151
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Deng MC. The evolution of patient-specific precision biomarkers to guide personalized heart-transplant care. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2021; 6:51-63. [PMID: 33768160 DOI: 10.1080/23808993.2021.1840273] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Introduction In parallel to the clinical maturation of heart transplantation over the last 50 years, rejection testing has been revolutionized within the systems biology paradigm triggered by the Human Genome Project. Areas Covered We have co-developed the first FDA-cleared diagnostic and prognostic leukocyte gene expression profiling biomarker test in transplantation medicine that gained international evidence-based medicine guideline acceptance to rule out moderate/severe acute cellular cardiac allograft rejection without invasive endomyocardial biopsies. This work prompted molecular re-classification of intragraft biology, culminating in the identification of a pattern of intragraft myocyte injury, in addition to acute cellular rejection and antibody-mediated rejection. This insight stimulated research into non-invasive detection of myocardial allograft injury. The addition of a donor-organ specific myocardial injury marker based on donor-derived cell-free DNA further strengthens the non-invasive monitoring concept, combining the clinical use of two complementary non-invasive blood-based measures, host immune activity-related risk of acute rejection as well as cardiac allograft injury. Expert Opinion This novel complementary non-invasive heart transplant monitoring strategy based on leukocyte gene expression profiling and donor-derived cell-free DNA that incorporates longitudinal variability measures provides an exciting novel algorithm of heart transplant allograft monitoring. This algorithm's clinical utility will need to be tested in an appropriately designed randomized clinical trial which is in preparation.
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Affiliation(s)
- Mario C Deng
- Advanced Heart Failure/Mechanical Support/Heart Transplant, David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, 100 Medical Plaza Drive, Suite 630, Los Angeles, CA 90095
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152
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Li Y, Yan L, Li Y, Wan Z, Bai Y, Wang X, Hu S, Wu X, Yang C, Fan J, Xu H, Wang L, Shi Y. Development and validation of routine clinical laboratory data derived marker-based nomograms for the prediction of 5-year graft survival in kidney transplant recipients. Aging (Albany NY) 2021; 13:9927-9947. [PMID: 33795527 PMCID: PMC8064213 DOI: 10.18632/aging.202748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 02/16/2021] [Indexed: 02/05/2023]
Abstract
Background: To develop and validate predictive nomograms for 5-year graft survival in kidney transplant recipients (KTRs) with easily-available laboratory data derived markers and clinical variables within the first year post-transplant. Methods: The clinical and routine laboratory data from within the first year post-transplant of 1289 KTRs was collected to generate candidate predictors. Univariate and multivariate Cox analyses and LASSO were conducted to select final predictors. X-tile analysis was applied to identify optimal cutoff values to transform potential continuous factors into category variables and stratify patients. C-index, calibration curve, dynamic time-dependent AUC, decision curve analysis, and Kaplan-Meier curves were used to evaluate models’ predictive accuracy and clinical utility. Results: Two predictive nomograms were constructed by using 0–6- and 0–12- month laboratory data, and showed good predictive performance with C-indexes of 0.78 and 0.85, respectively, in the training cohort. Calibration curves showed that the prediction probabilities of 5-year graft survival were in concordance with actual observations. Additionally, KTRs could be successfully stratified into three risk groups by nomograms. Conclusions: These predictive nomograms combining demographic and 0–6- or 0–12- month markers derived from post-transplant laboratory data could serve as useful tools for early identification of 5-year graft survival probability in individual KTRs.
