Clinical Focus

  • General Surgery
  • Kidney and Pancreas Transplantation
  • Liver Transplantation

Academic Appointments

Administrative Appointments

  • Director Adult Kidney and Pancreas Transplant Program, Stanford University School of Medicine (2001 - Present)
  • Member, Stanford Diabetes Research Center (2018 - Present)

Professional Education

  • Fellowship: California Pacific Medical Center (1995) CA
  • Residency: University of Montreal (1991) Canada
  • Medical Education: University of Montreal (1986) Canada
  • Internship: University of Montreal (1987) Canada
  • Board Certification: American Board of Surgery, General Surgery (1996)
  • Board Cerification, American Board of Surgery, General Surgery (1996)
  • M. Sc., Mc Gill University, Transplant Immunology (1995)
  • ., California Pacific Med Center, Multi-Organ Transplantation (1995)
  • FRCSC, University of Montreal, General Surgery (1991)
  • MD, Univerty of Montreal (1986)

Current Research and Scholarly Interests

My research interest is centered on the improvement of clinical immunosuppression. This involves the evaluation of new immunosuppressive drugs that are potentially more efficacious and/or less toxic or better monitoring of the effect of these drugs. We are participating in the drug development process from phase1 to phase 3 studies. I participate to trial design and data analysis of some of these trials. The ultimate goal is to achieve tolerance, a state that would obviate the need for any drugs. I am a clinical investigator in a multidisciplinary trial aimed at inducing tolerance after kidney transplantation. My other interests include the development and study of efficacy of strategies to desensitized organ transplant recipients and expending our capabilities to tailor the immunosuppression needs of specific patients through new immune-monitoring tests. Ultimately these research projects are aimed at improving the outcomes of organ transplant recipients.

Clinical Trials

  • Combined Blood Stem Cell and Kidney Transplant of One Haplotype Match Living Donor Pairs. Recruiting

    The Stanford Medical Center Program in Multi-Organ Transplantation and the Division of Bone marrow Transplantation are enrolling patients into a research study to determine if donor stem cells given after a living related one Haplotype match kidney transplantation will change the immune system such that immunosuppressive drugs can be completely withdrawn.

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  • Inducing Graft Tolerance in HLA Haplotype Matched Related and 3 Ag Matched Unrelated Living Donor Kidney Transplantation Recruiting

    This research study is to determine if donor blood stem cells given after living, related, HLA antigen (Ag) haplotype match or living, unrelated donor kidney transplantation. Minimal HLA antigen matching will include matching of 2 HLA antigens that can be either HLA A, B, and /or DR. This research will change the immune system such that immunosuppressive drugs can be completely withdrawn or reduced to minimal dose without kidney rejection.

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  • Delayed Blood Stem Transplantation in HLA Matched Kidney Transplant Recipients to Eliminate Immunosuppressive Drugs. Not Recruiting

    The study will determine whether patients with functioning Human Leukocyte Antigen (HLA) matched kidney transplants for at least one year and who want to discontinue immunosuppressive drugs can be treated with Total Lymphoid Irradiation (TLI) and rabbit Anti-Thymocyte Globulin (rATG) and an HLA matched donor hematopoietic progenitor cell infusion such that their drugs are successfully withdrawn while maintaining normal renal function.

    Stanford is currently not accepting patients for this trial.

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  • Kidney and Blood Stem Cell Transplantation That Eliminates Requirement for Immunosuppressive Drugs Not Recruiting

    The Stanford Medical Center Program in Multi-Organ Transplantation and the Division of Bone Marrow Transplantation are enrolling patients into a research study to determine if blood stem cells injected after kidney transplantation, in combination with lymphoid irradiation ,will change the immune system such that immunosuppressive drugs can be completely withdrawn. Patients must have a healthy, completely human leukocyte antigen (HLA)-matched brother or sister as the organ and stem cell donor. One to two months before kidney transplant surgery, blood stem cells will be removed from the donor and the cells will be frozen. After transplant surgery, the recipient will receive radiation and anti-T cell antibody treatments for two weeks to prepare for injection of the stem cells. The stem cells will be injected at the end of the two-week treatment. If the stem cells persist in the recipient, immunosuppressive drugs will be gradually reduced until they are withdrawn completely at least six months after transplantation. Patients will be followed in the Stanford clinics for transplant patients. Patients who live outside of the San Francisco Bay Area must remain near Stanford for six weeks after transplant surgery.

    Stanford is currently not accepting patients for this trial. For more information, please contact Stephan Busque, MD, 650-498-6189.

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2023-24 Courses

All Publications

  • Defining tumor-associated macrophages subpopulation in intrahepatic cholangiocarcinoma as prognostic and therapeutic targets Badshah, J., Aliwaisi, A., Subramanian, S., Hong, S., Teavir, W., Sasaki, K., Melcher, M., Bonham, C., Pham, T., Gallo, A., Esquivel, C., Busque, S., Reitsma, A., Krams, S., Pruett, T., Martinez, O., Kirchner, V. LIPPINCOTT WILLIAMS & WILKINS. 2023: 122-123
  • Obinutuzumab Effectively Depletes Key B-cell Subsets in Blood and Tissue in End-stage Renal Disease Patients. Transplantation direct Looney, C. M., Schroeder, A., Tavares, E., Garg, J., Schindler, T., Vincenti, F., Redfield, R. R., Jordan, S. C., Busque, S., Woodle, E. S., Khan, J., Eastham, J., Micallef, S., Austin, C. D., Morimoto, A. 2023; 9 (2): e1436


    The THEORY study evaluated the effects of single and multiple doses of obinutuzumab, a type 2 anti-CD20 antibody that induces antibody-dependent cell-mediated cytotoxicity and direct cell death, in combination with standard of care in patients with end-stage renal disease.Methods: We measured B-cell subsets and protein biomarkers of B-cell activity in peripheral blood before and after obinutuzumab administration in THEORY patients, and B-cell subsets in lymph nodes in THEORY patients and an untreated comparator cohort.Results: Obinutuzumab treatment resulted in a rapid loss of B-cell subsets (including naive B, memory B, double-negative, immunoglobulin D+ transitional cells, and plasmablasts/plasma cells) in peripheral blood and tissue. This loss of B cells was associated with increased B cell-activating factor and decreased CXCL13 levels in circulation.Conclusions: Our data further characterize the mechanistic profile of obinutuzumab and suggest that it may elicit greater efficacy in indications such as lupus where B-cell targeting therapeutics are limited by the resistance of pathogenic tissue B cells to depletion.

    View details for DOI 10.1097/TXD.0000000000001436

    View details for PubMedID 36700064

  • IDENTIFYING NOVEL GENE TARGETS FOR DIAGNOSIS AND TREATEMENT OF HCC IN ASIAN AND CAUCASIAN POPULATIONS BASED ON WHOLE GENOME SEQUENCING Hong, S., Badshah, J., Aliwaisi, A., Sasaki, K., Pruett, T., Melcher, M., Bonham, C., Gallo, A., Martinez, O., Krams, S., Pham, K., Busque, S., Reitsma, A., Esquivel, C., Kirchner, V. ELSEVIER SCIENCE INC. 2023: S28
  • Cellular and humoral immune response to SARS-CoV-2 vaccination and booster dose in immunosuppressed patients: An observational cohort study. Journal of clinical virology : the official publication of the Pan American Society for Clinical Virology Yang, L. M., Costales, C., Ramanathan, M., Bulterys, P. L., Murugesan, K., Schroers-Martin, J., Alizadeh, A. A., Boyd, S. D., Brown, J. M., Nadeau, K. C., Nadimpalli, S. S., Wang, A. X., Busque, S., Pinsky, B. A., Banaei, N. 2022; 153: 105217


    BACKGROUND: Humoral and cellular immune responses to SARS-CoV-2 vaccination among immunosuppressed patients remain poorly defined, as well as variables associated with poor response.METHODS: We performed a retrospective observational cohort study at a large Northern California healthcare system of infection-naive individuals fully vaccinated against SARS-CoV-2 (mRNA-1273, BNT162b2, or Ad26.COV2.S) with clinical SARS-CoV-2 interferon gamma release assay (IGRA) ordered between January through November 2021. Humoral and cellular immune responses were measured by anti-SARS-CoV-2 S1 IgG ELISA (anti-S1 IgG) and IGRA, respectively, following primary and/or booster vaccination.RESULTS: 496 immunosuppressed patients (54% female; median age 50 years) were included. 62% (261/419) of patients had positive anti-S1 IgG and 71% (277/389) had positive IGRA after primary vaccination, with 20% of patients having a positive IGRA only. Following booster, 69% (81/118) had positive anti-S1 IgG and 73% (91/124) had positive IGRA. Factors associated with low humoral response rates after primary vaccination included anti-CD20 monoclonal antibodies (P<0.001), sphingosine 1-phsophate (S1P) receptor modulators (P<0.001), mycophenolate (P=0.002), and B cell lymphoma (P=0.004); those associated with low cellular response rates included S1P receptor modulators (P<0.001) and mycophenolate (P<0.001). Of patients who had poor humoral response to primary vaccination, 35% (18/52) developed a significantly higher response after the booster. Only 5% (2/42) of patients developed a significantly higher cellular response to the booster dose compared to primary vaccination.CONCLUSIONS: Humoral and cellular response rates to primary and booster SARS-CoV-2 vaccination differ among immunosuppressed patient groups. Clinical testing of cellular immunity is important in monitoring vaccine response in vulnerable populations.

    View details for DOI 10.1016/j.jcv.2022.105217

    View details for PubMedID 35714462

  • Allocation Based on Acuity Circles: Effects on Pediatric Liver Allocation. Kim, M., Kim, M. H., Gallo, A., Pham, T., Melcher, M. L., Busque, S., Esquivel, C., Bonham, C. WILEY. 2022: 475-476
  • Allocation Based on Acuity Circles Decreases Waiting Time for Liver Transplant Patients. Kim, M. H., Sasaki, K., Gallo, A., Pham, T., Melcher, M. L., Busque, S., Esquivel, C., Bonham, C. WILEY. 2022: 829-830
  • Achievement of Persistent Mixed Chimerism in Recipients of Matched and Mismatched Living Donor Kidney Transplants in a Tolerance Induction Protocol. Scandling, J. D., Busque, S., Lowsky, R., Pham, T., Hoppe, R., Jensen, K., Shori, A., Wu, H., Pawar, R., Engleman, E., Meyer, E., Strober, S. WILEY. 2022: 408
  • Trends in Cost Attributable to Kidney Transplantation Evaluation and Waiting List Management in the United States, 2012-2017. JAMA network open Cheng, X. S., Han, J., Braggs-Gresham, J. L., Held, P. J., Busque, S., Roberts, J. P., Tan, J. C., Scandling, J. D., Chertow, G. M., Dor, A. 2022; 5 (3): e221847


    Importance: While recent policy reforms aim to improve access to kidney transplantation for patients with end-stage kidney disease, the cost implications of kidney waiting list expansion are not well understood. The Organ Acquisition Cost Center (OACC) is the mechanism by which Medicare reimburses kidney transplantation programs, at cost, for costs attributable to kidney transplantation evaluation and waiting list management, but these costs have not been well described to date.Objectives: To describe temporal trends in mean OACC costs per kidney transplantation and to identify factors most associated with cost.Design, Setting, and Participants: This economic evaluation included all kidney transplantation waiting list candidates and recipients in the United States from 2012 to 2017. A population-based study of cost center reports was conducted using data from all Center of Medicare & Medicaid-certified transplantation hospitals. Data analysis was conducted from June to August 2021.Exposures: Year, local price index, transplantation and waiting list volume of transplantation program, and comorbidity burden.Main Outcomes and Measures: Mean OACC costs per kidney transplantation.Results: In 1335 hospital-years from 2012 through 2017, Medicare's share of OACC costs increased from $0.95 billion in 2012 to $1.32 billion in 2017 (3.7% of total Medicare End-Stage Renal Disease program expenditure). Median (IQR) OACC costs per transplantation increased from $81 000 ($66 000 to $103 000) in 2012 to $100 000 ($82 000 to $125 000) in 2017. Kidney organ procurement costs contributed to 36% of mean OACC costs per transplantation throughout the study period. During the study period, transplantation hospitals experienced increases in kidney waiting list volume, kidney waiting list active volume, kidney transplantation volume, and comorbidity burden. For a median-sized transplantation program, mean OACC costs per transplantation decreased with more transplants (-$3500 [95% CI, -$4300 to -$2700] per 10 transplants; P<.001) and increased with year ($4400 [95% CI, $3500 to $5300] per year; P<.001), local price index ($1900 [95% CI, $200 to $3700] per 10-point increase; P=.03), patients listed active on the waiting list ($3100 [95% CI, $1700 to $4600] per 100 patients; P<.001), and patients on the waiting list with high comorbidities ($1500 [9% CI, $600 to $2500] per 1% increase in proportion of waitlisted patients with the highest comorbidity score; P=.002).Conclusions and Relevance: In this study, OACC costs increased at 4% per year from 2012 to 2017 and were not solely attributable to the cost of organ procurement. Expanding the waiting list will likely contribute to further increases in the mean OACC costs per transplantation and substantially increase Medicare liability.

    View details for DOI 10.1001/jamanetworkopen.2022.1847

    View details for PubMedID 35267033

  • SARS-CoV-2 Neutralizing Monoclonal Antibodies for the Treatment of COVID-19 in Kidney Transplant Recipients. Kidney360 Wang, A. X., Busque, S., Kuo, J., Singh, U., Roeltgen, K., Pinsky, B. A., Chertow, G. M., Scandling, J. D., Lenihan, C. R. 2022; 3 (1): 133-143


    Background: Morbidity and mortality associated with coronavirus disease 2019 (COVID-19) infection in kidney transplant recipients are high and early outpatient interventions to prevent progression to severe disease are needed. SARS-CoV-2 neutralizing mAbs, including bamlanivimab and casirivimab-imdevimab, received emergency use authorization in the United States in November 2020 for treatment of mild to moderate COVID-19 disease.Methods: We performed a retrospective analysis of 27 kidney transplant recipients diagnosed with COVID-19 between July 2020 and February 2021 who were treated with bamlanivimab or casirivimab-imdevimab and immunosuppression reduction. We additionally identified 13 kidney transplant recipients with COVID-19 who had mild to moderate disease at presentation, who did not receive mAbs, and had SARS-CoV-2 serology testing available.Results: There were no deaths or graft failures in either group. Both infusions were well tolerated. Four of the 27 patients treated with mAbs required hospitalization due to COVID-19. Four of 13 patients who did not receive mAbs required hospitalization due to COVID-19. Patients who received mAbs demonstrated measurable anti-SARS-CoV-2 IgG with angiotensin-converting enzyme 2 (ACE2) receptor blocking activity at the highest level detectable at 90 days postinfusion, whereas ACE2 blocking activity acquired from natural immunity in the mAb-untreated group was weak.Conclusions: Bamlanivimab and casirivimab-imdevimab combined with immunosuppression reduction were well tolerated and associated with favorable clinical outcomes in kidney transplant recipients diagnosed with mild to moderate COVID-19.

