Post-transplant glomerular diseases: update on pathophysiology, risk factors and management strategies

In recent years, advancements in immunosuppressive medications and post-transplant management have led to a significant decrease in acute rejection rates in renal allografts and consequent improvement in short-term graft survival. In contrast, recent data have shown an increased incidence of post-transplant glomerular diseases, which currently represent a leading cause of allograft loss. Although pathogenesis is not fully understood, growing evidence supports the role of inherited and immunological factors and has identified potential pre- and post-transplant predictors. In this review, we illustrate recent advancements in the pathogenesis of post-transplant glomerular disease and the role of risk factors and immunological triggers. In addition, we discuss potential prevention and management strategies.

Physical activity parameters as determinants of cardiovascular disease risk in kidney transplant recipients: an accelerometer-based study

Introduction

Cardiovascular diseases are the leading cause of morbidity and mortality after kidney transplantation. Physical inactivity is an important factor for the development of cardiovascular disease (CVD) risk.

Aim

To evaluate CVD risk and its association with accelerometer-based physical activity (PA) parameters in kidney transplant recipients (KTRs).

Material and methods

This cross-sectional study included 43 KTRs. Number of steps, total energy expenditure, average sleep and lying times, average metabolic equivalent (MET), and PA duration were assessed with SenseWear Armband. CVD risk was predicted using a web-based interactive tool (HeartScore program).

Results

CVD risk was negatively correlated with number of steps, average MET and PA duration. Average MET and PA duration were significantly higher in KTRs with low CVD risk compared to KTRs with moderate CVD risk (p = 0.004 and p = 0.007, respectively). Average MET, PA duration and number of steps were significantly higher in KTRs with low CVD risk compared to KTRs with high CVD risk (p < 0.001, p < 0.001 and p = 0.009, respectively). Number of steps was higher in KTRs with moderate CVD risk compared to KTRs with high CVD risk (p = 0.010). The linear regression analysis revealed that average MET was a predictor of CVD risk, accounting for 15.9% of the variance.

Conclusions

CVD risk is associated with accelerometer-based PA parameters and average MET is a significant predictor of CVD risk after kidney transplantation in KTRs. Wearable technologies can be used to objectively measure PA parameters in order to determine CVD risk and to monitor the efficiency of PA interventions after kidney transplantation.

Challenges in posttransplantation care for kidney transplant recipients: A qualitative study highlighting gaps in psychological, social and exercise support

BACKGROUND

Kidney transplantation offers meaningful health improvements compared to dialysis, yet the quality of life and life expectancy of kidney transplant recipients still lag behind those of their healthy peers. Physical inactivity and poor physical fitness are prevalent among kidney transplant recipients, affecting overall life participation.

OBJECTIVES

To explore challenges hindering life participation for kidney transplant recipients and reveal facilitators and barriers to integrating rehabilitation into their daily lives.

DESIGN

An explorative study using a qualitative method.

PARTICIPANTS

Fourteen purposively selected kidney transplant recipients.

APPROACH

Semistructured, individual interviews were conducted posttransplantation. The following topics were covered: living with chronic kidney disease, pretransplantation challenges, posttransplantation recovery, engagement in various activities, including physical activity, and the need for supervised exercise rehabilitation programmes. Interviews were recorded and transcribed verbatim, and an inductive thematic analysis approach was used.

FINDINGS

Data saturation occurred after analysing 12 interviews, revealing two main themes: the impact on life participation and the impact on physical and mental functioning. Participants expressed the need for comprehensive posttransplant care, including mental health support, family education and guidance on returning to work. Structured support in managing physical fitness, tailored to individual preferences, was also recognised as important.

CONCLUSIONS

The study underscores the necessity for a biopsychosocial approach to posttransplant care that addresses the multifaceted challenges faced by kidney transplant recipients. A multidisciplinary approach, tailored support, education and individualised exercise programmes are crucial for enhancing their overall well-being and integrating rehabilitation into their daily lives, considering both physical and psychosocial aspects.

Cancer mortality among solid organ transplant recipients: A systematic review and meta-analysis

OBJECTIVES

To evaluate the cancer mortality risk among solid organ transplant recipients through a systematic review and meta-analysis.

METHODS

Systematic searches were conducted in PubMed (starting from 1965), ISI Web of Science (starting from 1900), MEDLINE (starting from 1976), and Scopus (starting from 1968) from the inception of each database until July 15, 2024. Studies published in English reporting at least one type of cancer mortality risk among recipients of any type of solid organ transplantation were included. The main outcomes were the standardized mortality ratio (SMR) for cancer mortality in transplant recipients compared to the general population, and the hazard ratio (HR) for cancer mortality in transplant recipients versus cancer patients without prior transplantation.

RESULTS

Solid organ transplant recipients had a 2.06-fold increased cancer mortality risk (SMR, 2.06 [95 % CI, 1.56-2.71]) than the general population. Risks were higher in kidney (SMR 1.92 [95 % CI: 1.30-2.84]), liver (SMR 3.07 [95 % CI: 1.80-5.24]), and lung/heart (SMR 4.87 [95 % CI: 3.33-7.12]) transplant recipients. Cancer patients with prior transplantation had a 1.47-fold increased cancer mortality risk (HR 1.47 [95 % CI: 1.29-1.68]) than those without. East Asia female transplant recipients exhibited higher mortality risks from breast, ovarian, cervix and uterus cancers than those from other regions (SMR 3.13 [95 % CI: 1.93-5.07] vs. 1.16 [95 % CI: 0.88-1.53], P < 0.01).

CONCLUSIONS

Solid organ transplant recipients face significantly higher cancer mortality risks than the general population, highlighting the need for targeted cancer screening and interventions, especially for female solid organ transplant recipients from East Asia.

Composition of the neutralising antibody response predicts risk of BK virus DNAaemia in recipients of kidney transplants

BACKGROUND

BK polyomavirus (BKV) DNAaemia occurs in 10% of recipients of kidney transplants, contributing to premature allograft failure. Evidence suggests disease is donor derived. Hypothetically, recipient infection with a different BKV serotype increases risk due to poorer immunological control. Thus, understanding the composition and activity of the humoral anti-BKV responses in donor/recipient (D/R) pairs is critical.

METHODS

Using 224 paired pre-transplant D/R samples, BKV VP1 genotype-specific pseudoviruses were employed to define the breadth of the antibody response against different serotypes (ELISA) and, to characterise specific neutralising activity (nAb) using the 50% inhibitory concentration (LogIC50). Mismatch (MM) ratios were calculated using the ratio of recipient ELISA or nAb reactive BKV serotypes relative to the number of donor reactive serotypes.

FINDINGS

BKV DNAaemia was observed in 28/224 recipients of kidney transplants. These recipients had lower nAb titres against all the serotypes, with median logIC50 values of 1.19-2.91, compared to non-viraemic recipients' median logIC50 values of 2.13-3.30. nAb D/R MM ratios >0.67 associated with significantly higher risk of BKV viraemia, with an adjusted odds ratio of 5.12 (95% CI 2.07 to 13.04; p < 0.001). Notably, a mismatch against donor serotype Ic and II associated with adjusted odds ratios of 8.12 (95% CI 2.10 to 35.61; p = 0.002) and 4.52 (95% CI 1.19 to 19.23; p = 0.03) respectively. 21 recipients demonstrated broadly neutralising responses against all the serotypes, none of whom developed BKV DNAaemia post-transplant. In contrast, there was poor concordance with PsV-specific ELISA data that quantified the total antibody response against different serotypes.

INTERPRETATION

BKV nAb mismatch predicts post-transplant BKV DNAaemia. Specific mismatches in nAb, rather than total seroreactivity, are key indicators of BKV risk post-transplant. This has the potential to risk-stratify individuals and improve clinical outcomes by influencing the frequency of monitoring and individualised tailoring of immunosuppression. Furthermore, detailed examination of individuals with broadly neutralising responses may provide future therapeutic strategies.

FUNDING

The research was funded by St. Peters Trust, Royal Free Hospital Charity and Wellcome Trust (grant numbers RFCG1718/05, SPT97 and 204870/Z/WT_/Wellcome Trust/United Kingdom).

Accurate Multiplex qPCR Detection of Epstein-Barr Virus/Cytomegalovirus/BK Virus in Kidney Transplant Patients: Pilot Study

Chronic kidney disease is a really important heath issue, and transplantation is an intervention that can greatly increase patient quality of life and survival. The aim of this study was to perform a comprehensive evaluation of the BK virus, CMV, and EBV in kidney transplant recipients (KTRs); to assess the prevalence of infections; and to test if our detection method would be feasible for use in follow-ups with KTRs. A total of 157 KTRs registered at the Clinical Hospital "Dr. C. I. Parhon", Iași, Romania, were selected using specific inclusion/exclusion criteria. We tested the blood samples from each patient for BK, EBV, and CMV using a multiplex real-time PCR (qPCR) assay and the TaqMan PCR principle. The highest prevalence was detected for BKV (11/157, 7%), followed by CMV (9/157, 5.7%) and EBV (5/157, 3.2%). By simultaneously detecting three possible nephropathic viruses and oncogenes in KTRs using multiplex real-time PCR, we aimed to optimize their monitoring and follow-up. The prevalence of the tested nephropathogenic viruses-BKV, CMV, and EBV-was comparable to that analyzed in other studies. We demonstrate that the use of qPCR for viral detection in KTRs is a robust, cost-effective method for case monitoring.

