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Kneifel M, Scholze A, Burkert A, Offermann G, Rothermund L, Zidek W, Tepel M. Impaired renal allograft function is associated with increased arterial stiffness in renal transplant recipients. Am J Transplant 2006; 6:1624-30. [PMID: 16827863 DOI: 10.1111/j.1600-6143.2006.01341.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
It is important whether impairment of renal allograft function may deteriorate arterial stiffness in renal transplant recipients. In a cross-sectional study, arterial vascular characteristics were non-invasively determined in 48 patients with renal allograft using applanation tonometry and digital photoplethysmography. Mean age was 51 +/- 2 years (mean +/- SEM), and studies were performed 17 +/- 1 months after transplantation. The stage of chronic kidney disease was based on the glomerular filtration rate. We observed a significant association between the stage of chronic kidney disease and arterial stiffness of large arteries S1 and small arteries S2 in renal transplant recipients (each p < 0.05 by non-parametric Kruskal-Wallis test between groups). Multivariate linear regression analysis showed that male gender of patients with renal allograft (p < 0.01) reduced glomerular filtration rate (p = 0.01), and older age of kidney donor (p = 0.04) were independently associated with an increase of large artery stiffness S1. Furthermore, a significant association between the stage of chronic kidney disease and arterial vascular reactivity during reactive hyperemia was observed (p < 0.05 by non-parametric Kruskal-Wallis test between groups). It is concluded that impairment of renal allograft function is associated with an increased arterial stiffness in renal transplant recipients.
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Affiliation(s)
- M Kneifel
- Charité Campus Benjamin Franklin, Berlin, Germany
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52
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Abstract
The paradigm that chronic rejection causes all progressive late allograft failure has been replaced by a hypothesis of cumulative damage, where a series of time-dependent immune and nonimmune mechanisms injure the kidney and lead to chronic interstitial fibrosis and tubular atrophy, representing a final common pathway of injury and its consequent fibrotic healing response. Allograft damage is common, progressive, time-dependent, clinically important and modified by immunosuppression. Early after transplantation, tubulointerstitial damage is predominantly related to ischemia reperfusion injury, acute tubular necrosis, acute and subclinical rejection and/or calcineurin inhibitor nephrotoxicity, superimposed on preexisting donor disease. Later, cellular inflammation lessens and is replaced by microvascular and glomerular injury from calcineurin inhibitor nephrotoxicity, hypertension, immune-mediated fibrointimal vascular hyperplasia, transplant glomerulopathy and capillary injury, polyoma virus and/or recurrent glomerulonephritis. Additional mechanisms of injury include internal architectural disruption of the kidney, cortical ischemia, persistent chronic inflammation, replicative senescence, cytokine excess and fibrosis induced by epithelial-to-mesenchymal transition. Current understanding of the etiology, pathophysiology and evolution of pathological changes are detailed. An approach to histological assessment of the individual failing graft are presented and a series of postulates are defined for future studies of chronic allograft nephropathy.
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Affiliation(s)
- Brian J Nankivell
- Department of Renal Medicine, University of Sydney, Westmead Hospital, Sydney, Australia.
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53
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Rowshani AT, Scholten EM, Bemelman F, Eikmans M, Idu M, Roos-van Groningen MC, van Groningen MCR, Surachno JS, Mallat MJK, Paul LC, de Fijter JW, Bajema IM, ten Berge I, Florquin S. No difference in degree of interstitial Sirius red-stained area in serial biopsies from area under concentration-over-time curves-guided cyclosporine versus tacrolimus-treated renal transplant recipients at one year. J Am Soc Nephrol 2005; 17:305-12. [PMID: 16306168 DOI: 10.1681/asn.2005030249] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Interstitial fibrosis is the main characteristic of chronic allograft nephropathy and long-term graft failure. Cyclosporin (CsA) is thought to be more fibrogenic than tacrolimus. In a prospective, randomized, multicenter trial using a calcineurin-sparing regimen, renal interstitial volume was compared in CsA- and tacrolimus-treated renal transplant recipients by image analysis of Sirius red (SR)-stained cortical areas in protocol biopsies obtained at 6 mo (n = 94) and 12 mo (n = 97) after transplantation. Immunosuppression consisted of CsA or tacrolimus, CD25 mAb, mycophenolate mofetil, and prednisolone. CsA therapy increased the 6-mo risk for subclinical rejection. The prevalence of subclinical rejection was 38.8% in the CsA-treated and 15.2% in the tacrolimus-treated patient group (P = 0.012). Strikingly, no difference in the degree of interstitial SR-stained area was detectable between the two treatment groups. In particular, previous subclinical rejection episodes did not influence the degree of interstitial volume. Also, no difference in GFR occurred at 1 yr, when the mean GFR mounted 63 ml/min. No significant differences in the degree of interstitial SR-stained area could be observed at 6 and 12 mo between CsA- and tacrolimus-treated renal transplant recipients. Although CsA-treated patients developed significantly more subclinical rejections at 6 mo, this did not influence the degree of SR staining or the change in renal function at 1 yr.
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Affiliation(s)
- Ajda T Rowshani
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands.
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Veronese FV, Manfro RC, Roman FR, Edelweiss MI, Rush DN, Dancea S, Goldberg J, Gonçalves LF. Reproducibility of the Banff classification in subclinical kidney transplant rejection. Clin Transplant 2005; 19:518-21. [PMID: 16008598 DOI: 10.1111/j.1399-0012.2005.00377.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The Banff classification for kidney allograft pathology has proved to be reproducible, but its inter and intraobserver agreement can vary substantially among centres. The aim of this study was to evaluate Banff reproducibility of surveillance renal allograft biopsies among renal pathologists from different transplant centres. This study included 32 renal transplant patients with stable graft function. Biopsies were performed 2 and 12 months post-transplant. Histology was interpreted according to the Banff schema by three renal pathologists, and inter and intraobserver agreement were measured. The best reproducibility was obtained for the presence or absence of acute rejection (AR), with kappa values ranging from moderate (kappa = 0.47; p = 0.006) to good (kappa = 0.72; p = 0.0001). However, the agreement for 'suspicious for AR' category was poor between all observers. For scoring and grading interstitial inflammation and intimal arteritis the agreement were poor and moderate, respectively. Reproducibility for the presence or absence of chronic allograft nephropathy (CAN) was heterogeneous, ranging from poor (kappa = 0.13; p = NS) to moderate (kappa = 0.56; p = 0.007). Scoring chronic changes such as fibrous intimal thickening gave a reasonable interobserver agreement. Intraobserver reproducibility was good for presence or absence of AR, but was poor for the diagnosis of CAN. In conclusion, histologic analysis of stable renal allografts based on Banff criteria showed a good agreement for the diagnosis of AR and a reasonable kappa for CAN, but reproducibility for scoring and grading showed a substantial interobserver variation.
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Affiliation(s)
- Francisco Veríssimo Veronese
- Renal Division, Hospital de Clínicas de Porto Alegre and Post-Graduation Nephrology Program, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
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55
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Rush D. Protocol Transplant Biopsies: An Underutilized Tool in Kidney Transplantation. Clin J Am Soc Nephrol 2005; 1:138-43. [PMID: 17699200 DOI: 10.2215/cjn.00390705] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- David Rush
- University of Manitoba and Manitoba Adult Renal Transplant Program, Winnipeg, Manitoba, Canada.
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56
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Abstract
Studies suggest that surveillance or protocol biopsies that are performed during the first year after kidney transplantation may be clinically useful in identifying early acute rejection or chronic allograft nephropathy at a point when they may be amenable to treatment. Although the benefit of this approach has yet to be evaluated in large, multicenter, prospective trials, numerous studies suggest that implementation of protocol biopsies may improve long-term graft function. In particular, a number of reports suggest that detection of chronic allograft nephropathy in early protocol biopsies is predictive of subsequent graft function and loss and that early treatment may have a dramatic effect on the outcome of the graft. Protocol biopsies also have the potential to be of great value in high-risk patients, such as those with delayed graft function, by allowing for early intervention for acute rejection. Furthermore, the procedure seems to be relatively straightforward and safe. Nevertheless, paucity of data has meant that clear proof of a benefit of early treatment of subclinical rejection and chronic allograft nephropathy detected by protocol biopsy is lacking. Moreover, the optimal timing of protocol biopsies and reliable methods to quantify the histologic changes observed in biopsy specimens have yet to be determined. This review discusses the pros and cons of protocol biopsies and considers the place of this procedure in the routine treatment of kidney transplant patients.
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Affiliation(s)
- Alan Wilkinson
- David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1693, USA.
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57
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Racusen LC. Protocol Transplant Biopsies in Kidney Allografts: Why and When Are They Indicated?: Table 1. Clin J Am Soc Nephrol 2005; 1:144-7. [PMID: 17699201 DOI: 10.2215/cjn.01010905] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Lorraine C Racusen
- The Johns Hopkins University School of Medicine, Department of Pathology, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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58
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Cosio FG, Grande JP, Wadei H, Larson TS, Griffin MD, Stegall MD. Predicting subsequent decline in kidney allograft function from early surveillance biopsies. Am J Transplant 2005; 5:2464-72. [PMID: 16162196 DOI: 10.1111/j.1600-6143.2005.01050.x] [Citation(s) in RCA: 264] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Identifying factors that are predictive of allograft loss might be an important step toward prolonging kidney allograft survival. In this study we sought to determine the association between histologic changes on 1-year surveillance biopsies, changes in graft function and survival. This analysis included 292 adults, recipients of kidneys from living donors (69%) or deceased donors (31%), transplanted between 1998 and 2001 and followed up for 46 +/- 14 months. The primary end point was death-censored graft loss or a >50% reduction in GFR beyond 1 year. One-year biopsies were classified as: (i) Normal (N = 87, 30%), (ii) inflammation (N = 6, 2%), (iii) fibrosis (N = 131, 45%), (iv) fibrosis and inflammation (N = 53, 18%) and (v) transplant glomerulopathy (N = 15, 5%). By multivariate Cox analysis, survival related to biopsy classification (HR = 4.2, p = 0.001), graft function (HR = 0.97, p = 0.001) and HLA mismatches (HR = 1.003, p = 0.004). Using normal histology as a reference, fibrosis and inflammation (HR = 8.5, p < 0.0001) and glomerulopathy (HR = 10, p < 0.0001) related to poorer survival but mild fibrosis alone did not. Importantly, the degree of inflammation associated with fibrosis generally did not qualify for the diagnosis of borderline rejection. In conclusion, inflammation and glomerulopathy 1 year post-transplant predict loss of graft function and graft failure independently of function and other variables.