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Affiliation(s)
- Yamei Li
- Department of Laboratory Medicine/Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Lin Yan
- Department of Laboratory Medicine/Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Li
- Department of Laboratory Medicine/Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Zhengli Wan
- Department of Laboratory Medicine/Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yangjuan Bai
- Department of Laboratory Medicine/Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Xianding Wang
- Department of Urology/Organ Transplant Center, West China Hospital, Sichuan University, Chengdu, China
| | - Shumeng Hu
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaojuan Wu
- Department of Laboratory Medicine/Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Cuili Yang
- Department of Laboratory Medicine/Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Jiwen Fan
- Department of Laboratory Medicine/Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Huan Xu
- Department of Laboratory Medicine/Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Lanlan Wang
- Department of Laboratory Medicine/Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yunying Shi
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
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153
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Lee J, Kim EJ, Lee JG, Kim BS, Huh KH, Kim MS, Kim SI, Kim YS, Joo DJ. Clinical impact of serum bilirubin levels on kidney transplant outcomes. Sci Rep 2021; 11:6889. [PMID: 33767325 PMCID: PMC7994407 DOI: 10.1038/s41598-021-86330-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 03/15/2021] [Indexed: 02/06/2023] Open
Abstract
Serum bilirubin, a potent endogenous antioxidant, has been associated with decreased risks of cardiovascular disease, diabetes, and kidney disease. However, the effects of serum bilirubin on kidney transplant outcomes remain undetermined. We analyzed 1628 patients who underwent kidney transplantations between 2003 and 2017. Patients were grouped into sex-specific quartiles according to mean serum bilirubin levels, 3–12 months post-transplantation. Median bilirubin levels were 0.66 mg/dL in males and 0.60 mg/dL in females. The intra-individual variability of serum bilirubin levels was low (9%). Serum bilirubin levels were inversely associated with graft loss, death-censored graft failure, and all-cause mortality, independent of renal function, donor status, and transplant characteristics. Multivariable analysis revealed that the lowest serum bilirubin quartile was associated with increased risk of graft loss (HR 2.64, 95% CI 1.67–4.18, P < 0.001), death-censored graft failure (HR 2.97, 95% CI 1.63–5.42, P < 0.001), and all-cause mortality (HR 2.07, 95% CI 1.01–4.22, P = 0.046). Patients with lower serum bilirubin were also at greater risk of rejection and exhibited consistently lower glomerular filtration rates than those with higher serum bilirubin. Serum bilirubin levels were significantly associated with transplantation outcomes, suggesting that bilirubin could represent a therapeutic target for improving long-term transplant outcomes.
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Affiliation(s)
- Juhan Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Jin Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae Geun Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Beom Seok Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyu Ha Huh
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Myoung Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soon Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yu Seun Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.
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154
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Smith RN. In-silico performance, validation, and modeling of the Nanostring Banff Human Organ transplant gene panel using archival data from human kidney transplants. BMC Med Genomics 2021; 14:86. [PMID: 33740956 PMCID: PMC7977303 DOI: 10.1186/s12920-021-00891-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 01/31/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND RNA gene expression of renal transplantation biopsies is commonly used to identify the immunological patterns of graft rejection. Mostly done with microarrays, seminal findings defined the patterns of gene sets associated with rejection and non-rejection kidney allograft diagnoses. To make gene expression more accessible, the Molecular Diagnostics Working Group of the Banff Foundation for Allograft Pathology and NanoString Technologies partnered to create the Banff Human Organ Transplant Panel (BHOT), a gene panel set of 770 genes as a surrogate for microarrays (~ 50,000 genes). The advantage of this platform is that gene expressions are quantifiable on formalin fixed and paraffin embedded archival tissue samples, making gene expression analyses more accessible. The purpose of this report is to test in silico the utility of the BHOT panel as a surrogate for microarrays on archival microarray data and test the performance of the modelled BHOT data. METHODS BHOT genes as a subset of genes from downloaded archival public microarray data on human renal allograft gene expression were analyzed and modelled by a variety of statistical methods. RESULTS Three methods of parsing genes verify that the BHOT panel readily identifies renal rejection and non-rejection diagnoses using in silico statistical analyses of seminal archival databases. Multiple modelling algorithms show a highly variable pattern of misclassifications per sample, either between differently constructed principal components or between modelling algorithms. The misclassifications are related to the gene expression heterogeneity within a given diagnosis because clustering the data into 9 groups modelled with fewer misclassifications. CONCLUSION This report supports using the Banff Human Organ Transplant Panel for gene expression of human renal allografts as a surrogate for microarrays on archival tissue. The data modelled satisfactorily with aggregate diagnoses although with limited per sample accuracy and, thereby, reflects and confirms the modelling complexity and the challenges of modelling gene expression as previously reported.