Cytomegalovirus Infection After Solid Organ Transplantation: How I Use Cell-Mediated Immune Assays for Management

INTRODUCTION

The pathogenesis and outcome of cytomegalovirus (CMV) infection after solid organ transplantation (SOT) reflects the interplay between viral replication and CMV-specific immunity. Despite advances in its diagnosis and treatment, CMV continues to cause significant morbidity after SOT. Since CMV is an opportunistic pathogen that occurs as a result of impaired pathogen-specific immunity, laboratory assays that measure CMV-specific immune responses may be useful in assisting clinicians in its management.

METHODS AND RESULTS

The author summarizes the evolving and emerging data on the clinical utility of assays that quantify cell-mediated immune responses to CMV in SOT recipients. The majority of publications are observational studies that demonstrate that a lack or deficiency in CMV-specific cell-mediated immunity is correlated with a heightened risk of primary, reactivation, or recurrent CMV after transplantation. A few prospective interventional studies have utilized CMV-specific cell-mediated immune assays in guiding the duration of antiviral prophylaxis among CMV-seropositive SOT recipients. Likewise, CMV-specific cell-mediated immunity assays have been suggested to inform the need for secondary antiviral prophylaxis and immunologic optimization to prevent CMV relapse after treatment.

CONCLUSIONS

CMV-specific cell-mediated immune assays are emerging to assist transplant clinicians in predicting a patient's risk of CMV after transplantation, and these assays have been utilized to individualize the approach to CMV prevention and treatment. The author suggests the conduct of more interventional studies to further solidify the role of CMV-specific cell-mediated immune assays in routine clinical practice.

Elevated Plasma High Sensitive C-Reactive Protein and Triglyceride/High-Density Lipoprotein Cholesterol Ratio are Risks Factors of Diabetes Progression in Prediabetes Patients After Kidney Transplant: A 3-Year Single-Center Study in Vietnam

Purpose

Determination the rate of developing post-transplant diabetes mellitus (PTDM) in prediabetic patients and the relationship with plasma hs-CRP levels and TG/HDL-C ratio in patients after kidney transplantation from living donors followed for 3 years.

Subjects and Methods

A total of 206 post-transplant patients diagnosed with prediabetes by oral glucose tolerance test (OGTT) were included in the study. At the time of diagnosis of prediabetes, all patients were clinically examined, paraclinical tests were performed, plasma hs-CRP was quantified, and the TG/HDL-C ratio was determined. Patients are individualized and given a reasonable diet and exercise regimen. Patients had their fasting blood glucose measured monthly or had an OGTT every 3 months. Patients meeting the criteria for diagnosis of PTDM according to the American Diabetes Association (ADA)-2018 were collected during 3 years of follow-up.

Results

The study group had an average age of 39.46 ± 10.26 years old, including 74.8% males and 25.2% females. The rate of patients who had a development of PTDM from prediabetes was 29.6% (61/206 patients). BMI, plasma TG, HDL-C, hs-CRP, and TG/HDL-C ratio at the time of prediabetes diagnosis were factors related to the progression of PTDM, in which hs-CRP and TG/HDL-C ratio were good predictors (with AUC = 0.85 and 0.874, respectively; p < 0.001).

Conclusion

After 3 years of follow-up, nearly one-third of prediabetic patients developed PTDM post-living donor kidney transplantation. BMI, plasma TG, HDL-C, hs-CRP, and the TG/HDL-C ratio were linked to DM progression, with hs-CRP and TG/HDL-C being the strongest predictors.

Histopathology of Allograft Nephrectomies - A Ten Year Observational Study

Background

Though infrequent, allograft nephrectomies are performed for early and late graft loss. The study aims to analyze the histopathologic characteristics of allograft nephrectomy specimens.

Materials and Methods

We conducted an observational study of 103 cases of allograft nephrectomies from 21 centers from 2013 to 2023. All the pathology slides, including hematoxylin and eosin-stained sections, masson trichrome, jones methenamine silver, PAS, GMS, AFB, and immunohistochemistry (C4d, SV40) were reviewed. Pathologic findings were analyzed based on the transplant to nephrectomy interval (0-3 months, > 3 months) and type of donor (deceased, live donor).

Results

Of the total 103 cases, 77 were male. The mean age at the time of nephrectomy was 36.4 (range 5-64) years. The allografts were obtained from deceased (57) donors and live related (46) donors. Graft tenderness, oliguria/anuria, and fever were common clinical presentations. The majority (71.8%) of the nephrectomies were performed within the first 3 months of renal transplant. Renal vessel thrombosis (32.03%) was the most common pathologic finding. Infections were more common in the first 3 months after the transplant. Fungal infection had a significant association with deceased donor transplantation (p = 0.029).

Conclusion

Histopathological study of allograft nephrectomy specimens aids understanding of graft loss causes. The study also provides opportunities to prevent complications and implement measures to prolong graft survival in a subsequent transplant.

Improvement of Encapsulating Peritoneal Sclerosis After Medical Treatment and Successful Deceased Donor Kidney Transplant in a Child: A Case Report

BACKGROUND

Encapsulating peritoneal sclerosis (EPS) is an uncommon complication of long-term peritoneal dialysis (PD). Despite its rarity, EPS significantly increases morbidity and mortality in patients undergoing prolonged peritoneal dialysis. In children on PD, the incidence of EPS ranges from 0.5% to 7.3%.

CASE

We present the case of a 13-year-old Omani boy diagnosed with end-stage kidney disease (ESKD) secondary to steroid-resistant nephrotic syndrome due to diffuse mesangial sclerosis at the age of 2 years. He was started on automated peritoneal dialysis (APD) on the same year and experienced four episodes of peritonitis, which were treated successfully with intraperitoneal (IP) antibiotics. In January 2023, he developed intermittent abdominal pain and chronic constipation, which progressed to daily vomiting, reduced oral intake, and weight loss. He later developed subacute intestinal obstruction which was managed conservatively. A CT scan of the abdomen revealed findings consistent with EPS. Following the diagnosis of EPS, peritoneal dialysis (PD) was discontinued, and the patient transitioned to hemodialysis. Treatment for EPS began with steroids and Tamoxifen. Subsequently, he underwent deceased donor kidney transplantation and was started on multiple immunosuppressive medications. During subsequent follow-up appointments, he was maintained on total parenteral nutrition (TPN) along with a soft diet. His overall condition improved significantly, enhancing his quality of life.

CONCLUSION

This case highlights the risk of encapsulating peritoneal sclerosis (EPS) in patients undergoing long-term peritoneal dialysis. Transitioning to hemodialysis and kidney transplantation, combined with targeted treatments such as steroids and Tamoxifen, significantly improved the patient's condition and quality of life. Early diagnosis and intervention are crucial for effective management of EPS in children.

Immunosuppressive Therapy, Puberty and Growth Outcomes in Pediatric Kidney Transplant Recipients: A Pragmatic Review

Kidney transplantation in children with end-stage kidney disease significantly enhances survival and quality of life but poses unique challenges related to chronic immunosuppressive therapy. In fact, despite being essential for preventing organ rejection, immunosuppressive therapy can have significant side effects specific to pediatric patients, such as adverse impacts on physiological growth, puberty, and fertility. The resulting short stature and delayed or incomplete pubertal development can profoundly affect young patients' psychological and social well-being, impacting self-esteem and overall quality of life, and may significantly hamper compliance and therapeutic adherence. Most studies on immunosuppression in pediatric kidney transplant recipients focus on general side effects and outcomes like long-term graft survival or acute complications. On the other side, there is limited evidence in the current literature on the specific issues of growth, puberty, and fertility in this patient population. In this pragmatic review, we aimed to summarize the most relevant information available on these critical aspects of post-transplant management in pediatric patients, also providing some practical indications on management strategies for minimizing these often neglected but still important complications.

French AFU Cancer Committee Guidelines - Update 2024-2026: Management of kidney cancer

OBJECTIVE

To update the French recommendations for the management of kidney cancer.

METHODS

A systematic review of the literature was conducted for the period from 2014 to 2024. The most relevant articles concerning the diagnosis, classification, surgical treatment, medical treatment, and follow-up of kidney cancer were selected and incorporated into the recommendations. The recommendations have been updated specifying the level of evidence (strong or weak).

