A longitudinal exploration of perceptions of pharmacy practice preparedness among graduating pharmacy students and preceptors.

Graduating student pharmacists who are practice-ready is an essential responsibility of pharmacy programs and heavily emphasized by Accreditation Council of Pharmacy Education (ACPE), pharmacy education's accrediting body. Although several studies have examined students' readiness to engage in advanced pharmacy practice experiences (APPE), few studies examine graduating students' readiness to practice. The objective of this study was to examine national trends in graduating pharmacy students' and preceptors' perceptions of students' pharmacy practice preparedness across a six-year time frame (2016-2021) and trends in graduating students' overall impressions of their program and the pharmacy profession across the same time period. A longitudinal descriptive study to examine trends in graduating student and preceptor perception was conducted utilizing data from the 2016-2021 American Association of Colleges of Pharmacy (AACP) Graduating Student Surveys (GSS) (n = 65,461) and Preceptor Surveys (PS) (n = 41,951). Over six years of survey data analyzed, a large percentage of students at both public and private institutions reported they felt prepared for practice (96.5% vs 95.5% respectively, p < 0.001). There was overall agreement (>90%) among preceptors that graduating students were prepared to enter pharmacy practice based on responses, although preceptors had lower levels of agreement compared to students on most statements. Based on the findings, both graduating pharmacy students and preceptors feel that graduates are prepared to practice pharmacy, with consistent trends in perceptions over the last six years. However, results also indicate that a consistent downward trend in students' willingness to pursue pharmacy again, indicating decreased optimism of graduating students for the profession.

Review of Objective Structured Clinical Examination Practices Within Pharmacy Programs Throughout the United States.

OBJECTIVE: To update the description of current objective structured clinical examination (OSCE) practices within pharmacy schools in the United States and identify barriers to OSCE implementation and expansion. METHODS: A survey was deployed to all accredited Doctor of Pharmacy programs within the United States. The survey was designed to collect information regarding the curricular mapping of OSCEs, OSCE design, OSCE delivery, assessment of OSCE performance, and barriers to OSCE implementation and expansion. RESULTS: Of the 135 US-accredited programs identified, 109 (81%) programs completed the survey. In total, 93 (85%) programs reported using OSCEs to assess students; however, implementation throughout the curriculum and current practices varied by institution. Most programs place OSCEs within specific courses (96%), with the applied skills coursework being the most used (80%). The most common number of OSCEs that occur throughout a curriculum is 6 (18%), however, 20 (22%) programs execute 10 or more OSCEs throughout their curriculum. Forty (43%) programs use OSCEs as high-stakes assessments where poor performance could prevent a student from progressing to advanced pharmacy practice experiences. Of the responding programs, over half (56%) use teaching objective structured examinations to enhance learning. Common barriers to OSCE expansion exist and are related to resource utilization. CONCLUSION: Significant expansion of OSCE development and implementation has occurred over the last decade. There is substantial variability in implementation and utilization among programs. Although standards of best practice for OSCEs exist for other health professions, best practices in pharmacy education have not been widely accepted or adopted.

Cytomegalovirus Treatment in Solid Organ Transplantation: An Update on Current Approaches.

OBJECTIVE: The article reviews the safety and efficacy of treatments for cytomegalovirus (CMV) in solid organ transplantation. DATA SOURCES: A literature review was conducted in PubMed, MEDLINE, and Clinicaltrials.gov from database inception through January 2024, using terms CMV, therapy, and solid organ transplantation. STUDY SELECTION AND DATA EXTRACTION: Clinical trials, meta-analyses, cohort studies, case reports, and guidelines were included. Letters to the editor, reviews, and commentaries were excluded. DATA SYNTHESIS: After abstract screening and full-text review of 728 citations for eligibility, 53 were included. Valganciclovir and intravenous ganciclovir are drugs of choice for CMV management and, until recently, the availability of alternative options has been restricted due to toxicity. For instance, foscarnet and cidofovir serve as second-line agents due to potential bone marrow and renal toxicity. In patients with refractory or resistant CMV, maribavir, a novel oral agent, has proven efficacy and a lower adverse effect profile. However, in refractory or resistant CMV, foscarnet and cidofovir are preferred in invasive disease (CMV gastritis, CMV retinitis, and CMV encephalitis), high viral loads, and inability to tolerate oral preparations. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: Consensus guidelines have not been revised since approval of novel antivirals in solid organ transplantation. Valganciclovir and ganciclovir remain drugs of choice for initial CMV therapy. Foscarnet, cidofovir, and maribavir are treatments for refractory or resistant-CMV. CONCLUSIONS: Selection of CMV antiviral treatment should be determined by patient-specific factors, including severity of illness, resistant or refractory disease, dose-limiting adverse effects, and the preferred route of administration.