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Affiliation(s)
- Fernando G Cosio
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic and Foundation, Rochester, Minnnesota, USA.
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59
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Schwarz A, Mengel M, Gwinner W, Radermacher J, Hiss M, Kreipe H, Haller H. Risk factors for chronic allograft nephropathy after renal transplantation: a protocol biopsy study. Kidney Int 2005; 67:341-8. [PMID: 15610260 DOI: 10.1111/j.1523-1755.2005.00087.x] [Citation(s) in RCA: 148] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Chronic allograft nephropathy (CAN) leads to chronic allograft dysfunction and loss. Regular renal transplant biopsies may be useful to find risk factors for CAN. METHODS We carried out 688 protocol biopsies in 258 patients at 6, 12, and 26 weeks after renal transplantation. Patients with signs of CAN in the biopsy 3 (N= 70, CAN group), and those without (N= 120, non-CAN group), were compared. RESULTS Chronic tubulointerstitial changes increased from biopsy 1 to 3 (5% vs. 37%, P < 0.0001). Fifty-six of 190 patients had acute rejection within 6 months (30%), 33 of which were found in protocol biopsies (17%). On univariate analysis, the CAN group had CAN more often at biopsy 2 than the non-CAN group (23% vs. 4%, P < 0.0001), had a lower calculated creatinine clearance at biopsy 1 and 2 (49.4 +/- 25.8 vs. 57 +/- 20.2 mL/min, P= 0.01; 47.3 +/- 21.2 vs. 57.9 +/- 19.5 mL/min, P= 0.001, respectively), had a living donor less often than a brain dead donor (7% vs. 18%, P= 0.045), had a longer cold ischemia time (17.4 +/- 7 vs. 14.9 +/- 8.1 hours, P= 0.04), and had arterionephrosclerosis more often (24% vs. 12%, P= 0.02). On multivariate analysis, the differences in CAN at biopsy 2 (P= 0.001) and lower GFR at biopsy 2 (P= 0.002) were confirmed; in addition, nephrocalcinosis (P= 0.006) and acute rejection (P= 0.046) were found to occur more often. CONCLUSION Chronic tubulointerstitial changes develop early after renal transplantation and are associated with reduced kidney function. Risk factors for CAN are arterionephrosclerosis (donor-related), nephrocalcinosis (related to preexisting hyperparathyroidism), a long cold-ischemia time (ischemia-perfusion-related), and acute rejection. Renal functional decline precedes morphologic changes of CAN, expressed as tubular atrophy and interstitial fibrosis.
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Affiliation(s)
- Anke Schwarz
- Department of Nephrology; and Department of Pathology, Hannover Medical School, Hannover, Germany.
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60
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Cosio FG, Grande JP, Larson TS, Gloor JM, Velosa JA, Textor SC, Griffin MD, Stegall MD. Kidney allograft fibrosis and atrophy early after living donor transplantation. Am J Transplant 2005; 5:1130-6. [PMID: 15816896 DOI: 10.1111/j.1600-6143.2005.00811.x] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Kidney allograft failure is most often caused by chronic allograft nephropathy, a process of interstitial fibrosis (GIF) and tubular atrophy (TA). We assessed the pathology of living donor (LD) grafts compared to deceased donor (DD). Included are 321 recipients (245 LD; 76 DD) with protocol biopsies the first 2 years of transplant. In LD, GIF was present in 7%, 31%, 61% and 71% of grafts at 0, 4, 12 and 24 months. TA progressed in parallel to GIF. Compared to LD, more DD grafts had GIF at time 0 (29%, p = 0.002); thereafter the incidence of GIF was similar. In LD, GIF was associated with lower glomerular filtration rate (GFR)(1 year) (no GIF, 62 +/- 16; GIF, 49 +/- 15 mL/min/m(2) iothalamate clearance, p = 0.001) and reduced graft survival (HR = 2.2, p = 0.009). GIF in LD related to acute rejection (HR = 2.6, p = 0.01), polyoma nephropathy (OR = 4.4, p = 0.02) and lower levels of GFR 3 weeks post-transplant (HR = 0.961; p = 0.03, multivariate). However, GIF also developed in 53% of recipients lacking these covariates. Thus, GIF/TA develops in the majority of LD grafts, it is often mild but is associated with reduced function and survival. GIF frequently develops in the absence of risk factors. Lower GFR post-transplant identify patients at highest risk of GIF.
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Affiliation(s)
- Fernando G Cosio
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic and Foundation, Rochester, Minnesota, USA.
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61
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Laftavi MR, Stephan R, Stefanick B, Kohli R, Dagher F, Applegate M, O'Keefe J, Pierce D, Rubino A, Guzowski H, Leca N, Dayton M, Pankewycz O. Randomized prospective trial of early steroid withdrawal compared with low-dose steroids in renal transplant recipients using serial protocol biopsies to assess efficacy and safety. Surgery 2005; 137:364-71. [PMID: 15746793 DOI: 10.1016/j.surg.2004.10.013] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Corticosteroid therapy after renal transplantation is associated with many adverse effects. Newer immunosuppressive agents may allow for safe and effective reductions in dose or early steroid withdrawal. METHODS In this prospective, single-center clinical trial, 60 patients were randomized into 2 groups: control patients (n = 28), who received low doses of prednisone throughout, and study patients (n = 32), who were withdrawn from steroids 7 days posttransplant. Patients received a limited course of rabbit antilymphocyte globulin (rALG) induction therapy, tacrolimus (TAC), and mycophenolate mofetil (MMF). Patients were followed for clinical outcomes and renal function. Protocol biopsies were performed at 1, 6, and 12 months. RESULTS Clinical rejections occurred in 11% of controls and 13% of study patients. Renal function was well maintained and equivalent in both groups. In all, 111 protocol biopsies were performed without complications. Subclinical rejection was noted in only 2 protocol biopsies, and borderline changes were seen in 12 biopsies, all of which were distributed equally between both groups. Unsuspected acute TAC toxicity was seen in 8 biopsies. Protocol biopsies led to changes in therapy in 10% of patients. In both groups, serial protocol biopsies demonstrated increased allograft fibrosis over time, which was significant at 1 year in the steroid withdrawal group. CONCLUSION The immunosuppressive combination of rALG, TAC, and MMF prevents subclinical rejection and the need for high doses of steroids after transplantation. However, continual low-dose steroid therapy may aid in preventing chronic allograft fibrosis. Protocol biopsies help define the short-term and long-term risks of steroid withdrawal therapy.
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Affiliation(s)
- Mark R Laftavi
- Departments of Surgery, SUNY-University at Buffalo, Buffalo General Hospital, Buffalo, NY, USA
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62
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Lopes JA, Moreso F, Riera L, Carrera M, Ibernon M, Fulladosa X, Grinyó JM, Serón D. Evaluation of pre-implantation kidney biopsies: Comparison of Banff criteria to a morphometric approach. Kidney Int 2005; 67:1595-600. [PMID: 15780116 DOI: 10.1111/j.1523-1755.2005.00241.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Donor glomerulosclerosis, interstitial fibrosis, and fibrous intimal thickening correlate with graft outcome. We evaluate chronic lesions in donor biopsies according to Banff criteria and with a morphometric technique to ascertain their predictive value on graft outcome. METHODS We evaluated 77 cadaveric donor biopsies according to Banff criteria. Glomerulosclerosis was expressed as the percentage of global sclerotic glomeruli. The following morphometric parameters were obtained: cortical interstitial volume fraction (Vvint/c), cortical glomerular volume fraction (Vvglom/c), mean glomerular volume (Vg), mean and maximal intimal arterial volume fraction (Vvintima/art), and Vvintima/art of the largest artery. We evaluated the correlation of histologic lesions with delayed graft function, 3 months' glomerular filtration rate (GFR), and death-censored graft survival. RESULTS Multivariate logistic regression showed that delayed graft function was associated with cv score [relative risk (RR) 4.2 and 95% CI 1.1 to 16.0) and glomerulosclerosis (RR 1.06 and 95% CI 1.01 to 1.13). Stepwise regression showed that Vvint/c and glomerulosclerosis were independent predictors of 3 months' GFR (R= 0.62, P= 0.0001). Repeated analysis not considering morphometric parameters showed that glomerulosclerosis, cv score and ci score were independent predictors of 3 months' GFR (R= 0.64, P= 0.0001). A donor chronic damage score was generated considering glomerulosclerosis, cv score and ci score. This score after adjusting for clinical variables was associated with 3 months' GFR (R= 0.71, P < 0.0001) and death-censored graft survival (RR 2.2 and 95% CI 1.3 to 3.7). CONCLUSION Combined evaluation of donor glomerulosclerosis, chronic vascular and interstitial damage according to Banff criteria allows a precise prediction of graft outcome. Morphometric evaluation of donor biopsies does not improve the predictive value of semiquantitative grading.