    View details for DOI 10.34067/KID.0005732021

    View details for PubMedID 35368573

  • Development of immunosuppressive myeloid cells to induce tolerance in solid organ and hematopoietic cell transplant recipients. Blood advances Jensen, K. P., Hongo, D., Ji, X., Zheng, P., Pawar, R. D., Wu, H., Busque, S., Scandling, J. D., Shizuru, J. A., Lowsky, R., Shori, A., Dutt, S., Waters, J., Saraswathula, A., Baker, J., Tamaresis, J. S., Lavori, P., Negrin, R. S., Maecker, H. T., Engleman, E. G., Meyer, E., Strober, S. 2021


    Replacement of failed organs followed by safe withdrawal of immunosuppressive drugs have long been the goals of organ transplantation. We studied changes in the balance of T and myeloid cells in blood of HLA-matched and -mismatched patients given living donor kidney transplants (KTx) followed by total lymphoid irradiation (TLI), anti-thymocyte globulin (ATG) conditioning, and donor hematopoietic cell transplant (HCT) to induce mixed chimerism and immune tolerance. The clinical trials were based on a conditioning regimen used to establish mixed chimerism and tolerance in mice. In pre-clinical murine studies, there was a profound depletion of T cells and an increase in immunosuppressive, polymorphonuclear (pmn), myeloid derived suppressor cells (MDSCs) in the spleen and blood following transplant. Selective depletion of the pmn-MDSCs in mice abrogated mixed chimerism and tolerance. In our clinical trials, patients given an analogous tolerance conditioning regimen developed similar changes including profound depletion of T cells and a marked increase in MDSCs in blood post-transplant. Post-transplant pmn-MDSCs transiently increased expression of lectin-type, oxidized LDL receptor-1 (LOX-1), a marker of immunosuppression, and production of the T cell inhibitor, arginase-1. These post-transplant pmn-MDSCs suppressed the activation, proliferation, and inflammatory cytokine secretion of autologous, TCR microbead-stimulated, pre-transplant T cells when co-cultured in vitro. In conclusion, we elucidated changes in receptors, and function of immunosuppressive myeloid cells in patients enrolled in the tolerance protocol that were nearly identical to the that of MDSCs required for tolerance in mice. The clinical trials are registered in under NCT #s 00319657 and 01165762.

    View details for DOI 10.1182/bloodadvances.2020003669

    View details for PubMedID 34432869

  • MDR-101-MLK-MERCURY Kidney Transplant Tolerance Study Update Kaufman, D., Akkina, S., Stegall, M., Piper, J., Gaber, A. O., Marin, E., Busque, S., Alonso, D., De Vera, M., Shah, A., Patel, A., Chavin, K., Laftavi, M., Collette, S., Stites, E., Mai, M., Cooper, M., Brennan, D. WILEY. 2021: 406-407
  • Single Dose Rituximab and Anti-Thymocyte Globulin (ATG) Induction in Hypersensitized Kidney Transplant Recipients Wang, A. X., Wang, U., Busque, S., Lenihan, C. R. WILEY. 2020: 905–6
  • Mixed chimerism and acceptance of kidney transplants after immunosuppressive drug withdrawal. Science translational medicine Busque, S. n., Scandling, J. D., Lowsky, R. n., Shizuru, J. n., Jensen, K. n., Waters, J. n., Wu, H. H., Sheehan, K. n., Shori, A. n., Choi, O. n., Pham, T. n., Fernandez Vina, M. A., Hoppe, R. n., Tamaresis, J. n., Lavori, P. n., Engleman, E. G., Meyer, E. n., Strober, S. n. 2020; 12 (528)


    Preclinical studies have shown that persistent mixed chimerism is linked to acceptance of organ allografts without immunosuppressive (IS) drugs. Mixed chimerism refers to continued mixing of donor and recipient hematopoietic cells in recipient tissues after transplantation of donor cells. To determine whether persistent mixed chimerism and tolerance can be established in patients undergoing living donor kidney transplantation, we infused allograft recipients with donor T cells and hematopoietic progenitors after posttransplant lymphoid irradiation. In 24 of 29 fully human leukocyte antigen (HLA)-matched patients who had persistent mixed chimerism for at least 6 months, complete IS drug withdrawal was achieved without subsequent evidence of rejection for at least 2 years. In 10 of 22 HLA haplotype-matched patients with persistent mixed chimerism for at least 12 months, reduction of IS drugs to tacrolimus monotherapy was achieved. Withdrawal of tacrolimus during the second year resulted in loss of detectable chimerism and subsequent rejection episodes, unless tacrolimus therapy was reinstituted. Posttransplant immune reconstitution of naïve B cells and B cell precursors was more rapid than the reconstitution of naïve T cells and thymic T cell precursors. Robust chimerism was observed only among naïve T and B cells but not among memory T cells. No evidence of rejection was observed in all surveillance graft biopsies obtained from mixed chimeric patients withdrawn from IS drugs, and none developed graft-versus-host disease. In conclusion, persistent mixed chimerism established in fully HLA- or haplotype-matched patients allowed for complete or partial IS drug withdrawal without rejection.

    View details for DOI 10.1126/scitranslmed.aax8863

    View details for PubMedID 31996467

  • Influence of Immunosuppression on Seroconversion Against SARS-Cov-2 in Two Kidney Transplant Recipients. Transplant infectious disease : an official journal of the Transplantation Society Wang, A. X., Quintero Cardona, O. n., Ho, D. Y., Busque, S. n., Lenihan, C. R. 2020: e13423


    Solid organ transplant recipients are at risk for infectious complications due to chronic immunosuppression. The outbreak of Coronavirus Disease 2019 (COVID-19) in United States has raised growing concerns for the transplant patient population. We seek to add to the current limited literature on COVID-19 in transplant recipients by describing the clinical course of two kidney transplant recipients with SARS-Cov-2 infection monitored by both RT-PCR and serology. Through careful adjustment of their immunosuppression regimen, both patients had excellent recovery with intact graft function and development of anti-SARS-Cov-2 antibodies.

    View details for DOI 10.1111/tid.13423

    View details for PubMedID 32701196

  • Safety, pharmacokinetics, and pharmacodynamic activity of obinutuzumab, a type 2 anti-CD20 monoclonal antibody for the desensitization of candidates for renal transplant. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons Redfield, R. R., Jordan, S. C., Busque, S., Vincenti, F., Woodle, E. S., Desai, N., Reed, E. F., Tremblay, S., Zachary, A. A., Vo, A. A., Formica, R., Schindler, T., Tran, H., Looney, C., Jamois, C., Green, C., Morimoto, A., Rajwanshi, R., Schroeder, A., Cascino, M. D., Brunetta, P., Borie, D. 2019


    The limited effectiveness of rituximab plus intravenous immunoglobulin (IVIG) in desensitization may be due to incomplete B-cell depletion. Obinutuzumab is a type 2 anti-CD20 antibody that induces increased B-cell depletion relative to rituximab and may therefore be more effective for desensitization. This open-label Phase 1b study assessed the safety, pharmacokinetics, and pharmacodynamics of obinutuzumab in highly sensitized patients with end-stage renal disease. Patients received 1 (day 1, n=5) or 2 (days 1 and 15; n=20) infusions of 1000-mg obinutuzumab followed by 2 doses of IVIG on days 22 and 43. Eleven patients received additional obinutuzumab doses at the time of transplant and/or at week 24. The median follow-up duration was 9.4 months. Obinutuzumab was well tolerated, and most adverse events were Grade 1-2 in severity. There were 11 serious adverse events (SAEs) in 9 patients (36%); 10 of these SAEs were infections and 4 occurred after kidney transplant. Obinutuzumab plus IVIG resulted in profound peripheral B-cell depletion and appeared to reduce B cells in retroperitoneal lymph nodes. Reductions in anti-HLA antibodies, number of unacceptable antigens, and the calculated panel reactive antibody score as centrally assessed by single-antigen bead assay were limited and not clinically meaningful for most patients (NCT02586051). This article is protected by copyright. All rights reserved.

    View details for DOI 10.1111/ajt.15514

    View details for PubMedID 31257724

  • Persistent Mixed Chimerism, Immune Reconstitution, and Tolerance in Recipients of HLA Matched Kidney and Hematopoietic Cell Transplants. Busque, S., Scandling, J., Lowsky, R., Shizuru, J., Meyer, E., Jensen, K., Shori, A., Hoppe, R., Engleman, E., Pham, T., Strober, S. WILEY. 2019: 348–49
  • Impact of Immunosuppressive Drug Withdrawal on Persistent Mixed Chimerism in Recipients of HLA Haplo-Identical Kidney and Hematopoietic Cell Transplants. Busque, S., Scandling, J., Lowsky, R., Shizuru, J., Meyer, E., Jensen, K., Shori, A., Hoppe, R., Engleman, E., Strober, S. WILEY. 2019: 348
  • IE-1 Specific T Cell Receptor Repertoire Diversity and Protection against CMV Reactivation. Perez, M., Rubelt, F., Busque, S., Esquivel, C. O., Krams, S. M., Bestard, O., Martinez, O. M. WILEY. 2019: 640–41
  • Combined Deceased Donor Parathyroid and Kidney Transplantation - An Underutilized Approach for ESRD Patients with Permanent Hypoparathyroidism Lee, L., Pan, J., Vasa, P., Berry, G., Lenihan, C., Busque, S. WILEY. 2019: 56
  • Improved Short-Term Survival in HCV Seropositive Kidney Transplant Recipients during the Daa Era in the United States Wong, K., Cholankeril, G., Gadiparthi, C., Somasundar, P., Busque, S., Esquivel, C. O., Ahmed, A. WILEY. 2018: 140A
  • A New Approach to Kidney Waitlist Management in the Kidney Allocation System Era: Pilot Implementation and Evaluation. Clinical transplantation Cheng, X. S., Busque, S., Lee, J., Discipulo, K., Hartley, C., Tulu, Z., Scandling, J. D., Tan, J. C. 2018: e13406


    Kidney transplant waitlist management is becoming increasingly complex. We introduced a novel waitlist management strategy at our center, the Transplant Readiness Assessment Clinic (TRAC), whereby patients whose Kidney Allocation Scores surpass a threshold are actively managed. From January 1, 2016 through June 30, 2017, we evaluated 195 patients through TRAC. Compared to pre-TRAC systems at our institution, TRAC resulted in a higher proportion of activation at 18-months (38% versus 22-26%, p<0.0001), despite being enriched in patients with long dialysis duration. TRAC also resulted in a higher proportion of waitlist removal (15% versus 8-9%, p<0.05) although combined waitlist removal and death on waitlist did not differ (18% versus 16-17%). Median time-to-activation was 356 days from TRAC evaluation. Of the transplant barriers, need for cardiovascular studies was the most common (31%), followed by other medical issues (23%), poor functional status (13%), and psychosocial issues (10%). By concentrating center resources on patients most likely to be transplanted after activation and performing active patient management close to the time of transplant, TRAC has the potential to significantly enhance kidney transplant success in regions with long wait-times. This article is protected by copyright. All rights reserved.

    View details for PubMedID 30218580

  • Native Kidney Cytomegalovirus Nephritis and Cytomegalovirus Prostatitis in a Kidney Transplant Recipient. Transplant infectious disease : an official journal of the Transplantation Society Tan, S. K., Cheng, X. S., Kao, C., Weber, J., Pinsky, B. A., Gill, H. S., Busque, S., Subramanian, A. K., Tan, J. C. 2018: e12998


    We present a case of cytomegalovirus (CMV) native kidney nephritis and prostatitis in a CMV D+/R- kidney transplant recipient who had completed six months of CMV prophylaxis four weeks prior to the diagnosis of genitourinary CMV disease. The patient had a history of benign prostatic hypertrophy and urinary retention that required self-catheterization to relieve high post-voiding residual volumes. At 7 months post-transplant, he was found to have a urinary tract infection, moderate hydronephrosis of the transplanted kidney, and severe hydroureteronephrosis of the native left kidney and ureter, and underwent native left nephrectomy and transurethral resection of the prostate. Histopathologic examination of kidney and prostate tissue revealed CMV inclusions consistent with invasive CMV disease. This case highlights that CMV may extend beyond the kidney allograft to involve other parts of the genitourinary tract, including the native kidneys and prostate. Furthermore, we highlight the tissue-specific risk factors that preceded CMV tissue invasion. In addition to concurrent diagnoses, health care providers should have a low threshold for considering late-onset CMV disease in high-risk solid organ transplant recipients presenting with signs and symptoms of genitourinary tract pathology. This article is protected by copyright. All rights reserved.

    View details for PubMedID 30203504

  • Efficacy and Safety of a Tofacitinib-based Immunosuppressive Regimen After Kidney Transplantation: Results From a Long-term Extension Trial TRANSPLANTATION DIRECT Busque, S., Vincenti, F. G., Silva, H., O'Connell, P. J., Yoshida, A., Friedewald, J. J., Steinberg, S. M., Budde, K., Broeders, E. N., Kim, Y., Hahn, C. M., Li, H., Chan, G. 2018; 4 (9)
  • Efficacy and Safety of a Tofacitinib-based Immunosuppressive Regimen After Kidney Transplantation: Results From a Long-term Extension Trial. Transplantation direct Busque, S., Vincenti, F. G., Tedesco Silva, H., O'Connell, P. J., Yoshida, A., Friedewald, J. J., Steinberg, S. M., Budde, K., Broeders, E. N., Kim, Y. S., Hahn, C. M., Li, H., Chan, G. 2018; 4 (9): e380


    Tofacitinib is an oral Janus kinase inhibitor. This open-label, long-term extension (LTE) study (NCT00658359) evaluated long-term tofacitinib treatment in stable kidney transplant recipients (n = 178) posttransplant.Patients who completed 12 months of cyclosporine (CsA) or tofacitinib treatment in the phase IIb parent study (NCT00483756) were enrolled into this LTE study, evaluating long-term tofacitinib treatment over months 12 to 72 posttransplant. Patients were analyzed by tofacitinib less-intensive (LI) or more-intensive (MI) regimens received in the parent study. For both groups, tofacitinib dose was reduced from 10 to 5 mg twice daily by 6 months into the LTE. Patients were followed up through month 72 posttransplant, with a focus on month 36 results.Tofacitinib demonstrated similar 36-month patient and graft survival rates to CsA. Biopsy-proven acute rejection rates at month 36 were 11.2% for CsA, versus 10.0% and 7.4% (both P > 0.05) for tofacitinib LI and MI, respectively. Least squares mean estimated glomerular filtration rates were 9 to 15 mL/min per 1.73 m2 higher for tofacitinib versus CsA at month 36. The proportions of patients with grade 2/3 interstitial fibrosis and tubular atrophy in month 36 protocol biopsies were 20.0% for LI and 18.2% for MI (both P > 0.05) versus 33.3% for CsA. Kaplan-Meier cumulative serious infection rates at month 36 were numerically higher for tofacitinib LI (43.9%; P = 0.45) and significantly higher for MI (55.9%; P < 0.05) versus CsA (37.1%).Long-term tofacitinib continued to be effective in preventing renal allograft acute rejection and preserving renal function. However, long-term tofacitinib and mycophenolic acid product combination was associated with persistent serious infection risk.