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Affiliation(s)
- R N Smith
- Department of Pathology, Massachusetts General Hospital, 501 Warren Bldg, 55 Fruit Street, Boston, MA, 02114, USA.
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155
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Hruba P, Madill-Thomsen K, Mackova M, Maluskova J, Voska L, Slatinska J, Halloran PF, Viklicky O. Three-month course of intragraft transcriptional changes in kidney allografts with early histological minimal injury - a cohort study. Transpl Int 2021; 34:974-985. [PMID: 33650206 DOI: 10.1111/tri.13856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/08/2021] [Accepted: 02/24/2021] [Indexed: 11/30/2022]
Abstract
The tubulitis with/without interstitial inflammation not meeting criteria for T-cell-mediated rejection (minimal allograft injury) is the most frequent histological findings in early transplant biopsies. The course of transcriptional changes in sequential kidney graft biopsies has not been studied yet. Molecular phenotypes were analyzed using the Molecular Microscope® Diagnostic System (MMDx) in 46 indication biopsies (median 13 postoperative days) diagnosed as minimal allograft injury and in corresponding follow-up biopsies at 3 months. All 46 patients with minimal injury in early biopsy received steroid pulses. MMDx interpreted indication biopsies as no-rejection in 34/46 (74%), T-cell-mediated rejection (TCMR) in 4/46 (9%), antibody-mediated rejection in 6/46 (13%), and mixed rejection in 2/46 (4%) cases. Follow-up biopsies were interpreted by MMDx in 37/46 (80%) cases as no-rejection, in 4/46 (9%) as TCMR, and in 5/46 (11%) as mixed rejection. Follow-up biopsies showed a decrease in MMDx-assessed acute kidney injury (P = 0.001) and an increase of atrophy-fibrosis (P = 0.002). The most significant predictor of MMDx rejection scores in follow-up biopsies was the tubulitis classifier score in initial biopsies (AUC = 0.84, P = 0.002), confirmed in multivariate binary regression (OR = 16, P = 0.016). Molecular tubulitis score at initial biopsy has the potential to discriminate patients at risk for molecular rejection score at follow-up biopsy.
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Affiliation(s)
- Petra Hruba
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Katelynn Madill-Thomsen
- Alberta Transplant Applied Genomics Centre, Edmonton, AB, Canada.,University of Alberta, Edmonton, AB, Canada
| | - Martina Mackova
- Alberta Transplant Applied Genomics Centre, Edmonton, AB, Canada
| | - Jana Maluskova
- Department of Pathology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ludek Voska
- Department of Pathology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Janka Slatinska
- Department of Nephrology and Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Philip F Halloran
- Alberta Transplant Applied Genomics Centre, Edmonton, AB, Canada.,University of Alberta, Edmonton, AB, Canada
| | - Ondrej Viklicky
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Department of Nephrology and Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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156
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Ali I, Kalra PA. A validation study of the 4-variable and 8-variable kidney failure risk equation in transplant recipients in the United Kingdom. BMC Nephrol 2021; 22:57. [PMID: 33563222 PMCID: PMC7874608 DOI: 10.1186/s12882-021-02259-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/31/2020] [Indexed: 12/23/2022] Open
Abstract
Background There is emerging evidence that the 4-variable Kidney Failure Risk Equation (KFRE) can be used for risk prediction of graft failure in transplant recipients. However, geographical validation of the 4-variable KFRE in transplant patients is lacking, as is whether the more extensive 8-variable KFRE improves predictive accuracy. This study aimed to validate the 4- and 8-variable KFRE predictions of the 5-year death-censored risk of graft failure in patients in the United Kingdom. Methods A retrospective cohort study involved 415 transplant recipients who had their first renal transplant between 2003 and 2015 and were under follow-up at Salford Royal NHS Foundation Trust. The KFRE risk scores were calculated on variables taken 1-year post-transplant. The area under the receiver operating characteristic curves (AUC) and calibration plots were evaluated to determine discrimination and calibration of the 4- and 8-variable KFREs in the whole cohort as well as in a subgroup analysis of living and deceased donor recipients and in patients with an eGFR< 45 ml/min/1.73m2. Results There were 16 graft failure events (4%) in the whole cohort. The 4- and 8-variable KFREs showed good discrimination with AUC of 0.743 (95% confidence interval [CI] 0.610–0.876) and 0.751 (95% CI 0.629–0.872) respectively. In patients with an eGFR< 45 ml/min/1.73m2, the 8-variable KFRE had good discrimination with an AUC of 0.785 (95% CI 0.558–0.982) but the 4-variable provided excellent discrimination in this group with an AUC of 0.817 (0.646–0.988). Calibration plots however showed poor calibration with risk scores tending to underestimate risk of graft failure in low-risk patients and overestimate risk in high-risk patients, which was seen in the primary and subgroup analyses. Conclusions Despite adequate discrimination, the 4- and 8-variable KFREs are imprecise in predicting graft failure in transplant recipients using data 1-year post-transplant. Larger, international studies involving diverse patient populations should be considered to corroborate these findings. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02259-4.
