L.J. Stuckey

Six-Month Prophylaxis Is Cost Effective in Transplant Patients at High Risk for Cytomegalovirus Infection

The risk of late-onset cytomegalovirus (CMV) infection remains a concern in seronegative kidney and/or pancreas transplant recipients of seropositive organs despite the use of antiviral prophylaxis. The optimal duration of prophylaxis is unknown. We studied the cost effectiveness of 6- versus 3-mo prophylaxis with valganciclovir. A total of 222 seronegative recipients of seropositive kidney and/or pancreas transplants received valganciclovir prophylaxis for either 3 or 6 mo during two consecutive time periods. We assessed the incidence of CMV infection and disease 12 mo after completion of prophylaxis and performed cost-effectiveness analyses. The overall incidence of CMV infection and disease was 26.7% and 24.4% in the 3-mo group and 20.9% and 12.1% in the 6-mo group, respectively. Six-month prophylaxis was associated with a statistically significant reduction in risk for CMV disease (HR, 0.35; 95% CI, 0.17 to 0.72), but not infection (HR, 0.65; 95% CI, 0.37 to 1.14). Cost-effectiveness analyses showed that 6-mo prophylaxis combined with a one-time viremia determination at the end of the prophylaxis period incurred an incremental cost of

Abnormal Glucose Metabolism and Metabolic Syndrome in Non-Diabetic Kidney Transplant Recipients Early After Transplantation

34,362 and

Parametric Response Mapping as an Imaging Biomarker in Lung Transplant Recipients

16,215 per case of infection and disease avoided, respectively, and

Evaluation of a transplantation specialty pharmacy program.

8,304 per one quality adjusted life-year gained. Sensitivity analyses supported the cost effectiveness of 6-mo prophylaxis over a wide range of valganciclovir and hospital costs, as well as variation in the incidence of CMV disease. In summary, 6-mo prophylaxis with valganciclovir combined with a one-time determination of viremia is cost effective in reducing CMV infection and disease in seronegative recipients of seropositive kidney and/or pancreas transplants.

Clinical and Economic Outcomes of Rabbit Antithymocyte Globulin Induction in Adults Who Received Kidney Transplants from Living Unrelated Donors and Received Cyclosporine-Based Immunosuppression

Background. Abnormal glucose metabolism (AGM) and metabolic syndrome (MS) are individually associated with a poor cardiovascular outcome in kidney transplant recipients. We prospectively studied the relationship between AGM and MS in non-diabetic kidney transplant recipients early after transplantation. Methods. A total of 203 de novo kidney transplant recipients underwent standard 2-hr glucose tolerance test 10 weeks after transplantation. Demographic and clinical characteristics were collected. AGM was defined as impaired fasting glucose, impaired glucose tolerance, and new onset diabetes after transplant according to the WHO criteria, and MS was defined according to the National Cholesterol Education Expert Panel criteria. Results. Overall, 97 patients (47.8%) met the diagnosis of AGM and 98 patients (48.3%) met the criteria of MS. AGM and MS are highly associated (&khgr;2, P<0.001). Fasting plasma glucose levels before the transplant are independent predictors common for AGM and MS. Age predicts AGM with and without MS, whereas body mass index before transplant predicts MS. Patients with impaired glucose tolerance and new-onset diabetes after transplant displayed significant worsening of their fasting plasma glucose levels during the 10-week observational period. MS and the components of MS, but not AGM, were associated with reduced transplant renal function (P=0.002). Conclusion. The early screening of AGM and MS should be emphasized, and the role of early therapeutic interventions aimed at both conditions explored. The long-term follow-up of these patients will yield more insight on the significance of such findings.

Mechanistic Target of Rapamycin Complex 1 (mTORC1) and mTORC2 as Key Signaling Intermediates in Mesenchymal Cell Activation

Rationale: The predominant cause of chronic lung allograft failure is small airway obstruction arising from bronchiolitis obliterans. However, clinical methodologies for evaluating presence and degree of small airway disease are lacking. Objectives: To determine if parametric response mapping (PRM), a novel computed tomography voxel‐wise methodology, can offer insight into chronic allograft failure phenotypes and provide prognostic information following spirometric decline. Methods: PRM‐based computed tomography metrics quantifying functional small airways disease (PRMfSAD) and parenchymal disease (PRMPD) were compared between bilateral lung transplant recipients with irreversible spirometric decline and control subjects matched by time post‐transplant (n = 22). PRMfSAD at spirometric decline was evaluated as a prognostic marker for mortality in a cohort study via multivariable restricted mean models (n = 52). Measurements and Main Results: Patients presenting with an isolated decline in FEV1 (FEV1 First) had significantly higher PRMfSAD than control subjects (28% vs. 15%; P = 0.005), whereas patients with concurrent decline in FEV1 and FVC had significantly higher PRMPD than control subjects (39% vs. 20%; P = 0.02). Over 8.3 years of follow‐up, FEV1 First patients with PRMfSAD greater than or equal to 30% at spirometric decline lived on average 2.6 years less than those with PRMfSAD less than 30% (P = 0.004). In this group, PRMfSAD greater than or equal to 30% was the strongest predictor of survival in a multivariable model including bronchiolitis obliterans syndrome grade and baseline FEV1% predicted (P = 0.04). Conclusions: PRM is a novel imaging tool for lung transplant recipients presenting with spirometric decline. Quantifying underlying small airway obstruction via PRMfSAD helps further stratify the risk of death in patients with diverse spirometric decline patterns.

Lung Transplantation Across Donor-Specific Anti-Human Leukocyte Antigen Antibodies: Utility of Bortezomib Therapy in Early Graft Dysfunction

PURPOSE The value of a transplantation specialty pharmacy (TSP) program, including its impact on patient and health care provider satisfaction, selected clinical outcomes, and the institutions financial margin, was evaluated. METHODS Patient and health care provider surveys were distributed to evaluate satisfaction with the TSP program. Medication adherence (using continuous measures of medication adherence), hospital readmissions within 90 days of transplantation, and length of hospitalization were examined. Patients enrolled in the TSP program who received kidney transplants between July 1, 2009, and June 30, 2010, were included. Patients who received kidney transplants at the institution between July 1, 2007, and June 30, 2008, served as the control group. RESULTS Of the 838 patient surveys distributed, 290 (34.6%) were returned. Most patients (84%) reported being satisfied with the program, and 98% would recommend it to others. Ninety-six percent of providers believed the pharmacy improved continuity of care, and 91% reported spending less time on pharmacy-related problems after the programs initiation. Medication adherence appeared to be higher in patients enrolled in the TSP program compared with historical controls. Hospital readmissions and length of stay did not significantly differ between groups. The TSP program generated

Mycophenolic acid pharmacokinetics in lung transplant recipients with cystic fibrosis.

7.5 million in revenue during its first fiscal year. Roughly

Safety and Efficacy of Biologic Agents for the Management of Inflammatory Bowel Disease After Liver Transplantation

5.5 million was spent on incremental operating expenses, resulting in over

Use of Sirolimus in Lung Transplantation: A Single Center Experience

2 million in margin. CONCLUSION A TSP program provided a high level of satisfaction to patients and health care providers, may have influenced some clinical outcomes, and served as a source of positive margin for its institution.