 2000, women, and in a 6-month landmark analysis excluding early post-operative events and calcineurin-inhibitor switches. Cyclosporine did not reduce graft loss from PBC recurrence or affect laboratory markers of recurrence. In conclusion, we found no benefit of starting immunosuppression with cyclosporine after LT for PBC.
原发性胆汁性胆管炎(PBC)肝移植(LT)后的最佳钙神经蛋白抑制剂仍存在争议。我们在移植受者科学登记处进行的倾向得分匹配意向治疗分析中比较了他克莫司和环孢素。我们纳入了 1995-2022 年接受初治 LT 的成年 PBC 患者。初次接受环孢素治疗的患者与初次接受他克莫司治疗的患者按1:3配对,确保日历与时间完全匹配。主要结果是患者和移植物存活率。配对后,579 名首次接受环孢素治疗的 PBC 患者和 1348 名首次接受他克莫司治疗的患者的基线特征非常均衡。在中位 11.1 年的随访期间,有 1044 人(54%)死亡,124 人(6%)再次接受长程移植。在整个匹配样本中,环孢素和他克莫司的存活率没有明显差异。不过,在一些二次分析中,如2000年后的LT、女性,以及在排除早期术后事件和钙神经蛋白抑制剂转换的6个月标志性分析中,他克莫司具有生存优势。环孢素并不能减少PBC复发造成的移植物损失,也不会影响复发的实验室指标。总之,我们发现在PBC的LT术后开始使用环孢素进行免疫抑制没有任何益处。
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引用次数: 0
Lung Transplant Consortium: Collecting Data to Guide Best Practices. 肺移植联盟:收集数据,指导最佳实践。
IF 8.9 2区 医学 Q1 SURGERY Pub Date : 2024-10-10 DOI: 10.1016/j.ajt.2024.10.003
By Lara C Pullen
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引用次数: 0
Terminally differentiated effector memory T cells in kidney transplant recipients: New crossroads. 肾移植受者的 TEMRA:新的十字路口。
IF 8.9 2区 医学 Q1 SURGERY Pub Date : 2024-10-09 DOI: 10.1016/j.ajt.2024.10.001
Steven Van Laecke, Griet Glorieux

Immunosenescence, the age-related dysregulation of innate and adaptive immunity, impairs immune response and increases inflammation, leading to higher infection and cardiovascular risks, particularly outside the field of transplantation. In kidney transplant recipients (KTRs), conditions like cytomegalovirus infection, old age, uremia, smoking, and diabetes, linked to poor outcomes, are associated with enhanced immunosenescence. Recent studies highlight the pathogenic role of cytotoxic T cells, particularly terminally differentiated effector memory T cells that reexpress CD45RA (TEMRA), in graft dysfunction. A higher proportion of circulating CD8+ TEMRA cells is observed in KTRs with chronic rejection. In antibody-mediated rejection, they invade the graft by superior chemotactic properties and binding to human leukocyte antigen (HLA) antibodies through FcγRIIIa (CD16). Also in microvascular inflammation without donor-specific antibodies, and even in patients without rejection but faster decline of kidney function, intragraft CD8+ TEMRA cells were instrumental. CD8+ TEMRA cells may explain the unresolved dismal graft outcomes associated with donor age and cytomegalovirus-serostatus mismatching and could become a novel therapeutic target in KTRs.