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Affiliation(s)
- José António Lopes
- Department of Nephrology, Hospital Universitari de Bellvitge, Barcelona, Spain
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63
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Tinckam K, Rush D, Hutchinson I, Dembinski I, Pravica V, Jeffery J, Nickerson P. The Relative Importance of Cytokine Gene Polymorphisms in the Development of Early and Late Acute Rejection and Six-Month Renal Allograft Pathology. Transplantation 2005; 79:836-41. [PMID: 15818327 DOI: 10.1097/01.tp.0000155187.81806.df] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute rejection episodes and 6-month protocol biopsy acute pathology are highly correlated with long-term outcomes in renal transplant recipients. Recurrent, vascular, and late rejections are particularly deleterious. METHODS We determined the relative contribution of human leukocyte antigen matching, cytokine genotypes, delayed graft function (DGF), and baseline immunosuppression to the development of acute rejection and allograft pathology in 118 renal transplant recipients. RESULTS Multivariate logistic regression modeling demonstrated that the adjusted odds ratio and 95% confidence interval for recurrent (> or =2) early rejections (0-3 months) increased linearly for high (H) > intermediate (I) > low (L) interferon-gamma (1.8; 1.1-3.2) and tumor necrosis factor (TNF)alpha (3.0; 1.3-6.9) genotype, whereas every 1 microg/L increase in the cyclosporine A level was protective (0.991; 0.984-0.999). The odds ratio for recurrent late rejections (4-6 months) increased for H > I > L TNFalpha (5.1; 1.8-14.7) genotype and DGF (7.1; 1.6-30.2), whereas H > I/L transforming growth factor-beta1 genotype decreased the relative risk (0.09: 0.02-0.49). Vascular rejection was only predicted by H > I > L TNFalpha phenotype (3.0; 1.2-7.9). The odds ratio for the 6-month Banff Acute Score (6A > or= 4) increased for H > I > L TNFalpha (2.7; 1.1-6.7) and interleukin-10 (3.4; 1.2-6.2) genotype, and DGF (3.4; 1.1-11.5). Treatment of early subclinical rejection decreased the relative risk (0.20; 0.07-0.62). CONCLUSIONS High transforming growth factor-beta1 producer phenotype seems to be protective against acute inflammation, whereas H and I interferon-gamma, TNFalpha, and interleukin-10 producer genotypes correlate with adverse outcomes. Cytokine genotyping identifies individuals who may benefit from more intensive surveillance and treatment posttransplant.
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Affiliation(s)
- Kathryn Tinckam
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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64
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Ortiz F, Paavonen T, Törnroth T, Koskinen P, Finne P, Salmela K, Kyllönen L, Grönhagen-Riska C, Honkanen E. Predictors of renal allograft histologic damage progression. J Am Soc Nephrol 2005; 16:817-24. [PMID: 15689401 DOI: 10.1681/asn.2004060475] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The objective of this study was to analyze factors that are involved in the progression of renal allograft damage in the first 6 mo after transplantation. Donor and 6-mo protocol biopsies of 83 patients who received a renal transplant were classified using the Chronic Allograft Damage Index (CADI). Histologic changes were compared and correlated to clinical parameters at transplantation, at 6 mo, and annually over 2 yr. All CADI components increased significantly in the 6-mo posttransplantation period, except chronic vascular changes and the percentage of glomerulosclerosis. Total cholesterol and LDL- cholesterol at the time of biopsy correlated positively with mesangial matrix increase, and HDL cholesterol correlated negatively with vascular intima increase. High BP at biopsy was associated with tubular atrophy. Diastolic BP at biopsy correlated with 6-mo CADI (CADI-6). Patients with diastolic BP > or =85 mmHg at biopsy had a higher difference between CADI score in protocol biopsies and CADI score in donor biopsies (DeltaCADI) and higher creatinine at 1 and 2 yr. CADI in donor biopsies (CADI-0) >1 was more frequently found in older (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.01 to 1.14) and nontraumatic dead donors (OR, 3.89; 95% CI, 1.13 to 13.33). CADI-6 >3 was more frequently found in those with CADI-0 >1 (OR, 3.82; 95% CI, 1.19 to 12.21), older donors (OR, 1.05; 95% CI, 1.01 to 1.10), and number of AB mismatches (OR, 2.36; 95% CI, 1.09 to 5.10). CADI-0, CADI-6, and DeltaCADI correlated significantly with serum creatinine at hospital discharge, at 6 mo, and at 2 yr. DeltaCADI was affected by initial percentage of glomerulosclerosis (OR, 1.10; 95% CI, 1.02 to 1.19) and creatinine at hospital discharge (OR, 1.01; 95% CI, 1.00 to 1.02). Donor-related as well as nonimmunologic factors, such as hypertension and dyslipidemia, are associated with increased risk for renal allograft damage progression.
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Affiliation(s)
- Fernanda Ortiz
- Helsinki University Central Hospital, Kasarmikatu 11-13, 00029 HUCH, Helsinki, Finland
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65
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Nankivell BJ, Borrows RJ, Fung CLS, O'Connell PJ, Chapman JR, Allen RDM. Delta analysis of posttransplantation tubulointerstitial damage. Transplantation 2004; 78:434-41. [PMID: 15316373 DOI: 10.1097/01.tp.0000128613.74683.d9] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Chronic interstitial fibrosis (CIF) is an adverse prognostic feature of chronic allograft nephropathy. METHODS We evaluated the evolution, onset, potential causes, and outcomes of tubulointerstitial damage using 959 protocol kidney biopsy specimens obtained regularly until 10 years after transplantation. Specimens were scored by the Banff schema and analyzed for time-specific change or "delta damage" from sequential biopsy-pairs (n=839). RESULTS Substantial CIF occurred within 1 year after transplantation, comprising 67.6% of the total burden accumulated during the study period. The maximal intensity of CIF formation occurred within the first 3 months, as a result of acute tubular necrosis and acute and subclinical rejection (all P<0.05), where fibrosis rates exceeded loss from tubular atrophy. By 1 year, diminished CIF formation was accompanied by declining low-level subclinical inflammation (P<0.001) and increasingly prevalent calcineurin inhibitor nephrotoxicity (P<0.01). Banff CIF correlated with tubular atrophy (r=0.82, P<0.001), with tubulointerstitial damage showing a cumulative and irreversible pattern. Mononuclear cell infiltration within areas of tubulointerstitial damage correlated with CIF (r=0.49, P<0.001), tubular atrophy (r=0.43, P<0.001), and Banff i scores (r=0.34, P<0.001) and, most importantly, heralded histologic progression (P<0.001). CIF formation preceded and correlated with glomerulosclerosis (r=0.40, P<0.001), although isotopic glomerular filtration rates underestimated the severity of tubular damage. Cyclosporine (vs. tacrolimus, P<0.001) increased delta CIF, and mycophenolate was protective (vs. azathioprine, P<0.001), independent of their immunosuppressive and nephrotoxic properties when assessed by multivariate analysis of biopsy-pairs (n=849). CONCLUSION CIF was a result of early ischemia-reperfusion injury, acute, subacute or persistent interstitial inflammation occurring in a time-dependent manner and was considerably modified by immunosuppressive therapy.
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Affiliation(s)
- Brian J Nankivell
- Department of Renal Medicine, University of Sydney, Westmead Hospital, Westmead, Sydney, Australia.
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66
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Veronese FV, Noronha IL, Manfro RC, Edelweiss MI, Goldberg J, Gonçalves LF. Prevalence and immunohistochemical findings of subclinical kidney allograft rejection and its association with graft outcome. Clin Transplant 2004; 18:357-64. [PMID: 15233810 DOI: 10.1111/j.1399-0012.2004.00170.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Subclinical acute rejection (SAR) occurs in about 30% of stable renal transplant patients and may be a risk factor for a poor allograft outcome. In the present study, the prevalence and clinical features of subclinical rejection, and the expression of immune activation markers in surveillance graft biopsies were assessed and correlated with late graft outcomes. Protocol biopsies were obtained at 2 and 12 months post-transplant in 32 and 26 patients, respectively, with stable renal function. The Banff 1997 criteria were used for histological diagnosis. Graft function and survival and proteinuria were assessed during the 36 months of follow-up. Immunohistochemical evaluation of cell subpopulations and immunoactivation markers were performed on protocol biopsies. The prevalence of SAR at 2 months and of chronic allograft nephropathy (CAN) at 12 months in representative biopsies was 55 and 50%, respectively. Patients with SAR presented mononuclear cell infiltration with an increased expression of CD3, CD4, CD68, IL-2R and granzyme B. Kidney graft function was significantly worse in patients with SAR at 2 months who had chronic rejection on biopsy at 12 months, but SAR was not associated with a worse graft function, greater proteinuria or a lower graft survival in 3 yr of follow-up. In conclusion, we found an elevated prevalence of SAR at 2 months after transplantation with an increased expression of activation markers. Although an association of SAR with poor graft outcome was not observed, our results suggest that SAR is an immunologically active process and underscore the importance of protocol biopsies in the surveillance of transplanted kidneys.
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Affiliation(s)
- Francisco V Veronese
- Renal Division and Post-Graduation Nephrology Program, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
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67
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Câmara NOS, Silva MS, Nishida S, Pereira AB, Pacheco-Silva A. Proximal Tubular Dysfunction is Associated with Chronic Allograft Nephropathy and Decreased Long-Term Renal-Graft Survival. Transplantation 2004; 78:269-75. [PMID: 15280689 DOI: 10.1097/01.tp.0000128333.46949.a4] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Chronic allograft nephropathy is the major cause of graft loss after the first year of transplantation. Although many conditions are associated with its development, there is no method that can anticipate its risk in patients with good renal function. METHODS We prospectively studied 92 renal-transplant recipients with good and stable allograft function and correlated the development of chronic allograft nephropathy and graft loss with their levels of urinary retinol binding protein (uRBP). Patients were divided in two groups regarding the level of their tubular protein: high, above 0.400 mg/L, and normal levels, 0.400 mg/L or less. RESULTS Forty-eight (52%) patients had high levels of uRBP. At the enrollment time, patients with high and normal uRBP had comparable serum creatinine and cyclosporine trough levels. During a 5-year follow-up period, chronic allograft nephropathy was detected in 23 (25%) patients, 19 (82.6%) of whom had high levels of uRBP. Five-year chronic allograft nephropathy-free and graft survivals were significantly worse in patients with higher levels of uRBP than in patients with normal levels (57.5% vs. 89.9% P=0.0004; 70.7% vs. 100%, respectively, P=0.0002). High levels of uRBP were the strongest factor associated with the development of chronic allograft nephropathy (RR=5.3, 95% confidence interval 1.45-19.58, P=0.012). CONCLUSIONS Among renal-transplant patients with good and stable graft function, high levels of uRBP identify those having a high risk of developing chronic allograft nephropathy.