    View details for DOI 10.1097/TXD.0000000000000819

    View details for PubMedID 30234149

    View details for PubMedCentralID PMC6133407

  • Relationship Between Mixed Chimerism and Acceptance of HLA-matched and -Mismatched Kidney Transplants after Withdrawal of Immunosuppressive Drugs Busque, S., Scandling, J., Lowsky, R., Shizuru, J., Jensen, K., Shori, A., Hoppe, R., Engleman, E., Meyer, E., Strober, S. LIPPINCOTT WILLIAMS & WILKINS. 2018: S393
  • Relationship between Mixed Chimerism and Acceptance of HLA-Matched and Mismatched Kidney Transplants after Withdrawal of Immunosuppressive Drugs. Scandling, J., Busque, S., Lowsky, R., Shizuru, J., Jensen, K., Shori, A., Engleman, E., Meyer, E., Hoppe, R., Strober, S. WILEY. 2018: 470
  • Changes in Phenotype, Immune Suppressive, Function, and Gene Expression of Myeloid Derived Suppressor Cells in Patients Given Combined Kidney and Hematopoietic Cell Transplants in a Tolerance Protocol. Jensen, K., Zheng, P., Xuhuai, J., Saraswathula, A., Scandling, J., Busque, S., Shizuru, J., Lowsky, R., Shori, A., Maecker, H., Engleman, E., Meyer, E., Strober, S. WILEY. 2018: 495–96
  • Macrochimerism and clinical transplant tolerance. Human immunology Scandling, J. D., Busque, S., Lowsky, R., Shizuru, J., Shori, A., Engleman, E., Jensen, K., Strober, S. 2018


    Current theory holds that macrochimerism is essential to the development of transplant tolerance. Hematopoietic cell transplantation from the solid organ donor is necessary to achieve macrochimerism. Over the last 10-20 years, trials of tolerance induction with combined kidney and hematopoietic cell transplantation have moved from the preclinical to the clinical arena. The achievement of macrochimerism in the clinical setting is challenging, and potentially toxic due to the conditioning regimen necessary to hematopoietic cell transplantation and due to the risk of graft-versus-host disease. There are differences in chimerism goals and methods of the three major clinical stage tolerance induction strategies in both HLA-matched and HLA-mismatched living donor kidney transplantation, with consequent differences in efficacy and safety. The Stanford protocol has proven efficacious in the induction of tolerance in HLA-matched kidney transplantation, allowing cessation of immunosuppressive drug therapy in 80% of study participants, with the safety profile of conventional transplantation. In HLA-mismatched transplantation, multi-lineage macrochimerism of over a year's duration can now be consistently achieved with the Stanford protocol, with complete withdrawal of immunosuppressive drug therapy during the second post-transplant year as the next experimental step and test of tolerance.

    View details for PubMedID 29330112

  • Relationship Between Mixed Chimerism and Tolerance in HLA-Matched and -Mismatched Recipients of Kidney and Hematopoietic Cell Transplants Busque, S., Scandling, J., Shizuru, J., Lowsky, R., Shori, A., Kent, J., Engleman, E., Strober, S. WILEY. 2017: 276
  • A Cost Analysis of Tolerance Induction for Two-Haplotype Match Kidney Transplant Recipients AMERICAN JOURNAL OF TRANSPLANTATION Erickson, K. F., Winkelmayer, W. C., Busque, S., Lowsky, R., Scandling, J. D., Strober, S. 2016; 16 (1): 371–73

    View details for PubMedID 26551201

  • The Association of Predonation Hypertension with Glomerular Function and Number in Older Living Kidney Donors JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY Lenihan, C. R., Busque, S., Derby, G., Blouch, K., Myers, B. D., Tan, J. C. 2015; 26 (6): 1261-1267


    The effect of preexisting hypertension on living donor nephron number has not been established. In this study, we determined the association between preexisting donor hypertension and glomerular number and volume and assessed the effect of predonation hypertension on postdonation BP, adaptive hyperfiltration, and compensatory glomerular hypertrophy. We enrolled 51 living donors to undergo physiologic, morphometric, and radiologic evaluations before and after kidney donation. To estimate the number of functioning glomeruli (NFG), we divided the whole-kidney ultrafiltration coefficient (Kf) by the single-nephron ultrafiltration coefficient (SNKf). Ten donors were hypertensive before donation. We found that, in donors ages >50 years old, preexisting hypertension was associated with a reduction in NFG. In a comparison of 10 age- and sex-matched hypertensive and normotensive donors, we observed more marked glomerulopenia in hypertensive donors (NFG per kidney, 359,499±128,929 versus 558,239±205,152; P=0.02). Glomerulopenia was associated with a nonsignificant reduction in GFR in the hypertensive group (89±12 versus 95±16 ml/min per 1.73 m(2)). We observed no difference in the corresponding magnitude of postdonation BP, hyperfiltration capacity, or compensatory renocortical hypertrophy between hypertensive and normotensive donors. Nevertheless, we propose that the greater magnitude of glomerulopenia in living kidney donors with preexisting hypertension justifies the need for long-term follow-up studies.

    View details for DOI 10.1681/ASN.2014030304

    View details for Web of Science ID 000355386100007

    View details for PubMedID 25525178

    View details for PubMedCentralID PMC4446872

  • Evaluation of the Effect of Tofacitinib Exposure on Outcomes in Kidney Transplant Patients AMERICAN JOURNAL OF TRANSPLANTATION Vincenti, F., Silva, H. T., Busque, S., O'Connell, P. J., Russ, G., Budde, K., Yoshida, A., Tortorici, M. A., Lamba, M., Lawendy, N., Wang, W., Chan, G. 2015; 15 (6): 1644-1653


    Tofacitinib fixed-dose regimens attained better kidney function and comparable efficacy to cyclosporine (CsA) in kidney transplant patients, albeit with increased risks of certain adverse events. This post-hoc analysis evaluated whether a patient subgroup with an acceptable risk-benefit profile could be identified. Tofacitinib exposure was a statistically significant predictor of serious infection rate. One-hundred and eighty six kidney transplant patients were re-categorized to above-median (AME) or below-median (BME) exposure groups. The 6-month biopsy-proven acute rejection rates in AME, BME and CsA groups were 7.8%, 15.7% and 17.7%, respectively. Measured glomerular filtration rate was higher in AME and BME groups versus CsA (61.2 and 67.9 vs. 53.9 mL/min) at Month 12. Fewer patients developed interstitial fibrosis and tubular atrophy (IF/TA) at Month 12 in AME (20.5%) and BME (27.8%) groups versus CsA (48.3%). Serious infections occurred more frequently in the AME group (53.0%) than in BME (28.4%) or CsA (25.5%) groups. Posttransplant lymphoproliferative disorder (PTLD) only occurred in the AME group. In kidney transplant patients, the BME group preserved the clinical advantage of comparable acute rejection rates, improved renal function and a lower incidence of IF/TA versus CsA, and with similar rates of serious infection and no PTLD.

    View details for DOI 10.1111/ajt.13181

    View details for Web of Science ID 000354621200024

    View details for PubMedID 25649117

  • Identification of miRNAs Associated With Induced Tolerance to Allografts Vitalone, M., Wei, L., Esquivel, C., Busque, S., Martinez, O., Krams, S. WILEY-BLACKWELL. 2015
  • Stable and Unstable Chimerism During Immunosuppressive Drug Withdrawal in Tolerant Recipients of HLA Matched Combined Kidney and Hematopoietic Cell Transplants Pham, T., Busque, S., Scandling, J., Shizuru, J., Asha, S., Strober, S. WILEY-BLACKWELL. 2015
  • Chimerism, Graft Survival, and Withdrawal of Immunosuppressive Drugs in HLA Matched and Mismatched Patients After Living Donor Kidney and Hematopoietic Cell Transplantation. American journal of transplantation Scandling, J. D., Busque, S., Shizuru, J. A., Lowsky, R., Hoppe, R., Dejbakhsh-Jones, S., Jensen, K., Shori, A., Strober, J. A., Lavori, P., Turnbull, B. B., Engleman, E. G., Strober, S. 2015; 15 (3): 695-704


    Thirty-eight HLA matched and mismatched patients given combined living donor kidney and enriched CD34(+) hematopoietic cell transplants were enrolled in tolerance protocols using posttransplant conditioning with total lymphoid irradiation and anti-thymocyte globulin. Persistent chimerism for at least 6 months was associated with successful complete withdrawal of immunosuppressive drugs in 16 of 22 matched patients without rejection episodes or kidney disease recurrence with up to 5 years follow up thereafter. One patient is in the midst of withdrawal and five are on maintenance drugs. Persistent mixed chimerism was achieved in some haplotype matched patients for at least 12 months by increasing the dose of T cells and CD34(+) cells infused as compared to matched recipients in a dose escalation study. Success of drug withdrawal in chimeric mismatched patients remains to be determined. None of the 38 patients had kidney graft loss or graft versus host disease with up to 14 years of observation. In conclusion, complete immunosuppressive drug withdrawal could be achieved thus far with the tolerance induction regimen in HLA matched patients with uniform long-term graft survival in all patients.

    View details for DOI 10.1111/ajt.13091

    View details for PubMedID 25693475

  • Longitudinal study of living kidney donor glomerular dynamics after nephrectomy JOURNAL OF CLINICAL INVESTIGATION Lenihan, C. R., Busque, S., Derby, G., Blouch, K., Myers, B. D., Tan, J. C. 2015; 125 (3): 1311-1318


    Over 5,000 living kidney donor nephrectomies are performed annually in the US. While the physiological changes that occur early after nephrectomy are well documented, less is known about the long-term glomerular dynamics in living donors.We enrolled 21 adult living kidney donors to undergo detailed long-term clinical, physiological, and radiological evaluation pre-, early post- (median, 0.8 years), and late post- (median, 6.3 years) donation. A morphometric analysis of glomeruli obtained during nephrectomy was performed in 19 subjects.Donors showed parallel increases in single-kidney renal plasma flow (RPF), renocortical volume, and glomerular filtration rate (GFR) early after the procedure, and these changes were sustained through to the late post-donation period. We used mathematical modeling to estimate the glomerular ultrafiltration coefficient (Kf), which also increased early and then remained constant through the late post-donation study. Assuming that the filtration surface area (and hence, Kf) increased in proportion to renocortical volume after donation, we calculated that the 40% elevation in the single-kidney GFR observed after donation could be attributed exclusively to an increase in the Kf. The prevalence of hypertension in donors increased from 14% in the early post-donation period to 57% in the late post-donation period. No subjects exhibited elevated levels of albuminuria.Adaptive hyperfiltration after donor nephrectomy is attributable to hyperperfusion and hypertrophy of the remaining glomeruli. Our findings point away from the development of glomerular hypertension following kidney donation.Not applicable. FUNDING. NIH (R01DK064697 and K23DK087937); Astellas Pharma US; the John M. Sobrato Foundation; the Satellite Extramural Grant Foundation; and the American Society of Nephrology.

    View details for DOI 10.1172/JCI78885

    View details for Web of Science ID 000350616500041

    View details for PubMedID 25689253

  • Effects of Hypertension On Glomerular Function and Number in Living Kidney Donors. Lenihan, C., Busque, S., Myers, B., Tan, J. LIPPINCOTT WILLIAMS & WILKINS. 2014: 483
  • Early Excellent Outcomes of Flow Cross-Match Negative Kidney Transplant Recipients With Pre-Formed IgG DSA, C1q Negative With or Without Peri-Operative IVIg Infusion. Busque, S., Yabu, J., Melcher, M., Gallo, A., Kong, S., Makki, T., Burke-Barber, K., Scandling, J., Tyan, D. LIPPINCOTT WILLIAMS & WILKINS. 2014: 512
  • Tolerance, Mixed Chimerism, and Graft Survival in HLA Matched and Mismatched Recipients of Kidney and Hematopoietic Cell Transplants. Scandling, J., Busque, S., Shizuru, J., Lowsky, R., Dejbakhsh-Jones, S., Jensen, K., Shori, A., Turnbull, B., Engleman, E., Strober, S. LIPPINCOTT WILLIAMS & WILKINS. 2014: 901
  • Resolution of Acute Kidney Injury After Liver Transplantation: A Single Center Experience. Todo, T., Gallo, A., Berumen, J., Feinberg, E., Melcher, M., Bonham, C., Busque, S., Concepcion, W., Esquivel, C. LIPPINCOTT WILLIAMS & WILKINS. 2014: 759
  • The Long Term Follow Up of Aging Kidney Donors. Lenihan, C., Busque, S., Myers, B., Tan, J. LIPPINCOTT WILLIAMS & WILKINS. 2014: 489–90
  • Resolution of Acute Kidney Injury After Liver Transplantation: A Single Center Experience. Todo, T., Gallo, A., Berumen, J., Feinberg, E., Melcher, M., Bonham, C., Busque, S., Concepcion, W., Esquivel, C. WILEY-BLACKWELL. 2014: 759
  • Tolerance, Mixed Chimerism, and Graft Survival in HLA Matched and Mismatched Recipients of Kidney and Hematopoietic Cell Transplants. Scandling, J., Busque, S., Shizuru, J., Lowsky, R., Dejbakhsh-Jones, S., Jensen, K., Shori, A., Turnbull, B., Engleman, E., Strober, S. WILEY-BLACKWELL. 2014: 901
  • Effects of Hypertension On Glomerular Function and Number in Living Kidney Donors. Lenihan, C., Busque, S., Myers, B., Tan, J. WILEY-BLACKWELL. 2014: 483
  • Early Excellent Outcomes of Flow Cross-Match Negative Kidney Transplant Recipients With Pre-Formed IgG DSA, C1q Negative With or Without Peri-Operative IVIg Infusion Busque, S., Yabu, J., Melcher, M., Gallo, A., Kong, S., Makki, T., Burke-Barber, K., Scandling, J., Tyan, D. WILEY-BLACKWELL. 2014: 512
  • The Long Term Follow Up of Aging Kidney Donors Lenihan, C., Busque, S., Myers, B., Tan, J. WILEY-BLACKWELL. 2014: 489–90
  • A Preconditioning Regimen With a PKC epsilon Activator Improves Islet Graft Function in a Mouse Transplant Model CELL TRANSPLANTATION Hamilton, D., Rugg, C., Davis, N., Kvezereli, M., Tafti, B. A., Busque, S., Fontaine, M. 2014; 23 (7): 913-919


    BACKGROUND: Transplantation of islets isolated from deceased donor pancreata is an attractivemethod of β cell replacement therapy for patients with type 1 diabetes (T1D). However the loss of islet cell viability and function during the peritransplant period is a limiting factor to long-term islet engraftment. Activation of the isoenzyme PKCε may improve islet survival and function. The currentstudy assesses the effects of PKC εactivation on islet graft function in a syngeneic streptozotocininduced diabetic mouse model.METHODS: Islets were isolated from wild-type BALB/c mice preconditioned with either a PKCεactivator (ψεRACK) or a TAT carrier control peptide. Islets were further treated with the same agents during isolation, purification, and incubation prior to transplantation. 275 islet equivalents were transplanted under the kidney capsule of streptozotocin-induced diabetic BALB/c mice. Islet function was assessed by measurement of blood glucose levels every 3 days for 42 days after transplant and through an intra peritoneal glucose tolerance test (IPGTT).RESULTS: The time for return to euglycemia in mice transplanted with islets treated with ψεRACK was improved at 14 +/- 6 days versus 21+/- 6 days with TAT-treated islets. The IPGTT showed a 50% reduction in the area under the curve associated with an improved insulin response in mice transplanted with ψεRACK-treated islets compared to TAT-treated islets.CONCLUSION: A preconditioning regimen using PKCε agonist before pancreatic recovery and during islet isolation improves islet graft function and resistance to high glucose stress after transplantation.