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Affiliation(s)
- Ibrahim Ali
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK. .,Division of Cardiovascular Sciences, University of Manchester, Manchester, M13 9PL, UK.
| | - Philip A Kalra
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK.,Division of Cardiovascular Sciences, University of Manchester, Manchester, M13 9PL, UK
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157
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Gokhale A, Chancay J, Shapiro R, Randhawa P, Menon MC. Chronic transplant glomerulopathy: New insights into pathogenesis. Clin Transplant 2021; 35:e14214. [PMID: 33389755 DOI: 10.1111/ctr.14214] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/16/2020] [Accepted: 12/18/2020] [Indexed: 01/20/2023]
Abstract
There have been recent significant advances in short-term outcomes in renal transplantation, however, long-term allograft survival remains a challenge. With reported incidences as high of 74.5% of chronic graft loss in patients with biopsies showing transplant glomerulopathy (TG), this syndrome represents an important factor for chronic allograft complications. In this review we show an overview of the novel mechanistic insights into pathogenesis of TG, as well as a brief description of the pathology, diagnosis and newer prognostic indices within TG diagnosis. These data raise intriguing roles for cell-mediated immunity and podocyte stress in TG as well as reinforce previous associations of TG with ABMR. We also delve into management strategies for TG and report the paucity of existing clinical trial data for this prevalent condition in renal transplants.
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Affiliation(s)
- Avantee Gokhale
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jorge Chancay
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ron Shapiro
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Parmjeet Randhawa
- The Thomas E. Starzl Transplantation Institute, Division of Transplantation Pathology at University of Pittsburgh, Pittsburgh, PA, USA
| | - Madhav C Menon
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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158
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Maldonado AQ, West-Thielke P, Joyal K, Rogers C. Advances in personalized medicine and noninvasive diagnostics in solid organ transplantation. Pharmacotherapy 2021; 41:132-143. [PMID: 33156560 DOI: 10.1002/phar.2484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 09/29/2020] [Accepted: 10/08/2020] [Indexed: 12/13/2022]
Abstract
Personalized medicine has been a mainstay and in practice in transplant pharmacotherapy since the advent of the field. Decisions pertaining to the diagnosis, selection, and monitoring of transplant pharmacotherapy are aimed toward the individual, the allograft, and the overall immunologic needs of the patient. Recent advances in pharmacogenomics, noninvasive biomarkers, and artificial intelligence (AI) technologies have the promise of transforming the way we individualize treatment and monitor allograft function. Pharmacogenomic testing can provide clinicians with additional data that can minimize toxicity and maximize therapeutic dosing in high-risk patients, leading to more informed decisions that may decrease the risk of rejection and adverse outcomes related to immunosuppressive therapies. Development of noninvasive strategies to monitor allograft function may offer safer and more convenient methods to detect allograft injury. Cell free DNA and gene expression profiling offer the potential to serve as "liquid biopsies" minimizing the risk to patients and providing clinicians with useful molecular data that may help individualize immunosuppression and rejection treatment. Use of big data in transplant and novel AI platforms, such as the iBox, hold tremendous promise in providing clinicians a "glimpse into the future" thereby allowing for a more individualized approach to immunosuppressive therapy that may minimize future adverse outcomes. Advances in diagnostics, laboratory science, and AI have made the application of personalized medicine even more tailored for solid organ transplant recipients. In this perspective, we summarize the current and emerging tools available, literature supporting use, and the horizon for future personalization of transplantation.