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Affiliation(s)
- Niels O S Câmara
- Division of Nephrology, Universidade Federal de São Paulo, Rua Botucatu 740, 04023-900 São Paulo, Brazil
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68
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Hueso M, Beltran V, Moreso F, Ciriero E, Fulladosa X, Grinyó JM, Serón D, Navarro E. Splicing alterations in human renal allografts: detection of a new splice variant of protein kinase Par1/Emk1 whose expression is associated with an increase of inflammation in protocol biopsies of transplanted patients. Biochim Biophys Acta Mol Basis Dis 2004; 1689:58-65. [PMID: 15158914 DOI: 10.1016/j.bbadis.2004.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2003] [Revised: 01/16/2004] [Accepted: 01/27/2004] [Indexed: 10/26/2022]
Abstract
Protein kinase Emk1/Par1 (GenBank accession no. X97630) has been identified as a regulator of the immune system homeostasis. Since immunological factors are critical for the development of chronic allograft nephropathy (CAN), we reasoned that expression of Par1/Emk1 could be altered in kidney allografts undergoing CAN. In this paper, we have analysed the association among renal allograft lesions and expression of Par1/Emk1, studied by RT-PCR on total RNA from 51 protocol biopsies of transplanted kidneys, five normal kidneys, and five dysfunctional allografts. The most significant result obtained has been the detection of alterations in the normal pattern of alternative splicing of the Par1/Emk1 transcript, alterations that included loss of expression of constitutively expressed isoforms, and the inclusion of a cryptic exon to generate a new Emk1 isoform (Emk1C). Expression of Emk1C was associated with an increase in the extension of the interstitial infiltrate (0.88+/-0.33 in Emk1C([+]) vs. 0.41+/-0.50 in Emk1C([-]); P<0.011), and with a trend to display higher interstitial scarring (0.66+/-0.70 vs. 0.29+/-0.52; P=0.09) in protocol biopsies when evaluated according to the Banff schema. Moreover, a higher mean arterial pressure (MAP) was also observed (110+/-11 vs. 99+/-11 mm Hg; P=0.012). From these results we propose that Par1/Emk1 could have a role in the development of CAN in kidney allografts.
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Affiliation(s)
- Miguel Hueso
- Centre d'Oncologia Molecular, Institut de Recerca Oncológica (COM-IRO), Hospital Duran i Reynals, L'Hospitalet de Llobregat, Barcelona E08907, Spain
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69
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Abstract
The relationship between acute renal allograft rejection and histopathologic biopsy alterations recognized by the Banff Schema as "borderline changes" is not clear. Some evidence supports the contention that about one third of patients with borderline infiltrates and clinical evidence of graft dysfunction do indeed have acute rejection, which, if left untreated, progresses to a histologically more advanced stage of rejection. Several investigators recognize that not all patients with mild tubulitis respond clinically to antirejection therapy; a significant number of these biopsy specimens display additional histological alterations. The most common concurrent lesions are chronic allograft nephropathy, arteriolar lesions consistent with calcineurin inhibitor toxicity, acute tubular necrosis, and obstructive nephropathy. Management of patients with borderline changes must tightly correlate the pathologic features and the clinical information.
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Affiliation(s)
- L W Gaber
- Department of Pathology, University of Tennesee Health Science Center, Memphis, Tennesee, USA
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70
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Barama A, Sepandj F, Gough J, McKenna R. Correlation between neoral 2 hours post-dose levels and histologic findings on surveillance biopsies. Transplant Proc 2004; 36:465S-467S. [PMID: 15041389 DOI: 10.1016/j.transproceed.2003.12.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Use of 2-hour postdose (C2) monitoring has been a major step in optimizing immunosuppression following kidney transplantation, and extensive data has confirmed the superiority of C2 monitoring over the conventional trough monitoring (C0) in reducing the occurrence of acute rejection early after transplantation. In this retrospective study, we explored the relationship between Neoral pharmacokinetic parameters and the presence of subclinical rejections (ScRj). In the absence of acute rejection, lower C2 level was associated with more frequent episodes of ScRj. C0 monitoring was not predictive of AR, ScRj or any combinations thereof. Fast elimination in a subgroup of patients is not detected by the C0 and may lead to unnecessary increase of the drug dosage and increased risk of rejection.
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Affiliation(s)
- A Barama
- Department of Surgery, University of Montréal, Montreal, Canada.
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71
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Lietz K, Lewandowski Z, Lao M, Paczek L, Gaciong Z. Pretransplant and early posttransplant predictors of chronic allograft nephropathy in cadaveric kidney allograft-a single-center analysis of 1112 cases. Transpl Int 2004. [DOI: 10.1111/j.1432-2277.2004.tb00408.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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72
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Mizuiri S, Iwamoto M, Miyagi M, Kawamura T, Sakai K, Arai K, Aikawa A, Ohara T, Hemmi H, Hasegawa A. Activation of nuclear factor-kappa B and macrophage invasion in cyclosporin A- and tacrolimus-treated renal transplants. Clin Transplant 2004; 18:14-20. [PMID: 15108766 DOI: 10.1046/j.0902-0063.2003.00104.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This retrospective study was designed to compare the efficacy of cyclosporin A (CyA) and tacrolimus (FK506) on chronic rejection (CR) associated with nuclear factor-kappa B (NF-kappaB) activation and macrophage invasion. Non-episodic day 50 protocol renal biopsy was performed in 63 consecutive patients with renal transplants from living donors, treated with either CyA or FK506. Southwestern histochemistry for NF-kappaB, immunostaining for CD68, and Banff classification were performed, and these findings were compared with outcome over 34 +/- 13 months. Compared with specimens from FK506-treated patients (n = 20), specimens from CyA-treated patients (n = 43) showed a significant increase in tubulointerstitial CD68-positive cells (1.5 +/- 0.9 vs. 0.9 +/- 0.8, p < 0.01), although no significant differences were observed in NF-kappaB activation. Specimens with Banff acute rejection (AR) grade > or = 1A (n = 20) showed increased macrophages (p < 0.01) compared with specimens with AR < 1A (n = 43). Specimens from patients with clinical AR prior to day 50 biopsy (n = 23) also showed increased macrophage invasion (p < 0.01) compared with specimens from patients without prior clinical AR (n = 40). The cumulative well-functioning (serum creatinine < 1.5 mg/dL) graft survival rate was significantly lower in patients with increased tubulointerstitial CD68-positive cells (n = 63, p < 0.05). Our findings suggest that tacrolimus is more effective than CyA against CR with respect to macrophage invasion and AR.
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Affiliation(s)
- Sonoo Mizuiri
- Department of Nephrology, Toho University School of Medicine, Tokyo, Japan.
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73
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Diaz Encarnacion MM, Griffin MD, Slezak JM, Bergstralh EJ, Stegall MD, Velosa JA, Grande JP. Correlation of quantitative digital image analysis with the glomerular filtration rate in chronic allograft nephropathy. Am J Transplant 2004; 4:248-56. [PMID: 14974947 DOI: 10.1046/j.1600-6143.2003.00311.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Chronic allograft nephropathy (CAN) is characterized by progressive renal functional loss and histologic abnormalities of one or more tissue compartments. In this study, correlations between histologic abnormalities and graft function [glomerular filtration rate (GFR, measured by iothalamate clearance), serum creatinine (SCr) and urinary protein (UPr)] were investigated using biopsies from 49 patients with newly diagnosed CAN. Extent of tubulointerstitial fibrosis (%TIF), as assessed by a semi-quantitative score, correlated significantly with GFR, SCr and UPr. The close correlation between %TIF and GFR suggested that quantitative measurement of %TIF may predict functional consequences of CAN. Calculation of %TIF by computerized digital analysis was performed using four strategies: (a) quantitation of blue material in Masson's trichrome (MT)-stained sections, (b) quantitation of red material in Sirius Red-stained sections (SR-nonpolarized), (c) quantitation of birefringent material in Sirius Red stained-sections examined under polarized light (SR-polarized) and (d) quantification of brown material in sections stained by immunoperoxidase for alpha-smooth muscle actin. Only the SR-nonpolarized score correlated significantly with GFR at the time of biopsy-diagnosis of CAN. We conclude that digital analysis strategies demonstrate variable accuracy in quantifying %TIF. Validation of the SR-nonpolarized strategy against histologic scoring and GFR supports the application of this technique to longitudinal studies of CAN.
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Töz H, Sen S, Seziş M, Duman S, Ozkahya M, Ozbek S, Hoşcoşkun C, Atabay G, Ok E. Comparison of tacrolimus and cyclosporin in renal transplantation by the protocol biopsies. Transplant Proc 2004; 36:134-6. [PMID: 15013324 DOI: 10.1016/j.transproceed.2003.11.056] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Acute and chronic lesion scores on renal allograft protocol biopsies may predict long-term graft function. The aim of this study was to compare the effects of tacrolimus (Tac) and cyclosporine microemulsion (CsA) based immunosuppressive protocols using protocol biopsies from well-functioning renal allografts. 35 consecutive renal transplant patients were randomized to Tac (n: 17) versus CsA (n: 18) treatment arms. Patient age and sex, donor type and age, histocompatibility, cold ischemia time and prior delayed graft function were similar between the two groups. Treatment protocol consisted of prednisolone, azathioprine and Tac or CsA. Biopsies performed on the third, sixth and twelfth months were blindly evaluated by the same pathologist. The incidences of acute rejection (AR) episodes among CsA vs Tac groups were 33% vs 29%, respectively (NS). The Creatinine level was lower in Tac than CsA, although it was not significant (Table). Subclinical AR and subclinical chronic allograft nephropathy were detected on protocol biopsies in 3 (2 CsA, 1 Tac) and 12 (7 CsA, 5 Tac) patients, respectively. Acute lesion score at the third month PBx was significantly lower in the Tac group (p < 0.05). Chronic lesion scores in all biopsies were lower in the Tac group, although not significantly. The protocol biopsy findings suggest that graft injury may be less pronounced among the Tac group.
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Affiliation(s)
- H Töz
- Ege University Medical School, Nephrology Department, 35100 Bornova, zmir, Turkey.