RESULTS

Kidney cancer following prolonged occupational exposure to trichloroethylene should be considered an occupational disease. The reference examination for the diagnosis and staging of kidney cancer is the contrast-enhanced thoraco-abdominal CT scan. PET scans are not indicated in the staging of kidney cancer. Percutaneous biopsy is recommended in situations where its results will influence therapeutic decisions. It should be used to reduce the number of surgeries for benign tumors, particularly avoiding unnecessary radical nephrectomies. Kidney tumors should be classified according to the pTNM 2017 classification, the WHO 2022 classification, and the ISUP nucleolar grade. Metastatic kidney cancers should be classified according to IMDC criteria. Surveillance of tumors smaller than 2cm should be prioritized and can be offered regardless of patient age. Robot-assisted laparoscopic partial nephrectomy is the reference surgical treatment for T1 tumors. Ablative therapies and surveillance are options for elderly patients with comorbidities for tumors larger than 2cm. Stereotactic radiotherapy is an option to discuss for treating localized kidney tumors in patients not eligible for other treatments. Radical nephrectomy is the first-line treatment for locally advanced localized cancers. Pembrolizumab is recommended for patients at high risk of recurrence after surgery for localized kidney cancer. In metastatic patients, cytoreductive nephrectomy can be immediate in cases of good prognosis, delayed in cases of intermediate or poor prognosis for patients stabilized by medical treatment, or as "consolidation" in patients with complete or major partial response at metastatic sites after systemic treatment. Surgical or local treatment of metastases can be proposed for single lesions or oligometastases. Recommended first-line drugs for metastatic clear cell renal carcinoma are combinations of axitinib/pembrolizumab, nivolumab/ipilimumab, nivolumab/cabozantinib, and lenvatinib/pembrolizumab. Patients with non-clear cell metastatic kidney cancer should be presented to the CARARE Network and prioritized for inclusion in clinical trials.

CONCLUSION

These updated recommendations are a reference that will enable French and French-speaking practitioners to optimize their management of kidney cancer.

Pathogen-specific cell-mediated immunity to guide the management of cytomegalovirus in solid organ transplantation: state of the art clinical review

INTRODUCTION

Cytomegalovirus (CMV) is a common opportunistic infection after solid organ transplantation, with significant impact on morbidity and long-term survival. Despite advances in diagnostics and therapeutics, the management of CMV remains very challenging.

AREAS COVERED

This article reviews emerging data on the clinical utility of laboratory assays that quantify cell-mediated immune responses to CMV. Observational studies have consistently demonstrated that a deficiency in pathogen-specific cell-mediated immunity is correlated with a heightened risk of primary, reactivation or recurrent CMV after transplantation. A limited number of interventional studies have recently investigated cell-mediated immune assays in guiding the prevention and treatment of CMV infection after solid organ transplantation.

EXPERT OPINION

The pathogenesis and outcome of CMV after solid organ transplantion reflect the interplay between viral replication and CMV-specific immune reconstitution. Research in CMV-specific cell-mediated immunity paved way for the development of several laboratory assays that may assist clinicians in predicting the risk of CMV after transplantation, individualize the approach to CMV disease prevention, guide the need and duration of treatment of CMV infection, and predict the risk of relapse after treatment. More interventional studies are needed to further solidify the role of cell-mediated immune assays in various clinical situations after transplantation.

BK Polyomavirus DNAemia With a High DNA Load Is Associated With De Novo Donor-Specific HLA Antibodies in Kidney Transplant Recipients

BK polyomavirus-associated nephropathy (BKPyVAN) is a well-known complication of kidney transplantation (KTx). The mainstay of prevention is the reduction of immunosuppression upon detection of BK polyomavirus (BKPyV) DNAemia, which precedes BKPyVAN. However, this reduction may inadvertently increase the risk of alloimmunity particularly in patients with a high BKPyV DNA load, where significant immunosuppression reduction is often necessary. This single-center, retrospective cohort study assesses the risk of de novo donor-specific antibodies (dnDSA) development and biopsy-proven acute rejection (BPAR) following high and low BKPyV DNAemia. All patients who underwent KTx at Leiden University Medical Center between 2011 and 2020 were included. Patients were grouped according to high (maximum BKPyV DNA load > 4log10 copies/mL), low (maximum serum BKPyV DNA load ≤ 10E4 copies/mL), and absent BKPyV DNAemia, and analyzed for the development of dnDSA and BPAR, using Cox regression. Of 1076 KTx recipients included, 108 (10%) developed a BKPyV DNAemia with a maximum DNA load below 4log10 copies/mL, whereas 121 (11.2%) developed a BKPyV DNAemia exceeding 4log10 copies/mL. The risk of dnDSA development was higher in patients with a high BKPyV DNAemia, compared to patients without DNAemia (adjusted hazard ratio of 1.9 (95% CI 1.1-3.2, p = 0.017). No significant difference in dnDSA risk was observed between patients with low and absent BKPyV DNAemia. Risk of BPAR did not differ between groups. Our study shows that higher BKPyV DNA loads in KTx patients are associated with a higher risk for dnDSA development, highlighting the importance of exploring additional strategies for the prevention and treatment of BKPyV infections in KTx recipients.

Perspectives on donor-derived infections from Germany

AIM

Often, organ transplantation is the only option to improve the life expectancy and quality of life of patients with terminal organ failure. Despite improved donor and organ assessment, a residual risk remains for transmitting infection, tumor, or other disease from the donor to recipients. Analysis, reporting, and managing of donor-derived diseases through a vigilance and surveillance system (V&S) is mandatory in many countries. We report on suspected and proven/probable donor-derived infections (DDI) in Germany over a period of 8 years (2016-2023).

METHODS

All incoming serious-adverse-event and serious-adverse-reaction (SAE/SAR) reports from 01.01.2016 to 31.12.2023 were evaluated for suspected DDI. Analysis of imputability followed the definition of the US Disease Transmission Advisory Committee (DTAC). Only probable and proven cases according to DTAC classification were defined as DDI.

RESULTS

During the study period, 9771 donors in Germany donated post-mortem organs to 27 919 recipients. In that period 612 SAE/SAR cases were reported, 377 (62%) involved infections. 41 cases were proven/probable DDI affecting 58 recipients (seven recipients died, 12%). Suspected infections were bacterial (182/377, 48%), fungal (135/377, 36%), viral (55/377, 15%), and parasitic (5/377, 1%). In case of bacterial DDI, no recipient died, but organ loss occurred in six recipients. In case of fungal or viral DDI, 19% (3/16) and 21% (3/14) of the recipients died, respectively.

CONCLUSIONS

DDI are rare in solid organ transplantation (58/27 919, 0.21%), but when they occur, they are associated with high morbidity and mortality in affected recipients. Careful and detailed donor evaluation and a reliable V&S help improve recipient safety.

The incidence and risk factors of post-transplant diabetes mellitus in living donor kidney transplantation patients: a retrospective study

BACKGROUND

Post-transplant diabetes mellitus (PTDM) is a well-known complication of kidney transplantation that significantly impacts recipient morbidity and mortality. Over the recent years, the incidence of PTDM has increased considerably worldwide. Therefore, the primary purpose of this study was to evaluate the incidence and risk factors for PTDM in living donor kidney transplantation patients in Riyadh, Saudi Arabia.

METHODS

A retrospective cohort study was conducted at a tertiary transplant center in Riyadh, Saudi Arabia, and data were extracted between February 2016 and March 2022. Patients aged ≥ 18 years who underwent renal transplant with at least one year of post-transplant follow-up were included in the analysis, and their medical records were comprehensively reviewed. Patients < 18 years of age, history of diabetes mellitus, other organ transplants, or those who underwent transplantation outside the Kingdom of Saudi Arabia were excluded from the study.

RESULTS

The study included 247 living donor kidney transplant patients, with a mean age of 39.5 ± 14.6 years. 17.0% of the patients were diagnosed with PTDM. Patient age and fasting glucose levels at 6-months and 12-months after transplantation were found to be significant risk factors for the development of PTDM.

CONCLUSION

An increased occurrence of PTDM emphasizes the importance of identifying high-risk patients prior to transplantation and implementing early interventions to prevent potential complications that could affect graft and patient survival.

Association between physical activity and immunosuppressive medication adherence among renal transplant recipients: a case-control study

BACKGROUND

Behavioural interventions are closely associated with immunosuppressive medication (IM) adherence. We aimed to explore the relationship between physical activity and IM adherence among renal transplant patients (RTPs) to determine potential interventions to improve IM adherence.

DESIGN

A case-control study.

SETTING

Single-centre study in Changsha, China.

PARTICIPANTS

The study population included 624 RTPs who were adherent to IM and 417 RTPs who were non-adherent to IM.

MAIN OUTCOME MEASURES

Sociodemographic characteristics of RTPs, IM adherence and the association between physical activity patterns or frequency and IM adherence.

RESULTS

The proportion of RTPs who were non-adherent to IM was 40.06%. Compared with RTPs non-adherent to IM, those who were adherent were older, more likely to be married, were evaluated closer to initial time of transplant, had shorter pretransplant waiting times and engaged in more physical activity. Multivariate logistic regression analysis showed that, in the pretransplant stage, only high-frequency aerobic physical activity was significantly associated with IM adherence. However, in the post-transplant stage, patients engaging in low-frequency aerobic physical activity, high-frequency resistance physical activity or high-frequency aerobic physical activity had 2.01, 2.96 and 2.67 times greater odds of being adherent to IM, respectively, compared with patients with no physical activity. RTPs without physical activity in the pretransplant stage were more likely to be adherent to IM if they engaged in post-transplant physical activity. RTPs engaging in low-frequency physical activity in the pretransplant stage may have better IM adherence if they engaged in post-transplant physical activity. RTPs engaging in high-frequency post-transplant physical activity were significantly associated with a greater likelihood of being adherent to IM compared with RTPs engaging in low-frequency post-transplant physical activity.