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Affiliation(s)
| | | | - Kayla Joyal
- Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
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159
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Mayer KA, Doberer K, Eskandary F, Halloran PF, Böhmig GA. New concepts in chronic antibody-mediated kidney allograft rejection: prevention and treatment. Curr Opin Organ Transplant 2021; 26:97-105. [PMID: 33315763 DOI: 10.1097/mot.0000000000000832] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Chronic antibody-mediated rejection (AMR) is a cardinal cause of transplant failure, with currently no proven effective prevention or treatment. The present review will focus on new therapeutic concepts currently under clinical evaluation. RECENT FINDINGS One interesting treatment approach may be interference with interleukin-6 (IL-6) signaling to modulate B-cell immunity and donor-specific antibody (DSA) production. Currently, a large phase III randomized controlled trial is underway to clarify the safety and efficacy of clazakizumab, a high-affinity anti-IL-6 antibody, in chronic AMR. A prevention/treatment strategy may be costimulation blockade using belatacept to interfere with germinal center responses and DSA formation. In a recent uncontrolled study, belatacept conversion was shown to stabilize renal function and dampen AMR activity. Moreover, preliminary clinical results suggest efficacy of CD38 antibodies to deplete plasma and natural killer cells to treat AMR, with anecdotal reports demonstrating at least transient resolution of active rejection. SUMMARY There are promising concepts on the horizon for the prevention and treatment of chronic AMR. The design of adequately powered placebo-controlled trials to clarify the safety and efficacy of such new therapies, however, remains a big challenge, and will rely on the definition of precise surrogate endpoints predicting long-term allograft survival. Mapping the natural history of AMR would greatly help the understanding of who would derive benefits from treatment.
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Affiliation(s)
- Katharina A Mayer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Konstantin Doberer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Philip F Halloran
- Alberta Transplant Applied Genomics Centre (ATAGC), University of Alberta, Edmonton, AB, Canada
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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160
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Coutance G, Kransdorf E, Bonnet G, Loupy A, Kobashigawa J, Patel JK. Statistical performance of 16 posttransplant risk scores in a contemporary cohort of heart transplant recipients. Am J Transplant 2021; 21:645-656. [PMID: 32713121 DOI: 10.1111/ajt.16217] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/06/2020] [Accepted: 07/19/2020] [Indexed: 01/25/2023]
Abstract
Accurate risk stratification of early heart transplant failure is required to avoid futile transplants and rationalize donor selection. We aimed to evaluate the statistical performance of existing risk scores on a contemporary cohort of heart transplant recipients. After an exhaustive search, we identified 16 relevant risk scores. From the UNOS database, we selected all first noncombined adult heart transplants performed between 2014 and 2017 for validation. The primary endpoint was death or retransplant during the first year posttransplant. For all scores, we analyzed their association with outcomes, sensitivity, specificity, likelihood ratios, and discrimination (concordance index and overlap of individual scores). The cohort included 9396 patients. All scores were significantly associated with the primary outcome (P < .001 for all scores). Their likelihood ratios, both negative and positive, were poor. The discriminative performance of all scores was limited, with concordance index ranging from 0.544 to 0.646 (median 0.594) and an important overlap of individual scores between patients with or without the primary endpoint. Subgroup analyses revealed important variation in discrimination according to donor age, recipient age, and the type of assist device used at transplant. Our findings raise concerns about the use of currently available scores in the clinical field.
