Improvement in renal function in kidney transplant recipients switched from cyclosporine or tacrolimus to belatacept: 2-year results from the long-term extension of a phase II study

Kidney transplant recipients who switched from a calcineurin inhibitor (CNI) to belatacept demonstrated higher calculated glomerular filtration rates (cGFRs) at 1 year in a Phase II study. This report addresses whether improvement was sustained at 2 years in the long‐term extension (LTE). Patients receiving cyclosporine or tacrolimus were randomized to switch to belatacept or continue CNI. Of 173 randomized patients, 162 completed the 12‐month main study and entered the LTE. Two patients (n = 1 each group) had graft loss between Years 1–2. At Year 2, mean cGFR was 62.0 ml/min (belatacept) vs. 55.4 ml/min (CNI). The mean change in cGFR from baseline was +8.8 ml/min (belatacept) and +0.3 ml/min (CNI). Higher cGFR was observed in patients switched from either cyclosporine (+7.8 ml/min) or tacrolimus (+8.9 ml/min). The frequency of acute rejection in the LTE cohort was comparable between the belatacept and CNI groups by Year 2. All acute rejection episodes occurred during Year 1 in the belatacept patients and during Year 2 in the CNI group. There were more non‐serious mucocutaneous fungal infections in the belatacept group. Switching to a belatacept‐based regimen from a CNI‐based regimen resulted in a continued trend toward improved renal function at 2 years after switching.     

Impact of post-transplant anemia on patient and graft survival rates after kidney transplantation: a meta-analysis

The impact of post-kidney transplant anemia (PTA) on patient and graft survival rates remains controversial. We performed a meta-analysis to evaluate its impact in causing death of a patient with a functioning graft (DPWFG) and death-censored graft loss (DCGL). A systematic review of 11 observational studies (11,632 kidney transplant patients) that reported the impact of PTA or hemoglobin (Hb) level on these endpoints was performed. Using the World Health Organization (WHO) definition (Hb <12 g/dL in women and Hb <13 g/dL in men), PTA was not associated with DPWFG when results were expressed as an adjusted hazard ratio (aHR: 1.23 [0.97-1.57]), but was associated with higher DPWFG when results were expressed as unadjusted rates (aHR: 2.48 [1.36-4.52]) and when cut-off level for anemia was lower than the WHO definition (aHR: 3.12 [1.92-5.07]). A -1 g/dL decrease in Hb level was associated with higher DPWFG rates (aHR: 1.19 [1.12-1.26]). Using WHO criteria, PTA was associated with higher DCGL rates when results were expressed as aHR (aHR: 1.53 [1.26-1.85]) or as unadjusted rates (aHR: 3.55 [2.36-5.33]); a -1 g/dL decrease in Hb level was associated with higher DCGL rates (aHR: 1.14 [1.11-1.16]). This meta-analysis reveals that the association between PTA and DPWFG varies with PTA definition and adjustment for confounders. In all sub-meta-analyses, PTA was significantly associated with DCGL.     

Successful treatment of orbital hemangioma with propranolol in a 5-year-old girl

We report a 5-year-old girl, who presented with proptosis due to an orbital capillary hemangioma. After 8 months of treatment with oral propranolol at a dose of 2 mg/kg/day, the mass reduced significantly in size and regrowth was not observed within 20 months of follow-up.     

Instigating change: trainee doctors' perspective

In the 21st century, the core skills of trainee doctors are evolving as clinicians, leaders and innovators. Leadership skills are an essential tool for all doctors and need to be an integral part of their training and learning as set out in the General Medical Council's Good Medical Practice. It is essential to develop these skills at an early stage and continually improve them. A group of junior doctors participated in a pilot programme for leadership with the aim of executing a quality improvement (QI) project. This article describes our experiences of both the course itself and the project undertaken by our group. As part of the process of implementing change, we faced a number of challenges which contributed to our learning. These have been explored as well as potential ways to overcome them to enable the swift and smooth development of future QI projects. Using an example of a QI project looking at handover, this article demonstrates how a trainee doctor can implement their project for both professional and institutional improvement.     

Effect of the new legislation and single-embryo transfer policy in Turkey on assisted reproduction outcomes: preliminary results

New legislation concerning assisted reproduction treatments was introduced in Turkey in March 2010 in order to reduce the number of multiple pregnancies. This new legislation limits the number of embryos to be transferred to one under 35 years of age in the first or second treatment cycles and to two in the third or further cycles or for 35 and older ages. The aim of this multicentre study was to investigate the effect of this new law on clinical pregnancy and multiple pregnancy rates. Outcomes were compared in equal periods of 2.5 months before and after the new law, and further investigation was conducted for two different age groups: <35 and ≥ 35. The clinical pregnancy rates decreased from 39.9 to 34.5% and multiple pregnancy rates decreased from 23.1 to 5.3% (P<0.001) for the overall population. The outcomes of the <35 age group and ≥ 35 age group were also similar to that of the overall population. These results suggest that under the new legislation multiple pregnancy rates are significantly reduced without causing a significant decline in the pregnancy rates.     

Remdesivir for COVID‐19 pneumonia in patients with severe chronic kidney disease: A Case series and review of the literature

Remdesivir was the first antiviral agent to receive FDA authorization for severe COVID‐19 management, which restricts its use with severe renal impairment due to concerns that active metabolites might accumulate, causing renal toxicities. With limited treatment options, available evidence on such patient groups is important to assess for future safety.     

Long-term outcome of liver transplantation for autoimmune hepatitis: A French nationwide study over 30 years

Background & Aims

Autoimmune hepatitis (AIH) is a rare indication for liver transplantation (LT). The aims of this study were to evaluate long-term survival after LT for AIH and prognostic factors, especially the impact of recurrent AIH (rAIH).

Methods

A multicentre retrospective nationwide study including all patients aged ≥16 transplanted for AIH in France was conducted. Early deaths and retransplantations (≤6 months) were excluded.

Results

The study population consisted of 301 patients transplanted from 1987 to 2018. Median age at LT was 43 years (IQR, 29.4–53.8). Median follow-up was 87.0 months (IQR, 43.5–168.0). Seventy-four patients (24.6%) developed rAIH. Graft survival was 91%, 79%, 65% at 1, 10 and 20 years respectively. Patient survival was 94%, 84% and 74% at 1, 10 and 20 years respectively. From multivariate Cox regression, factors significantly associated with poorer patient survival were patient age ≥58 years (HR = 2.9; 95% CI, 1.4–6.2; p = 0.005) and occurrence of an infectious episode within the first year after LT (HR = 2.5; 95% CI, 1.2–5.1; p = 0.018). Risk factors for impaired graft survival were: occurrence of rAIH (HR = 2.7; 95% CI, 1.5–5.0; p = 0.001), chronic rejection (HR = 2.9; 95% CI, 1.4–6.1; p = 0.005), biliary (HR = 2.0; 95% CI, 1.2–3.4; p = 0.009), vascular (HR = 1.8; 95% CI, 1.0–3.1; p = 0.044) and early septic (HR = 2.1; 95% CI, 1.2–3.5; p = 0.006) complications.

Conclusion

Our results confirm that survival after LT for AIH is excellent. Disease recurrence and chronic rejection reduce graft survival. The occurrence of an infectious complication during the first year post-LT identifies at-risk patients for graft loss and death.