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75
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Nankivell BJ, Borrows RJ, Fung CLS, O'Connell PJ, Allen RDM, Chapman JR. The natural history of chronic allograft nephropathy. N Engl J Med 2003; 349:2326-33. [PMID: 14668458 DOI: 10.1056/nejmoa020009] [Citation(s) in RCA: 1454] [Impact Index Per Article: 69.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND With improved immunosuppression and early allograft survival, chronic allograft nephropathy has become the dominant cause of kidney-transplant failure. METHODS We evaluated the natural history of chronic allograft nephropathy in a prospective study of 120 recipients with type 1 diabetes, all but 1 of whom had received kidney-pancreas transplants. We obtained 961 kidney-transplant-biopsy specimens taken regularly from the time of transplantation to 10 years thereafter. RESULTS Two distinctive phases of injury were evident as chronic allograft nephropathy evolved. An initial phase of early tubulointerstitial damage from ischemic injury (P<0.05), prior severe rejection (P<0.01), and subclinical rejection (P<0.01) predicted mild disease by one year, which was present in 94.2 percent of patients. Early subclinical rejection was common (affecting 45.7 percent of biopsy specimens at three months), and the risk was increased by the occurrence of a prior episode of severe rejection and reduced by tacrolimus and mycophenolate therapy (both P<0.05) and gradually abated after one year. Both subclinical rejection and chronic rejection were associated with increased tubulointerstitial damage (P<0.01). Beyond one year, a later phase of chronic allograft nephropathy was characterized by microvascular and glomerular injury. Chronic rejection (defined as persistent subclinical rejection for two years or longer) was uncommon (5.8 percent). Progressive high-grade arteriolar hyalinosis with luminal narrowing, increasing glomerulosclerosis, and additional tubulointerstitial damage was accompanied by the use of calcineurin inhibitors. Nephrotoxicity, implicated in late ongoing injury, was almost universal at 10 years, even in grafts with excellent early histologic findings. By 10 years, severe chronic allograft nephropathy was present in 58.4 percent of patients, with sclerosis in 37.3 percent of glomeruli. Tubulointerstitial and glomerular damage, once established, was irreversible, resulting in declining renal function and graft failure. CONCLUSIONS Chronic allograft nephropathy represents cumulative and incremental damage to nephrons from time-dependent immunologic and nonimmunologic causes.
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Affiliation(s)
- Brian J Nankivell
- Department of Renal Medicine, University of Sydney, Westmead Hospital, Sydney, NSW, Australia.
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76
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Pape L, Henne T, Offner G, Strehlau J, Ehrich JHH, Mengel M, Grimm PC. Computer-assisted quantification of fibrosis in chronic allograft nephropaty by picosirius red-staining: a new tool for predicting long-term graft function. Transplantation 2003; 76:955-8. [PMID: 14508360 DOI: 10.1097/01.tp.0000078899.62040.e5] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Chronic allograft nephropathy (CAN) has become the predominant limiting factor for long-term transplant survival. A cardinal histomorphologic correlate for CAN is interstitial fibrosis. Currently, no method has been established in routine use that reliably quantifies the extent of interstitial fibrosis in renal grafts. We have used staining with picrosirius red followed by computerized image analysis to study the correlation between graft fibrosis and future development of glomerular filtration rate (GFR) in a group of children with advanced CAN. METHODS Renal biopsies were performed in 56 children (mean age, 13.7+/-3.6 years) after a mean period of 4.6+/-3.1 years after transplantation because of significant increases in serum creatinine. All biopsy specimens were stained with picrosirius red. The magnitude of fibrotic tissue was calculated by computerized image analysis. Linear regression analysis was performed correlating the intensity of graft fibrosis and the changes in the GFR at the time points of renal biopsy and 2 years later. RESULTS There was a significant positive correlation (r=0.62, P<0.001) between the picrosirius red-stained cortical fractional interstitial fibrosis volume (V(intFib)) and the decrease of GFR within 2 years postrenal biopsy. When V(intFib) was below 5%, 82% of the patients had an increase in GFR within 2 years. Ninety-three percent of the patients with greater than 10% of fibrosis experienced a worsening renal function after 2 years. When comparing patients with stable GFR with patients having a decrease in GFR, a highly significant difference in V(intFib) was found (P=0.008). CONCLUSIONS The quantitative measurement of fibrosis by picrosirius red staining appears to be a useful prognostic indicator for estimating long-term graft function in CAN and may provide an easy, fast, and inexpensive tool helpful for treatment decisions in patients developing CAN.
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Affiliation(s)
- Lars Pape
- Department of Pediatric Nephrology, Medical School of Hannover, Hannover, Germany.
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77
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Wigmore SJ, Forsythe JLR. Protocol Biopsy of the Stable Renal Transplant: A Multicenter Study of Methods and Complication Rates. Transplantation 2003; 76: 969. P. N. Furness, C. M. Philpott, M. T. Chorbadjian, M. L. Nicholson, J.-L. Bosmans, B. L. Corthouts, J. J. P. M. Bogers, A. Schwarz, W. Gwinner, H. Haller, M. Mengel, D. Seron, F. Moreso, C. Ca??as. Transplantation 2003; 76:909-10. [PMID: 14531395 DOI: 10.1097/01.tp.0000082543.17341.67] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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78
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Moreso F, Alperovich G, Fulladosa X, Gil-Vernet S, Ibernon M, Carrera M, Castelao AM, Hueso M, Grinyo JM, Serón D. Histologic findings in protocol biopsies performed in stable renal allografts under different immunosuppressive schedules. Transplant Proc 2003; 35:1666-8. [PMID: 12962749 DOI: 10.1016/s0041-1345(03)00616-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Protocol biopsies performed in stable renal allografts show different degrees of acute and chronic lesions. Histologic findings in protocol biopsies have been related to graft outcome. We evaluated histologic lesions observed in protocol biopsies performed in patients under different immunosuppression therapies. From June 1988 a protocol biopsy was performed at approximately 4 months in patients who fulfilled the following criteria: serum creatinine <300 micromol/L; stable renal function; and proteinuria <1 g/d. Histologic lesions were graded according to 1997 Banff criteria. For the present study we considered the following groups according to immunosuppressive schedule: (i) induction therapy with polyclonal or monoclonal antilymphocytic antibodies associated with cyclosporine and prednisone (n=201); (ii) cyclosporine, mycophenolate mofetil, and prednisone (n=127); and (iii) tacrolimus, mycophenolate mofetil, and prednisone (n=51). On protocol biopsy patients treated with tacrolimus displayed a lower acute score (0.61+/-1.01 vs 1.24+/-1.23 in group I, 1.28+/-1.41 in group II; P<.0001) and a higher proportion of normal biopsies (57.1% vs 41.9% in group I, 45.1% in group II; P=.016). A similar proportion of chronic lesions (chronic score of group I: 1.30+/-1.56; group II: 1.34+/-1.80; group III: 1.51+/-0.95; P=NS) was observed in the three groups. Protocol biopsies displayed fewer acute lesions in patients treated with tacrolimus. This result suggests that the efficacy of new immunosuppression schedules can be evaluated using the protocol biopsy as a surrogate marker of graft outcome.
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Affiliation(s)
- F Moreso
- Department of Nephrology, Hospital Bellvitge, Barcelona, Spain
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79
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Hricik DE, Rodriguez V, Riley J, Bryan K, Tary-Lehmann M, Greenspan N, Dejelo C, Schulak JA, Heeger PS. Enzyme linked immunosorbent spot (ELISPOT) assay for interferon-gamma independently predicts renal function in kidney transplant recipients. Am J Transplant 2003; 3:878-84. [PMID: 12814480 DOI: 10.1034/j.1600-6143.2003.00132.x] [Citation(s) in RCA: 151] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Post-transplant monitoring of cellular immunity might be useful in predicting long-term outcomes of kidney transplant recipients. We used an enzyme linked immunoabsorbent spot (ELISPOT) assay to serially measure the frequency of peripheral blood lymphocytes producing interferon-gamma in response to stimulator cells from donors or third parties in 55 primary kidney transplant recipients. Mean frequencies measured during the first 6 months after transplantation correlated significantly with the serum creatinine concentration at both 6 and 12 months following transplantation. The mean frequencies were higher in patients with acute rejection than in those without acute rejection. Multiple regression analyses indicated that the correlations between the early ELISPOT measurements of interferon-gamma and serum creatinine were independent of acute rejection, delayed graft function, or the presence of panel reactive antibodies before transplantation. Patients with low mean frequencies of interferon-producing cells in the early post-transplant period were generally free from acute rejection and exhibited excellent renal function at 6 and 12 months post-transplant. In conclusion, using the ELISPOT assay, we show an independent correlation between early cellular alloreactivity and long-term renal function. Increased levels of early alloreactivity measured with this assay may serve as a surrogate for chronic allograft dysfunction.
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Affiliation(s)
- Donald E Hricik
- Department of Medicine, Case Western Reserve University and University Hospitals of Cleveland, Cleveland, OH, USA.
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80
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Feucht HE. Complement C4d in graft capillaries -- the missing link in the recognition of humoral alloreactivity. Am J Transplant 2003; 3:646-52. [PMID: 12780555 DOI: 10.1034/j.1600-6143.2003.00171.x] [Citation(s) in RCA: 142] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Staining of C4d in graft capillaries has emerged as a useful method to detect antibody-mediated rejections in situ. Demonstration of capillary C4d has provided substantial clinical results and allows several conclusions: Antidonor antibodies (preformed or produced de novo) activate complement directly in the graft. Capillary C4d is present in about 30% of biopsies with acute and chronic rejections and separates rejections with a humoral component from 'pure' cell-mediated rejections. Recognition of humoral alloreactivity is important, since effective treatment is now available. Since capillary C4d can appear and disappear at any time post transplantation, every transplant biopsy should be tested. Capillary C4d is now incorporated in the 'Banff classification'. The incidence of C4d-positive cases will probably decline because of the 'routine' application of potent immunosuppressants, including mycophenolate mofetil, that can inhibit antibody production. Presensitization, however, will remain a potential threat to allografts.
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Affiliation(s)
- Helmut E Feucht
- Department of Organ Transplantation/Nephrology, Fachklinik Bad Heilbrunn, Woernerweg 30, D-83670 Bad Heilbrunn, Germany.
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81
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Grimm PC, Nickerson P, Gough J, McKenna R, Stern E, Jeffery J, Rush DN. Computerized image analysis of Sirius Red-stained renal allograft biopsies as a surrogate marker to predict long-term allograft function. J Am Soc Nephrol 2003; 14:1662-8. [PMID: 12761269 DOI: 10.1097/01.asn.0000066143.02832.5e] [Citation(s) in RCA: 163] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Chronic allograft nephropathy (CAN) is a major problem in posttransplant management. The lack of a reliable and early surrogate marker of CAN has hampered patient care and research. In this study, the Cortical Fractional Interstitial Fibrosis Volume (V(IntFib)), quantitated with computerized image analysis of Sirius Red-stained protocol biopsies, was examined as a potential surrogate for time to graft failure (TTGF) in 68 renal allograft recipients. At 6 mo posttransplant, V(IntFib) was highly correlated with TTGF (r = 0.64, P < 0.001). Both the Banff Chronic Sum and the Acute Sum Scores were also correlated with TTGF, but less strongly (r = 0.28, P < 0.02; r = 0.35, P < 0.003, respectively). As V(IntFib) was not correlated with the Banff Chronic Score, a multivariate model was created that incorporated V(IntFib) and both Acute and Chronic Banff pathology. This model was highly correlated with TTGF (r = 0.7, P < 0.0001). These findings suggest that V(IntFib) determined by computerized image analysis of Sirius Red-stained protocol biopsies at 6 mo posttransplant, with or without incorporation of Banff acute and chronic scoring, may provide an early surrogate for time to graft failure in renal allograft recipients.