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Affiliation(s)
- Guillaume Coutance
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, California, USA.,Paris Translational Research Centre for Organ Transplantation, Université de Paris, INSERM UMR 970, Paris, France
| | - Evan Kransdorf
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, California, USA
| | - Guillaume Bonnet
- Paris Translational Research Centre for Organ Transplantation, Université de Paris, INSERM UMR 970, Paris, France
| | - Alexandre Loupy
- Paris Translational Research Centre for Organ Transplantation, Université de Paris, INSERM UMR 970, Paris, France
| | - Jon Kobashigawa
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, California, USA
| | - Jignesh K Patel
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, California, USA
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161
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Lenain R, Dantan E, Giral M, Foucher Y, Asar Ö, Naesens M, Hazzan M, Fournier MC. External Validation of the DynPG for Kidney Transplant Recipients. Transplantation 2021; 105:396-403. [PMID: 32108750 DOI: 10.1097/tp.0000000000003209] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In kidney transplantation, dynamic prediction of patient and kidney graft survival (DynPG) may help to promote therapeutic alliance by delivering personalized evidence-based information about long-term graft survival for kidney transplant recipients. The objective of the current study is to externally validate the DynPG. METHODS Based on 6 baseline variables, the DynPG can be updated with any new serum creatinine measure available during the follow-up. From an external validation sample of 1637 kidney recipients with a functioning graft at 1-year posttransplantation from 2 European transplantation centers, we assessed the prognostic performance of the DynPG. RESULTS As one can expect from an external validation sample, differences in several recipient, donor, and transplantation characteristics compared with the learning sample were observed. Patients were mainly transplanted from deceased donors (91.6% versus 84.8%; P < 0.01), were less immunized against HLA class I (18.4% versus 32.7%; P < 0.01) and presented less comorbidities (62.2% for hypertension versus 82.7%, P < 0.01; 25.1% for cardiovascular disease versus 33.9%, P < 0.01). Despite these noteworthy differences, the area under the ROC curve varied from 0.70 (95% confidence interval [CI], 0.64-0.76) to 0.76 (95% CI, 0.64-0.88) for prediction times at 1 and 6 years posttransplantation respectively, and calibration plots revealed reasonably accurate predictions. CONCLUSIONS We validated the prognostic capacities of the DynPG in terms of both discrimination and calibration. Our study showed the robustness of the DynPG for informing both the patient and the physician, and its transportability for a cohort presenting different features than the one used for the DynPG development.
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Affiliation(s)
- Rémi Lenain
- Department of Nephrology, Huriez Hospital, Lille University Hospital, Lille, France
| | - Etienne Dantan
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
| | - Magali Giral
- CRTI UMR 1064, Inserm, Université de Nantes, ITUN, CHU Nantes, RTRS Centaure, Nantes, France
- Centre d'Investigation Clinique en Biothérapie, Nantes, France
| | - Yohann Foucher
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Özgür Asar
- Department of Biostatistics and Medical Informatics, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Marc Hazzan
- Department of Nephrology, Huriez Hospital, Lille University Hospital, Lille, France
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162
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Hoogduijn MJ, Issa F, Casiraghi F, Reinders MEJ. Cellular therapies in organ transplantation. Transpl Int 2021; 34:233-244. [PMID: 33207013 PMCID: PMC7898347 DOI: 10.1111/tri.13789] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/15/2020] [Accepted: 11/13/2020] [Indexed: 02/06/2023]
Abstract
Cellular therapy is a promising tool for improving the outcome of organ transplantation. Various cell types with different immunoregulatory and regenerative properties may find application for specific transplant rejection or injury-related indications. The current era is crucial for the development of cellular therapies. Preclinical models have demonstrated the feasibility of efficacious cell therapy in transplantation, early clinical trials have shown safety of several of these therapies, and the first steps towards efficacy studies in humans have been made. In this review, we address the current state of the art of cellular therapies in clinical transplantation and discuss monitoring tools and endpoints for these studies.