CONCLUSION

Our study revealed that physical activity, especially in the post-transplant stage, is closely associated with IM adherence and presents a potential intervention for improving IM adherence by RTPs.

Peritoneal dialysis-related peritonitis due to Pasteurella multocida in Australia

Domestic animals are common in Australian households; however, there is little research into the potential risks these animals pose to patients undergoing in-home peritoneal dialysis (PD). Cats and dogs are known to carry many potential pathogens, including Pasteurella multocida. We reviewed the ANZDATA Peritoneal Dialysis Peritonitis Registry for cases of peritonitis due to Pasteurella multocida between 2011 and 2023. Cases identified were younger and more likely to be female compared with the Australian PD population who developed peritonitis due to other organisms. Of the total 32 episodes, 75% were using automated PD with glucose-based solutions. Two cases requiring removal of the PD catheter and transfer to haemodialysis and no deaths were reported. Whilst outcomes were largely favourable, it is likely that many of these cases could have been prevented. Education for people undergoing PD should include information about the potential infectious hazards of domestic animals.

Evaluation and Management of Urological Complications Following Pediatric Kidney Transplantation: Experience from a Single Tertiary Center

Background/Objectives: Kidney transplantation is the treatment of choice for children with end-stage renal disease (ESRD), but its outcome can be affected by urological complications, with incidence rates of 2.5-25%. The aim of this study was to evaluate the occurrence of urological complications and their management in a cohort of pediatric kidney transplant recipients. Materials and Methods: A retrospective analysis on 178 patients who received a renal transplant at our Pediatric Kidney Transplant Center between 2011 and 2023 was conducted. Demographic and clinical data were analyzed. Urological complications were categorized as early, intermediate, or late based on their onset time. Results: Out of 178 patients, 28 (15.7%) experienced urological complications. Most patients (61%) had a pre-existing uropathy. Early complications (7-30 days) were all obstructive, namely, ureterovesical junction obstruction and perirenal collections. Intermediate complications (1-3 months) comprised ureteral stenosis, symptomatic vesicoureteral reflux (VUR), and obstructive lymphocele. Late complications (>3 months) included symptomatic VUR and ureteral stenosis, with one case leading to ureteral rupture. Early complications were often detected due to acute graft dysfunction, while late ones were mainly identified during routine clinical, laboratory, or ultrasound follow-up. Urological complications requiring surgical or endoscopic therapy were 13.4%. Most ureteral stenoses were treated with initial endoscopic stents, followed by definitive surgery. VUR was treated with endoscopic correction with a high success rate (75%), while open surgery was reserved for cases where initial treatments failed or complications recurred. No clear correlations were found between patient characteristics and risk of urological complication. Urological complications required multiple diagnostic procedures and therapeutic interventions (+2.5 admissions in mean and approximately +EUR 24,000) compared to an uncomplicated post-transplant course. However, they did not significantly impact transplant outcomes, with a graft survival rate comparable to that of the control group. Conclusions: Regular post-transplant follow-up is crucial, especially for patients with known risk factors, to allow for timely detection and treatment of urological complications, avoiding detrimental effects on graft function and improving transplantation outcomes.

Differences in safety profiles of anti-herpesvirus medications: a real-world pharmacovigilance study based on the FAERS database

BACKGROUND

Anti-herpesvirus drug safety profiles have not been systematically compared. Understanding variations in adverse events (AEs) could provide reference for rational clinical use.

METHODS

We collected data on acyclovir, ganciclovir, valaciclovir, and foscarnet from the FDA Adverse Event Reporting System (FAERS) database from Q1 2004 to Q3 2023. Disproportionality analyses were conducted to evaluate the risk of AEs.

RESULTS

All drugs exhibited significant associations with hematotoxicity, with ganciclovir and foscarnet being more myelosuppressive. The correlation with renal impairment ranked as follows: foscarnet, ganciclovir, valaciclovir, and acyclovir (ROR = 16.72, 7.06, 3.51, and 2.02, respectively). Regarding hepatotoxicity, ganciclovir was associated with acute-on-chronic liver failure (ROR = 52.83), and foscarnet was associated with fulminant hepatitis (ROR = 49.91). In the nervous system, acyclovir showed the highest intensity of neurotoxicity (ROR = 14.95). Valaciclovir ranked first in toxic encephalopathy (ROR = 64.70). Foscarnet showed the highest intensity of status epilepticus (ROR = 6.45). Besides, acyclovir showed the strongest association with severe cutaneous adverse reactions (SCARs).

CONCLUSIONS

Our study revealed differences in safety profiles of four anti-herpesvirus medications. Ganciclovir exhibited the highest risk of hematotoxicity but appeared relatively safe in seizures and SCARs. Foscarnet was more likely to induce nephrotoxicity, seizures, and electrolyte imbalances than others. Acyclovir and valaciclovir were strongly associated with plasmacytosis, neurotoxicity, and SCARs.

Kidney transplantation restores sex hormone profile and improves sexual function in ESRD patients with erectile dysfunction

BACKGROUND

Erectile dysfunction (ED) and sex hormone profile disturbances are common in ESRD patients.

OBJECTIVE

To assess the effect of kidney transplant (KT) and Hemodialysis/peritoneal dialysis (HD/PD) on the serum sex hormone profile and sexual functions in ESRD patients with ED.

PATIENTS AND METHODS

A single-center, nonconcurrent cohort study included a hundred ESRD patients with ED, on regular HD/PD (group A, n = 50) and after KT (group B, n = 50) at Armed Forces Hospitals Southern Region, KSA.

RESULTS

the mean age of patients was 47.3 ± 7.01 and 56.8 ± 9.6 years in groups A and B, respectively. The cohorts were comparable regarding patient demographics, apart from a higher incidence of comorbidities in group B. After KT the mean testosterone level was higher in Group B (13.64 ± 3.21 nmol/L vs 10.26 ± 3.26 nmol/L, p < 0.001). Similarly, LH and prolactin levels were lower in group B than in group A (p < 0.05). As regards sexual function, ED was reported in 92% of patients in group A compared to 42% in group B (p < 0.001). In groups A and B, mild ED was found in 48% and 14% of patients, while moderate ED was found in 16% and 8%, respectively. The mean total IIEF-15 score was 36.42 ± 9.33 and 43.87 ± 9.146 in groups A and B, respectively (p = 0.0001). Sexual desire and orgasm were significantly better in Group B.

CONCLUSIONS

Our study showed that kidney transplantation could improve erectile function and restore normal sex hormone levels in ESRD male patients with ED, with better outcomes compared to HD/PD.

Perceptions of COVID-19 Vaccination Among Organ Transplant Recipients

BACKGROUND

Understanding COVID-19 vaccine hesitancy in organ transplant recipients (OTRs) is critical given clear-albeit attenuated-benefits from vaccination.

METHODS

Adult OTRs were surveyed regarding sociodemographic data, medical history, and vaccine-related values. A novel outcome variable called the Vaccine Acceptance Composite Score (VACS) was built as the average Likert score of seven domains of vaccine confidence. To examine its association with several factors and individual adherence to COVID-19 vaccine recommendations, univariable odds ratios and relative operating characteristic areas under the curve (AUC) values were calculated.

RESULTS

Of 46 OTRs included, 32.6% identified as female, 13.3% as Black, and 6.77% as Hispanic or Latino/a/x. The median age was 58 years old. 93.5% of patients were kidney transplant recipients, and 63.0% previously had COVID-19. Patients were most concerned about COVID-19 vaccine-associated risks (46.3%), its potential effect on allograft (47.6%), and motives of government officials involved with vaccine policy (55.6%). Politically conservative patients were likelier to have lower VACS, whereas those who lived with someone ≥65 years old were likelier to have higher VACS. The VACS was not significantly associated with race, income, religious beliefs, comorbidities, COVID-19 history, or influenza vaccination status. Higher VACS was associated with ≥3 and ≥4 COVID-19 immunizations.

CONCLUSIONS

This study highlighted political beliefs and elderly household members as correlates of vaccine acceptance among OTRs. The VACS may be a useful tool to help standardize multifaceted analyses in vaccination-focused behavioral research. In clinical practice, it could help identify individuals and groups at risk for vaccine hesitancy, who may benefit from tailored outreach and educational interventions.

Guiding the starting dose of the once-daily formulation of tacrolimus in "de novo" adult renal transplant patients: a population approach

Aims

The once-daily extended-release tacrolimus formulation (ER-Tac) has demonstrated similar efficacy and safety to the twice-daily immediate-release formulation (IR-Tac), but few population-based pharmacokinetic models have been developed in de novo kidney transplant patients to optimize doses. Therefore, this study aimed i) at developing a population pharmacokinetic model for ER-Tac in de novo adult kidney transplant patients ii) and identifying genetic factors and time-varying covariates predictive of pharmacokinetic variability to guide tacrolimus dosage during the early post-transplant period.