Perceptions and Utility of Course Evaluations in US Pharmacy Schools.

OBJECTIVE: This study aimed to describe the purpose, implementation, and perceived utility of course evaluations in pharmacy programs. METHODS: After a literature review, a 34-item survey was developed, pretested, and sent to assessment administrators at accredited pharmacy programs (N = 139) with at least 3 follow-ups. Descriptive and inferential statistics were performed in IBM SPSS Statistics software. RESULTS: A total of 90 programs responded (64.7% response rate). Most students (94%) were offered the opportunity to complete course evaluations. Some students completed evaluations during the course (47%), while others did so within 1 week of completion of the course (49%). Whether or not class time was given for students to complete the survey was often dependent on faculty choice (52.2%). Results were typically released after final grades were posted (92%), in time to use for the next semester of teaching (77%). Faculty were chosen to be evaluated by the number of teaching hours (50%) followed by all instructors (45.6%). Programs used the results for performance reviews by chairs (91%), course coordinator reviews (84%), and committee continuous quality improvement efforts (72%). Most programs did not provide faculty guidance on using evaluations (78%) nor development/mentoring (57%); only 22% of programs offered student development in completing evaluations. CONCLUSION: While most programs invite feedback from all students via evaluations, most did not provide guidance to faculty on how to use this feedback for faculty or course development purposes. A more robust process to optimize the use of course evaluations should be developed.

Racial, Ethnic, and Sex Diversity Trends in Health Professions Programs From Applicants to Graduates.

Importance: Diversity is an essential element of an effective health care system. A key to developing a diverse workforce is establishing a diverse student population in health professions programs. Objective: To examine the diversity of students in Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), Doctor of Dental Surgery (DDS), Doctor of Dental Medicine (DMD), and Doctor of Pharmacy (PharmD) programs with emphasis on the trends of underrepresented minoritized groups (American Indian or Alaska Native, Black or African American, Hispanic or Latino, and Native Hawaiian or Other Pacific Islander) and sex relative to the overall age-adjusted US population. Design, Setting, and Participants: This cross-sectional study used deidentified, self-reported data from 2003 to 2019 from the Association of American Medical Colleges, American Association of Colleges of Osteopathic Medicine, American Dental Education Association, American Dental Association, and American Association of Colleges of Pharmacy. Data analysis was performed from 2003 to 2004 and from 2018 to 2019. Exposures: Data on the race, ethnicity, and sex of applicants, matriculants, and degrees conferred by health professions programs were collected and compared with the age-adjusted population in the US Census (aged 20-34 years) over time. Main Outcomes and Measures: The main outcomes were trends in the proportions of underrepresented minoritized groups and sex diversity among applicants, matriculants, and degrees conferred relative to the overall age-adjusted US population. Trends were measured using the representation quotient, which is defined as the ratio of the proportion of each subgroup to the total population of applicants, matriculants, or graduates relative to the proportion for that subgroup within the US Census population of similar age. Regression analysis was used to evaluate the trend over time. Results: A total of 594 352 applicants were analyzed across the examined programs. From 2003 to 2019, the proportions of individuals from underrepresented groups increased for DDS and DMD (applicants, from 1003 of 8176 to 1962 of 11 298 [5.1%]; matriculants, from 510 of 4528 to 966 of 6163 [4.2%]; degrees awarded, from 484 of 4350 to 878 of 6340 [2.7%]), PharmD (applicants, from 9045 of 71 966 to 11 653 of 50 482 [9.0%]; matriculants, from 5979 of 42 627 to 10 129 to 62 504 [6.3%]; degrees awarded, from 922 of 7770 to 2190 of 14 800 [3.0%]), and DO (applicants, from 740 of 6814 to 3478 of 21 090 [5.4%]; degrees awarded, 199 of 2713 to 582 of 6703 [1.4%]) programs, but decreased for MD programs (applicants, from 6066 of 34 791 to 7889 of 52 777 [-2.3%]; matriculants, 2506 of 16 541 to 2952 of 21 622 [-2.4%]; degrees awarded, from 2167 of 15 829 to 2349 of 19 937 [-0.1%]). Compared with age-adjusted US Census data, all programs had more Asian students and fewer male, American Indian or Alaska Native, Black or African American, Hispanic or Latino, and Native Hawaiian or Other Pacific Islander students (representation quotient <1). Conclusions and Relevance: In this cross-sectional study, most of the health professions in the study saw increases in underrepresented minority applicants, matriculants, and degrees conferred from 2003 to 2019; however, all programs were below the age-adjusted US Census data. The increased racial, ethnic, and sex diversity in the programs illustrates progress, but additional strategies are needed to achieve a more representative health care workforce.