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Affiliation(s)
- Martin J. Hoogduijn
- Nephrology and TransplantationDepartment of Internal MedicineErasmus University Medical CenterErasmus Medical CenterRotterdamThe Netherlands
| | - Fadi Issa
- Transplantation Research and Immunology GroupNuffield Department of Surgical SciencesJohn Radcliffe HospitalUniversity of OxfordOxfordUK
| | | | - Marlies E. J. Reinders
- Nephrology and TransplantationDepartment of Internal MedicineErasmus University Medical CenterErasmus Medical CenterRotterdamThe Netherlands
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Giarraputo A, Barison I, Fedrigo M, Burrello J, Castellani C, Tona F, Bottio T, Gerosa G, Barile L, Angelini A. A Changing Paradigm in Heart Transplantation: An Integrative Approach for Invasive and Non-Invasive Allograft Rejection Monitoring. Biomolecules 2021; 11:biom11020201. [PMID: 33535640 PMCID: PMC7912846 DOI: 10.3390/biom11020201] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/23/2021] [Accepted: 01/27/2021] [Indexed: 02/06/2023] Open
Abstract
Cardiac allograft rejection following heart transplantation is challenging to diagnose. Tissue biopsies are the gold standard in monitoring the different types of rejection. The last decade has seen an increased emphasis on identifying non-invasive methods to improve rejection diagnosis and overcome tissue biopsy invasiveness. Liquid biopsy, as an efficient non-invasive diagnostic and prognostic oncological monitoring tool, seems to be applicable in heart transplant follow-ups. Moreover, molecular techniques applied on blood can be translated to tissue samples to provide novel perspectives on tissue and reveal new diagnostic and prognostic biomarkers. This review aims to provide a comprehensive overview of the state-of-the-art of the new methodologies in cardiac allograft rejection monitoring and investigate the future perspectives on invasive and non-invasive rejection biomarkers identification. We reviewed literature from the most used scientific databases, such as PubMed, Google Scholar, and Scopus. We extracted 192 papers and, after a selection and exclusion process, we included in the review 81 papers. The described limitations notwithstanding, this review show how molecular biology techniques and omics science could be deployed complementarily to the histopathological rejection diagnosis on tissue biopsies, thus representing an integrated approach for heart transplant patients monitoring.
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Affiliation(s)
- Alessia Giarraputo
- Cardiovascular Pathology and Pathological Anatomy, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy; (A.G.); (I.B.); (M.F.); (C.C.)
| | - Ilaria Barison
- Cardiovascular Pathology and Pathological Anatomy, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy; (A.G.); (I.B.); (M.F.); (C.C.)
| | - Marny Fedrigo
- Cardiovascular Pathology and Pathological Anatomy, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy; (A.G.); (I.B.); (M.F.); (C.C.)
| | - Jacopo Burrello
- Laboratory for Cardiovascular Theranostics, Cardiocentro Ticino Foundation, 6900 Lugano, Switzerland; (J.B.); (L.B.)
| | - Chiara Castellani
- Cardiovascular Pathology and Pathological Anatomy, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy; (A.G.); (I.B.); (M.F.); (C.C.)
| | - Francesco Tona
- Division of Cardiac Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy; (F.T.); (T.B.); (G.G.)
| | - Tomaso Bottio
- Division of Cardiac Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy; (F.T.); (T.B.); (G.G.)
| | - Gino Gerosa
- Division of Cardiac Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy; (F.T.); (T.B.); (G.G.)
| | - Lucio Barile
- Laboratory for Cardiovascular Theranostics, Cardiocentro Ticino Foundation, 6900 Lugano, Switzerland; (J.B.); (L.B.)
- Faculty of Biomedical Sciences, Università Svizzera Italiana, 6900 Lugano, Switzerland
- Institute of Life Sciences, Scuola Superiore Sant’Anna, 56127 Pisa, Italy
| | - Annalisa Angelini
- Cardiovascular Pathology and Pathological Anatomy, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy; (A.G.); (I.B.); (M.F.); (C.C.)