    View details for DOI 10.3727/096368913X665567

    View details for Web of Science ID 000337989700010

    View details for PubMedID 23562311

  • Resolution of Acute Kidney Injury after Liver Transplantation: Single Center Experience Todo, T., Gallo, A., Beruman, J., Feinberg, E., Melcher, M., Bonham, C., Busque, S., Concepcion, W., Esquivel, C. WILEY-BLACKWELL. 2014: 101
  • EFFECT OF TOFACITINIB EXPOSURE ON OUTCOMES IN KIDNEY TRANSPLANT PATIENTS (KT PTS) Vincenti, F., Tedesco-Silva, H., O'Connell, P., Busque, S., Tortorici, M., Hahn, C. M., Wang, W., Chan, G. WILEY-BLACKWELL. 2013: 101
  • Uniform Long-Term Graft Survival in a Clincial Trial of the Induction of Tolerance to Kidney Transplants. 13th American Transplant Congress (ATC) Scandling, J., Busque, S., Shori, A., Dejbakhsh-Jones, S., Shizuru, J., Lowsky, R., Benike, C., Engleman, E., Strober, S. WILEY-BLACKWELL. 2013: 200–200
  • Safety and Effectiveness of Valganciclovir for Cytomegalovirus Prophylaxis in Solid Organ Transplant Patients on Hemodialysis Wang, U., Yang, A., Dong, M., Busque, S. WILEY-BLACKWELL. 2013: 212
  • Adverse Events of Over-Immunosuppression Are Dependent on Tofacitinib Exposure in Kidney Transplant (KT) Patients. Busque, S., Vincenti, F., Tedesco Silva, H., O'Connell, P., Tortorici, M., Lawendy, N., Wang, W., Chan, G. WILEY-BLACKWELL. 2013: 86
  • Evaluating Deceased Donor Registries: Identifying Predictive Factors of Donor Designation AMERICAN SURGEON Hajhosseini, B., Stewart, B., Tan, J. C., Busque, S., Melcher, M. L. 2013; 79 (3): 235-241


    The objectives of this study were to evaluate and compare the performance of the deceased donor registries of the 50 states and the District of Columbia and to identify possible predictive factors of donor designation. Data were collected retrospectively by Donate Life America using a questionnaire sent to Donor Designation Collaborative state teams between 2007 and 2010. By the end of 2010, there were 94,669,081 designated donors nationwide. This accounted for 39.8 per cent of the U.S. population aged 18 years and over. The number of designated organ donors and registry-authorized recovered donors increased each year; however, the total number of recovered donors in 2010 was the lowest since 2004. Donor designation rate was significantly higher when license applicants were verbally questioned at the Department of Motor Vehicles (DMV) regarding their willingness to register as a donor and when DMV applicants were not given an option on DMV application forms to contribute money to support organ donation, compared with not being questioned verbally, and being offered an option to contribute money. State registries continue to increase the total number of designated organ donors; however, the current availability of organs remains insufficient to meet the demand. These data suggest that DMV applicants who are approached verbally regarding their willingness to register as a donor and not given an option on DMV application forms to contribute money to support organ donation might be more likely to designate themselves to be a donor.

    View details for Web of Science ID 000315606500003

    View details for PubMedID 23461946

  • Desensitization Combined With Paired Exchange Leads to Successful Transplantation in Highly Sensitized Kidney Transplant Recipients: Strategy and Report of Five Cases TRANSPLANTATION PROCEEDINGS Yabu, J. M., Pando, M. J., Busque, S., Melcher, M. L. 2013; 45 (1): 82-87


    Sensitization remains a major barrier to kidney transplantation. Sensitized patients comprise 30% of the kidney transplant waiting list but fewer than 15% of highly sensitized patients are transplanted each year. Options for highly sensitized patients with an immunologically incompatible living donor include desensitization or kidney paired donation (KPD). However, these options when used alone may still not be sufficient to allow a compatible transplant for recipients who are broadly sensitized with cumulative calculated panel-reactive antibody (cPRA) > 95%. We describe in this report the combined use of both desensitization and KPD to maximize the likelihood of finding a compatible match with a more immunologically favorable donor through a kidney exchange program. This combined approach was used in five very highly sensitized patients, all with cPRA 100%, who ultimately received compatible living and deceased donor kidney transplants. We conclude that early enrollment in paired kidney donor exchange and tailored desensitization protocols are key strategies to improve care and rates of kidney transplantation in highly sensitized patients.

    View details for DOI 10.1016/j.transproceed.2012.08.007

    View details for PubMedID 23375278

  • A Decade'S Experience with Safety and Efficacy of Tolerance Induction in Clinical Kidney Transplantation Scandling, J. D., Busque, S., Dejbakhsh-Jones, S., Benike, C., Shori, A., Shizuru, J., Lowsky, R., Engleman, E., Strober, S. LIPPINCOTT WILLIAMS & WILKINS. 2012: 55
  • Randomized Phase 2b Trial of Tofacitinib (CP-690,550) in De Novo Kidney Transplant Patients: Efficacy, Renal Function and Safety at 1 Year AMERICAN JOURNAL OF TRANSPLANTATION Vincenti, F., Silva, H. T., Busque, S., O'Connell, P., Friedewald, J., Cibrik, D., Budde, K., Yoshida, A., Cohney, S., Weimar, W., Kim, Y. S., Lawendy, N., Lan, S., Kudlacz, E., Krishnaswami, S., Chan, G. 2012; 12 (9): 2446-2456


    In this Phase 2b study, 331 low-to-moderate risk de novo kidney transplant patients (approximately 60% deceased donors) were randomized to a more intensive (MI) or less intensive (LI) regimen of tofacitinib (CP-690, 550), an oral Janus kinase inhibitor or cyclosporine (CsA). All patients received basiliximab induction, mycophenolic acid and corticosteroids. Primary endpoints were: incidence of biopsy-proven acute rejection (BPAR) with a serum creatinine increase of ≥0.3 mg/dL and ≥20% (clinical BPAR) at Month 6 and measured GFR at Month 12. Similar 6-month incidences of clinical BPAR (11%, 7% and 9%) were observed for MI, LI and CsA. Measured GFRs were higher (p < 0.01) at Month 12 for MI and LI versus CsA (65 mL/min, 65 mL/min vs. 54 mL/min). Fewer (p < 0.05) patients in MI or LI developed chronic allograft nephropathy at Month 12 compared with CsA (25%, 24% vs. 48%). Serious infections developed in 45%, 37% and 25% of patients in MI, LI and CsA, respectively. Anemia, neutropenia and posttransplant lymphoproliferative disorder occurred more frequently in MI and LI compared with CsA. Tofacitinib was equivalent to CsA in preventing acute rejection, was associated with improved renal function and less chronic allograft histological injury, but had side-effects at the doses evaluated.

    View details for DOI 10.1111/j.1600-6143.2012.04127.x

    View details for Web of Science ID 000307945000023

    View details for PubMedID 22682022

  • Chain Transplantation: Initial Experience of a Large Multicenter Program AMERICAN JOURNAL OF TRANSPLANTATION Melcher, M. L., Leeser, D. B., Gritsch, H. A., Milner, J., Kapur, S., Busque, S., Roberts, J. P., Katznelson, S., Bry, W., Yang, H., Lu, A., Mulgaonkar, S., Danovitch, G. M., Hil, G., VEALE, J. L. 2012; 12 (9): 2429-2436


    We report the results of a large series of chain transplantations that were facilitated by a multicenter US database in which 57 centers pooled incompatible donor/recipient pairs. Chains, initiated by nondirected donors, were identified using a computer algorithm incorporating virtual cross-matches and potential to extend chains. The first 54 chains facilitated 272 kidney transplants (mean chain length = 5.0). Seven chains ended because potential donors became unavailable to donate after their recipient received a kidney; however, every recipient whose intended donor donated was transplanted. The remaining 47 chains were eventually closed by having the last donor donate to the waiting list. Of the 272 chain recipients 46% were ethnic minorities and 63% of grafts were shipped from other centers. The number of blood type O-patients receiving a transplant (n = 90) was greater than the number of blood type O-non-directed donors (n = 32) initiating chains. We have 1-year follow up on the first 100 transplants. The mean 1-year creatinine of the first 100 transplants from this series was 1.3 mg/dL. Chain transplantation enables many recipients with immunologically incompatible donors to be transplanted with high quality grafts.

    View details for DOI 10.1111/j.1600-6143.2012.04156.x

    View details for PubMedID 22812922

  • Incidental kidney stones: a single center experience with kidney donor selection CLINICAL TRANSPLANTATION Kim, I. K., Tan, J. C., Lapasia, J., Elihu, A., Busque, S., Melcher, M. L. 2012; 26 (4): 558-563


    The presence of kidney stones has been a relative contraindication for living donation. With the widespread use of more sensitive imaging techniques as part of the routine living donor workup, kidney stones are more frequently detected, and their clinical significance in this setting is largely unknown. Records from 325 potential kidney donors who underwent MRA or CT-angiography were reviewed; 294 proceeded to donation. The prevalence of kidney stones found incidentally during donor evaluation was 7.4% (24 of 325). Sixteen donors with stones proceeded with kidney donation. All incidental calculi were nonobstructing and small (median 2 mm; range 1-9 mm). Eleven recipients were transplanted with allografts containing stones. One recipient developed symptomatic nephrolithasis after transplantation. This recipient was found to have newly formed stones secondary to hyperoxaluria, suggesting a recipient-driven propensity for stone formation. The remaining ten recipients have stable graft function, postoperative ultrasound negative for nephrolithiasis, and no sequelae from stones. No donor developed symptomatic nephrolithiasis following donation. Judicious use of allografts with small stones in donors with normal metabolic studies may be acceptable, and careful follow-up in recipients of such allografts is warranted.

    View details for DOI 10.1111/j.1399-0012.2011.01567.x

    View details for PubMedID 22168332

  • Tolerance and Withdrawal of Immunosuppressive Drugs in Patients Given Kidney and Hematopoietic Cell Transplants AMERICAN JOURNAL OF TRANSPLANTATION Scandling, J. D., Busque, S., Dejbakhsh-Jones, S., Benike, C., Sarwal, M., Millan, M. T., Shizuru, J. A., Lowsky, R., Engleman, E. G., Strober, S. 2012; 12 (5): 1133-1145


    Sixteen patients conditioned with total lymphoid irradiation (TLI) and antithymocyte globulin (ATG) were given kidney transplants and an injection of CD34+ hematopoietic progenitor cells and T cells from HLA-matched donors in a tolerance induction protocol. Blood cell monitoring included changes in chimerism, balance of T-cell subsets and responses to donor alloantigens. Fifteen patients developed multilineage chimerism without graft-versus-host disease (GVHD), and eight with chimerism for at least 6 months were withdrawn from antirejection medications for 1-3 years (mean, 28 months) without subsequent rejection episodes. Four chimeric patients have just completed or are in the midst of drug withdrawal, and four patients were not withdrawn due to return of underlying disease or rejection episodes. Blood cells from all patients showed early high ratios of CD4+CD25+ regulatory T cells and NKT cells versus conventional naive CD4+ T cells, and those off drugs showed specific unresponsiveness to donor alloantigens. In conclusion, TLI and ATG promoted the development of persistent chimerism and tolerance in a cohort of patients given kidney transplants and hematopoietic donor cell infusions. All 16 patients had excellent graft function at the last observation point with or without maintenance drugs.

    View details for DOI 10.1111/j.1600-6143.2012.03992.x

    View details for Web of Science ID 000303235100012

    View details for PubMedID 22405058

    View details for PubMedCentralID PMC3338901

  • Gene Array Pattern for Induced Human Kidney Transplant Tolerance with Safe Immunosuppression Withdrawal Li, L., Hsieh, S., Lowsky, R., Busque, S., Scandling, J., Jones, S., Strober, S., Sarwal, M. WILEY-BLACKWELL. 2012: 183
  • Validity of Surrogate Measures for Functional Nephron Mass TRANSPLANTATION Tan, J. C., Paik, J., Chertow, G. M., Grumet, F. C., Busque, S., Lapasia, J., Desai, M. 2011; 92 (12): 1335-1341


    Transplanted nephron mass is an important determinant of long-term allograft survival, but accurate assessment before organ retrieval is challenging. Newer radiologic imaging techniques allow for better determination of total kidney and cortical volumes.Using volume measurements reconstructed from magnetic resonance or computed tomography imaging from living donor candidates, we characterized total kidney (n=312) and cortical volumes (n=236) according to sex, age, weight, height, body mass index (BMI), and body surface area (BSA).The mean cortical volume was 204 mL (range 105-355 mL) with no significant differences between left and right cortical volumes. The degree to which existing anthropomorphic surrogates predict nephron mass was quantified, and a diligent attempt was made to derive a better surrogate model for nephron mass. Cortical volumes were strongly associated with sex and BSA, but not with weight, height, or BMI. Four prediction models for cortical volume constructed using combinations of age, sex, race, weight, and height were compared with models including either BSA or BMI.Among existing surrogate measures, BSA was superior to BMI in predicting renal cortical volume. We were able to construct a statistically superior proxy for cortical volume, but whether relevant improvements in predictive accuracy could be gained needs further evaluation in a larger population.

    View details for DOI 10.1097/TP.0b013e31823705ef

    View details for PubMedID 22011765

  • The PROMISE Study: A Phase 2b Multicenter Study of Voclosporin (ISA247) Versus Tacrolimus in De Novo Kidney Transplantation AMERICAN JOURNAL OF TRANSPLANTATION Busque, S., Cantarovich, M., Mulgaonkar, S., Gaston, R., Gaber, A. O., Mayo, P. R., Ling, S., Huizinga, R. B., Meier-Kriesche, H. 2011; 11 (12): 2675-2684


    Voclosporin (VCS, ISA247) is a novel calcineurin inhibitor being developed for organ transplantation. PROMISE was a 6-month, multicenter, randomized, open-label study of three ascending concentration-controlled groups of VCS (low, medium and high) compared to tacrolimus (TAC) in 334 low-risk renal transplant recipients. The primary endpoint was demonstration of noninferiority of biopsy proven acute rejection (BPAR) rates. Secondary objectives included renal function, new onset diabetes after transplantation (NODAT), hypertension, hyperlipidemia and pharmacokinetic-pharmacodynamic evaluation. The incidence of BPAR in the VCS groups (10.7%, 9.1% and 2.3%, respectively) was noninferior to TAC (5.8%). The incidence of NODAT for VCS was 1.6%, 5.7% and 17.7% versus 16.4% in TAC (low-dose VCS, p = 0.03). Nankivell estimated glomerular filtration rate was respectively: 71, 72, 68 and 69 mL/min, statistically lower in the high-dose group, p = 0.049. The incidence of hypertension and adverse events was not different between the VCS groups and TAC. VCS demonstrated an excellent correlation between trough and area under the curve (r(2) = 0.97) and no difference in mycophenolic acid exposure compared to TAC. This 6-month study shows VCS to be as efficacious as TAC in preventing acute rejection with similar renal function in the low- and medium-exposure groups, and potentially associated with a reduced incidence of NODAT.

    View details for DOI 10.1111/j.1600-6143.2011.03763.x

    View details for Web of Science ID 000297411800019

    View details for PubMedID 21943027

  • Induced Immune Tolerance for Kidney Transplantation NEW ENGLAND JOURNAL OF MEDICINE Scandling, J. D., Busque, S., Shizuru, J. A., Engleman, E. G., Strober, S. 2011; 365 (14): 1359-1360

    View details for Web of Science ID 000295578700034

    View details for PubMedID 21991976

    View details for PubMedCentralID PMC3334358

  • Living donor evaluation and exclusion: the Stanford experience CLINICAL TRANSPLANTATION Lapasia, J. B., Kong, S., Busque, S., Scandling, J. D., Chertow, G. M., Tan, J. C. 2011; 25 (5): 697-704


    The proportion of prospective living donors disqualified for medical reasons is unknown. The objective of this study is to delineate and quantify specific reasons for exclusion of prospective living donors from kidney donation.All adult prospective kidney donors who contacted our transplant program between October 1, 2007 and April 1, 2009 were included in our analysis (n = 484). Data were collected by review of an electronic transplant database.Of the 484 prospective donors, 39 (8%) successfully donated, 229 (47%) were excluded, 104 (22%) were actively undergoing evaluation, and 112 (23%) were withdrawn before evaluation was complete. Criteria for exclusion were medical (n = 150), psychosocial (n = 22), or histocompatibility (n = 57) reasons. Of the 150 prospective donors excluded for medical reasons, 79% were excluded because of obesity, hypertension, nephrolithiasis, and/or abnormal glucose tolerance. One hundred and forty-seven (61%) intended recipients had only one prospective living donor, of whom 63 (42%) were excluded.A significant proportion of prospective living kidney donors were excluded for medical reasons such as obesity (body mass index >30), hypertension, nephrolithiasis, and abnormal glucose tolerance. Longer-term studies are needed to characterize the risks to medically complex kidney donors and the potential risks and benefits afforded to recipients.