Methods

A total of 1,067 blood tacrolimus concentrations from 138 kidney transplant patients were analyzed. A total of 29 out of 138 patients were intensively sampled for 24 h on the day 5 post-transplantation; meanwhile, for the remaining patients, concentrations were collected on days 5, 10, and 15 after transplantation. Tacrolimus daily doses and genetic and demographic characteristics were retrieved from the medical files. Biochemistry time-varying covariates were obtained on different days over the pharmacokinetic (PK) study. A simultaneous PK analysis of all concentrations was carried out using the non-linear mixed-effects approach with NONMEM 7.5.

Results

A two-compartment model with linear elimination and delayed absorption best described the tacrolimus pharmacokinetics. Between-patient variability was associated with oral blood clearance (CL/F) and the central compartment distribution volume (Vc/F). Tacrolimus concentrations standardized to a hematocrit value of 45% significantly improved the model (p < 0.001). This method outperformed the standard covariate modeling of the hematocrit-blood clearance relationship. The effect of the CYP3A5 genotype was statistically (p < 0.001) and clinically significant on CL/F. The CL/F of patients who were CYP3A5*1 carriers was 51% higher than that of CYP3A5*1 non-carriers. Age also influenced CL/F variability (p < 0.001). Specifically, CL/F declined by 0.0562 units per each increased year from the value estimated in patients who were 60 years and younger.

Conclusion

The 36% between-patient variability in CL/F was explained by CYP3A5 genotype, age, and hematocrit. Hematocrit standardization to 45% explained the variability of tacrolimus whole-blood concentrations, and this was of utmost importance in order to better interpret whole-blood tacrolimus concentrations during therapeutic drug monitoring. The dose requirements of CYP3A5*/1 carriers in patients aged 60 years or younger would be highest, while CYP3A5*/1 non-carriers older than 60 years would require the lowest doses.

The impact of JC viruria on renal transplant recovery and prognosis

Postoperative JC viruria is common in kidney transplant recipients, however there remains a dearth of research on perioperative JCV infection in this population. The clinical significance of JCV monitoring in kidney transplant recipients remains unclear. Based on JCV urine monitoring during the perioperative phase, renal transplant recipients who underwent perioperative and postoperative monitoring at our center were categorized into two groups: the perioperative JC virus infection group and the control group consisting of recipients without detectable JCV DNA in plasma or urine during the two-year follow-up period. A comparative analysis of baseline data was initially performed, followed by a 1:1 propensity score matching of 80 cases from each group. Within the first month after transplantation, the JC viruria group exhibited a significant decrease in the incidence of delayed graft function compared to the control group (P = 0.031).Over the two-year postoperative period, the JC viruria group displayed a significantly lower rate of acute rejection (P = 0.027). Notably, the JC viruria group demonstrated higher estimated glomerular filtration rate levels compared to the control group, particularly within the first year post-transplantation. Moreover, recipient and transplant kidney survival rates did not significantly differ between the two groups (P = 0.642). Perioperative JC viruria in kidney transplant recipients may persist beyond the initial two postoperative years. The presence of JCV is associated with lower rates of DGF and acute rejection, indicating a favorable post-transplant recovery. These findings provide novel insights into the importance of postoperative JCV monitoring.

Gut mucosa alterations after kidney transplantation: a cross sectional study

BACKGROUND

Kidney transplant recipients (KTRs) rely on immunosuppressants like mycophenolate to prevent organ rejection. However, mycophenolate often causes intestinal symptoms and inflammation in various organs, including the skin and the colon. While KTRs have an increased risk for skin cancer, the risk of colorectal cancer is not increased. Elucidating the histological alterations in the colon of KTRs and comparing these changes with known skin alterations would help understand how immunosuppressants influence cancer development and progression.

METHODS

Whole slide images from gut biopsies (Non-transplanted subjects n = 35, KTRs n = 49) were analyzed using the ImageJ and R programming environment. A total of 22,035 epithelial cells, 38,870 interstitial cells, 3465 epithelial cell mitoses, and 7477 endothelial cells, each characterized by multiple microscopy parameters, from a total of 1788 glands were analyzed. The large database was subsequently analyzed to verify the changes of inflammatory milieu in KTRs and in cancer.

RESULTS

KTRs without colon-cancer showed a significantly higher density of interstitial cells in the colon compared to non-transplanted patients. Moreover, the increase in interstitial cell number was accompanied by subtle modifications in the architecture of the colon glands, without altering the epithelial cell density. We could not identify significant structural modifications in cancer samples between KTRs and non-transplanted patients.

CONCLUSIONS

Our findings demonstrate an increased number of resident interstitial cells in the colon of KTRs, as in other patients treated with mycophenolate. These changes are associated with subtle alterations in the architecture of colon glands.

Is End-Stage Renal Disease Tumor Suppressive? Dispelling the Myths

The prevalence of end-stage renal disease is increasing worldwide. Malignancies accompanying end-stage renal disease are detected in approximately 120 individuals per 10,000 person-years. Most studies have suggested that end-stage renal disease causes carcinogenesis and promotes tumor development; however, this theory remains questionable. Contrary to the theory that end-stage renal disease is predominantly carcinogenic, recent findings have suggested that after controlling for biases and sampling errors, the overall cancer risk in patients with end-stage renal disease might be lower than that in the general population, except for renal and urothelial cancer risks. Additionally, mortality rates associated with most cancers are lower in patients with end-stage renal disease than in the general population. Several biological mechanisms have been proposed to explain the anticancer effects of end-stage renal disease, including premature aging and senescence, enhanced cancer immunity, uremic tumoricidal effects, hormonal and metabolic changes, and dialysis therapy-related factors. Despite common beliefs that end-stage renal disease exacerbates cancer risk, emerging evidence suggests potential tumor-suppressive effects. This review highlights the potential anticancer effects of end-stage renal disease, proposing reconsideration of the hypothesis that end-stage renal disease promotes cancer development and progression.

The Oncoprotein Fra-2 Drives the Activation of Human Endogenous Retrovirus Env Expression in Adult T-Cell Leukemia/Lymphoma (ATLL) Patients

Human endogenous retroviruses (HERVs) are retroviral sequences integrated into 8% of the human genome resulting from ancient exogenous retroviral infections. Unlike endogenous retroviruses of other mammalian species, HERVs are mostly replication and retro-transposition defective, and their transcription is strictly regulated by epigenetic mechanisms in normal cells. A significant addition to the growing body of research reveals that HERVs' aberrant activation is often associated with offsetting diseases like autoimmunity, neurodegenerative diseases, cancers, and chemoresistance. Adult T-cell leukemia/lymphoma (ATLL) is a very aggressive and chemoresistant leukemia caused by the human T-cell leukemia virus type 1 (HTLV-1). The prognosis of ATLL remains poor despite several new agents being approved in the last few years. In the present study, we compare the expression of HERV genes in CD8+-depleted PBMCs from HTLV-1 asymptomatic carriers and patients with acute ATLL. Herein, we show that HERVs are highly upregulated in acute ATLL. Our results further demonstrate that the oncoprotein Fra-2 binds the LTR region and activates the transcription of several HERV families, including HERV-H and HERV-K families. This raises the exciting possibility that upregulated HERV expression could be a key factor in ATLL development and the observed chemoresistance, potentially leading to new therapeutic strategies and significantly impacting the field of oncology and virology.

The Effectiveness of the Surgical Correction of Vesicoureteral Reflux on Febrile Urinary Tract Infections after a Kidney Transplant: A Single-Center Retrospective Study

Background/Objectives: Vesicoureteral reflux (VUR) is considered one of the major causes of post-renal transplant febrile urinary tract infections (UTI), leading to impaired renal function and the premature loss of the renal graft. We aimed to evaluate whether surgical VUR correction, such as open redo ureteric reimplantation, could be an option for treatment and provide better outcomes in post-transplant care for patients with UTI compared to their pre-VUR correction clinical state. Methods: Our study presents a retrospective analysis of 10 kidney transplant recipients with febrile UTI at the Renal Transplant Service of a Brazilian public hospital from 2010 to 2020. We selected patients who primarily underwent a surgical correction of post-transplant VUR, which was corrected by extravesical reimplantation without a stent in all patients by the same professional surgeon. Results: From 710 patients who received kidney transplants, 10 patients (1.4%) suffered from febrile UTI post-transplant and underwent surgical correction for VUR. Despite the study's limitations, such as its retrospective nature and limited sample size, the efficacy of open extravesical ureteral reimplantation in reducing post-operative febrile UTI in renal transplant patients was observed. Conclusions: As febrile UTI can contribute significantly to patient mortality after kidney transplantation and VUR emerges as a major cause of post-transplant febrile UTI, it is essential to treat it and consider the surgical outcome. This study emphasizes the timely detection and effective treatment of VUR via extravesical techniques to reduce febrile UTI occurrences post-transplant and it contributes insights into the role of surgical interventions in addressing VUR-related complications post-kidney transplantation.