A critique of validity analysis from instruments assessing the affective domain.

BACKGROUND: Schools and colleges of pharmacy need to show evidence that their students have internalized professional values, and many choose to do so through quantitative instruments. A review of the literature was completed to identify the evidence of validity of the scores from instruments designed to assess pharmacy students in the affective domain. METHODS: Electronic databases were searched to identify instruments. Basic information regarding the instruments, the facets of validity assessed, and the evidence for validity were reviewed. RESULTS: Of the studies identified, 25 focused on assessing the affective domain and reported evidence of at least one facet of validity. Most reported evidence of validity from two or more sources, and most reported evidence concerning test content and internal structure (i.e. internal consistency reliability or factor analysis). Other sources of validity were missing from most studies. IMPLICATIONS: More research is needed to investigate the validity of the scores of instruments developed to assess pharmacy students within the affective domain, especially regarding relations to other variables, response processes, and consequences of use.

Belatacept for the prophylaxis of organ rejection in kidney transplant patients: an evidence-based review of its place in therapy.

BACKGROUND: Belatacept is a novel immunosuppressive therapy designed to improve clinical outcomes associated with kidney transplant recipients while minimizing use of calcineurin inhibitors (CNIs). METHODS: We searched for clinical trials related to administration of belatacept to kidney transplant patients compared to various immunosuppression regimens, as well as for studies that utilized data from belatacept trials to validate new surrogate measures. The purpose of this review is to consolidate the published evidence of belatacept's effectiveness and safety in renal transplant recipients to better elucidate its place in clinical practice. RESULTS: Analysis of the results from the Belatacept Evaluation of Nephroprotection and Effi-cacy as First-Line Immunosuppressive Trial (BENEFIT) study, a de novo trial that compared cyclosporine (CsA)-based therapy to belatacept-based therapy in standard criteria donors, found a significant difference in mean estimated glomerular filtration rate (eGFR) of 13-15 mL/min/1.73 m(2) and 23-27 mL/min/1.73 m(2) at 1 year and 7 years, respectively. The BENEFIT-EXT study was similarly designed with the exception that it included extended criteria donors. Renal function improved significantly for the more intensive belatacept group in all years of the BENEFIT-EXT study; however, it was not significant in the less intensive group until 5 years after transplant. Belatacept regimens resulted in lower blood pressure, cholesterol levels, and incidence of new-onset diabetes after transplant compared to CsA-based regimens. Results from conversion of CNIs to belatacept therapy, dual therapy of belatacept with sirolimus, and belatacept with corticosteroid avoidance therapy are also included in this article. CONCLUSION: The evidence reviewed in this article suggests that belatacept is an effective alternative in kidney transplant recipients. Compared to CNI-based therapy, belatacept-based therapy results in superior renal function and similar rates of allograft survival. In terms of safety, belatacept was shown to have lower incidence of hypertension, hyperlipidemia, and diabetes; however, incidence of posttransplantation lymphoproliferative disorder and the cost of belatacept may hinder use of this medication.

Treatment of antibody-mediated rejection in renal transplant patients: a clinical practice survey.

INTRODUCTION: Preferences for the testing and treatment of antibody-mediated rejection (AMR) in renal transplant patients vary among programs and individual practitioners. The description of these preferences and identification of commonalities can contribute to creating a standard of care. METHODS: A survey was distributed through the Transplant Listserv of the American College of Clinical Pharmacy (ACCP) and via email to members of the American Society of Transplantation Community of Pharmacy (AST CoP), collected, and analyzed. RESULTS: Most clinicians (26/28) test for donor-specific antibodies (DSAs) when evaluating a patient with possible AMR. Treatments for AMR varied widely among responding clinicians and included intravenous immune globulin (IVIG, n = 25), plasmapheresis (n = 24), rituximab (n = 8), bortezomib (n = 4), rabbit antithymocyte globulin (n = 2), and eculizumab (n = 1). Weight-based dosing of IVIG averaged 1.8 g/kg total dose. Six centers use rituximab as initial therapy, while two use rituximab if other therapy fails. Four centers use bortezomib as initial therapy, while two centers use it for severe/persistent AMR. One center uses eculizumab as initial therapy and one center uses it for severe AMR. CONCLUSION: Methods for the detection of AMR are similar, yet treatment of AMR varies widely. Most centers utilize DSA for detection and a combination of IVIG and plasmapheresis for treatment.