    View details for DOI 10.1111/j.1399-0012.2010.01336.x

    View details for PubMedID 21044160

  • Managing Finances of Shipping Living Donor Kidneys for Donor Exchanges AMERICAN JOURNAL OF TRANSPLANTATION Mast, D. A., Vaughan, W., Busque, S., VEALE, J. L., Roberts, J. P., Straube, B. M., Flores, N., Canari, C., Levy, E., Tietjen, A., Hil, G., Melcher, M. L. 2011; 11 (9): 1810-1814


    Kidney donor exchanges enable recipients with immunologically incompatible donors to receive compatible living donor grafts; however, the financial management of these exchanges, especially when an organ is shipped, is complex and thus has the potential to impede the broader implementation of donor exchange programs. Representatives from transplant centers that utilize the National Kidney Registry database to facilitate donor exchange transplants developed a financial model applicable to paired donor exchanges and donor chain transplants. The first tenet of the model is to eliminate financial liability to the donor. Thereafter, it accounts for the donor evaluation, donor nephrectomy hospital costs, donor nephrectomy physician fees, organ transport, donor complications and recipient inpatient services. Billing between hospitals is based on Medicare cost report defined costs rather than charges. We believe that this model complies with current federal regulations and effectively captures costs of the donor and recipient services. It could be considered as a financial paradigm for the United Network for Organ Sharing managed donor exchange program.

    View details for DOI 10.1111/j.1600-6143.2011.03690.x

    View details for PubMedID 21831153

  • C1q-Fixing Human Leukocyte Antigen Antibodies Are Specific for Predicting Transplant Glomerulopathy and Late Graft Failure After Kidney Transplantation TRANSPLANTATION Yabu, J. M., Higgins, J. P., Chen, G., Sequeira, F., Busque, S., Tyan, D. B. 2011; 91 (3): 342-347


    Human leukocyte antigen (HLA) antibodies, especially those that fix complement, are associated with antibody-mediated rejection and graft failure. The C1q assay on single antigen beads detects a subset of HLA antibodies that can fix complement and precede C4d deposition. The aim of this study was to determine whether C1q-fixing antibodies distinguish de novo donor-specific antibodies (DSA) that are clinically relevant and harmful.We retrospectively studied 31 of 274 kidney transplant recipients who had pretransplant and concurrent biopsy and serum specimens, 13 with C4d-positive and 18 with C4d-negative staining. We measured IgG and C1q DSA pretransplant and at the time of biopsy using single antigen bead assays. We identified 13 recipients who developed de novo DSA by IgG or C1q and examined associations with C4d deposition, transplant glomerulopathy, and graft failure.Testing for DSA by IgG is more sensitive for C4d deposition (IgG: 100%, 95% confidence interval [CI] 0.60-1; C1q: 75%, 95% CI 0.36-0.96). Testing for DSA by C1q is more specific for transplant glomerulopathy (C1q: 81%, 95% CI 0.57-0.94; IgG: 67%, 95% CI 0.43-0.85) and graft loss (C1q: 79%, 95% CI 0.54-0.93; IgG: 63%, 95% CI 0.39-0.83). Absence of de novo DSA by IgG and C1q has a high negative predictive value for the absence of C4d deposition (IgG: 100%, 95% CI 0.73-1; C1q: 88%, 95% CI 0.62-0.98), transplant glomerulopathy (IgG: 100%, 95% CI 0.73-1; C1q: 100%, 95% CI 0.77-1), and graft failure (IgG: 86%, 95% CI 0.56-0.97; C1q: 88%, 95% CI 0.62-0.98).Monitoring patients with the C1q assay, which detects antibodies that fix complement, offers a minimally invasive means of identifying patients at risk for transplant glomerulopathy and graft loss.

    View details for DOI 10.1097/TP.0b013e318203fd26

    View details for Web of Science ID 000286624400014

    View details for PubMedID 21116220

  • Population Pharmacokinetic Analysis of Mycophenolic Acid Coadministered With Either Tasocitinib (CP-690,550) or Tacrolimus in Adult Renal Allograft Recipients THERAPEUTIC DRUG MONITORING Lamba, M., Tafti, B., Melcher, M., Chan, G., Krishnaswami, S., Busque, S. 2010; 32 (6): 778-781


    Tasocitinib (CP-690,550) is an orally active Janus kinase inhibitor that is in development for prophylaxis of acute rejection after kidney transplantation and for the treatment of select autoimmune diseases. The current study was conducted to evaluate the systemic exposure of mycophenolic acid (MPA) in de novo kidney transplant patients when coadministered with tasocitinib compared with exposure in patients receiving tacrolimus, which has no effect on MPA pharmacokinetics. Plasma MPA concentrations were obtained from 17 adult patients who received either 15 mg or 30 mg tasocitinib twice daily (eight patients) or tacrolimus (nine patients) after kidney transplantation. All patients also received concomitant mycophenolate mofetil, prednisone, and basiliximab induction. The median mycophenolate mofetil dose was 1000 mg twice daily. A two-compartment population pharmacokinetic model estimating oral clearance, between-patient variability in oral clearance, central volume of distribution, and residual variability in combination with historical estimates of first-order absorption rate constant, intercompartmental clearance, and peripheral volume of distribution adequately described the sparse MPA data. Based on individual estimates oral clearance from the population pharmacokinetic model, mean steady-state area under the concentration-time curve values for a mycophenolate mofetil dose of 1000 mg twice daily were 63 mg·hr/L (22%) and 59 mg·hr/L (36%) for the tasocitinib and tacrolimus groups, respectively. These results indicate that tasocitinib does not influence systemic MPA exposure.

    View details for DOI 10.1097/FTD.0b013e3181f361c9

    View details for Web of Science ID 000284103400017

    View details for PubMedID 20926996

  • Effects of aging on glomerular function and number in living kidney donors KIDNEY INTERNATIONAL Tan, J. C., Busque, S., Workeneh, B., Ho, B., Derby, G., Blouch, K. L., Sommer, F. G., Edwards, B., Myers, B. D. 2010; 78 (7): 686-692


    To elucidate the pathophysiologic changes in the kidney due to aging, we used physiological, morphometric, and imaging techniques to quantify GFR and its determinants in a group of 24 older (≥ 55 years) compared to 33 younger (≤ 45 years) living donors. Mathematical modeling was used to estimate the glomerular filtration coefficients for the whole kidney (K(f)) and for single nephrons (SNK(f)), as well as the number of filtering glomeruli (N(FG)). Compared to younger donors, older donors had a modest (15%) but significant depression of pre-donation GFR. Mean whole-kidney K(f), renocortical volume, and derived N(FG) were also significantly decreased in older donors. In contrast, glomerular structure and SNK(f) were not different in older and younger donors. Derived N(FG) in the bottom quartile of older donors was less than 27% of median-derived N(FG) in the two kidneys of younger donors. Nevertheless, the remaining kidney of older donors exhibited adaptive hyperfiltration and renocortical hypertrophy post-donation, comparable to that of younger donors. Thus, our study found the decline of GFR in older donors is due to a reduction in K(f) attributable to glomerulopenia. We recommend careful monitoring for and control of post-donation comorbidities that could exacerbate glomerular loss.

    View details for DOI 10.1038/ki.2010.128

    View details for Web of Science ID 000281824200011

    View details for PubMedID 20463656

    View details for PubMedCentralID PMC3353650

  • Imprecision of Creatinine-Based GFR Estimates in Uninephric Kidney Donors CLINICAL JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY Tan, J. C., Ho, B., Busque, S., Blouch, K., Derby, G., Efron, B., Myers, B. D. 2010; 5 (3): 497-502


    To ensure long-term safety of living kidney donors, it is now recommended that they be followed for at least 2 years after donation and that serum creatinine levels be monitored. Such levels are often subjected by clinical laboratories to estimating equations and are reported as estimated GFR (eGFR). The accuracy of such equations in uninephric living donors has yet to be validated. This is especially important in older living donors, who often have senescence-related depression of GFR.We compared urinary creatinine clearance, four-variable Modification of Diet in Renal Disease estimating equation (eGFR), and the recently reported CKD-EPI GFR estimating equation with true GFR measured by the urinary iothalamate clearance (iGFR) in 64 subjects after kidney donation.Creatinine clearance overestimated iGFR. Both creatinine-based estimating equations were poorly correlated with and underestimated iGFR. More than half of kidney donors had eGFR <60 ml/min per 1.73 m(2) after donation, a level that categorized them as having stage 3 chronic kidney disease by our current laboratory reporting, whereas only 25% had iGFR <60 ml/min per 1.73 m(2). This misclassification disproportionately affected older donors age > or =55 years, of whom 80% had eGFR <60 ml/min per 1.73 m(2). Neither significant albuminuria nor hypertension was observed.The current practice of reporting eGFR after donation commonly leads to a misclassification of chronic kidney disease, particularly in older donors. To ensure long-term well-being of living kidney donors, more precise estimates of GFR are required, particularly among older potential donors.

    View details for DOI 10.2215/CJN.05280709

    View details for Web of Science ID 000275325000017

    View details for PubMedID 20110343

    View details for PubMedCentralID PMC2827575

  • Factors Associated With Progression of Interstitial Fibrosis in Renal Transplant Patients Receiving Tacrolimus and Mycophenolate Mofetil TRANSPLANTATION Rush, D. N., Cockfield, S. M., Nickerson, P. W., Arlen, D. J., Boucher, A., Busque, S., Girardin, C. E., Knoll, G. A., Lachance, J., Landsberg, D. N., Shapiro, R. J., Shoker, A., Yilmaz, S. 2009; 88 (7): 897-903


    We recently reported a randomized study in renal transplant patients (RTP) receiving tacrolimus, mycophenolate mofetil, and prednisone in which patients who had early protocol biopsies (PBx) derived no benefit compared with controls (no PBx) at 6 months, likely due to the low prevalence of subclinical rejection. We report on the follow-up of these patients to 24 months at which time a repeat PBx and tests of renal function were performed.Of the 240 RTP randomized, 22 were excluded for a protocol violation. Approximately 75% of the remaining 218 (111 PBx and 107 controls) completed the study.At 24 months, graft function was excellent with a mean creatinine clearance of approximately 74 mL/min and negligible proteinuria; however, the prevalence of interstitial fibrosis and tubular atrophy (IF/TA)-ci + ct more than or equal to 2-increased from approximately 3% at baseline to up to 40% to 50%. By logistic regression analysis, the only independent positive correlate of IF/TA was transplantation with a deceased donor. However, by post hoc analysis, use of angiotensin-II-converting enzyme inhibitors or angiotensin II receptor blockers was negatively correlated with both the prevalence of IF/TA at 24 months and its progression between 6 and 24 months in RTP that had paired biopsies.A regimen of tacrolimus, mycophenolate mofetil, and prednisone results in excellent renal function at 24 months posttransplant but with a progressive increase in IF/TA. A potential inhibitory effect of angiotensin-II-converting enzyme inhibitor/angiotensin II receptor blockers on IF/TA is suggested that requires confirmation in a randomized study.

    View details for DOI 10.1097/TP.0b013e3181b723f4

    View details for Web of Science ID 000270842500009

    View details for PubMedID 19935461

  • Asynchronous, Out-of-Sequence, Transcontinental Chain Kidney Transplantation: A Novel Concept AMERICAN JOURNAL OF TRANSPLANTATION Butt, F. K., Gritsch, H. A., Schulam, P., Danovitch, G. M., Wilkinson, A., Del Pizzo, J., Kapur, S., Serur, D., Katznelson, S., Busque, S., Melcher, M. L., McGuire, S., Charlton, M., Hil, G., Veale, J. L. 2009; 9 (9): 2180-2185


    The organ donor shortage has been the most important hindrance in getting listed patients transplanted. Living kidney donors who are incompatible with their intended recipients are an untapped resource for expanding the donor pool through participation in transplant exchanges. Chain transplantation takes this concept further, with the potential to benefit even more recipients. We describe the first asynchronous, out of sequence transplant chain that was initiated by transcontinental shipment of an altruistic donor kidney 1 week after that recipient's incompatible donor had already donated his kidney to the next recipient in the chain. The altruistic donor kidney was transported from New York to Los Angeles and functioned immediately after transplantation. Our modified-sequence asynchronous transplant chain (MATCH) enabled eight recipients, at four different institutions, to benefit from the generosity of one altruistic donor and warrants further exploration as a promising step toward addressing the organ donor shortage.

    View details for DOI 10.1111/j.1600-6143.2009.02730.x

    View details for Web of Science ID 000269180500027

    View details for PubMedID 19563335

  • Calcineurin-Inhibitor-Free Immunosuppression Based on the JAK Inhibitor CP-690,550: A Pilot Study in De Novo Kidney Allograft Recipients AMERICAN JOURNAL OF TRANSPLANTATION Busque, S., Leventhal, J., Brennan, D. C., Steinberg, S., Klintmalm, G., Shah, T., Mulgaonkar, S., Bromberg, J. S., Vincenti, F., Hariharan, S., Slakey, D., Peddi, V. R., Fisher, R. A., Lawendy, N., Wang, C., Chan, G. 2009; 9 (8): 1936-1945


    This randomized, pilot study compared the Janus kinase inhibitor CP-690,550 (15 mg BID [CP15] and 30 mg BID [CP30], n = 20 each) with tacrolimus (n = 21) in de novo kidney allograft recipients. Patients received an IL-2 receptor antagonist, concomitant mycophenolate mofetil (MMF) and corticosteroids. CP-690,550 doses were reduced after 6 months. Due to a high incidence of BK virus nephropathy (BKN) in CP30, MMF was discontinued in this group. The 6-month biopsy-proven acute rejection rates were 1 of 20, 4 of 20 and 1 of 21 for CP15, CP30 and tacrolimus groups, respectively. BKN developed in 4 of 20 patients in CP30 group. The 6-month rates of cytomegalovirus disease were 2 of 20, 4 of 20 and none of 21 for CP15, CP30 and tacrolimus groups, respectively. Estimated glomerular filtration rate was >70 mL/min at 6 and 12 months (all groups). NK cells were reduced by

    View details for DOI 10.1111/j.1600-6143.2009.02720.x

    View details for Web of Science ID 000268050200032

    View details for PubMedID 19660021

  • Glomerular Function, Structure, and Number in Renal Allografts from Older Deceased Donors JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY Tan, J. C., Workeneh, B., Busque, S., Blouch, K., Derby, G., Myers, B. D. 2009; 20 (1): 181-188


    The 5-yr survival rate of renal allografts is significantly lower for grafts from older deceased donors than from younger deceased donors. For evaluation of the potential contribution of renal senescence in this shortened graft survival, glomerular function and structure were analyzed in allografts from deceased donors older than 55 yr ("aging") or younger than 40 yr ("youthful"). Aging donors had a significantly higher prevalence of sclerotic glomeruli (P < 0.002), and their nonsclerotic glomeruli tended to be larger, had a larger filtration surface area (P = 0.02), and had a higher single-nephron ultrafiltration coefficient (K(f); P = 0.07), suggesting a compensatory response to functional loss of glomeruli. After serum creatinine reached a stable nadir in the transplant recipients, GFR and its hemodynamic determinants were evaluated and the whole allograft K(f) was computed. Compared with the allografts from youthful donors, allografts from aging donors exhibited a 32% lower GFR, which was exclusively attributable to a 45% reduction in allograft K(f) (both P < 0.001). In addition, the number of functioning glomeruli per allograft was profoundly lower in grafts from aging donors than from youthful donors (3.6 +/- 2.1 x 10(5) versus 8.5 +/- 3.4 x 10(5); P < 0.01), and this could not be explained by the relatively modest 17% prevalence of global glomerulosclerosis in the aging group. The marked reduction in overall glomerular number in many aging donors may lead to a "remnant kidney" phenomenon, potentially explaining the shorter mean survival of these allografts.