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Affiliation(s)
- Paul C Grimm
- Department of Pediatrics, University of California at San Diego, La Jolla, 92093-0831, California, USA.
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82
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Shishido S, Asanuma H, Nakai H, Mori Y, Satoh H, Kamimaki I, Hataya H, Ikeda M, Honda M, Hasegawa A. The impact of repeated subclinical acute rejection on the progression of chronic allograft nephropathy. J Am Soc Nephrol 2003; 14:1046-52. [PMID: 12660340 DOI: 10.1097/01.asn.0000056189.02819.32] [Citation(s) in RCA: 174] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Chronic allograft nephropathy (CAN) is due to both immunologic and non-immunologic factors and results in the development of nonspecific pathologic features that may even be present in long-term well-functioning renal allografts. To investigate the natural history of CAN and potential risk factors associated with progression of these histologic lesions, this study evaluated the of histologic alterations of 124 sequential protocol biopsies performed at 2, 3, and 5 yr after transplantation in 46 patients who exhibited histologic evidence of CAN in the 1-yr biopsy. The occurrence of late acute rejection (AR) greater than 4 mo posttransplant was significantly associated with the development of histologic CAN. In contrast, early clinical AR occurring within 3 mo had no impact on the subsequent development of CAN at 1 yr. Subclinical AR was evident in association with CAN in 50%, 32%, 19%, and 16% of cases with CAN at 1, 2, 3, and 5 yr, respectively. These acute lesions correlated significantly with histologic progression defined as an increased CADI score of the follow-up biopsies. Furthermore, a group of patients who exhibited repeated subclinical AR in the sequential follow-up biopsies had a lower creatinine clearance at 5 yr after transplantation and worse long-term graft survival. In contrast, the absence of evidence of acute inflammation in association with CAN at any time point was associated with minimal deterioration in renal function or progression of renal lesions during the observation period. These results suggest that the persistence of chronic active inflammation may be responsible for the histologic progression of CAN.
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Affiliation(s)
- Seiichirou Shishido
- Department of Pediatric Urology and Kidney Transplantation, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan.
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83
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Yilmaz S, Tomlanovich S, Mathew T, Taskinen E, Paavonen T, Navarro M, Ramos E, Hooftman L, Häyry P. Protocol core needle biopsy and histologic Chronic Allograft Damage Index (CADI) as surrogate end point for long-term graft survival in multicenter studies. J Am Soc Nephrol 2003; 14:773-9. [PMID: 12595515 DOI: 10.1097/01.asn.0000054496.68498.13] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This study is an investigation of whether a protocol biopsy may be used as surrogate to late graft survival in multicenter renal transplantation trials. During two mycophenolate mofetil trials, 621 representative protocol biopsies were obtained at baseline, 1 yr, and 3 yr. The samples were coded and evaluated blindly by two pathologists, and Chronic Allograft Damage Index (CADI) score was constructed. At 1 yr, only 20% of patients had elevated (>l.5 mg/100 ml) serum creatinine, whereas 60% of the biopsies demonstrated an elevated (>2.0) CADI score. The mean CADI score at baseline, 1.3 +/- 1.1, increased to 3.3 +/- 1.8 at 1 yr and to 4.1 +/- 2.2 at 3 yr. The patients at 1 yr were divided into three groups, those with CADI <2, between 2 and 3.9, and >4.0, the first two groups having normal (1.4 +/- 0.3 and 1.5 +/- 0.6 mg/dl) and the third group pathologic (1.9 +/- 0.8 mg/dl) serum creatinine. At 3 yr, there were no lost grafts in the low CADI group, six lost grafts (4.6%) in the in the elevated CADI group, and 17 lost grafts (16.7%) in the high CADI group (P < 0.001). One-year histologic CADI score predicts graft survival even when the graft function is still normal. This observation makes it possible to use CADI as a surrogate end point in prevention trials and to identify the patients at risk for intervention trials.
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Affiliation(s)
- Serdar Yilmaz
- Data Analysis Center, Division of Transplantation, Department of Surgery, University of Calgary, Alberta, Canada
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84
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Salomon DR. Protocol biopsies should be part of the routine management of kidney transplant recipients. Con. Am J Kidney Dis 2002; 40:674-7. [PMID: 12324899 DOI: 10.1053/ajkd.2002.36426] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel R Salomon
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, and Center for Organ and Cell Transplantation, Scripps Health, La Jolla, CA, USA
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85
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Rush D. Protocol biopsies should be part of the routine management of kidney transplant recipients. Pro. Am J Kidney Dis 2002; 40:671-3. [PMID: 12324898 DOI: 10.1053/ajkd.2002.36427] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- David Rush
- Winnipeg Transplant Program Winnipeg, Manitoba, Canada
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86
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Affiliation(s)
- Helena Isoniemi
- Transplantation and Liver Surgery Clinic, Helsinki University Hospital, Kasarmik 11, FIN 00130 Helsinki, Finland
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87
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Haas M, Kraus ES, Samaniego-Picota M, Racusen LC, Ni W, Eustace JA. Acute renal allograft rejection with intimal arteritis: histologic predictors of response to therapy and graft survival. Kidney Int 2002; 61:1516-26. [PMID: 11918760 DOI: 10.1046/j.1523-1755.2002.00254.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Acute renal allograft rejection with intimal arteritis is designated by the widely used Banff 97 classification as type 2A or 2B depending on the extent of arteritis, without regard to interstitial inflammation or tubulitis. We examined whether the distinction between type 2A and 2B is relevant to short- and long-term clinical outcomes, and if outcomes in this subset of acute rejection also are affected by tubulitis, interstitial inflammation, and several additional histologic and clinical parameters. METHODS Pathology records were searched to identify cases of acute renal allograft rejection with intimal arteritis diagnosed between January 1985 and September 2000. For each case, the patient's chart was reviewed to determine the response of the rejection episode to therapy, type(s) of therapy given, and length of graft survival. All biopsies were reviewed and Banff acute and chronic indices recorded by a pathologist blinded to these data. Biopsies not showing type 2A or 2B rejection were excluded, as were repeat biopsies from the same patient and cases with recurrent glomerular disease, viral infection, donor-specific antibodies, or more than mild chronic change. RESULTS The initial response to anti-rejection therapy was significantly worse in patients with type 2B acute rejection (N = 29) than in those with type 2A (N = 102) by univariate and multivariate analyses, despite more aggressive treatment of type 2B rejection. In a Cox proportional hazards model the hazard ratio for graft failure for 2B versus 2A was 1.9 (P = 0.05), but this was not significant when adjusted for the initial response to therapy. Cases with minimal or mild tubulitis responded better to therapy than those with moderate or severe tubulitis, although graft survival was not significantly affected by the tubulitis score. CONCLUSIONS The distinction between types 2A and 2B acute rejection in the Banff 97 classification has significant prognostic value with regard to both short- and long-term clinical outcomes, although the difference in long-term graft survival is mainly related to the initial response to therapy. Reports of biopsies showing type 2A or 2B rejection also should specify the degree of tubulitis present, as the latter may significantly influence the initial response to therapy.
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Affiliation(s)
- Mark Haas
- Department of Pathology and Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
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88
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Abstract
In this review, we discuss current and future issues in the management of pediatric renal transplant recipients, including the optimization of long-term graft function and the minimization of complications caused by immunosuppression. Long-term management involves not only the monitoring of graft function but also the identification of patients at risk for the development of complications. The identification of patients with immunoreactive or immunoregulatory responses can be performed molecular monitoring of the immune response. Also, the use of frequent surveillance kidney biopsies, surrogate markers of chronic rejection, and glomerular filtration rate will be a part of future management. Identifying high-risk patients enables the physician to optimize immunosuppression to limit acute rejection. Short-and long-term management of pediatric transplant patients also includes adequate monitoring of growth and the monitoring for post-transplant lymphoproliferative disease. Ongoing clinical trials are underway that focus on these novel approaches in caring for pediatric transplant recipients.
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Affiliation(s)
- Dmitry Samsonov
- Division of Nephrology, Department of Medicine, Children's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA
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89
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Racusen LC, Solez K, Colvin R. Fibrosis and atrophy in the renal allograft: interim report and new directions. Am J Transplant 2002; 2:203-6. [PMID: 12096781 DOI: 10.1034/j.1600-6143.2002.20303.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The topic of chronic allograft nephropathy/chronic rejection is reviewed, with focus on fibrosing/sclerosing changes and late loss of function in renal allografts. Discussion includes a review of the problem, pathological and clinical findings, and new directions. Emphasis is placed on definition of specific diagnostic entities in these allografts, and identification of ongoing/active processes in this setting that might be amenable to direct intervention. A schema for categorizing these cases is proposed.
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90
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Serón D, Moreso F, Fulladosa X, Hueso M, Carrera M, Grinyó JM. Reliability of chronic allograft nephropathy diagnosis in sequential protocol biopsies. Kidney Int 2002; 61:727-33. [PMID: 11849416 DOI: 10.1046/j.1523-1755.2002.00174.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Chronic allograft nephropathy (CAN) progresses rapidly during the first few months and slowly thereafter. Although the presence of CAN in protocol renal biopsies is a predictor of outcome, the reliability of this diagnosis according to Banff criteria has not been characterized. METHODS Renal lesions were evaluated according to the Banff criteria in sequential protocol biopsies performed at 4 and 14 months in 310 biopsies obtained from 155 patients. RESULTS CAN progressed from 40 to 53% (P=0.001) while serum creatinine remained stable (146 +/- 44 vs. 147 +/- 48 micromol/L, P=NS). Graft survival in patients with and without CAN in the first biopsy was 74 versus 91% (P < 0.05), and in the second biopsy 75 versus 94% (P < 0.05). In 54 patients (35%) no CAN was present in both biopsies, 39 (25%) showed progression to CAN, 19 (12%) showed regression of CAN, and 43 (28%) showed CAN in both biopsies. Graft survival was: 100%, 81.6%, 82.6% and 69.4%, respectively (P < 0.01). Assuming that CAN does not regress and sampling error is normally distributed, we estimated that 25% of biopsies cannot be properly classified. CONCLUSIONS The increase in the incidence of CAN between the 4th and 14th month is lower than the proportion of misclassified biopsies. Thus, monitoring the progression of CAN by means of two sequential biopsies at 4 and 14 months is inaccurate. We suggest that progression of scarring be monitored by means of a donor and a protocol biopsy performed during the first year evaluated with a quantitative approach.
