Outcome after steroid withdrawal in pediatric renal transplant patients receiving tacrolimus-based immunosuppression

Background. Corticosteroids have always been an integral part of immunosuppressive regimens in renal transplantation. The primary goal of this analysis was to assess the safety of steroid withdrawal in our pediatric renal transplant recipients receiving tacrolimus-based immunosuppression. Methods. Between December 1989 and December 1996, 82 renal transplantations were performed in pediatric patients receiving tacrolimus-based immunosuppression. Two of these patients lost their grafts within 3 weeks of transplantation (and were still on steroids at the time of graft loss), and were excluded from further analysis. Seventy-four patients (92.5%) were taken off prednisone a median of 5.7 months after transplantation. Of these 74, 56 (70%) remained off prednisone (OFF), and 18 (22.5%) were restarted on prednisone a median of 14.8 months after discontinuing steroids (OFF → ON). 6(7.5%) were never taken off prednisone (ON). The mean follow-up was 59±23 months. Results. The 1-, 3-, and 5-year actuarial patient survival rates in the OFF group were 100%, 98%, and 96%, respectively; in the OFF → ON group, they were 100%, 100%, and 100%, and in the ON group, they were 100%, 83%, and 83%. The 1-, 3-, and 5- year actuarial graft survival rates in the OFF group were 100%, 95%, and 82%, respectively; in the OFF → ON group, they were 100%, 89%, and 83%; and in the ON group, they were 100%, 50%, and 33%. Two of the six graft losses in the OFF group, three out of four in the OFF → ON Group, and two out of five in the ON group, were to chronic rejection. A time-dependent Cox regression analysis showed that the hazard for graft failure for those who came and stayed off prednisone was 0.178 relative to those who were never withdrawn from prednisone (P=0.005). Patients who were 10 years of age or younger were withdrawn from prednisone earlier (median: 5 months) than those older than 10 years (median: 7.3 months, P=0.02). In addition, patients who never had acute rejection were withdrawn from steroids earlier (median: 5 months) than those who had one or more episodes of acute rejection (median: 7.6 months, P=0.001). There was no effect of donor age, race, sex, recipient race, sex, cadaveric versus living donor, 48-hr graft function, panel reactive antibody, and total HLA mismatches or matches on the likelihood of being weaned off steroids. Serum creatinine at most recent follow-up in the OFF group was 1.2±0.5 mg/dl; in the OFF → ON group, it was 1.8±0.9 mg/dl, and in the ON group it was 2.0 mg/dl (P<0.003). The incidence of rejection in the OFF, OFF → ON, and ON groups was 39%, 77%, and 100%, respectively (P<0.05). Conclusion. These data suggest that steroid withdrawal in pediatric renal transplant patients receiving tacrolimus-based immunosuppression is associated with reasonable short- and medium-term patient and graft survival, and acceptable renal function. Patients who discontinue and then resume steroids had patient and graft survival rates comparable with those in patients who discontinue and stay off steroids, but had a higher serum creatinine and a higher incidence of rejection

Pediatric renal transplantation under tacrolimus-based immunosuppression

Background. Tacrolimus has been used as a primary immunosuppressive agent in adult and pediatric renal transplant recipients, with reasonable outcomes. Methods. Between December 14, 1989 and December 31, 1996, 82 pediatric renal transplantations alone were performed under tacrolimus-based immunosuppression without induction anti-lymphocyte antibody therapy. Patients undergoing concomitant or prior liver and/or intestinal transplantation were not included in the analysis. The mean recipient age was 10.6±5.2 years (range: 0.7-17.9). Eighteen (22%) cases were repeat transplantations, and 6 (7%) were in patients with panel-reactive antibody levels over 40%. Thirty-four (41%) cases were with living donors, and 48 (59%) were with cadaveric donors. The mean donor age was 27.3±14.6 years (range: 0.7-50), and the mean cold ischemia time in the cadaveric cases was 26.5±8.8 hr. The mean number of HLA matches and mismatches was 2.8±1.2 and 2.9±1.3; there were five (6%) O-Ag mismatches. The mean follow-up was 4.0±0.2 years. Results. The 1- and 4-year actuarial patient survival was 99% and 94%. The 1- and 4-year actuarial graft survival was 98% and 84%. The mean serum creatinine was 1.1±0.5 mg/all, and the corresponding calculated creatinine clearance was 88±25 ml/min/1.73 m2. A total of 66% of successfully transplanted patients were withdrawn from prednisone. In children who were withdrawn from steroids, the mean standard deviation height scores (Z-score) at the time of transplantation and at 1 and 4 years were - 2.3±2.0, -1.7±1.0, and +0.36±1.5. Eighty-six percent of successfully transplanted patients were not taking anti-hypertensive medications. The incidence of acute rejection was 44%; between December 1989 and December 1993, it was 63%, and between January 1994 and December 1996, it was 23% (P=0.0003). The incidence of steroid-resistant rejection was 5%. The incidence of delayed graft function was 5%, and 2% of patients required dialysis within 1 week of transplantation. The incidence of cytomegalovirus was 13%; between December 1989 and December 1992, it was 17%, and between January 1993 and December 1996, it was 12%. The incidence of early Epstein- Barr virus-related posttransplant lymphoproliferative disorder (PTLD) was 9%; between December 1989 and December 1992, it was 17%, and between January 1993 and December 1996, it was 4%. All of the early PTLD cases were treated successfully with temporary cessation of immunosuppression and institution of antiviral therapy, without patient or graft loss. Conclusions. These data demonstrate the short- and medium-term efficacy of tacrolimus-based immunosuppression in pediatric renal transplant recipients, with reasonable patient and graft survival, routine achievement of steroid and anti- hypertensive medication withdrawal, gratifying increases in growth, and, with further experience, a decreasing incidence of both rejection and PTLD