    View details for DOI 10.1681/ASN.2008030306

    View details for Web of Science ID 000262677200025

    View details for PubMedID 18815243

    View details for PubMedCentralID PMC2615719

  • Islet cell survival during isolation improved through protein kinase C epsilon activation Joint Meeting of the International-Xenotransplantation-Association/International-Pancreas-and-Islet-Transplant-Association/Cell-Transplant-Society Kvezereli, M., Vallentin, A., Mochly-Rosen, D., Busque, S., Fontaine, M. J. ELSEVIER SCIENCE INC. 2008: 375–78


    Strategies inhibiting cell death signaling pathways may enhance the availability of islet transplantation for patients with type 1 diabetes mellitus. The epsilon isoform of protein kinase C (PKC epsilon) has been shown to have an anti-apoptotic effect in many cell types. The present study investigated whether activation of PKC epsilon may improve the yield of functional islet cells for transplantation. Islet cells were isolated from wild-type BALB/c mice preconditioned with either a PKC epsilon activator (psi epsilon RACK) or a TAT carrier control peptide and further treated with the same agents during isolation and in vitro for either 0, 1, 16, or 40 hours. Islet cells were assessed at each time point for viability, apoptosis, and function. psi epsilon RACK-treated islets showed significantly decreased islet cell death up to 40 hours after isolation compared with TAT-treated control islets. Beta-cell function in response to high glucose challenge remained unchanged.

    View details for DOI 10.1016/j.transproceed.2008.01.014

    View details for Web of Science ID 000254695600014

    View details for PubMedID 18374073

  • Tolerance and chimerism after renal and hematopoietic-cell transplantation. New England journal of medicine Scandling, J. D., Busque, S., Dejbakhsh-Jones, S., Benike, C., Millan, M. T., Shizuru, J. A., Hoppe, R. T., Lowsky, R., Engleman, E. G., Strober, S. 2008; 358 (4): 362-368


    We describe a recipient of combined kidney and hematopoietic-cell transplants from an HLA-matched donor. A post-transplantation conditioning regimen of total lymphoid irradiation and antithymocyte globulin allowed engraftment of the donor's hematopoietic cells. The patient had persistent mixed chimerism, and the function of the kidney allograft has been normal for more than 28 months since discontinuation of all immunosuppressive drugs. Adverse events requiring hospitalization were limited to a 2-day episode of fever with neutropenia. The patient has had neither rejection episodes nor clinical manifestations of graft-versus-host disease.

    View details for DOI 10.1056/NEJMoa074191

    View details for PubMedID 18216356

  • Brief report: Tolerance and chimerism after renal and hematopoietic-cell transplantation NEW ENGLAND JOURNAL OF MEDICINE Scandling, J. D., Busque, S., Dejbakhsh-Jones, S., Benike, C., Millan, M. T., Shizuru, J. A., Hoppe, R. T., Lowsky, R., Engleman, E. G., Strober, S. 2008; 358 (4): 362-368


    We describe a recipient of combined kidney and hematopoietic-cell transplants from an HLA-matched donor. A post-transplantation conditioning regimen of total lymphoid irradiation and antithymocyte globulin allowed engraftment of the donor's hematopoietic cells. The patient had persistent mixed chimerism, and the function of the kidney allograft has been normal for more than 28 months since discontinuation of all immunosuppressive drugs. Adverse events requiring hospitalization were limited to a 2-day episode of fever with neutropenia. The patient has had neither rejection episodes nor clinical manifestations of graft-versus-host disease.

    View details for Web of Science ID 000252507900006

  • Lack of benefit of early protocol biopsies in renal transplant patients receiving TAC and MMF: A randomized study AMERICAN JOURNAL OF TRANSPLANTATION Rush, D., Arlen, D., Boucher, A., Busque, S., Cockfield, S. M., Girardin, C., Knoll, G., Lachance, J., Landsberg, D., Shapiro, J., Shoker, A., Yilmaz, S. 2007; 7 (11): 2538-2545


    We conducted a randomized, multicenter study to determine whether treatment of subclinical rejection with increased corticosteroids resulted in beneficial outcomes in renal transplant patients receiving tacrolimus (TAC), mycophenolate mofetil (MMF) and prednisone. One hundred and twenty-one patients were randomized to biopsies at 0,1,2,3 and 6 months (Biopsy arm), and 119 to biopsies at 0 and 6 months only (Control arm). The primary endpoint of the study was the prevalence of the sum of the interstitial and tubular scores (ci + ct)> 2 (Banff) at 6 months. Secondary endpoints included clinical and subclinical rejection and renal function. At 6 months, 34.8% of the Biopsy and 20.5% of the Control arm patients had a ci + ct score >or= 2 (p = 0.07). Between months 0 and 6, clinical rejection episodes were 12 in 10 Biopsy arm patients and 8 in 8 Control arm patients (p = 0.44). Overall prevalence of subclinical rejection in the Biopsy arm was 4.6%. Creatinine clearance at 6 months was 72.9 +/- 21.7 in the Biopsy and 68.90 mL/min +/- 18.35 mL/min in the Control arm patients (p = 0.18). In conclusion, we found no benefit to the procurement of early protocol biopsies in renal transplant patients receiving TAC, MMF and prednisone, at least in the short term. This is likely due to their low prevalence of subclinical rejection.

    View details for DOI 10.1111/j.1600-6143.2007.01979.x

    View details for Web of Science ID 000250077600014

    View details for PubMedID 17908280

  • Improving pancreatic islet cell function and survival through PKC epsilon activation Kvezereli, M., Alice, V., Mochly-Rosen, D., Busque, S., Fontaine, M. J. BLACKWELL PUBLISHING. 2007: 516–17
  • Once-daily tacrolimus extended release formulation: Experience at 2 years postconversion from a Prograf-based regimen in stable liver transplant recipients TRANSPLANTATION Florman, S., Alloway, R., Kalayoglu, M., Punch, J., Bak, T., Melancon, J., Klintmalm, G., Busque, S., Charlton, M., Lake, J., Dhadda, S., Wisemandle, K., Wirth, M., Fitzsimmons, W., Holman, J., First, M. R. 2007; 83 (12): 1639-1642


    Compliance with complex immunosuppressant drug therapies in transplant recipients might be improved with regimens that require less frequent dosing. A once-daily extended release (XL) formulation of tacrolimus has been developed that allows a 1:1 conversion from the twice-a-day tacrolimus (TAC) formulation and has a good exposure to trough concentration correlation. In an open-label, multicenter study, stable liver transplant recipients (n=69) were converted from twice-a-day TAC to XL once-daily in the morning, and were maintained for at least 2 years postconversion using the same therapeutic monitoring and patient care techniques employed with TAC. Two years after conversion, the incidence of biopsy-confirmed acute rejection was 5.8% (4 of 69); patient and graft survival was 98.6% (68 of 69). The safety profile of XL was consistent with that previously reported for TAC. Liver transplant recipients can be converted from twice-a-day TAC to once-daily XL and maintained for at least 2 years postconversion with neither unique efficacy nor safety concerns.

    View details for DOI 10.1097/

    View details for Web of Science ID 000247578200019

    View details for PubMedID 17589349

  • Transjugular intrahepatic portosystemic shunt creation in a polycystic liver facilitated by hybrid cross-sectional/angiographic imaging JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Sze, D. Y., Strobel, N., Fahrig, R., Moore, T., Busque, S., Frisoli, J. K. 2006; 17 (4): 711-715


    Polycystic liver disease (PCLD) has long been considered to represent a contraindication to transjugular intrahepatic portosystemic shunt (TIPS) creation, primarily because of the risk of hemorrhage. Three-dimensional (3D) navigation within the enlarged and potentially disorienting parenchyma can now be performed during the procedure with the development of C-arm cone-beam computed tomography, which relies on the same equipment already used for angiography. Such a hybrid 3D reconstruction-enabled angiography system was used for safe image guidance of a TIPS procedure in a patient with PCLD. This technology has the potential to expedite any image-guided procedure that requires 3D navigation.

    View details for DOI 10.1097/01.RVI.0000208984.17697.58

    View details for Web of Science ID 000236836700015

    View details for PubMedID 16614155

  • Circulating growth hormone binding protein levels and mononuclear cell growth hormone receptor expression in uremia 7th Symposium on Growth and Development in Children with Chronic Kidney Disease Greenstein, J., Guest, S., Tan, J. C., Tummala, P., Busque, S., Rabkin, R. W B SAUNDERS CO-ELSEVIER INC. 2006: 141–49


    Resistance to growth hormone (GH) in end-stage renal disease (ESRD) causes growth retardation and muscle wasting. In humans, circulating GH binding protein (GHBP), the extracellular domain of the GH receptor that is shed into the circulation and is believed to reflect tissue GH receptor levels, is reduced in uremia and suggests that cellular GH receptor levels are correspondingly reduced. If true, this could be a cause of GH resistance. We set out to establish whether serum GHBP levels reflect cellular GH receptor levels and whether changes in serum GHBP levels are related to nutritional or inflammatory status.GH receptor protein expression in peripheral blood mononuclear cells (PBMC) from 21 ESRD and 14 normal subjects were analyzed by fluorochrome flow cytometry.The GH receptor density and percent total PBMCs expressing the GH receptor were similar in the 2 groups, and there was no difference in percent GH receptor positive T or B cells or monocytes. In contrast, serum GHBP levels were 80% lower in ESRD. GHBP levels did not correlate with serum albumin, body mass index, or muscle mass but seemed to be partly related to the log serum C-reactive protein levels.Serum GHBP levels are markedly reduced in ESRD; this seems to occur independent of nutritional status and may in part be caused by inflammation. Because GH receptor expression on PBMC of ESRD and control subjects was similar, our findings argue against a reduction in GH receptor as a cause of GH resistance and the use of serum GHBP levels as a reliable marker of specific tissue GH receptor levels.

    View details for DOI 10.1053/j.jrn.2006.01.007

    View details for Web of Science ID 000236735600007

    View details for PubMedID 16567271

  • Validation of a screening protocol for identifying low-risk candidates with type 1 diabetes mellitus for kidney with or without pancreas transplantation 35th Annual Meeting of the American-Society-of-Nephrology Ma, I. W., Valantine, H. A., Shibata, A., Waskerwitz, J., Dafoe, D. C., Alfrey, E. J., Tan, J. C., MILLAN, M., Busque, S., Scandling, J. D. WILEY-BLACKWELL PUBLISHING, INC. 2006: 139–46


    Certain clinical risk factors are associated with significant coronary artery disease in kidney transplant candidates with diabetes mellitus. We sought to validate the use of a clinical algorithm in predicting post-transplantation mortality in patients with type 1 diabetes. We also examined the prevalence of significant coronary lesions in high-risk transplant candidates.All patients with type 1 diabetes evaluated between 1991 and 2001 for kidney with/without pancreas transplantation were classified as high-risk based on the presence of any of the following risk factors: age >or=45 yr, smoking history >or=5 pack years, diabetes duration >or=25 yr or any ST-T segment abnormalities on electrocardiogram. Remaining patients were considered low risk. All high-risk candidates were advised to undergo coronary angiography. The primary outcome of interest was all-cause mortality post-transplantation.Eighty-four high-risk and 42 low-risk patients were identified. Significant coronary artery stenosis was detected in 31 high-risk candidates. Mean arterial pressure was a significant predictor of coronary stenosis (odds ratio 1.68; 95% confidence interval 1.14-2.46), adjusted for age, sex and duration of diabetes. In 75 candidates who underwent transplantation with median follow-up of 47 months, the use of clinical risk factors predicted all eight deaths. No deaths occurred in low-risk patients. A significant mortality difference was noted between the two risk groups (p = 0.03).This clinical algorithm can identify patients with type 1 diabetes at risk for mortality after kidney with/without pancreas transplant. Patients without clinical risk factors can safely undergo transplantation without further cardiac evaluation.

    View details for DOI 10.1111/j.1399-0012.2005.00461.x

    View details for Web of Science ID 000237095200001

    View details for PubMedID 16640517

  • Treatment of hepatic venous outflow obstruction after piggyback liver transplantation RADIOLOGY Wang, S. L., Sze, D. Y., Busque, S., Razavi, M. K., Kee, S. T., Frisoli, J. K., Dake, M. D. 2005; 236 (1): 352-359


    To evaluate retrospectively the endovascular management of hepatic venous outflow obstruction after piggyback orthotopic liver transplantation.The study was performed with the approval and under the guidelines of the institutional review board and complied with the Health Insurance Portability and Accountability Act. Informed consent from patients was not required by the institutional review board for this retrospective study. From 1995 to 2003, 13 patients (eight male, five female), including 12 adults and one adolescent (age range, 14-67 years; median age, 52 years), underwent endovascular treatment of hepatic venous outflow obstruction after piggyback orthotopic liver transplantation. Patients gave informed consent for all procedures. Eleven patients received whole livers, and two received living-related donor right liver lobes. Four underwent repeat piggyback orthotopic liver transplantation prior to intervention. Primary stent placement was performed in 12 patients. One patient refused primary stent placement and chose venoplasty alone, but required a stent 5 months later. Short balloon-expandable stents (mean diameter, 14.6 mm +/- 1.1 [standard deviation]) were used to minimize jailing of branch vessels and to resist recoil. Pre- and post-procedural pressure gradients were measured. Follow-up included venography, cross-sectional imaging, and laboratory tests. The Wilcoxon signed rank test or the sign test was performed to compare pre- and post-procedural pressure gradients, body weights, and laboratory values.Technical success (pressure gradient < or = 3 mm Hg) was achieved in 13 of 13 patients, and clinical success, in 12 of 13. Mean pre- and post-procedural pressure gradients were 13.0 mm Hg +/- 1.4 and 0.8 mm Hg +/- 0.3. Mean interval from transplantation to intervention was 348 days +/- 159. Mean follow-up was 678 days (range, 16-2880 days). Technical success did not result in clinical improvement in one patient. Biopsy demonstrated severe hepatic necrosis, likely from prolonged venous congestion, and the patient required repeat transplantation. Only one patient required reintervention for stent migration, and no other complications occurred. No significant restenosis was encountered after stent placement.Hepatic venous outflow obstruction is an uncommon but potentially fatal complication of piggyback orthotopic liver transplantation. Endovascular treatment with balloon-expandable stents is effective, safe, and apparently durable.