免疫衰老是与年龄有关的先天性免疫和适应性免疫失调,会损害免疫反应并增加炎症,从而导致更高的感染和心血管风险,尤其是在移植领域之外。在肾移植受者(KTRs)中,CMV 感染、高龄、尿毒症、吸烟和糖尿病等与不良预后相关的疾病都与免疫衰老的增强有关。最近的研究强调了细胞毒性 T 细胞,尤其是重新表达 CD45RA(TEMRA)的终末分化效应记忆 T 细胞在移植物功能障碍中的致病作用。在出现慢性排斥反应的 KTR 中,可观察到较高比例的循环 CD8+ TEMRA 细胞。在抗体介导的排斥反应中,TEMRA 细胞通过 FcγRIIIa (CD16) 与 HLA 抗体结合,并通过其卓越的趋化特性侵入移植物。在无 DSA 的微血管炎症中,甚至在无排斥反应但肾功能下降较快的患者中,移植物内 CD8+ TEMRA 细胞也发挥了重要作用。CD8+ TEMRA细胞可能解释了与供体年龄和CMV-血清状态不匹配相关的令人沮丧的移植结果,并可能成为KTR的一个新的治疗靶点。
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引用次数: 0
The burden of COVID-19 mortality among solid organ transplant recipients in the United States. 美国实体器官移植受者的 COVID-19 死亡率负担。
IF 8.9 2区 医学 Q1 SURGERY Pub Date : 2024-10-09 DOI: 10.1016/j.ajt.2024.10.004
Karena D Volesky-Avellaneda, Ruth M Pfeiffer, Meredith S Shiels, David Castenson, Jonathan M Miller, Jeanny H Wang, Kelly J Yu, Florent Avellaneda, Allan B Massie, Dorry L Segev, Ajay K Israni, Jon J Snyder, Eric A Engels

Solid organ transplant recipients (SOTRs) have a heightened risk of adverse coronavirus disease 2019 (COVID-19) outcomes because of immunosuppression and medical comorbidity. We quantified the burden of COVID-19 mortality in United States (US) SOTRs. A sample of deaths documented in the US solid organ transplant registry from June 2020 through December 2022 was linked to the National Death Index to identify COVID-19 deaths and weighted to represent all SOTR deaths during the study period. Among 505 757 SOTRs, 57 575 deaths occurred, and based on the linkage, 12 396 (21.5%) were due to COVID-19. COVID-19 mortality was higher in males (mortality rate ratio [MRR]: 1.13), SOTRs aged 65 years and older (MRR: 1.50 in ages 65-74 vs ages 55-64 years), and non-Hispanic Black and Hispanic SOTRs (MRRs: 1.55 and 1.79 vs non-Hispanic White SOTRs). Kidney and lung recipients had the highest COVID-19 mortality, followed by heart, and then liver recipients. COVID-19 mortality also varied over time and across US states. Overall, SOTRs had a 7-fold increased risk of COVID-19 death compared to the US general population. SOTRs comprised 0.13% of the US population but accounted for 1.46% of all US COVID-19 deaths. SOTRs experience greatly elevated COVID-19 mortality. Clinicians should continue to prioritize COVID-19 prevention and treatment in this high-risk population.

由于免疫抑制和内科合并症,实体器官移植受者(SOTRs)发生 COVID-19 不良结局的风险更高。我们对美国实体器官移植受者的 COVID-19 死亡率进行了量化。我们将 2020 年 6 月至 2022 年 12 月期间美国实体器官移植登记处记录的死亡样本与国家死亡指数(National Death Index)进行了链接,以识别 COVID-19 死亡病例,并对研究期间所有 SOTR 死亡病例进行了加权。在505,757例SOTR中,有57,575例死亡,根据链接结果,有12,396例(21.5%)是由于COVID-19引起的。男性(死亡率比 [MRR]:1.13)、65 岁及以上的 SOTR(65-74 岁与 55-64 岁相比,死亡率比为 1.50)以及非西班牙裔黑人和西班牙裔 SOTR(与非西班牙裔白人相比,死亡率比分别为 1.55 和 1.79)的 COVID-19 死亡率较高。肾脏和肺部受者的 COVID-19 死亡率最高,其次是心脏受者,然后是肝脏受者。COVID-19 死亡率也随时间和美国各州而变化。总体而言,与美国普通人群相比,SOTRs 的 COVID-19 死亡风险增加了 7 倍。SOTRs占美国总人口的0.13%,但却占美国COVID-19死亡总人数的1.46%。SOTRs的COVID-19死亡率大大增加。临床医生应继续优先考虑这一高风险人群的 COVID-19 预防和治疗。
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引用次数: 0
Serum and tissue biomarkers of plasma cell-rich rejection in liver transplant recipients. 肝移植受者富含浆细胞排斥反应的血清和组织生物标志物。
IF 8.9 2区 医学 Q1 SURGERY Pub Date : 2024-10-09 DOI: 10.1016/j.ajt.2024.10.006
Nivetha Saravanan, Anthony Demetris, Maria Isabel Fiel, Claire Harrington, Nigar Anjuman Khurram, Thomas D Schiano, Josh Levitsky