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Affiliation(s)
- Daniel Serón
- Nephrology and Pathology Departments, Hospital de Bellvitge, Universitat de Barcelona, L'Hospitalet, Barcelona, Spain.
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91
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Najafian N, Salama AD, Fedoseyeva EV, Benichou G, Sayegh MH. Enzyme-linked immunosorbent spot assay analysis of peripheral blood lymphocyte reactivity to donor HLA-DR peptides: potential novel assay for prediction of outcomes for renal transplant recipients. J Am Soc Nephrol 2002; 13:252-259. [PMID: 11752045 DOI: 10.1681/asn.v131252] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Chronic allograft dysfunction, which is the most common cause of late allograft failure, is in part caused by an ongoing immune response orchestrated by T lymphocytes primed by the indirect pathway of allorecognition. The low frequencies of such T cells have made it difficult to study indirect alloreactivity by using currently available assays. The development of a sensitive, clinically useful method of measuring indirect alloreactivity among human renal transplant recipients was thus attempted. Furthermore, in a pilot immunologic study, the contribution of the indirect pathway was studied in two groups of renal transplant recipients, i.e., patients with no prior acute rejection episodes and stable renal function ("stable" patients) and patients with at least one previous episode of biopsy-proven acute rejection, who were thus at risk for the development of chronic rejection ("high-risk" patients). The frequencies of type 1 T helper (interferon-gamma-producing) and type 2 T helper (interleukin-5- and -10-producing) peripheral blood lymphocytes reactive with a panel of synthetic peptides (corresponding to sequences from donor HLA-DR molecules) were determined for renal transplant recipients and normal control subjects by using an enzyme-linked immunosorbent spot assay (ELISPOT). Among recipients of DR-mismatched allografts, a cut-off value of 60 interferon-gamma spots/10(6) cells significantly (P = 0.02) separated stable patients (creatinine concentration, 1.1 +/- 0.3 mg/dl) from high-risk patients (creatinine concentration, 2.3 +/- 1.7 mg/dl). This is the first demonstration that the enzyme-linked immunosorbent spot assay can be used to monitor indirect alloreactivity to donor HLA-DR peptides among renal transplant recipients. These data provide the rationale for the prospective study of indirect alloreactivity among transplant recipients, to allow predictions of which patients would be at risk for the development of chronic rejection and thus allow appropriate planning of future interventions.
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Affiliation(s)
- Nader Najafian
- *Laboratory of Immunogenetics and Transplantation, Brigham and Women's Hospital, Nephrology Division, Children's Hospital, Harvard Medical School, Boston, Massachusetts, and Cellular and Molecular Immunology Laboratory, Schepens Eye Research Institute, and Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Alan D Salama
- *Laboratory of Immunogenetics and Transplantation, Brigham and Women's Hospital, Nephrology Division, Children's Hospital, Harvard Medical School, Boston, Massachusetts, and Cellular and Molecular Immunology Laboratory, Schepens Eye Research Institute, and Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Eugenia V Fedoseyeva
- *Laboratory of Immunogenetics and Transplantation, Brigham and Women's Hospital, Nephrology Division, Children's Hospital, Harvard Medical School, Boston, Massachusetts, and Cellular and Molecular Immunology Laboratory, Schepens Eye Research Institute, and Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Gilles Benichou
- *Laboratory of Immunogenetics and Transplantation, Brigham and Women's Hospital, Nephrology Division, Children's Hospital, Harvard Medical School, Boston, Massachusetts, and Cellular and Molecular Immunology Laboratory, Schepens Eye Research Institute, and Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Mohamed H Sayegh
- *Laboratory of Immunogenetics and Transplantation, Brigham and Women's Hospital, Nephrology Division, Children's Hospital, Harvard Medical School, Boston, Massachusetts, and Cellular and Molecular Immunology Laboratory, Schepens Eye Research Institute, and Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
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92
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Freese P, Svalander CT, Mölne J, Nordén G, Nyberg G. Chronic allograft nephropathy--biopsy findings and outcome. Nephrol Dial Transplant 2001; 16:2401-6. [PMID: 11733633 DOI: 10.1093/ndt/16.12.2401] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Chronic allograft nephropathy (CAN) is a composite term for various types of damage to a kidney transplant. We wanted to analyse its components in relation to baseline biopsy findings, transplant function, and outcome. METHODS Among renal transplantations performed from 1985 to 1997, 156 were identified where allograft biopsies had been obtained on clinical indication 6 months after transplantation or later, baseline biopsies were available in each case and the patient's original disease was known. Time after transplantation was median 2.2 years (range 0.5-13). The biopsies were reviewed and the Banff 1997 CAN score obtained. RESULTS All but one late biopsy showed some CAN grade, 48% grade II, and 7.5% grade III. Acute tubulointerstitial rejection was seen in 9% but vascular rejection in only 3%. Arterial wall thickening was present in 66% of the late biopsies, correlated with donor age and its presence at baseline but also with time after transplantation. The Banff CAN score and serum creatinine level were both independent predictors of further graft survival, relative risk 0.35 (confidence interval 0.15-0.82, P=0.015) for CAN grade I vs III and 0.30 (0.14-0.67, P=0.003) for serum creatinine <170 vs >250 micromol/l. Presence of arterial wall thickening had no prognostic impact. CONCLUSION The CAN grade is predictive of further graft survival independently of the serum creatinine level. Interstitial fibrosis and tubular atrophy are more prominent features of chronic graft damage than vascular rejection. Unspecific arterial wall thickening is partly dependent on baseline conditions and lacks prognostic impact in this late stage.
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Affiliation(s)
- P Freese
- Department of Nephrology, Rigshospitalet, Copenhagen, Denmark
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93
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Lehtonen SR, Taskinen EI, Isoniemi HM. Histological alterations in implant and one-year protocol biopsy specimens of renal allografts. Transplantation 2001; 72:1138-44. [PMID: 11579313 DOI: 10.1097/00007890-200109270-00026] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND The natural course of histological changes and their correlations with clinical parameters have not been studied in large numbers in renal allograft specimens. The aim of this study was to determine whether any histological alterations developed during the first posttransplantation year. Immunological and nonimmunological factors possibly associated with subsequent histopathological changes and development of chronic rejection were also assessed. METHODS We studied 102 cadaveric kidney allografts for which both implant and 1-year protocol biopsy specimens were available. The chronic allograft damage index (CADI) was used to quantify the extent of histological changes that developed during the first year. RESULTS Overall, an increase in histological alterations were seen during the first posttransplantation year, and the CADI increased significantly. The mean CADI was 0.7 in relation to implant biopsy samples and 2.9 in relation to 1-year biopsy samples (P<0.05). Although the degree of changes increased during the first posttransplantation year, they were seldom severe. Significant increases in incidences of interstitial inflammation and fibrosis, tubular atrophy, and basement-membrane thickening were seen. Vascular intimal proliferation and glomerular mesangial matrix increase and glomerular sclerosis were also noted. In contrast, anisometric vacuolization in the tubular epithelium decreased significantly in incidence during the first year. CADI values 1 year after transplantation were significantly affected by donor age, occurrence of acute rejection episodes, and prevalence of HLA-DR mismatches. CADIs were also significantly higher in grafts with decreased function. CONCLUSIONS Histopathological alterations increased in almost every graft, even well-functioning grafts, during the first year. The CADIs relating to alterations seen in cases of chronic rejection increased significantly and were strongly affected by both immunological and nonimmunological factors.
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Affiliation(s)
- S R Lehtonen
- Transplantation and Liver Surgery, Department of Surgery, Helsinki University, FInland
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94
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Akalin E, Hendrix RC, Polavarapu RG, Pearson TC, Neylan JF, Larsen CP, Lakkis FG. Gene expression analysis in human renal allograft biopsy samples using high-density oligoarray technology. Transplantation 2001; 72:948-53. [PMID: 11571464 DOI: 10.1097/00007890-200109150-00034] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND High-density oligoarray technology is a novel method for screening the expression of thousands of genes in a small tissue sample. Oligoarray analysis of genes expressed during human renal allograft rejection has not been reported previously. METHODS Seven human renal allograft biopsies with histologic evidence of acute cellular rejection and three renal allograft biopsies without evidence of rejection (control) were analyzed for the expression of 6800 human genes using high-density oligoarrays (GeneChip, Affymetrix, Santa Clara, CA). Quantitative expression of gene transcripts was determined and a comparison analysis between acute rejection and control biopsy samples was performed. Up-regulation of a specific gene transcript during acute rejection was considered to be significant if transcript abundance increased fourfold or more relative to control biopsy samples. RESULTS Comparison analysis revealed that between 32 and 219 gene transcripts are up-regulated (>fourfold) during acute rejection. Of these transcripts, only four (human monokine induced by interferon-gamma, T-cell receptor active beta-chain protein, interleukin-2 stimulated phosphoprotein, and RING4 (a transporter involved in antigen presentation)) were consistently up-regulated in each acute rejection sample relative to at least two of three control biopsy samples. Six other genes were up-regulated in six of seven acute rejection samples. These were interferon-stimulated growth factor-3, complement factor 3, nicotinamide N-methyltransferase, macrophage inflammatory protein-3beta, myeloid differentiation protein, and CD18. Only two gene transcripts were down-regulated in five of seven acute rejection samples. Significant up-regulation of cytotoxic T-cell effector molecules, previously reported as markers of acute renal rejection in humans, was not detected. CONCLUSIONS High-density oligoarray technology is useful for screening gene expression in transplanted tissues undergoing acute rejection. Because this method does not rely on a priori knowledge of which genes are involved in acute rejection, it is likely to yield novel insights into the mechanisms and diagnosis of rejection.