Impact of participation on a solid organ transplant team on student pharmacists' perceptions of interprofessional roles.

OBJECTIVE: To examine student pharmacists' perceptions of interprofessional roles before and after completing an advanced pharmacy practice experience on solid organ transplantation. METHODS: Student pharmacists across the United States participating in an APPE on a solid organ transplant team completed an online pre- and post-APPE survey instrument examining perceptions of interprofessional roles, communication, and teamwork. RESULTS: Student pharmacists' scores on interprofessionalism increased significantly on 17 of 22 items. Positive changes were seen in the interprofessional education core competency areas of roles and responsibilities, interprofessional communication, and teams and teamwork. CONCLUSION: Student pharmacist participation in interprofessional clinical APPEs can positively influence their professional development as they prepare to become members of multi-disciplinary teams in the healthcare workforce.

Admission variables predictive of academic struggle in a PharmD program.

Objective. To characterize and describe admission variables predictive of poor grade attainment by students in 2 pathways to a doctor of pharmacy (PharmD) program.Methods. A retrospective analysis of course grades of PharmD students admitted from 2000 to 2009 (N= 1,019) in the traditional degree pathway ("1 plus 5" degree program) and the provisional pathway (admitted directly from high school) was performed.Results. Four hundred three grades of D or less were earned by 183 (18%) students. There were more grades of D or less in the first pharmacy year. Receipt of an unsatisfactory grade was associated with all Pharmacy College Admission Test (PCAT) subcategory scores, PCAT composite score, cumulative prepharmacy coursework hours, prepharmacy grade point average (GPA), prepharmacy science and math GPA, and interview score for accepted students in the traditional pathway. For students in the provisional pathway, PCAT-quantitative analysis, PCAT composite score, prepharmacy cumulative GPA, prepharmacy science and math GPA, English American College Testing (ACT) score, and composite ACT score predicted poor grades. Conclusion. Admissions committees should heed PCAT scores and GPAs, regardless of program pathway, while progression committees should focus on early program coursework when designing strategies to optimize retention.

Selection of induction therapy in kidney transplantation.

Currently available immunosuppressive agents can be classified into three categories: induction agents, maintenance therapy, and treatment for rejection. This review article will focus on induction immunosuppression. There are three antibodies which are used for induction therapy: the lymphocyte-depleting agents - anti-thymocyte globulin and alemtuzumab, and basiliximab which is nondepleting. Historically, immunosuppressant selection was solely based on efficacy for prevention of rejection. In the current era of transplantation, it is now common practice in the transplant community to select induction therapy on the basis of risk-benefit considerations for each patient. This article will focus on the efficacy of available induction agents and the selection of induction agent based on donor and recipient risk factors.

Hidden sources of grapefruit in beverages: potential interactions with immunosuppressant medications.

PURPOSE: The interaction between grapefruit-containing beverages and immunosuppressants is not well defined in the literature. This study was conducted to investigate possible sources of grapefruit juice or grapefruit extract in common US-manufactured beverages. The goal was to identify those products that might serve as hidden sources of dietary grapefruit intake, increasing a transplant patient's risk for drug interactions. METHODS: A careful review of the ingredients of the 3 largest US beverage manufacturer's product lines was conducted through manufacturer correspondence, product labeling examination, and online nutrition database research. Focus was placed on citrus-flavored soft drinks, teas, and juice products and their impact on a patient's immunosuppressant regimens. RESULTS: Twenty-three beverages were identified that contained grapefruit. Five did not contain the word "grapefruit" in the product name. In addition to the confirmed grapefruit-containing products, 17 products were identified as possibly containing grapefruit juice or grapefruit extract. CONCLUSION: A greater emphasis should be placed upon properly educating patients regarding hidden sources of grapefruit in popular US beverages and the potential for food-drug interactions.

Novel immunosuppressive agents in kidney transplantation.