The distinction between autoimmune and alloimmune reactions in liver transplant recipients can be challenging. Plasma cell-rich rejection (PCRR), previously known as de novo autoimmune hepatitis or plasma cell hepatitis, is an atypical and underrecognized form of allograft rejection observed post-liver transplantation, often in conjunction with features of T cell-mediated and antibody-mediated rejection. If PCRR is not recognized and treated with prompt immunosuppressive augmentation, patients can develop advanced hepatic fibrosis, necroinflammation, and allograft failure. Given the significant morbidity and mortality associated with PCRR, there exists a need to develop noninvasive biomarkers which can be used in screening, diagnosis, and treatment monitoring of PCRR. This study is a literature review of candidate serum-based and tissue-based biomarkers in adult and pediatric liver transplant PCRR. We also discuss biomarkers from plasma cell-rich processes observed in other disease states and other organ transplant recipients that might be tested in liver transplant PCRR. We conclude with proposed future directions in which biomarker implementation into clinical practice could lead to advances in personalized management of PCRR.

区分肝移植受者的自身免疫反应和同种免疫反应可能很有难度。富含浆细胞的排斥反应(PCRR)以前被称为 "新生自身免疫性肝炎 "或 "浆细胞肝炎",是肝移植术后出现的一种非典型、未得到充分认识的异体移植排斥反应,通常与T细胞介导的排斥反应和抗体介导的排斥反应并存。如果 PCRR 没有被及时发现并通过增强免疫抑制进行治疗,患者可能会发展为晚期肝纤维化、坏死性炎症和异体移植失败。鉴于 PCRR 会导致严重的发病率和死亡率,因此有必要开发可用于 PCRR 筛查、诊断和治疗监测的无创生物标志物。本文对成人和儿童肝移植 PCRR 的候选血清和组织生物标志物进行了文献综述。我们还讨论了在其他疾病状态和其他器官移植受者中观察到的血浆细胞丰富过程中的生物标记物,这些标记物可能会在肝移植 PCRR 中进行测试。最后,我们提出了未来的发展方向,将生物标志物应用于临床实践可促进 PCRR 的个性化管理。
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引用次数: 0
Antiplasma cell antibodies: A new era of human leukocyte antigen antibody control in solid organ transplantation. 抗浆细胞抗体:实体器官移植中 HLA 抗体控制的新时代?
IF 8.9 2区 医学 Q1 SURGERY Pub Date : 2024-10-09 DOI: 10.1016/j.ajt.2024.10.005
Sindhu Chandran, Flavio Vincenti

New therapies directed against plasma cells such as anti-CD38 antibodies and the bispecific anti-B cell maturation antigen antibodies, represent not only an important advance in the treatment of multiple myeloma but have the potential to change the treatment landscape of other antibody-mediated diseases. In solid organ transplantation, the therapeutic armamentarium targeting humoral alloimmune responses in desensitization of highly sensitized transplant candidates and posttransplant antibody-mediated rejection has lagged behind advances in preventing and treating T cell-mediated rejection. Intravenous immunoglobulin and plasmapheresis are used extensively but have limited efficacy. Currently available anti-CD20 antibodies are only partially effective in achieving B cell depletion and leaving mature plasma cells untouched. Although interleukin 6 plays an important role in the humoral alloimmune response and injury, the benefits of interleukin 6 inhibition have failed to be demonstrated in clinical trials. Even proteasome inhibitors developed specifically to target plasma cells have not fulfilled their promise, due to limited efficacy as single agents. This review focuses on the recent experience with, and potential applicability of, anti-CD38 antibodies in the field of organ transplantation and experimental data supporting their use and development for human leukocyte antigen desensitization and antibody-mediated rejection.