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Affiliation(s)
- E Akalin
- Renal Division, Department of Medicine, Transplantation Section, Emory University, Atlanta, Georgia, USA
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95
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Messias NC, Eustace JA, Zachary AA, Tucker PC, Charney D, Racusen LC. Cohort study of the prognostic significance of acute transplant glomerulitis in acutely rejecting renal allografts. Transplantation 2001; 72:655-60. [PMID: 11544426 DOI: 10.1097/00007890-200108270-00016] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute transplant glomerulitis is a unique lesion in renal allografts, the prognostic significance of which is controversial. We conducted this retrospective cohort study to examine the independent prognostic significance of moderate-to-severe transplant glomerulitis in acute rejection. METHODS Renal allograft survival for patients with acute rejection were studied, comparing one group with significant glomerulitis (G, n=28) with those with no glomerulitis (NG, n=35). Clinical, biopsy, and demographic data and renal graft survival were compared, and the association of G with graft failure was examined. RESULTS In the G versus NG group, a greater percentage of patients were highly sensitized (peak panel reactive antibody value >80%; P=0.009), had had a previous renal transplant (40% vs. 11%; P=0.02), or had suffered from delayed graft function (P=0.03). The G group had a trend toward earlier rejection episodes (P=0.07), a significantly higher serum creatinine at the time of index biopsy (P=0.01), a higher prevalence of vascular rejection (P=0.02), and less improvement in mean reciprocal serum creatinine at 1-2 weeks after biopsy (P=0.02). Although there was a trend toward shorter allograft survival in the G group (P=0.09), the level of significance of which increased with adjustment for transplantation time period and the duration of the transplant-biopsy interval (P=0.06), the relative risk for graft loss was no longer significant when additionally adjusted for index biopsy Banff score (relative risk, 0.97; P=0.97). CONCLUSION In this study, G was significantly more common in highly sensitized patients and was strongly associated with vascular rejection biopsies but was not an independent predictor of graft survival.
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Affiliation(s)
- N C Messias
- Department of Pathology, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
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96
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Joseph JT, Kingsmore DB, Junor BJ, Briggs JD, Mun Woo Y, Jaques BC, Hamilton DN, Jardine AG, Jindal RM. The impact of late acute rejection after cadaveric kidney transplantation. Clin Transplant 2001; 15:221-7. [PMID: 11683814 DOI: 10.1034/j.1399-0012.2001.150401.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Acute graft rejection (AR) following renal transplantation results in reduced graft survival. However, there is uncertainty regarding the definition, aetiology and long-term graft and patient outcome of AR occurring late in the post-transplant period. AIM To determine if rejection episodes can be classified by time from transplantation by their impact on graft survival into early acute rejection (EAR) and late acute rejection (LAR). MATERIALS AND METHODS 687 consecutive adult renal transplant recipients who received their first cadaveric renal transplant at a single centre. All received cyclosporine (CyA)-based immunosuppression, from 1984 to 1996, with a median follow-up of 6.9 yr. Details were abstracted from clinical records, with emphasis on age, sex, co-morbid conditions, HLA matching, rejection episodes, patient and graft survival. ANALYSIS Patients were classified by the presence and time to AR from the date of transplantation. Using those patients who had no AR (NAR) as a baseline, we determined the relative risk of graft failure by time to rejection. The characteristics of patients who had no rejection, EAR and LAR were compared. RESULTS Compared with NAR, the risk of graft failure was higher for those patients who suffered a rejection episode. A much higher risk of graft failure was seen when the first rejection episode occurred after 90 d. Thus, a period of 90 d was taken to separate EAR and LAR (relative risk of 3.06 and 5.27 compared with NAR as baseline, p<0.001). Seventy-eight patients (11.4%) had LAR, 271 (39.4%) had EAR and 338 (49.2%) had NAR. The mean age for each of these groups differed (LAR 39.6 yr, EAR 40.8 yr compared with NAR 44 yr, p<0.003). The 5-yr graft survival for those who had LAR was 45% and 10-yr survival was 28%. HLA mismatches were more frequent in those with EAR vs. NAR (zero mismatches in HLA-A: 36 vs. 24%, HLA-B: 35 vs. 23% and HLA-DR: 63 vs. 41%, p<0.003). There was no difference in mismatching frequency between NAR and LAR. CONCLUSIONS AR had a deleterious impact on graft survival, particularly if occurring after 90 d. AR episodes should therefore be divided into early and late phases. In view of the very poor graft survival associated with LAR, it is important to gain further insight into the main aetiological factors. Those such as suboptimal CyA blood levels and non-compliance with medication should be further investigated with the aim of developing more effective immunosuppressive regimens in order to reduce the incidence of LAR.
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Affiliation(s)
- J T Joseph
- Department of Transplantation Surgery, University of Glasgow and the Western Infirmary, Glasgow, UK
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97
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Moreso F, Lopez M, Vallejos A, Giordani C, Riera L, Fulladosa X, Hueso M, Alsina J, Grinyó JM, Serón D. Serial protocol biopsies to quantify the progression of chronic transplant nephropathy in stable renal allografts. Am J Transplant 2001; 1:82-8. [PMID: 12095044 DOI: 10.1034/j.1600-6143.2001.010115.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
AIM To evaluate the utility of intimal thickness and interstitial width as a primary efficacy variable in the design of clinical trials aimed to modify the natural history of chronic allograft nephropathy. METHODS A donor and a 4-month protocol biopsy were evaluated in 40 stable grafts according to the Banff schema. In 27 patients, a second protocol biopsy was done at 1 yr. Arterial intimal volume fraction (Vvintima/artery) and cortical interstitial volume fraction (Vvinterstitium/cortex) were estimated with a point counting technique. RESULTS Chronic Banff scores increased during follow-up, while acute scores reached its peak at 4 months. Vvintima/artery and Vvinterstitium/cortex significantly increased at 4 months, but not at 1 yr. Vvintima/artery at 4 months correlated with donor Vvintima/artery (r = 0.57, p < 0.001), histocompatibility (r = 0.38, p = 0.01) and serum cholesterol (r = 0.31, p = 0.047). Vvinterstitium/cortex at 4 months correlated with recipient body surface area (r = 0.44, p = 0.004) and delayed graft function (p = 0.016). Power calculations showed that Vvintima/artery and Vvinterstitium/cortex allow an important reduction in minimum sample size of a hypothetical trial aimed to prevent chronic allograft nephropathy. CONCLUSIONS Intimal thickening and interstitial widening progresses rapidly during the first 4 months after transplantation and slowly thereafter. These parameters can be considered as a primary efficacy variable in trials aimed to prevent chronic allograft nephropathy.
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Affiliation(s)
- F Moreso
- Nephrology Department, Hospital de Bellvitge, Barcelona, Spain
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98
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Abstract
The safety of the renal allograft biopsy and the standardization of allograft histopathology interpretation have renewed interest in the performance of protocol (surveillance) biopsies. Recent surveillance biopsy studies in the areas of pre-implantation and in the early and late post-transplant periods are discussed.
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Affiliation(s)
- P Nickerson
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Nankivell BJ, Fenton-Lee CA, Kuypers DR, Cheung E, Allen RD, O'Connell PJ, Chapman JR. Effect of histological damage on long-term kidney transplant outcome. Transplantation 2001; 71:515-23. [PMID: 11258430 DOI: 10.1097/00007890-200102270-00006] [Citation(s) in RCA: 206] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Chronic renal allograft failure remains a major challenge to overcome. Factors such as donor quality, delayed graft function (DGF), acute rejection, and immunosuppression are known to affect long-term outcome, but their relationship to histological damage to graft outcome is unclear. METHODS Protocol kidney biopsies (n=112) obtained at 3 months after transplantation yielded 102 with adequate tissue. Histology was scored by the Banff schema, and compared with implantation biopsies (n=91), repeat 12-month histology (n=39), decline in serum creatinine and serial isotopic glomerular filtration rate, onset of chronic allograft nephropathy (CAN), and actuarial graft survival censored for death with a functioning graft. RESULTS At a median follow-up of 9.3 years, 20 patients had graft failure and 26 died with a functioning graft. Banff chronic nephropathy was present in 24% of 3-month biopsies, and was predicted by microvascular disease in the donor, cold ischemia, DGF, and acute vascular rejection (P<0.001). Acute glomerulitis at 3 months correlated with segmental glomerulosclerosis at 12 months, subsequent recurrent glomerulonephritis, and graft failure (P<0.01). Subclinical rejection at 3 months occurred in 29% of biopsies, correlated with prior acute rejection and HLA mismatch, and led to chronic histological damage by 12 months (r=0.25-0.67, P<0.05-0.001). Subclinical rejection, arteriolar hyalinosis, and tubulitis present at 3 months had resolved by 12 months. The 10-year survival rates for Banff chronic nephropathy were 90.4% for grade 0, 81.0% grade 1, and 57.9% for grades 2 or greater (P<0.01). Early tubulointerstitial damage at 3 months profoundly influenced graft survival beyond 10 years. CAN was predicted by kidney ischemia, 3-month chronic intimal vascular thickening, tubular injury, proteinuria, and late rejection. Chronic fibrointimal thickening of the small arteries and chronic interstitial fibrosis at 3 months independently predicted graft loss and decline in renal function (P<0.05-0.001). CONCLUSIONS Early transplant damage occurs in the tubulointerstitial compartment from preexisting donor kidney injury and discrete events such as vascular rejection and DGF. Subsequent chronic damage and graft failure reflect accumulated previous injury and chronic interstitial fibrosis, vascular impairment, subclinical rejection, and injury from late rejection. CAN may be conceptualized as the sequelae of incremental and cumulative damage to the transplanted kidney. The duration of graft survival is dependent and predicted by the quality of the transplanted donor kidney combined with the intensity, frequency, and irreversibility of these damaging insults.
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Affiliation(s)
- B J Nankivell
- Department of Renal Medicine, University of Sydney, Westmead Hospital, New South Wales, Australia
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Paul LC, Sijpkens YW. Early biomarkers for late graft loss. Transplant Proc 2001; 33:295-6. [PMID: 11266825 DOI: 10.1016/s0041-1345(00)02015-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- L C Paul
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
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