Excellent outcomes have been achieved in the field of renal transplantation. A significant reduction in acute rejection has been attained at many renal transplant centers using contemporary immunosuppressive, consisting of an induction agent, a calcineurin inhibitor, an antiproliferative agent plus or minus a corticosteroid. Despite improvements with these regimens, chronic allograft injury and adverse events still persist. The perfect immunosuppressive regimen would limit or eliminate calcineurin inhibitors and/or corticosteroid toxicity while providing enhanced allograft outcomes. Potential improvements to the calcineurin inhibitor class include a prolonged release tacrolimus formulation and voclosporin, a cyclosporine analog. Belatacept has shown promise as an agent to replace calcineurin inhibitors. A novel, fully-human anti-CD40 monoclonal antibody, ASKP1240, is currently enrolling patients in phase 2 trials with calcineurin minimization and avoidance regimens. Another future goal of transplant immunosuppression is effective and safe treatment of allograft rejection. Novel treatments for antibody mediated rejection include bortezomib and eculizumab. Several investigational agents are no longer being pursed in transplantation including the induction agents, efalizumab and alefacept, and maintenance agents, sotrastaurin and tofacitinib. The purpose of this review is to consolidate the published evidence of the effectiveness and safety of investigational immunosuppressive agents in renal transplant recipients.

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

STUDY OBJECTIVE: To determine the influence of pill burden and drug cost on outcomes after renal transplantation. DESIGN: Retrospective medical record review. SETTING: Kidney and pancreas transplantation center. PATIENTS: Sixty-eight adults who underwent kidney or kidney-pancreas transplantation during 2007. MEASUREMENTS AND MAIN RESULTS: The median pretransplantation pill burden was 15 pills/day, which increased to 25 pills/day at 1 month after transplantation and returned to 16 pills/day by 1 year after transplantation. Pretransplantation pill burden was lower than the burden at 1, 3, 6, 12, and 24 months after transplantation (p<0.05). The mean pretransplantation drug cost of $1918/month was lower than the cost at 1 month after transplantation ($2564/mo, p=0.04) but was similar thereafter. Higher pretransplantation pill burden was associated with increased serum creatinine concentration at 6 months after transplantation (r=0.288, p=0.017). Higher pill burdens at 1 month (r=0.364, p=0.002), 3 months (r=0.332, p=0.006), and 6 months (r=0.374, p=0.002) were associated with increased 3-month serum creatinine concentration. Higher drug costs were associated with increased serum creatinine concentrations throughout the study. CONCLUSION: Higher pretransplantation pill burden and higher drug cost may be associated with poor renal function after transplantation. Further study addressing factors associated with nonadherence is needed.

Current state of renal transplant immunosuppression: Present and future.

For kidney transplant recipients, immunosuppression commonly consists of combination treatment with a calcineurin inhibitor, an antiproliferative agent and a corticosteroid. Many medical centers use a sequential immunosuppression regimen where an induction agent, either an anti-thymocyte globulin or interleukin-2 receptor antibody, is given at the time of transplantation to prevent early acute rejection which is then followed by a triple immunosuppressive maintenance regimen. Very low rejection rates have been achieved at many transplant centers using combinations of these agents in a variety of protocols. Yet, a large number of recipients suffer chronic allograft injury and adverse events associated with drug therapy. Regimens designed to limit or eliminate calcineurin inhibitors and/or corticosteroid use are actively being pursued. An ideal immunosuppressive regimen limits toxicity and prolongs the functional life of the graft. This article contains a critical analysis of clinical data on currently available immunosuppressive strategies and an overview of therapeutic moieties in development.

Inhibitory interactions between BK and JC virus among kidney transplant recipients.

BK and JC polyomaviruses can reactivate after transplantation, causing renal dysfunction and graft loss. The incidence of JC reactivation after renal transplant is not well understood. Here, we characterized JC reactivation using samples collected during the first year after transplantation from 200 kidney recipients. We detected BK and JC viruses in the urine of 35 and 16% of transplant recipients, respectively. The median viral load in the urine was 400 times higher for BK virus than JC virus. The presence of BK viruria made concurrent JC viruria less likely: JC viruria was detected in 22% of non-BK viruric recipients compared with 4% of BK viruric recipients (P=0.001). The co-detection rate was 1.5%, which is less than the expected 5.6% if reactivation of each virus was independent (P=0.001). We did not observe JC viremia, JC nephropathy, or progressive multifocal leukoencephalopathy. The onset of JC viruria was associated with donor, but not recipient, JC-specific antibody in a titer-dependent fashion and inversely associated with donor and recipient BK-specific antibody. Donor and recipient JC seropositivity did not predict BK viruria or viremia. In conclusion, among renal transplant recipients, infection with one polyomavirus inversely associates with infection with the other.