针对浆细胞的新疗法,如抗CD38抗体和双特异性抗BCMA抗体,不仅是治疗多发性骨髓瘤的重要进展,而且有可能改变其他抗体介导疾病的治疗格局。在实体器官移植领域,针对高敏移植候选者脱敏过程中的体液同种免疫反应和移植后抗体介导的排斥反应的治疗手段落后于预防和治疗 T 细胞介导的排斥反应的进展。IVIg和血浆置换被广泛使用,但疗效有限。目前可用的抗 CD20 抗体只能部分有效地清除 B 细胞,而成熟的浆细胞则不受影响。虽然白细胞介素 6 在体液同种免疫反应和损伤中发挥着重要作用,但抑制 IL-6 所带来的益处却未能在临床试验中得到证实。即使是专门针对浆细胞开发的蛋白酶体抑制剂,由于单药疗效有限,也未能实现其承诺。本综述将重点介绍抗CD38抗体在器官移植领域的最新应用经验和潜在适用性,以及支持其用于HLA脱敏和抗体介导的排斥反应的实验数据。
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引用次数: 0
Use of COVID-19 vaccines for persons aged ≥6 months: Recommendations of the Advisory Committee on Immunization Practices - United States, 2024-2025. 对年龄≥6 个月者使用 COVID-19 疫苗:免疫实践咨询委员会的建议 - 美国,2024-2025 年。
IF 8.9 2区 医学 Q1 SURGERY Pub Date : 2024-10-05 DOI: 10.1016/j.ajt.2024.10.002
Marcus R Pereira
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引用次数: 0
Belatacept-related cytomegalovirus infection: Advocacy for tailored immunosuppression based on individual assessment of immune fitness. 与贝拉替塞相关的巨细胞病毒感染:提倡根据个人免疫健康状况的评估采取有针对性的免疫抑制措施。
IF 8.9 2区 医学 Q1 SURGERY Pub Date : 2024-10-04 DOI: 10.1016/j.ajt.2024.09.035
Julien Zuber, Juliette Leon, Julie Déchanet-Merville, Hannah Kaminski

Belatacept, a fusion protein combining cytotoxic T-lymphocyte antigen-4 (CTLA-4) and the Fc region of human IgG1, is increasingly used as a calcineurin inhibitor-sparing regimen in patients with chronic graft dysfunction. Older kidney transplant recipients, particularly from expanded criteria donors, may be switched to belatacept due to poor renal recovery. However, late-onset cytomegalovirus (CMV) reactivation is increasingly reported with this treatment, especially in older patients with graft dysfunction. This suggests a progressive loss of CMV-specific T cell response, potentially driven by T cell exhaustion. Contributing factors include preexisting T cell dysfunction, increased viral antigen exposure, and interference in the PD-L1/PD-1 pathway by belatacept. mTOR inhibitors have shown efficacy in preventing CMV reactivation by reinvigorating CMV-specific T cells. These findings support combining belatacept with mTOR inhibitors in high-risk CMV-seropositive recipients and emphasize the need for personalized immune assessments to guide immunosuppressive strategies.

贝拉替塞(Belatacept)是一种结合了 CTLA-4 和人类 IgG1 Fc 区的融合蛋白,越来越多地被用作慢性移植物功能障碍患者的钙神经抑制剂备用方案。年龄较大的肾移植受者,尤其是来自扩大标准供体的肾移植受者,可能会因肾功能恢复不佳而改用贝拉他赛普。然而,越来越多的报告显示,在接受这种治疗时,尤其是在移植物功能障碍的老年患者中,会出现晚期 CMV 再激活的情况。这表明 CMV 特异性 T 细胞反应逐渐丧失,可能是 T 细胞衰竭所致。mTOR抑制剂已显示出通过重振CMV特异性T细胞来预防CMV再激活的疗效。这些研究结果支持在 CMV 血清阳性的高风险受者中将贝拉替塞与 mTOR 抑制剂联合使用,并强调了进行个性化免疫评估以指导免疫抑制策略的必要性。
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引用次数: 0
Unique multidisciplinary approach in living donor liver transplantation to achieve total physiological revascularization in a patient with complete occlusion of portal vein system with combined chronic and subacute thrombosis. 在活体肝移植手术中采用独特的多学科方法,为一名门静脉系统完全闭塞并合并慢性和亚急性血栓形成的患者实现完全生理性血管再通。
IF 8.9 2区 医学 Q1 SURGERY Pub Date : 2024-10-04 DOI: 10.1016/j.ajt.2024.09.033
Francesca Albanesi, Jae-Yoon Kim, Kwang-Woong Lee, YoungRok Choi, Nam-Joon Yi, Suk-Kyun Hong, Kyung-Suk Suh