Impact of cultural diversity on COVID-19 vaccination hesitancy in kidney transplant recipients

AIM

To study COVID-19 vaccination status in kidney transplant recipients (KTRs), reasons for incomplete vaccination and the clinical impact of vaccination on patient outcomes.

METHODS

A single-centre retrospective analysis of KTR (n = 543) conducted between 1970 and December 2022. Data included baseline demographics, number of vaccinations, reason for incomplete vaccination and patient outcomes following COVID-19 infection. A completed course of COVID-19 vaccination was defined as four or more vaccine doses.

EXCLUSION CRITERIA

those deceased prior December 2019, managed by another health service, failed graft, or deceased secondary to non-COVID cause.

RESULTS

273 of 543 patients met inclusion criteria. Mean age was 58.1 ± 12.2 years, 66% were male. 58.2% of patients were fully vaccinated, 22.7% received three doses, 7.7% received two doses, 0.7% received one dose, 0.7% received zero doses, and 10% incomplete records. The most common reasons for incomplete vaccination were COVID-19 infection, concern for side effects, and patient unawareness of booster recommendations. Vaccination uptake was greater in Australian born patients compared with those born overseas, odds ratio 0.40 (95% CI 0.23-0.69). KTR with incomplete vaccination had poorer outcomes, higher rate of AKI, long COVID, and increased hospitalization.

CONCLUSION

The majority of KTR were fully vaccinated. KTR with incomplete vaccination status had poorer outcomes with COVID-19 infection and other issues. Patient education is a major area for improvement targeting patients born overseas and better information regarding side effects. Potential interventions need to address improved communication, cultural relevancy, and language.

Histopathological Features and Role of Allograft Kidney Biopsy Among Recipients With Prolonged Delayed Graft Function: A Review

Delayed graft function (DGF) is an early posttransplant complication predictive of adverse outcomes. This "acute kidney injury of transplantation" is often defined as allograft dysfunction requiring renal replacement within 7 d posttransplantation. DGF is an important area of study because it is emerging with efforts to expand the donor pool and address the supply-demand gap in kidney transplantation. DGF is often caused by severe kidney injury mechanisms because of multiple donors, recipients, and immunologic factors. The role of kidney biopsy, particularly in prolonged DGF, is an ongoing area of research and inquiry for clinicians and researchers alike to better define, manage, and predict outcomes of this early posttransplant event. This review aims to provide an in-depth, comprehensive summary of the literature to date on the histopathology of DGF and the role of kidney transplant biopsies in prolonged DGF.

Exploring the nexus: The place of kidney diseases within the cardiovascular-kidney-metabolic syndrome spectrum

Cardiovascular-kidney-metabolic (CKM) syndrome and chronic kidney disease (CKD) are two significant comorbidities affecting a large proportion of the general population with considerable crosstalk. In addition to substantial co-incidence of CKD and CKM syndrome in epidemiological studies, clinical and pre-clinical studies have identified similar pathophysiological pathways leading to both entities. Patients with CKM syndrome are more prone to develop acute kidney injury and CKD, while therapeutic alternatives and their success rates are considerably lower in such patient groups. Nevertheless, the association between CKM syndrome and CKD or ESKD is bidirectional rather than being a cause-effect relationship as patients with CKD are also prone to develop peripheral insulin resistance, high blood pressure, and dyslipidemia. Furthermore, such patients are less likely to receive kidney transplantation in addition to the higher allograft dysfunction risk. We hereby aim to evaluate the association in-between kidney diseases and CKM syndrome, including epidemiological data, pre-clinical studies with pathophysiological pathways, and potential therapeutic perspectives.

Dialysis Duration, Time Interaction, and Visceral Fat Accumulation: A 6-Year Posttransplantation Study

BACKGROUND

Kidney transplantation (KT) leads to body composition change, particularly increasing the fat mass. However, limited researches have focused on the long-term follow-up of these changes and factors influencing body composition after KT.

METHODS

This study evaluated body composition in 31 adult KT recipients, measuring body mass index (BMI), the psoas muscle mass index (PMI) representing muscle mass, visceral and subcutaneous adipose tissue (VAT and SAT) representing fat mass, and skeletal muscle radiodensity (SMR) representing muscle quality before KT and at 2, 4, and 6 years posttransplantation using computed tomography. Linear mixed models (LMM) analyzed temporal changes and contributing factors, while growth curve models assessed influence of these factors on body composition changes posttransplantation.

RESULTS

Following KT, BMI, and PMI remained stable, while SAT increased significantly, revealing a 1.30-fold increase from baseline 2 years after transplantation. Similarly, a substantial increase in VAT was observed, with a 1.47-fold increase from baseline 2 years after transplantation with a further 1.75-fold increase 6 years after transplantation. In contrast, SMR decreased with a 0.86-fold decrease from baseline after 2 years. VAT increase was significantly influenced by the interaction between posttransplantation and dialysis duration. Growth curve models confirmed this interaction effect persistently influenced VAT increase posttransplantation.

CONCLUSIONS

The study revealed that KT promoted significant alterations in body composition characterized by increase in the VAT and SAT and a decline in SMR. Notably, dialysis duration and its interaction with posttransplantation duration emerged as significant factors influencing VAT increase.

The Second International Consensus Guidelines on the Management of BK Polyomavirus in Kidney Transplantation

BK polyomavirus (BKPyV) remains a significant challenge after kidney transplantation. International experts reviewed current evidence and updated recommendations according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Risk factors for BKPyV-DNAemia and biopsy-proven BKPyV-nephropathy include recipient older age, male sex, donor BKPyV-viruria, BKPyV-seropositive donor/-seronegative recipient, tacrolimus, acute rejection, and higher steroid exposure. To facilitate early intervention with limited allograft damage, all kidney transplant recipients should be screened monthly for plasma BKPyV-DNAemia loads until month 9, then every 3 mo until 2 y posttransplant (3 y for children). In resource-limited settings, urine cytology screening at similar time points can exclude BKPyV-nephropathy, and testing for plasma BKPyV-DNAemia when decoy cells are detectable. For patients with BKPyV-DNAemia loads persisting >1000 copies/mL, or exceeding 10 000 copies/mL (or equivalent), or with biopsy-proven BKPyV-nephropathy, immunosuppression should be reduced according to predefined steps targeting antiproliferative drugs, calcineurin inhibitors, or both. In adults without graft dysfunction, kidney allograft biopsy is not required unless the immunological risk is high. For children with persisting BKPyV-DNAemia, allograft biopsy may be considered even without graft dysfunction. Allograft biopsies should be interpreted in the context of all clinical and laboratory findings, including plasma BKPyV-DNAemia. Immunohistochemistry is preferred for diagnosing biopsy-proven BKPyV-nephropathy. Routine screening using the proposed strategies is cost-effective, improves clinical outcomes and quality of life. Kidney retransplantation subsequent to BKPyV-nephropathy is feasible in otherwise eligible recipients if BKPyV-DNAemia is undetectable; routine graft nephrectomy is not recommended. Current studies do not support the usage of leflunomide, cidofovir, quinolones, or IVIGs. Patients considered for experimental treatments (antivirals, vaccines, neutralizing antibodies, and adoptive T cells) should be enrolled in clinical trials.

Current Perspectives on Endourological Ex Vivo Stone Interventions in Kidney Transplantation: A Systematic Review

OBJECTIVE

To conduct a systematic review (SR) of literature to assess the existing evidence concerning the success and complications of endourological ex vivo stone surgeries.

METHODS

Eligible studies for inclusion focused on investigating the success and/or complications related to endourological ex vivo surgeries in donors with nephrolithiasis. A SR was undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search included databases of Web of Science, PubMed, and Scopus and only article in English were included. Studies published between 2002 and 2023 included in this SR.

RESULTS

After screening 1726 abstracts, this SR included 16 studies with a total of 209 patients. The mean stone size was 5.6 mm and majority of kidneys contained single stones, located in the lower calyx. After ex vivo endourological stone surgeries, the average stone-free rate was found to be 95.4%. The mean duration of ex vivo surgery was 17.3 minutes. Regarding intraoperative complications, two patients (1%) experienced mucosal injuries during pneumatic lithotripsy. As for postoperative complications, two patients (1%) experienced vascular complications. In terms of urological complications, hematuria was observed in 24 patients (11.5%), while one patient (0.5%) experienced clot formation in renal pelvis. Seven patients (3.3%) had urinary tract infections, and three patients (1.4%) developed urolithiasis during the follow-up. Additionally, one patient (0.5%) experienced complete occlusion of ureteroneocystostomy and required revision.

CONCLUSION

Given the advancements in current technology and techniques, endourological ex vivo stone surgeries are increasingly recognized as an effective and safe option for donors with nephrolithiasis.

TRIAL REGISTRATION

This systematic review was registered under the protocol registration number CRD42024538384/PROSPERO.