The influence of bortezomib on donor specific antibody reduction in patients with antibody mediated rejection.

Renal allograft biopsy is the gold standard for monitoring and diagnosing antibody mediated rejection (AMR), yet a biopsy is invasive, expensive, and may result in complications. Monitoring antibodies may aid in diagnosing and monitoring AMR, although many questions remain unanswered regarding the clinical utility of antibody monitoring. The purpose of this review is to examine the influence of bortezomib on reduction of donor specific antibody after AMR in renal transplant recipients. A retrospective review of patients was performed. Patients who received bortezomib after suffering AMR refractory to intravenous immunoglobulin and plasmapheresis from 2009 to 2011 were selected. Seven patients were identified. Three patients had antibodies tested after IVIG treatment with a mean antibody lowering of 29 percent from baseline. Five of the seven patients had antibodies tested after bortezomib treatment and the mean antibody reduction was 47 percent from baseline. Four patients were biopsied after treatment and all were C4d negative. The other three patients were not biopsied. Renal function improved in most patients. One patient returned to dialysis 16 months after transplant and treatment and another patient died with a functioning graft, due to pneumonia five months after transplant and treatment. In these seven cases, the use of intravenous immune globulin, plasmapheresis, and bortezomib appear to decrease antibodies, improve renal function, and reverse histological markers for rejection. Long-term, prospective follow-up is warranted to determine the influence of bortezomib on donor antibody removal, histological changes, and graft survival.

Thymoglobulin induction dosing strategies in a low-risk kidney transplant population: three or four days?

The optimal dose and duration of rabbit antithymocyte globulin (rATG) induction has not been defined. Methods. We compared the safety and efficacy of 2 dosing strategies, rATG 1.5 mg/kg for 4 days (n = 59) versus 2 mg/kg for 3 days (n = 59), in a retrospective, cohort study. Results. Two-year rejection-free survival was 95% in each group (P = .983). Renal function and infection rates were similar. The incidence of leucopenia was similar, although the 2 mg/kg group was more likely to be thrombocytopenic on day 2 (4% versus 28%, P = .04). Length of stay tended to be longer for the 1.5 mg/kg group (6.0 ± 3.7 versus 5.1 ± 1.9 days P = .104). A cost savings of $920 per patient for rATG were seen in the 2 mg/kg group (P = .122). Conclusions. Shorter, more intense dosing of rATG is safe and effective. The 3-day dose strategy resulted in a clinically shorter length of stay and may result in cost savings.

Serum sickness after treatment with rabbit antithymocyte globulin in kidney transplant recipients with previous rabbit exposure.

Serum sickness after rabbit antithymocyte globulin administration has a reported incidence of 7% to 27% in kidney transplant recipients. We describe 4 patients with previous exposure to rabbits who developed serum sickness after primary rabbit antithymocyte globulin induction. All patients presented with jaw pain. Three of 4 patients treated with plasmapheresis and steroids had prompt recovery, and 1 patient treated with steroids had slower recovery. We performed a telephone interview of 214 patients who contemporaneously underwent transplantation between November 2006 and July 2008 regarding rabbit exposure. More than half the patients had some type of previous rabbit exposure. There was a suggestion that patients with serum sickness were exposed more frequently to rabbits than those without. Jaw pain appears to be a hallmark symptom, and treatment with plasmapheresis and steroids relieves symptoms more rapidly than steroids alone.

Bortezomib as rescue therapy for antibody mediated rejection: a single-center experience.

Case series have reported the use of bortezomib for treatment of primary and refractory treatment of cell-mediated acute rejection. The purpose of this article is to review a single-center experience with bortezomib used to treat humoral rejection in four transplant recipients. All patients received bortezomib after suffering antibody-mediated rejection refractory to intravenous immunoglobulin and plasmapheresis. Each patient had improved renal function after bortezomib treatment, biopsies became c4d negative in three of the four patients and the level of donor specific antibody reduction was mixed. Adverse drug events were not encountered, although two patients suffered infections, H1N1 pneumonia and cytomegalovirus colitis. In conclusion, these four cases demonstrate the promising use of bortezomib as rescue therapy for antibody mediated rejection. Future research is needed to explore the impact of bortezomib on HLA removal, histological reversal of rejection, and long-term graft function after transplantation.