    View details for DOI 10.1148/radiol.2361040327

    View details for Web of Science ID 000229905300046

    View details for PubMedID 15955856

  • Conversion from cyclosporine microemulsion to tacrolimus-based immunoprophylaxis improves cholesterol profile in heart transplant recipients with treated but persistent dyslipidemia: The Canadian multicentre randomized trial of tacrolimus vs cyclosporine microemulsion JOURNAL OF HEART AND LUNG TRANSPLANTATION White, M., Haddad, H., Leblanc, M. H., Giannetti, N., Pflugfelder, P., Davies, R., Isaac, D., Burton, J., Chan, M., AZEVEDO, E., Howlett, J., Ignaszewski, A., Busque, S., Cantarovich, M., Ferguson, R., Genest, J., Ross, H. 2005; 24 (7): 798-809


    Tacrolimus improves lipid profile in renal and liver transplant recipients. The impact of conversion from cyclosporine microemulsion (Neoral) to tacrolimus (Prograf) in a large randomized study of stable heart transplant recipients with treated but persistent mild dyslipidemia is reported.One hundred twenty-nine long-term (>or=12 months) cyclosporine microemulsion-treated heart transplant recipients with low-density lipoprotein cholesterol >2.5 mmol/liter and/or a total cholesterol/high-density lipoprotein cholesterol ratio >4 were recruited for the study. Complete lipid profile was assessed before (baseline) and after 6 months of treatment with either cyclosporine microemulsion maintenance (n=64) or tacrolimus conversion (n=65).At 6 months, tacrolimus-converted patients exhibited a greater decrease in total cholesterol (from 5.51 +/- 0.16 to 4.88 +/- 1.22 mmol/liter [tacrolimus], vs 5.61 +/- 1.36 to 5.38 +/- 0.87 mmol/liter [cyclosporine]; p = 0.0078). This decrease in cholesterol was caused largely by a decrease in low-density lipoprotein cholesterol (-0.41 +/- 0.54 [tacrolimus] vs -0.13 +/- 0.55 [cyclosporine]; p=0.0018). There were no changes in high-density lipoprotein cholesterol and triglyceride levels, but apolipoprotein B therapy was reduced in tacrolimus-converted vs cyclosporine-maintained patients (p=0.0003). By 6 months, 23.7% of tacrolimus- vs 6.7% of cyclosporine-treated patients met the target lipid levels for high-risk patients (p=0.0094). Conversion from cyclosporine to tacrolimus resulted in decreases in blood urea nitrogen, creatinine, and uric acid without any changes in glucose, HbA(1C), and insulin levels.Conversion from cyclosporine microemulsion- to tacrolimus-based immunoprophylaxis resulted in decreased cholesterol, apolipoprotein B, urea, creatinine, and uric acid without any clinically evident perturbation of glucose metabolism in stable heart transplant recipients with treated but persistent mild dyslipidemia.

    View details for DOI 10.1016/j.healun.2004.05.023

    View details for Web of Science ID 000230423400002

    View details for PubMedID 15982605

  • Donor renal cortical volumes and 6-month graft function in living donor transplantation. 6th American Transplant Congress Yan, J., Busque, S., Myers, B. D., Tan, J. C. WILEY-BLACKWELL. 2005: 262–262
  • Post kidney transplantation weight gain is not associated with steroid usage 6th American Transplant Congress Yan, J., Scandling, Y., Busque, S., Tan, J. C. WILEY-BLACKWELL. 2005: 534–534
  • Conversion of stable liver transplant recipients from a twice-daily prograf-based regimen to a once-daily modified release tacrolimus-based regimen 20th International Congress of the Transplantation-Society Florman, S., Alloway, R., Kalayoglu, M., Lake, K., Bak, T., Klein, A., Klintmalm, G., Busque, S., Brandenhagen, D., Lake, J., Wisemandle, K., Fitzsimmons, W., First, M. R. ELSEVIER SCIENCE INC. 2005: 1211–13


    Modified release (MR) tacrolimus is an extended release formulation administered once daily. The purpose of this pharmacokinetic (PK) study was to evaluate tacrolimus exposure in stable liver transplant recipients converted from Prograf twice a day to MR tacrolimus once daily.This was an open-label, multicenter study with a single sequence, four-period crossover design. Eligible patients were 18 to 65 years of age, >6 months posttransplant with stable renal and hepatic function and receiving stable doses of Prograf twice a day for >2 weeks prior to enrollment. Patients received Prograf twice a day on days 1 to 14 and 29 to 42. Patients were converted to the same milligram-for-milligram daily dose of MR once daily on days 15 to 28 and 43 to 56. Twenty-four-hour PK profiles were obtained on days 14, 28, 42, and 56. Laboratory and safety parameters were also evaluated.Of 70 patients, 62 completed all four PK profiles. The AUC0-24 of tacrolimus was comparable for Prograf twice a day (days 14 and 42) and MR tacrolimus once daily (days 28 and 56). The 90% confidence intervals for MR tacrolimus versus Prograf at steady state (days 28 and 56 vs days 14 and 42) was 0.85 to 0.92 for AUC0-24. MR tacrolimus was well tolerated with a safety profile comparable to that of Prograf. AUC0-24 was highly correlated to Cmin for Prograf (day 14, r = .93; Day 42, r = .89) and for MR tacrolimus (day 28, r = .93; day 56, r = .92). Renal and liver function remained stable. One patient experienced acute rejection.The steady-state tacrolimus exposure of MR tacrolimus once daily is equivalent to Prograf twice a day after a milligram-for-milligram conversion in stable liver transplant recipients.

    View details for DOI 10.1016/j.transproceed.2004.11.086

    View details for Web of Science ID 000228568900224

    View details for PubMedID 15848672

  • A prospective 3-yr evaluation of tacrolimus-based immunosuppressive therapy in immunological high risk renal allograft recipients CLINICAL TRANSPLANTATION Zaltzman, J. S., Boucher, A., Busque, S., Halloran, P. F., Landsberg, D. N., McAlister, V. C., Russell, D., Shoker, A., Shapiro, J., Tchervenkov, J. I., Ferguson, R. 2005; 19 (1): 26-32


    There have been no published data on use of the the newer immunosuppressants tacrolimus and mycophenolate mofetil (MMF) in high immunological risk renal transplantation. We therefore undertook a prospective study to systematically assess outcomes using these agents as part of an aggressive immunosuppressive regimen.Fifty-nine high-risk renal allograft recipients were enrolled at 10 Canadian sites and given a regimen of: a biological induction agent, tacrolimus, MMF, and corticosteroids. Patients included 10 (17%) who had lost a previous graft to rejection <1 yr, 31 (53%) with a current panel reactive antibody (PRA) >30%, 47 (80%) with a historic PRA >50%, four (7%) who had a positive historical T-cell crossmatch with the current donor, and six (10%) with a current positive B-cell crossmatch. The mean peak PRA was 76 +/- 33%.The estimated 3-yr Kaplan-Meier patient and graft survival estimates were 89% and 75%, respectively. There were nine graft losses other than deaths with a functioning graft, of which six were preceded by delayed graft function (p = 0.01, chi2). Sixteen (27%) recipients experienced at least one episode of biopsy-confirmed acute rejection. Infections included cytomegalovirus in 16 patients, eight of whom had tissue-invasive disease. Only one malignancy occurred.The immunosuppressive strategy investigated is effective and displays a satisfactory safety profile in high immunological risk renal allograft recipients.

    View details for DOI 10.1111/j.1399-0012.2005.00275.x

    View details for Web of Science ID 000226347700005

    View details for PubMedID 15659130

  • Preoperative renal volumes as a predictor of graft function in living donor transplantation AMERICAN JOURNAL OF KIDNEY DISEASES Saxena, A. B., Busque, S., Arjane, P., Myers, B. D., Tan, J. C. 2004; 44 (5): 877-885


    Nephron underdosing and donor kidney-recipient body size mismatch can lead to poor allograft function. The purpose of this study is to examine the relationship between donor kidney volume and posttransplantation graft function by using magnetic resonance imaging (MRI) to obtain renal volumes. Previous investigators used donor body surface area as a surrogate for kidney size or measured renal volume by using ultrasonography; both these techniques are inaccurate measures of renal volume. Intraoperative weights are more accurate, but provide information only after the transplantation is underway. More recently, MRI has been used preoperatively to screen living donors; these novel MRI techniques also provide information regarding renal size.We performed a retrospective analysis of 54 patients who underwent living donor transplantation at our institution from 2000 to 2002. All living donors underwent preoperative renovascular imaging using MRI, and renal volumes were obtained for each donor. A transplant kidney volume-recipient body weight (Vol/Wt) ratio was determined for each donor-recipient pair, and patients were divided into tertiles corresponding to 3 groups: high (>2.7), medium (2 to 2.7), and low (<2) "nephron dose" ratios.Glomerular filtration rate (GFR) correlated with Vol/Wt ratio at 6 and 12 months (r = 0.46; P = 0.0005 and r = 0.41; P = 0.003). At 6 months, mean GFRs in the low, medium, and high groups were 52.4 +/- 2.8 (SEM), 64.5 +/- 6.2, and 82.0 +/- 4.4 mL/min, respectively (P < 0.0005). At 12 months, GFRs in the low, medium, and high groups were 51.6 +/- 3.6, 63.3 +/- 3.8, and 83.9 +/- 5.4 mL/min, respectively (P < 0.0001).Transplantation of donor-recipient pairs with a Vol/Wt ratio less than 2 cm 3 /kg was associated with significantly worse graft function. Donor kidney volumes measured by means of preoperative MRI can be used to calculate Vol/Wt ratios before transplantation and identify patients at risk for a low GFR posttransplantation.

    View details for DOI 10.1053/j.ajkd.2004.07.012

    View details for Web of Science ID 000225044100015

    View details for PubMedID 15492954

  • Effect of steroid avoidance on early graft function after kidney transplantation 5th American Transplant Congress Roozrokh, H. C., Chen, L., Scandling, J. D., Momsen, A., Tan, J., Busque, S. WILEY-BLACKWELL. 2004: 354–354
  • Pre-operative MRI kidney volumes as a predictor of graft function in living donor kidney transplantation. 36th Annual Meeting of the American-Society-of-Nephrology Bhatt, A., Arjane, P., Busque, S., Tan, J. C. AMER SOC NEPHROLOGY. 2003: 11A–11A
  • Synergistic effects of RAD and Neoral in inhibition of host-vs.-graft and graft-vs.-host immune responses in rat small-bowel transplantation 6th Congress of the International-Society-for-Experimental-Microsurgery JOHNSON, S., Qi, S. J., Xu, D. S., Jolicoeur, M., Liu, D. Y., Barama, A., Busque, S., Smeesters, C., Daloze, P., Chen, H. F. WILEY-LISS. 2003: 476–82


    The combined effects of RAD and Neoral were tested in a rat orthotopic small-bowel transplantation model. Seven groups (n = 6) were involved in this study, and each one was included in three rejection models for the evaluation of host-vs.-graft disease (HVG) (LBN-F1 to LEW), graft-vs.-host disease (GVH) (LEW to LBN-F1), and combined HVG and GVH immune responses (BN to LEW). Both drugs were administered orally throughout the study. Low doses of RAD (1.0-2.5 mg/kg/day) combined with Neoral (2.0-5.0 mg/kg/day) produced strong synergistic effects in the prolongation of small-bowel graft survival in HVG (combination index, CI = 0.095, 0.1212), GVH (CI = 0.027, 0.020), and combined HVG and GVH immune responses (CI = 0.070, 0.301). The combination therapy of RAD and Neoral produces a strong synergistic effect toward the inhibition of HVG, GVH, and combined HVG and GVH immune responses in a rat small-bowel transplantation model.

    View details for DOI 10.1002/micr.10167

    View details for Web of Science ID 000186223500016

    View details for PubMedID 14558006

  • Detection of coronary artery disease in kidney and/or pancreas transplant candidates with type I diabetes mellitus. Ma, I. W., Valantine, H. A., Shibata, A., Waskerwitz, J., Dafoe, D., Alfrey, E., Tan, J., Millan, M., Busque, S., Scandling, J. D. LIPPINCOTT WILLIAMS & WILKINS. 2002: 192A
  • Low-dose tacrolimus, trough-monitored mycophenolate mofetil, and planned steroid withdrawal for cadaveric kidney transplantation: A single center experience 2nd International Congress on Immunosuppression Beaunoyer, M., Busque, S., St-Louis, G., Smeesters, C., Paquet, M. P., Lallier, M., Fugere, J., Girardin, C., Hebert, M. J., Daloze, P. ELSEVIER SCIENCE INC. 2002: 1694–95

    View details for Web of Science ID 000177369700141

    View details for PubMedID 12176540

  • Chest wall and liver resection for chondrosarcoma ANNALS OF THORACIC SURGERY Noiseux, N., Ferraro, P., Busque, S., Harris, P., Duranceau, A. 2002; 74 (2): 598-598

    View details for Web of Science ID 000177320600079

    View details for PubMedID 12173862

  • In vivo higher glucuronidation of mycophenolic acid in male than in female recipients of a cadaveric kidney allograft and under immunosuppressive therapy with mycophenolate mofetil THERAPEUTIC DRUG MONITORING Morissette, P., Albert, C., Busque, S., St-Louis, G., Vinet, B. 2001; 23 (5): 520-525


    Mycophenolate mofetil (MMF), an immunosuppressant drug used in organ transplantation to prevent rejection, is being used increasingly in association with cyclosporine and tacrolimus. Mycophenolic acid (MPA) is primarily metabolized in the liver to its 7-O-glucuronide (MPAG) derivative. The concentrations of MPAG in serum are many times the concentrations of MPA. Although MPAG has not shown immunosuppressant activity, it was postulated that it could displace MPA from its binding sites on albumin and hence increase the biologic effects of MPA. This effect could be important for patients with acute renal failure; under this condition, MPAG was shown to accumulate. The goal of this study was to document the MPAG/MPA concentration ratio in 100 renal transplant patients under a mixed immunosuppressive therapy. Further, the study addressed the question of whether MPAG can displace MPA in vivo from bound albumin in a representative renal transplant patient population under immunosuppressive therapy. Levels of MPAG and MPA were measured by high-performance liquid chromatography. The distribution of the ratios was not parametric as it tailed toward elevated values. After a square root transformation of the data, parametric analysis was possible. The average MPAG/MPA ratio was 15.0 +/- 2.2 for men versus 7.7 +/- 0.9 for women. Men treated with MMF and tacrolimus showed a lower ratio than patients treated with MMF and cyclosporine, confirming that tacrolimus inhibits glucuronidation of MPA. Further, it was determined that at physiologic concentrations, MPAG does not increase the amount of free MPA. Because MPAG can favor the elimination of MPA, it can be concluded that gender differences and cotreatment with tacrolimus must be taken into consideration when MMF is being administered.

