Daniel Murillo

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

Abstract:u2002 Enteric‐coated mycophenolate sodium (MPS) has been developed to help circumvent the upper gastrointestinal side‐effects of mycophenolic acid by facilitating drug release in the small intestine. Many questions regarding the side‐effect profile of MPS remain. Therefore, the purpose of this study is to review a single‐center’s experience with mycophenolate mofetil (MMF) and MPS.

Long‐Term Survival of Kidneys Transplanted from Live A2 Donors to O and B Recipients

The long‐term outcome of kidneys transplanted from blood group A2 live donors into blood group O or B candidates is not known. From 1986 through 2006, we transplanted eight blood group O patients and one blood group B patient with kidneys from blood group A2 live donors. Immunosuppression was no different for these patients than for ABO‐compatible recipients. All patients received methylprednisolone, cyclosporine or tacrolimus and azathioprine or mycophenolate mofetil with or without antibody induction (monoclonal or polyclonal). Of the nine live‐donor A2 to O and B transplants performed, seven grafts remain functioning. One of those seven was lost to follow‐up at 9.2 years with a functioning kidney. Of the remaining six patients, length of follow‐up is 10.4, 6.5, 5.3, 4, 2.1 and 1 years. Of the two patients who lost their grafts, one died with a functioning graft (DWFG) at 8.8 years and one lost his graft at 13.2 years due to noncompliance with immunosuppression. These data show that good long‐term graft survival can be expected in live‐donor A2 to O and B transplantation despite some of those patients experiencing the type of clinical problems seen with ABO‐compatible transplants.

Renal graft survival is not influenced by a positive flow B‐cell crossmatch

Abstract:u2002 Introduction:u2002 The influence of a positive B‐cell crossmatch on graft outcome in renal transplantation is controversial.

Influence of pill burden and drug cost on renal function after transplantation.

To determine the influence of pill burden and drug cost on outcomes after renal transplantation.

Sharing kidneys across donor-service area boundaries with sensitized candidates can be influenced by HLA C

Bryan CF, Luger AM, Smith JL, Warady BA, Wakefield M, Schadde E, Murillo D, Nelson PW. Sharing kidneys across donor‐service area boundaries with sensitized candidates can be influenced by HLA C.u2028Clin Transplant 2010: 24: 56–61.

Improving access to kidney transplantation without decreasing graft survival: long-term outcomes of blood group A2/A2B deceased donor kidneys in B recipients.

Background. The transplantation of blood group A2/A2B deceased donor kidneys into B recipients could improve access to transplantation for blood group B recipients. However, this practice is controversial, and long-term data are lacking. This study analyzed the long-term outcomes of A2/A2B deceased donor kidneys transplanted into selected B recipients. Methods. We retrospectively assessed the outcomes (graft survival, transplant rates, and acute rejection) of deceased-donor kidneys using an allocation system that transplanted A2/A2B donors into B recipients with low anti-A blood group antibody titers between 1994 and 2003. Patients received conventional immunosuppression without any specific antibody reduction procedures. We further assessed the impact this system had on access to transplantation by blood group. Results. Of 1,400 kidney transplants, 56 (4.0%) were A2/A2B to B recipients. The system reduced waiting time for all B recipients, even shorter than for blood group A recipients (median waiting times of A2/A2B to B transplants=182 days vs. B to B transplants=297 days; and A to A=307 days). Although there was a trend toward increased acute rejection in A2/A2B to B transplants, the actuarial 7-year death censored graft survival was 72% for B recipients regardless of donor type. Conclusions. Transplanting A2/A2B deceased donor kidneys into B recipients leads to an equalization of waiting time between blood groups with similar patient and graft survival using conventional immunosuppression. This protocol could lead to more equal access to kidney transplantation in blood group B recipients.

Successful renal transplantation despite low levels of donor-specific HLA class I antibody without IVIg or plasmapheresis.

Abstract:u2002 We prospectively transplanted 10 primary kidney recipients with deceased donor organs (nine kidney and one pancreas/kidney) when their flow cytometric T‐cell IgG, HLA class I donor‐specific crossmatch was positive but the AHG T‐cell crossmatch was negative, with a median follow‐up of 1.8u2003yr. No pre‐ or peri‐operative IVIg or plasmapheresis was administered to any patient. All but one of the 11 organs transplanted into patients with a flow T+/AHG− crossmatch is currently functioning despite the continued presence of circulating low levels of HLA class I antibody. Flow HLA class I antigen‐coated beads showed the presence of at least one donor‐specific HLA class I antibody at transplantation in each of the 10 cases. No rejections were observed in seven of the 10 cases (70%). Six rejection episodes, four cellular and two humoral, occurred in three patients. Each rejection was successfully treated. The only graft loss occurred in a kidney recipient on day 667 secondary to ischemia to the kidney because of cardiac surgery. Thus, short‐term (one to two years) graft survival in primary transplants was not influenced by low levels of donor‐specific HLA class I antibody present at transplantation and no prophylactic treatment such as IVIg, plasmapheresis, anti‐CD20 or splenectomy was needed peri‐operatively.

Flow cytometry beads rather than the antihuman globulin method should be used to detect HLA Class I IgG antibody (PRA) in cadaveric renal regraft candidates

Abstract: HLA Class I antibody screening can be performed by flow cytometry using a mixture of 30 distinct bead populations each coated with the Class I antigen phenotype derived from different cell lines. In this study we compared the efficacy of Class I antibody screens done by flow cytometry beads with the antihuman globulin (AHG) method for patients awaiting cadaveric renal retransplantation. Class I panel reactive antibody (PRA) screening by flow cytometric beads of 21 regraft serum samples that had all been found to be negative by AHG DTT Class I PRA, revealed that 57.1% (12 of 21) had a flow Class I PRA of ≥u200a10%. Furthermore, when five regraft sera with an intermediate PRA were screened (mean AHG DTT PRAu2003=u200333.2u2003±u200313%) the mean flow Class I PRA almost doubled (mean flow PRAu2003=u200372.4u2003±u200310.2%) (u200apu2003<u20030.01). When active UNOS waiting list regraft candidates, after several months of screening the Class I PRA by flow beads, were divided into the three PRA categories based on their peak flow Class I PRA value (0−20%, 21−79% and ≥u200380%), the incidence of a positive flow cross‐match was 0%, 72% and 85% and the incidence of retransplantation was 60%, 22% and 10%, in each of these groups, respectively. These data provided our histocompatibility laboratory with the rationale to stop performing the AHG PRA and perform only the flow Class I PRA method for regraft candidates.

Point‐of‐care testing in an organ procurement organization donor management setting

Abstract: Purpose:u2002 Our organ procurement organization (OPO) evaluated the clinical and financial efficacy of point‐of‐care testing (POCT) in management of our deceased organ donors.

A new role for the virtual crossmatch in kidney allograft reuse.

In this era of aggressive organ recovery and transplantation, our human leukocyte antigen (HLA) laboratory recently (February 2009) crossmatched for a kidney and a liver from a deceased donor that were transplanted into a single patient. However, the kidney from the donor had been transplanted 7 months earlier into the patient who was now the donor. Although a few cases of kidney reuse (1– 4) have been reported, this is the first report pointing out the potential need of a virtual crossmatch in cases of kidney reuse for HLA-sensitized candidates if cells from the kidney reuse donor are not available.