The use of denosumab in osteoporosis - an update on efficacy and drug safety

INTRODUCTION

Denosumab (Prolia) is a fully human monoclonal antibody against the receptor activator of the nuclear factor kappaB ligand. It is a potent antiresorptive agent that reduces osteoclastogenesis.

AREAS COVERED

Denosumab has been shown to improve bone mineral density and reduce the incidence of new fractures in postmenopausal women and men. It is also used in the treatment of glucocorticoid-induced osteoporosis, as well as for the prevention of bone loss and reduction of fracture risk in men receiving androgen deprivation therapy for non-metastatic prostate cancer and women receiving adjuvant aromatase inhibitor therapy for breast cancer. Initial safety concerns included infections, cancer, skin reactions, cardiovascular disease, hypocalcemia, osteonecrosis of the jaw, and atypical femur fractures; however, further study and experience provide reassurance on these issues. Anecdotal reports have raised concerns about an increased risk of multiple vertebral fractures following discontinuation of denosumab.

EXPERT OPINION

Although bisphosphonates are often selected as initial therapy for osteoporosis, denosumab may be an appropriate initial therapy in patients at high risk for fracture, including older patients who have difficulty with the dosing requirements of oral bisphosphonates, as well as patients who are intolerant of, unresponsive to, or have contraindications to other therapies. Additional data is needed to address questions regarding treatment duration and discontinuation.

Report on post-transplantation cancer in southeast Asia from the Thai kidney transplantation cohort

Post-transplantation cancer is a significant cause of mortality among kidney transplant recipients (KTR). The incidence of post-transplantation cancer varies based on geographic region and ethnicity. However, data on KTR from South East Asia, where characteristics differ from other parts of Asia, is lacking. We conducted a retrospective cohort study at a transplant center in Thailand to investigate the incidence of post-transplantation cancer and mortality rates. Factors associated with post-transplantation cancer and patient outcomes were analyzed using competing-risks regression. The study included 1156 KTR with a post-transplant follow-up duration of 5.1 (2.7-9.4) years. The age- and sex-adjusted incidence rate of post-transplant cancer was highest for urothelial cancer (6.9 per 1000 person-years), which also resulted in the highest standardized incidence ratio (SIR) of 42.5 when compared to the general population. Kidney cancer had the second-highest SIR of 24.4. Increasing age was the factor associated with an increased risk of post-transplant cancer (SHR 1.03; 95% CI 1.01-1.05). Human leukocyte antigen (HLA) DR mismatch was associated with a decreased risk of post-transplant cancer (SHR 0.72; 95% CI 0.52-0.98). Post-transplantation cancer was significantly associated with patient mortality (HR 3.16; 95% CI 2.21-4.52). Cancer significantly contributes to KTR mortality, and the risk profile for cancer development in Thai KTRs differs from that of Western and most Asian counterparts. Further research is essential to explore appropriate screening protocols for countries with high rates of urothelial and kidney cancer, including Thailand.

Post-Kidney Transplant Cancer: A Real-World Retrospective Analysis From a Single Italian Center

We describe the epidemiology of cancer after kidney transplantation (KTx), investigating its risk factors and impact on therapeutic management and survival in KTx recipients (KTRs). The association between modification of immunosuppressive (IS) therapy after cancer and survival outcomes was analyzed. We collected data from 930 KTRs followed for 7 [1-19] years. The majority of KTRs received KTx from a deceased donor (84%). In total, 74% of patients received induction therapy with basiliximab and 26% with ATG. Maintenance therapy included steroids, calcineurin inhibitors, and mycophenolate. Patients with at least one cancer (CA+) amounted to 19%. NMSC was the most common tumor (55%). CA+ were older and had a higher BMI. Vasculitis and ADPKD were more prevalent in CA+. ATG was independently associated with CA+ and was related to earlier cancer development in survival and competing risk analyses (p = 0.01 and <0.0001; basiliximab 89 ± 4 vs. ATG 40 ± 4 months). After cancer diagnosis, a significant prognostic impact was derived from the shift to mTOR inhibitors compared to a definitive IS drug suspension (p = 0.004). Our data confirm the relevance of cancer as a complication in KTRs with ATG as an independent risk factor. An individualized choice of IS to be proposed at the time of KTx is crucial in the prevention of neoplastic risk. Finally, switching to mTORi could represent an important strategy to improve patient survival.

Senescence in Adipose-Derived Stem Cells: Biological Mechanisms and Therapeutic Challenges

Adipose tissue-derived stem cells (ADSCs) represent a subset of the mesenchymal stem cells in every adipose compartment throughout the body. ADSCs can differentiate into various cell types, including chondrocytes, osteocytes, myocytes, and adipocytes. Moreover, they exhibit a notable potential to differentiate in vitro into cells from other germinal lineages, including endothelial cells and neurons. ADSCs have a wide range of clinical applications, from breast surgery to chronic wounds. Furthermore, they are a promising cell population for future tissue-engineering uses. Accumulating evidence indicates a decreased proliferation and differentiation potential of ADSCs with an increasing age, increasing body mass index, diabetes mellitus, metabolic syndrome, or exposure to radiotherapy. Therefore, the recent literature thoroughly investigates this cell population's senescence mechanisms and how they can hinder its possible therapeutic applications. This review will discuss the biological mechanisms and the physio-pathological causes behind ADSC senescence and how they can impact cellular functionality. Moreover, we will examine the possible strategies to invert these processes, re-establishing the full regenerative potential of this progenitor population.

Normalization of impaired glucose tolerance after kidney transplantation is associated with improved β-cell function

Our previous study revealed that over 50% of recipients with pretransplant impaired glucose tolerance (IGT) improved to normal glucose tolerance after kidney transplantation. However, the mechanism is unclear. We aimed to investigate whether the changes in glucose tolerance are associated with β-cell function and insulin resistance in Japanese kidney transplant recipients with pretransplant IGT. Of the 265 recipients who received kidney transplantation, 54 with pretransplant IGT were included. We divided the recipients into improvement and nonimprovement groups according to the change in the area under the curve for glucose obtained from the oral glucose tolerance test (OGTT). β-Cell function was estimated by the insulin secretion sensitivity index-2 (ISSI-2) and the disposition index (DI). Insulin resistance was estimated by the Matsuda index (MI) and the homeostasis model assessment of insulin resistance (HOMA-IR). ISSI-2 and DI increased significantly after transplantation in the improved group (P < 0.01, P < 0.05, respectively), but not in the nonimproved group. ΔISSI-2 and ΔDI were significantly and positively associated with pretransplant 60-min OGTT plasma glucose levels (both P < 0.01). There were no differences in MI or HOMA-IR between these two groups after transplantation. In recipients not on pretransplant dialysis, a significant negative association was found between Δblood urea nitrogen (BUN) and ΔDI (correlation coefficient = -0.48, P < 0.05). In pretransplant IGT recipients, improvements in glucose tolerance after kidney transplantation were linked to improvements in β-cell function. The higher the 60-min OGTT plasma glucose level, the greater the improvement in posttransplant β-cell function. Improvements in BUN after transplantation were associated with improvements in β-cell function.NEW & NOTEWORTHY In recipients with pretransplant impaired glucose tolerance, improvements in glucose tolerance after kidney transplantation were associated with improvements in β-cell function. The higher the pretransplant 60-min OGTT plasma glucose level, the greater the improvement in posttransplant β-cell function. Although glucose tolerance is known to be impaired after transplantation, the present study focused on the reason for the improvement in glucose tolerance rather than the development of posttransplantation diabetes mellitus.

Skin cancer in renal transplant recipients: outcomes from a safety net hospital in Boston

BACKGROUND

Renal transplant recipients (RTRs) are prone to skin cancer due to the immunosuppression required to maintain graft function. Existing studies of skin cancer in RTRs focus on patients with Fitzpatrick skin types I-II, with limited documentation of incidence in skin types III-VI. This study seeks to better characterize skin cancers in RTRs with skin types III-VI.

PRIMARY AIMS

Compare the incidence of skin cancer in RTRs of skin types I-II with skin types III-VI.

SECONDARY AIMS

Explore the association between the development of skin cancer and other contributing factors in RTRs of skin types I-VI.

METHODS

Retrospective chart review of RTRs at a single institution between January 1, 2000 and December 31, 2022. Patients were followed from the date of transplant to the last clinical follow-up or death. 777 RTRs were included in the study, including 245 patients with Fitzpatrick skin types I-II and 532 with skin types III-VI. A total of 48 patients developed NMSCs, 2 patients developed melanoma, and 3 patients developed Kaposi sarcoma.

RESULTS AND CONCLUSIONS

There is a higher incidence of skin cancer in RTRs with Fitzpatrick skin types III-VI compared to the reported incidence among non-transplant recipients of the same skin types, but the incidence remains considerably lower compared to RTR of skin types I-II.

Bortezomib for antibody-mediated rejection of kidney transplant in youth: Associations with donor-specific antibody

BACKGROUND

Antibody-mediated rejection is one of the most significant risk factors for allograft dysfunction and failure in children and adolescents with kidney transplants, yet optimal treatment remains unidentified. To date, there are mixed findings regarding the use of Bortezomib, a plasma cell apoptosis inducer, as an adjunct therapy in the treatment of antibody-mediated rejection.