    View details for Web of Science ID 000171210300004

    View details for PubMedID 11591897

  • Tacrolimus, MMF, steroid, and ALG immunotherapy for high immunological risk renal transplant recipients 18th World Congress of the Transplantation-Society Zaltzman, J., McAlister, V., Russell, D., Halloran, P., Landsberg, D., Busque, S., Shoker, A., Boucher, A., Shapiro, J., Tchervenkov, J., Peets, J. ELSEVIER SCIENCE INC. 2001: 1044–45

    View details for Web of Science ID 000167629900490

    View details for PubMedID 11267183

  • Canadian multicentre trial of tacrolimus/azathioprine/steroids versus tacrolimus/mycophenolate mofetil/steroids versus neoral/mycophenolate mofetil/steroids in renal transplantation 18th World Congress of the Transplantation-Society Busque, S., Shoker, A., Landsberg, D., McAlister, V., Halloran, P., Shapiro, J., Peets, J., Schulz, M. ELSEVIER SCIENCE INC. 2001: 1266–67

    View details for Web of Science ID 000167629900592

    View details for PubMedID 11267285

  • Effect of intraoperative blood transfusion on patient outcome in hepatic transplantation ARCHIVES OF SURGERY Cacciarelli, T. V., Keeffe, E. B., Moore, D. H., BURNS, W., Busque, S., Concepcion, W., So, S. K., Esquivel, C. O. 1999; 134 (1): 25-29


    To evaluate the effect of intraoperative transfusion of red blood cells (RBCs) on patient and graft survival.A retrospective study.A tertiary care referral center.Between January 1, 1992, and December 31, 1994, medical records from 225 adult patients who underwent primary liver transplantations were analyzed.Overall patient survival was 90% at 1 year and 86% at 3 years, while graft survival was 89% at 1 year and 85% at 3 years. The following factors were associated with patient and graft survival: age, sex, medical condition at the time of transplantation, and intraoperative transfusion of RBCs. When these factors were subjected to a multivariate analysis, all were independently associated with survival. Fifty-four recipients (24%) underwent transplantation without intraoperative transfusion of RBCs, while 171 recipients (76%) received at least 1 U of RBCs intraoperatively. Recipients who did not receive transfusion of RBCs had higher patient and graft survival rates than patients who did receive RBCs. By multivariate analysis, transplantation without intraoperative transfusion of RBCs no longer remained statistically significant, and only sex and the patient's medical condition were independently associated with patient and graft survival. Patient and graft survival decreased if 5 or more U were transfused, but transfusion of 5 or more U was not independently associated with survival by multivariate analysis.Increased transfusion requirement for RBCs was independently associated with patient and graft survival. While transplantation without transfusion of intraoperative RBCs was associated with superior patient and graft survival, these effects were overridden by patient sex and medical condition at the time of transplantation.

    View details for Web of Science ID 000078053500006

    View details for PubMedID 9927126

  • Regression of hypertrichosis and gingival hypertrophy in renal transplant recipients following replacement of cyclosporin by tracrolimus. ANNALES DE CHIRURGIE Busque, S., Demers, P., Saint-Louis, G., Boily, J. G., Tousignant, J., Lemieux, F., Martin, G., Smeesters, C., Corman, J., Daloze, P. 1999; 53 (8): 687-689
  • [Hypertrichosis and gingival hypertrophy regression in renal transplants following the substitution of cyclosporin by tacrolimus]. Annales de chirurgie Busque, S., Demers, P., Saint-Louis, G., Boily, J. G., Tousignant, J., Lemieux, F., Martin, G., Smeesters, C., Corman, J., Daloze, P. 1999; 53 (8): 687-689


    Gingival Hyperplasia (GH) and hypertrichosis (HT) are two sides effects associated with the usage of cyclosporine (CyA) but not with tacrolimus (FK 506). The aim of this study is to evaluate the efficacy and security of the conversion from CsA to FK 506 to treat those two complications. From August 1996 to May 1997, 15 patients (9 males, 6 females) aged from 23 to 63 years old (38 +/- 14, mean +/- SD) were switched from CsA to FK 506, 12 for GH, 2 for HT and one for combined presentation. FK 506 was first initiated at a dose of 0.15 mg/kg/day and then adjusted to a level target of 8 ng/ml. The conversion was done on an out patient basis at average 35 (5-83) months after transplantation. Patients were followed prospectively for 12 months. There was a significant reduction in GH in all patients within 3 months. Five out 13 patients had a complete resolution of GH within three months of conversion, 9/12 within 6 months and all by 12 months. HT resolved completely within 6 months. No rejection episode occurred and the serum creatinin remain stable over one year post conversion. Conversion from CsA to FK 506 is thus a safe and valid option to treat CsA induced GH and HT.

    View details for PubMedID 10584376

  • Mycophenolate mofetil's effect on accelerated heart allograft rejection and rejection markers in the rat International Congress on Immunosuppression Chen, H., Qi, S., Xu, D., Wu, J., Busque, S., Daloze, P. ELSEVIER SCIENCE INC. 1998: 1049–50

    View details for Web of Science ID 000074150800049

    View details for PubMedID 9636424

  • Conversion from neoral (cyclosporine) to tacrolimus of kidney transplant recipients for gingival hyperplasia or hypertrichosis International Congress on Immunosuppression Busque, S., Demers, P., St-Louis, G., Boily, J. G., Tousignant, J., Lemieux, F., Smeesters, C., Corman, J., Daloze, P. ELSEVIER SCIENCE INC. 1998: 1247–48

    View details for Web of Science ID 000074150800132

    View details for PubMedID 9636507

  • Experience with the piggyback technique without caval occlusion in adult orthotopic liver transplantation TRANSPLANTATION Busque, S., Esquivel, C. O., Concepcion, W., So, S. K. 1998; 65 (1): 77-82


    To assess the feasibility and outcome of a piggyback technique without caval occlusion or veno-venous bypass (VB), we retrospectively reviewed 131 consecutive adult orthotopic liver transplantation (OLT) performed in 129 patients between May 1993 and February 1995. Six were second transplants, and six were combined liver-kidney transplants. The piggyback technique was attempted in all cases.We were able to perform the piggyback technique in 98 OLTs (75%). The remaining 33 OLTs (25%) were converted to the standard technique; of these, 20 (15%) required VB. The reasons for conversion to the standard technique were: anatomical (22 transplants), severe portal hypertension requiring VB (8 transplants), tumor (1 transplant), and other reasons (2 transplants). Six retransplantations were performed (four piggyback, two standard).There was no significant difference in age, United Network for Organ Sharing status, Child's classification, and diagnosis between the patients in whom piggyback was possible or not. The actuarial patient and graft survival at 1 year were similar between the piggyback group and the group of patients converted to standard technique (87/85% vs. 86/86%, respectively). No death was related to either technique. With piggyback, the average operative time was 8.6+/-1.9 hr, median amount of blood transfused intraoperatively was 2 U (33% did not require transfusion), and median intensive care unit and hospital stays were 3 and 11 days, respectively. With the piggyback technique, the mean preoperative and maximum postoperative serum creatinine levels were 1.4+/-1.0 and 1.8+/-1.5 mg/dl.The piggyback technique without caval occlusion is possible in the majority of patients. It is safe and has reduced the use of VB to 15% of our adult OLTs. The piggyback technique avoids retrocaval dissection, facilitates retransplantation, and is associated with a short anhepatic phase, low blood product usage, and short intensive care unit stay.

    View details for Web of Science ID 000071516900014

    View details for PubMedID 9448148

  • Tacrolimus (FK506) and sirolimus (rapamycin) in combination are not antagonistic but produce extended graft survival in cardiac transplantation in the rat 16th Annual Meeting of the American-Society-of-Transplant-Physicians Vu, M. D., Qi, S. J., Xu, D. S., Wu, J. P., Fitzsimmons, W. E., Sehgal, S. N., Dumont, L., Busque, S., Daloze, P., Chen, H. F. LIPPINCOTT WILLIAMS & WILKINS. 1997: 1853–56


    Combined use of tacrolimus (FK506) with sirolimus (rapamycin [RAPA]) was examined in a model of vascularized heart allograft in the rat. For prevention of acute rejection, three different combinations of low doses of FK506 and RAPA from day 1 up to day 14 after transplantation produced significantly longer cardiac allograft survival than each agent alone (P<0.05). Identical results were observed in a model of reversal of ongoing acute rejection, where two combinations of low doses of FK506 and RAPA from day 4 up to day 18 after surgery also demonstrated significantly longer graft survival than each immunosuppressant alone (P<0.05). All the low-dose-treated groups in these two models presented significantly longer heart graft survival than naive controls (P<0.05), confirming that both agents are potent immunosuppressants in the models chosen. These results also indicate that, in contrast with in vitro studies, the combined use of FK506 and RAPA in vivo did not produce antagonism, but rather had synergistic effect in prolonging the allograft survival as compared with each agent alone. It appears likely that the abundance of FKBP-12 available for binding in vivo prevents inhibitive competition of the two agents for their receptor.

    View details for Web of Science ID 000071404400039

    View details for PubMedID 9422432

  • Left hepaticogastrostomy for biliary obstruction: Long-term results RADIOLOGY Soulez, G., Therasse, E., Oliva, V. L., Pomp, A., Busque, S., Dagenais, M., DESLANDRES, E., GHATTAS, G., Gagner, M. 1997; 204 (3): 780-786


    To evaluate the long-term results of peripheral biliary diversion by means of anastomoses of the left lobe of the liver to the stomach.Transhepatic perforation of the left lobe of the liver into the lesser curvature of the stomach was performed in 35 patients with a presumed diagnosis of malignant obstructive jaundice. Jaundice was found to be caused by a malignant stricture in 32 patients and a benign stricture in three. Perforation was performed under fluoroscopic, endoscopic, and laparoscopic guidance in 33 patients and without laparoscopy in the other two. The hepaticogastric anastomosis was secured with a gastrostomy tube; patency of the tract was maintained with placement of a metallic stent. Kaplan-Meier analysis was used to evaluate survival, anastomosis patency rate, and jaundice recurrence.Technical success was achieved in all patients. Two (6%) patients had anastomotic obstruction. The actuarial survival rate was 91%, 80%, 59%, and 26% at 1, 3, 6, and 12 months. The mean patency was 234 days +/- 252. The jaundice-free rate among surviving patients was 100%, 96%, 93%, and 80% at 1, 3, 6, and 12 months. The reintervention rate was 14%. Late cholangitis occurred in seven (20%) patients.This peripheral diversion procedure appears to be safe and shows good long-term patency.

    View details for Web of Science ID A1997XR60200031

    View details for PubMedID 9280259

  • Induction of long-term small bowel graft survival by low-dose immunosuppression in tolerized recipient rats XVI International Congress of the Transplantation-Society Chen, H., Xu, D., Qi, S., Busque, S., Tan, A., Daloze, P. ELSEVIER SCIENCE INC. 1997: 697–98

    View details for Web of Science ID A1997WM12700297

    View details for PubMedID 9123486

  • Intra-hepatic glutathione and oxidative stress in liver transplantation in the pig. ANNALES DE CHIRURGIE Yandza, T., Manika, A., Huynh, T., Lavoie, J. C., Champagne, J., Lepage, G., Chessex, P., Busque, S., Proulx, F. 1997; 51 (8): 839-844


    To determine the loss of endogenous GSH from livers cold-stored and reperfused, using a model of liver transplantation in the pig.Four female Yorkshire pigs weighing 19 to 40 kg received a liver allograft. Donor livers were cold-stored in the UW solution. Mean cold ischemic time was 6.5 hours. Malondialdehyde (MDA) levels were used as an index of oxidative stress. MDA plasma levels were measured following recipient laparotomy (H0), immediately (H1), and 90 minutes after liver reperfusion (H2). MDA and GSH levels in liver were measured following donor laparotomy (T0), at the end of cold ischemic period (T1), and at 90 minutes following liver reperfusion (T2).Three animals survived. MDA liver levels decreased of 44% between T0 and T1, then increased to 92% at T2. In contrast, in plasma, graft reperfusion was associated with an increase of MDA to 140% of the baseline values which reached 188% at H2. Intrahepatic GSH levels decreased of 49% at T1, then to 72% at T2.our study suggests that in liver transplantation: (1) Hepatic GSH is depleted to 49% during cold-storage, and an additional 23% is lost after reperfusion; (2) GSH contained in the UW solution does not prevent the loss of hepatocellular glutathione during preservation and reperfusion; (3) after short periods of cold ichemia, endogenous hepatic GSH may protect against oxydative stress in the transplanted liver.

    View details for Web of Science ID A1997YF47800002

    View details for PubMedID 9734091

  • Primary liver transplantation without transfusion of red blood cells 53rd Annual Meeting of the Central-Surgical-Association Cacciarelli, T. V., Keeffe, E. B., Moore, D. H., BURNS, W., Chuljian, P., Busque, S., Concepcion, W., So, S. K., Esquivel, C. O. MOSBY-ELSEVIER. 1996: 698–704


    This study examines factors associated with the performance of orthotopic liver transplantation (OLT) without red blood cell (RBC) transfusion.Between January 1992 and December 1994, 306 primary OLTs were performed with recipients divided into two groups: group 1 patients (61 recipients, 20% of total) underwent transplantation without packed RBCs, and group 2 patients (245 recipients, 80% of cases) received a transfusion of at least 1 unit of RBCs during operation.Recipients in group 1 compared with group 2 had less advanced liver disease (20% hospitalized and 48% Child's class C versus 58% hospitalized and 73% Child's class C, p < 0.01) and lower frequency of right upper quadrant surgery (13% versus 25%, p < 0.05). Group 1 recipients also had significantly higher preoperative hematocrits (38% versus 33%, p < 0.01), lower prothrombin times (15.4 versus 16.7 seconds, p < 0.001) and partial thromboplastin times (36.9 versus 42.2 seconds, p < 0.01), a greater proportion of patients transplanted by piggyback technique (87% versus 59%, p < 0.001), and shorter operative times (7.9 hours versus 9.2 hours, p < 0.001). Moreover, a greater percentage of patients underwent OLT without RBC transfusion in each successive year: 9% in 1992, 21% in 1993, and 31% in 1994 (p < 0.001). Logistic regression analysis showed the following factors to be independent predictors of OLT without RBC transfusion. Preoperative Hct, United Network of Organ Sharing status, piggyback technique, operative time, and year of transplantation.OLT can be performed without transfusion of RBCs in recipients with less advanced liver disease, and surgical technique, along with increased experience by the transplant team, are important factors.

    View details for Web of Science ID A1996VP42300036

    View details for PubMedID 8862380

  • CYCLOSPORINE AND THE REVERSIBILITY OF CHRONIC VASCULAR REJECTION 3rd International Congress on Cyclosporine Guttmann, R. D., Forbes, R. D., Zheng, S., Busque, S. ELSEVIER SCIENCE INC. 1994: 2564–66


    A model of chronic vascular rejection of cardiac allografts has been developed in inbred rats using the WF.1L/Gut congenic strain as donor into LEW recipients. The hearts beat for more than 200 days without the need for exogenous immunosuppression. The histopathology is characterized by cellular rejection, vasculitis, and myointimal arterial wall thickening, and by day 60 posttransplant, there are widespread occlusive vascular changes similar to those seen in human cardiac allografts. CsA, at a dose of 15 mg/kg/d, is effective in preventing as well as reversing the vasculopathy. These data (1) confirm other studies of ours on the reliability of the experimental model using this strain combination, (2) establish the time window of days 40 to 60 whereby mechanisms of lesion regression can be studied, (3) prove the MHC class I and class II antigen incompatibility are not a necessary condition for the generation of the vascular lesions, (4) show that CsA is a useful probe for study of the vasculopathy, and (5) suggest that the model is a useful probe of the mechanism of action of CsA.

    View details for Web of Science ID A1994PM60300032

    View details for PubMedID 7940792


    View details for Web of Science ID A1993KN62100029

    View details for PubMedID 8438504



    Simultaneous harvesting of the liver and whole pancreas is usually not performed because it is believed that the shared vascular supply of both organs is incompatible with safe grafting. A careful review of the vascular anatomy, however, shows that simultaneous removal of the two organs is feasible, and a technique is described by which the liver is revascularized in the recipient through the celiac axis or the common hepatic artery and the pancreas is revascularized through the superior mesenteric and splenic arteries. When the vascular supply is abnormal, reconstruction of the vascular tree of one or both organs may be needed. The results of this technique used on 10 recipients are analysed.

    View details for Web of Science ID A1990DV37100008

    View details for PubMedID 2383835