Beyond Static Benchmarking: Using Experimental Manipulations to Evaluate Land Model Assumptions

Land models are often used to simulate terrestrial responses to future environmental changes, but these models are not commonly evaluated with data from experimental manipulations. Results from experimental manipulations can identify and evaluate model assumptions that are consistent with appropriate ecosystem responses to future environmental change. We conducted simulations using three coupled carbon-nitrogen versions of the Community Land Model (CLM, versions 4, 4.5, and-the newly developed-5), and compared the simulated response to nitrogen (N) and atmospheric carbon dioxide (CO2) enrichment with meta-analyses of observations from similar experimental manipulations. In control simulations, successive versions of CLM showed a poleward increase in gross primary productivity and an overall bias reduction, compared to FLUXNET-MTE observations. Simulations with N and CO2 enrichment demonstrate that CLM transitioned from a model that exhibited strong nitrogen limitation of the terrestrial carbon cycle (CLM4) to a model that showed greater responsiveness to elevated concentrations of CO2 in the atmosphere (CLM5). Overall, CLM5 simulations showed better agreement with observed ecosystem responses to experimental N and CO2 enrichment than previous versions of the model. These simulations also exposed shortcomings in structural assumptions and parameterizations. Specifically, no version of CLM captures changes in plant physiology, allocation, and nutrient uptake that are likely important aspects of terrestrial ecosystems' responses to environmental change. These highlight priority areas that should be addressed in future model developments. Moving forward, incorporating results from experimental manipulations into model benchmarking tools that are used to evaluate model performance will help increase confidence in terrestrial carbon cycle projections

Beyond Static Benchmarking: Using Experimental Manipulations to Evaluate Land Model Assumptions.

Land models are often used to simulate terrestrial responses to future environmental changes, but these models are not commonly evaluated with data from experimental manipulations. Results from experimental manipulations can identify and evaluate model assumptions that are consistent with appropriate ecosystem responses to future environmental change. We conducted simulations using three coupled carbon-nitrogen versions of the Community Land Model (CLM, versions 4, 4.5, and-the newly developed-5), and compared the simulated response to nitrogen (N) and atmospheric carbon dioxide (CO2) enrichment with meta-analyses of observations from similar experimental manipulations. In control simulations, successive versions of CLM showed a poleward increase in gross primary productivity and an overall bias reduction, compared to FLUXNET-MTE observations. Simulations with N and CO2 enrichment demonstrate that CLM transitioned from a model that exhibited strong nitrogen limitation of the terrestrial carbon cycle (CLM4) to a model that showed greater responsiveness to elevated concentrations of CO2 in the atmosphere (CLM5). Overall, CLM5 simulations showed better agreement with observed ecosystem responses to experimental N and CO2 enrichment than previous versions of the model. These simulations also exposed shortcomings in structural assumptions and parameterizations. Specifically, no version of CLM captures changes in plant physiology, allocation, and nutrient uptake that are likely important aspects of terrestrial ecosystems' responses to environmental change. These highlight priority areas that should be addressed in future model developments. Moving forward, incorporating results from experimental manipulations into model benchmarking tools that are used to evaluate model performance will help increase confidence in terrestrial carbon cycle projections

Increasing the spatial and temporal impact of ecological research: A roadmap for integrating a novel terrestrial process into an Earth system model

Terrestrial ecosystems regulate Earth’s climate through water, energy, and biogeochemical transformations. Despite a key role in regulating the Earth system, terrestrial ecology has historically been underrepresented in the Earth system models (ESMs) that are used to understand and project global environmental change. Ecology and Earth system modeling must be integrated for scientists to fully comprehend the role of ecological systems in driving and responding to global change. Ecological insights can improve ESM realism and reduce process uncertainty, while ESMs offer ecologists an opportunity to broadly test ecological theory and increase the impact of their work by scaling concepts through time and space. Despite this mutualism, meaningfully integrating the two remains a persistent challenge, in part because of logistical obstacles in translating processes into mathematical formulas and identifying ways to integrate new theories and code into large, complex model structures. To help overcome this interdisciplinary challenge, we present a framework consisting of a series of interconnected stages for integrating a new ecological process or insight into an ESM. First, we highlight the multiple ways that ecological observations and modeling iteratively strengthen one another, dispelling the illusion that the ecologist’s role ends with initial provision of data. Second, we show that many valuable insights, products, and theoretical developments are produced through sustained interdisciplinary collaborations between empiricists and modelers, regardless of eventual inclusion of a process in an ESM. Finally, we provide concrete actions and resources to facilitate learning and collaboration at every stage of data- model integration. This framework will create synergies that will transform our understanding of ecology within the Earth system, ultimately improving our understanding of global environmental change, and broadening the impact of ecological research.Terrestrial ecology has historically been underrepresented in the Earth system models (ESMs) that are used to understand and project global environmental change. The prevalent existing paradigm in ecology- ESM integration separates tasks along disciplinary lines. We recommend a new set of steps for ecology- ESM integration that shifts away from this historical paradigm toward a more collaborative one in which empiricists and modelers are involved in coproducing knowledge at every stage of data collection, theory development, and model integration.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/171207/1/gcb15894_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/171207/2/gcb15894.pd