METHODS

In a retrospective single center study, we reviewed the efficacy and tolerability of bortezomib as adjunct therapy for treatment-refractory antibody-mediated rejection.

RESULTS

Six patients with a median age of 14.6 years (range 6.9-20.1 years) received bortezomib at a mean of 71 months (range 15-83 months) post-kidney transplant. Four patients experienced decline in estimated glomerular filtration rate (eGFR) from 4% to 42%. One patient started bortezomib while on hemodialysis and did not recover graft function, and another patient progressed to hemodialysis 6 months after receiving bortezomib. Although DSA did not completely resolve, there was a statistically significant decline in DSA MFI pre and 12-months post-BZ (p = .012, paired t-test) for the subjects who were not on dialysis at the time of bortezomib. Chronic Allograft Damage Index (CADI) score of ≥3 was seen in all six subjects at their biopsy prior to therapy. No adverse effects were reported.

CONCLUSIONS

Bortezomib was well tolerated and resulted in improvements in MFI of DSA among four pediatric subjects without allograft failure, although no effects were observed on eGFR trajectory. Further studies are needed to clarify whether earlier intervention with bortezomib could prevent renal failure progression.

Atypical Presentation of Multiple Myeloma Affecting Appendicular Skeleton Associated with Pathological Neck of Femur and Proximal Humerus Fractures - A Case Report

Introduction

The increasing incidence of atraumatic neck of femur (NOF) fractures, often linked to age-related bone weakening, is a notable clinical trend. This case report highlights a 72-year-old male presenting with NOF and proximal humerus fractures post-trivial fall, revealing lytic lesions suggestive of multiple myeloma (MM). Despite inconclusive skeletal and metabolic evaluations, a comprehensive surgical approach confirmed MM, emphasizing the importance of thorough diagnostic and therapeutic management in complex cases.

Case Report

A 72-year-old male presented with a trivial fall resulting in hip and shoulder trauma, revealing right transcervical NOF and proximal humerus fractures on X-rays, alongside multiple lytic lesions suggesting MM. Despite inconclusive metabolic evaluations, conservative management was pursued for the humerus fracture, while a complex surgical approach involving curettage and cemented bipolar hemiarthroplasty was undertaken for the femur fracture, confirming MM on histopathology.

Conclusion

Evaluating atypical MM manifestations in the appendicular skeleton requires comprehensive assessment and diagnostic procedures to influence outcomes and improve quality of life. Managing suspected pathological fractures involves detailed evaluation and surgical planning, highlighting the importance of collaboration among different specialties.

Renal cell carcinoma in a transplanted kidney: a retrospective evaluation

INTRODUCTION

Kidney transplantation is the optimal treatment modality for patients with end-stage chronic kidney disease. The long-term mortality of kidney recipients is 48-82% lower than that of patients on the waiting list. However, the risk of developing malignancies in these patients is twice as high as in the healthy population. Specifically, the incidence of renal cell carcinoma (RCC) in transplant recipients is 10-30 times higher than in non-transplanted patients. The reason for the increased risk is poorly understood, but is most likely related to continuous immunosuppressive therapy. The problem of kidney graft neoplasia has not been adequately addressed in the medical literature.

OBJECTIVE

To determine the incidence of renal cell carcinoma in transplanted kidneys, enhance the efficacy of its treatment, and study the etiology of RCC development.

MATERIALS AND METHODS

A retrospective analysis of RCC incidence in kidney grafts was conducted in 3,270 patients who underwent kidney transplantation between 2013 and 2023. We evaluated the effectiveness of surgical interventions for these complications. Patients with histologically confirmed RCC of the transplanted kidney underwent genetic study to determine the etiology of the neoplasm.

RESULTS

The incidence of RCC in transplanted kidneys was found to be 0.95% (n = 31), 28 patients underwent laparoscopic resection of the renal transplant tumor, 2 patients were treated with radiofrequency ablation of the tumor. Transplantectomy was performed in 1 patient.

CONCLUSION

Laparoscopic resection is an effective and safe method for the treatment of RCC in kidney transplants. Transplanted kidney cancer originates from the donor tissue. The clear cell variant of transplanted kidney cancer is a genetically determined disease.

Managing Post-Transplant Diabetes Mellitus after Kidney Transplantation: Challenges and Advances in Treatment

Kidney transplantation is the most effective treatment for end-stage renal failure but is associated with complications, including post-transplant diabetes mellitus (PTDM). It affects the quality of life and survival of patients and the transplanted organ. It can cause complications, including infections and episodes of acute rejection, further threatening graft survival. The prevalence of PTDM, depending on the source, can range from 4 to 30% in transplant patients. This article aims to discuss issues related to diabetes in kidney transplant patients and the latest treatments. Knowledge of the mechanisms of action of immunosuppressive drugs used after transplantation and their effect on carbohydrate metabolism is key to the rapid and effective detection of PTDM. Patient therapy should not only include standard management such as lifestyle modification, insulin therapy or pharmacotherapy based on well-known oral and injection drugs. New opportunities are offered by hypoglycemic drugs still in clinical trials, including glucokinase activators, such as dorzagliatin, ADV-1002401, LY2608204, TMG-123, imeglimine, amycretin and pramlintide. Although many therapeutic options are currently available, PTDM often creates uncertainty about the most appropriate treatment strategy. Therefore, more research is needed to individualize therapeutic plans and monitor these patients.

Comprehensive Approaches to Urolithiasis in Renal Transplants: A Narrative Review

This review addresses the management of urolithiasis in renal transplant recipients, a notably vulnerable group due to the unique anatomical and physiological alterations of the transplanted organ. The prevalence of nephrolithiasis in these patients varies between 0.1% and 6.3%, with a significant impact on graft longevity and function. Surgical access complications due to the renal graft's position on the iliac vessels and the variety of urinary anastomoses complicate the treatment approaches. This study evaluates the effectiveness and outcomes of percutaneous nephrolithotomy (PCNL) and ureteroscopy (URS), two primary minimally invasive strategies for managing graft stones. Through a narrative review using the PubMed and EMBASE databases, it was found that PCNL offers high stone-free rates especially beneficial for large stones, whereas URS provides a less invasive option with a lower risk of complications for small stones. Both techniques require tailored approaches based on stone composition-mostly calcium oxalate-and specific patient anatomical factors. This review underscores the importance of early diagnosis, appropriate treatment selection, and continuous post-treatment monitoring to mitigate risks and promote long-term renal function in transplant recipients.

The risk of solid organ tumors in patients with chronic kidney disease: A narrative review of literature

Chronic kidney disease (CKD) has been correlated with certain pathological conditions such as cardiovascular diseases and other renal-related dysfunctions. Some other reports suggested an association between CKD and the development of certain solid cancers. Therefore, we aimed to generate this narrative review to present the available literature on the risk of solid cancer development in CKD patient populations. We explored the associations between CKD, organ transplantation, and the development of specific solid organ tumors such as kidney, thyroid, lung, breast, bladder, gastric, and prostate cancers. In conclusion, the previous reports showed an increase in the risk of certain solid cancers such as kidney, lung, bladder, and possibly breast cancer in CKD patients and transplant recipients. On the other hand, thyroid, gastric, and prostate cancers showed unclear association with CKD. Despite the suggested impact of smoking and immunosuppression on the development of cancers in CKD patients, more studies are needed to elucidate the mechanism and the risk factors that might be related to the development of cancer in CKD patients.

Anterior quadratus lumborum block provided superior pain control and reduced opioid consumption in kidney transplantation: A randomized controlled trial

BACKGROUND

The research aimed to assess the effectiveness of inside-out anterior quadratus lumborum (QL3) block and local wound infiltration in managing postoperative pain and total morphine dosage following kidney transplantation.

METHODS

In this prospective, randomized, double-blind study; 46 end-stage renal disease patients undergoing kidney transplantation were randomly allocated into 2 groups: a QL group (n = 23) receiving 20 mL of 0.25% bupivacaine using the ultrasound-assisted inside-out technique before wound closure, while the local wound infiltration (LA) group (n = 23) receiving the same dose around the surgical wound and drain at the time of skin closure. The primary outcome measure was the numerical pain rating scale, with secondary outcomes including amount of morphine consumption at various postoperative time points (2nd, 4th, 6th, 12th, 18th and 24th hours).

RESULTS

Patients in the QL group had significantly lower numerical rating scale scores at the 2nd and 4th hours, both at rest and during movement (P < .05). Although pain scores at rest and during movement at later time points were lower in the QL group compared to the LA group, these differences were not statistically significant. Cumulative morphine consumption at postoperative 4th, 6th, 12th, 18th and 24th hours was significantly lower in the QL group (P < .05). No patients experienced complications from the QL3 block.

CONCLUSION

Ultrasound-assisted inside-out QL3 block significantly reduced postoperative pain levels at the 2nd and 4th hours, both at rest and during movement, and led to a reduction in cumulative morphine consumption from the 4th hour postoperatively, and persisting throughout the 24-hour period.