Patients receiving liver transplantation in a setting of complete portal vein (PV) and superior mesenteric vein (SMV) thrombosis (Yerdel grade 4) experience lower outcomes after surgery; prognosis is independently influenced by the portal flow reconstruction technique, showing better outcomes in physiological surgical strategies. We describe a case of living donor liver transplantation in which the patient could not receive common physiological reconstructions preoperatively due to multiple small collaterals and extensive thrombosis down to first branches of SMV. We performed thromboendovenectomy of the PV and SMV first, but acute thrombosis developed recurrently even with interposition venous homograft between pericholedochal collateral vein and proximal recipient PV. Immediate after surgery, an intervention radiologist performed stent insertion into 3 stenotic points. Through multidisciplinary approach, complete physiological recanalization was obtained with normal liver function.

在门静脉(PV)和肠系膜上静脉(SMV)完全血栓形成(耶德尔4级)的情况下接受肝移植的患者术后预后较差;预后受门静脉血流重建技术的独立影响,生理手术策略的预后较好。我们描述了一例活体肝移植病例,患者术前无法接受普通的生理性重建,原因是存在多条小分支和SMV第一分支的广泛血栓形成。我们首先对门静脉和 SMV 进行了血栓内静脉切除术,但即使在胆总管旁静脉和受体门静脉近端之间进行了静脉同种异体移植,急性血栓仍反复形成。手术后,放射科介入医生立即对 3 个狭窄点进行了支架植入术。通过多学科合作,手术后肝功能恢复正常,实现了完全的生理性再通畅。
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引用次数: 0
Cytomegalovirus (CMV) Prophylaxis in Pediatric Liver Transplantation (PLT): A Comparison of Strategies Across the SPLIT Consortium. 小儿肝移植 (PLT) 中的巨细胞病毒 (CMV) 预防:SPLIT联盟的策略比较。
IF 8.9 2区 医学 Q1 SURGERY Pub Date : 2024-10-03 DOI: 10.1016/j.ajt.2024.09.025
Elizabeth D Knackstedt, Sarah G Anderson, Ravinder Anand, Jeff Mitchell, Ronen Arnon, Linda Book, Udeme Ekong, Scott A Elisofon, Katryn Furuya, Ryan Himes, Ajay K Jain, Nadia Ovchinsky, Shikha S Sundaram, John Bucuvalas, Lara Danziger-Isakov

Although cytomegalovirus (CMV) is a common complication after pediatric liver transplantation (PLT), the optimal method for CMV prevention is uncertain and lacks multi-centered investigation. We compared the effectiveness of short (<120d) versus long (>180d) CMV primary antiviral prophylaxis to prevent CMV disease in PLT, through a prospective cohort study of primary PLT (<18 yrs of age) recipients enrolled in the Society of Pediatric Liver Transplantation (SPLIT) registry from 2015 to 2019 with either donor or recipient CMV seropositivity. Participants were grouped into short or long prophylaxis based on their center's practice and intended duration. 199 PLT recipients were enrolled including 112 (56.3%) short and 87 (43.7%) long prophylaxis. End-organ disease was rare and similar between groups (2.7% and 1.1%; p=0.45). CMV DNAemia and syndrome were more common in the short compared to long (26.8% v. 13.8%; p=0.03 and 18.8% v. 6.9%; p=0.02). Neutropenia occurred more commonly with long prophylaxis (55.2% vs. 16.1%; p<0.001). Graft and patient survival were similar. Consideration of a short prophylaxis must weigh increased risk of CMV syndrome/DNAemia against medication burden and neutropenia of longer prophylaxis.

虽然巨细胞病毒(CMV)是小儿肝移植(PLT)后的常见并发症,但预防CMV的最佳方法尚不确定,也缺乏多中心调查。我们通过一项前瞻性队列研究比较了短期(180 天)CMV 初级抗病毒预防对预防小儿肝移植中 CMV 疾病的有效性。
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引用次数: 0
期刊
American Journal of Transplantation
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