- Correspondence: ; Tel.: +39-049-821-1699
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Development and external validation study combining existing models and recent data into an up-to-date prediction model for evaluating kidneys from older deceased donors for transplantation. Kidney Int 2020; 99:1459-1469. [PMID: 33340517 DOI: 10.1016/j.kint.2020.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/11/2020] [Accepted: 11/05/2020] [Indexed: 11/20/2022]
Abstract
With a rising demand for kidney transplantation, reliable pre-transplant assessment of organ quality becomes top priority. In clinical practice, physicians are regularly in doubt whether suboptimal kidney offers from older donors should be accepted. Here, we externally validate existing prediction models in a European population of older deceased donors, and subsequently developed and externally validated an adverse outcome prediction tool. Recipients of kidney grafts from deceased donors 50 years of age and older were included from the Netherlands Organ Transplant Registry (NOTR) and United States organ transplant registry from 2006-2018. The predicted adverse outcome was a composite of graft failure, death or chronic kidney disease stage 4 plus within one year after transplantation, modelled using logistic regression. Discrimination and calibration were assessed in internal, temporal and external validation. Seven existing models were validated with the same cohorts. The NOTR development cohort contained 2510 patients and 823 events. The temporal validation within NOTR had 837 patients and the external validation used 31987 patients in the United States organ transplant registry. Discrimination of our full adverse outcome model was moderate in external validation (C-statistic 0.63), though somewhat better than discrimination of the seven existing prediction models (average C-statistic 0.57). The model's calibration was highly accurate. Thus, since existing adverse outcome kidney graft survival models performed poorly in a population of older deceased donors, novel models were developed and externally validated, with maximum achievable performance in a population of older deceased kidney donors. These models could assist transplant clinicians in deciding whether to accept a kidney from an older donor.
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165
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Xin Z, Wu L, Zhou J, Zhuang J, Peng W, Song T, Lin T, Lu X, Ying B. Analysis of Factors Influencing Kidney Function of Recipients After Renal Transplantation in Southwestern China: A Retrospective Study. Front Med (Lausanne) 2020; 7:519582. [PMID: 33282882 PMCID: PMC7689199 DOI: 10.3389/fmed.2020.519582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 10/19/2020] [Indexed: 11/26/2022] Open
Abstract
Background: Factors influencing the kidney function of patients after renal transplantation include both recipient-related factors and donor-related factors. To gain a better understanding of these factors and to improve clinical decision-making, we performed a retrospective study of southwestern Chinese people receiving kidney transplantation. Methods: In this retrospective analysis, a total of 2,462 recipients receiving allogeneic kidney transplantation in West China Hospital of Sichuan University from December 13, 2008 to January 10, 2018 were included. Data on recipient and donor characteristics were extracted from the Transplant Center Database and stratified by discrete time points after kidney transplantation. Univariate and multivariate logistic regression analyses were carried out on the study variables, and kidney function of postoperative patients was monitored using cystatin C (CysC) as the outcome indicator. Results: From the univariate analysis, several factors showed statistically significant short-term impact on kidney function based on CysC after kidney transplantation, including age, ethnicity, body mass index (BMI), and HLA A-B-DR-DQ loci mismatch. Gender of recipients and gender-consistency between donors and recipients revealed both short-term and long-term influence. Younger donors had significantly better medium-and-long-term influence on kidney function. From the multivariate logistic regression analysis, recipient gender, ethnicity, BMI, and donor age were independent factors affecting postoperative CysC recovery at discrete time points. Conclusion: Several factors of recipients related to renal function after kidney transplantation, such as gender, ethnicity, BMI and donor's age should be paid more attention to. Moreover, female and non-Han recipients decreased the risk of poor outcome during postoperative kidney function recovery while large BMI of recipients and higher donor age increased the risk. It is useful to predict the postoperative renal function earlier according to corresponding factors, and improve the patient's quality of life.
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Affiliation(s)
- Zhaodan Xin
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Lijuan Wu
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Juan Zhou
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Jie Zhuang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Wu Peng
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Turun Song
- Department of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Tao Lin
- Department of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaojun Lu
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Xiaojun Lu
| | - Binwu Ying
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
- Binwu Ying
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166
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Research Highlights. Transplantation 2020. [DOI: 10.1097/tp.0000000000003464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Rationale & Objective The Kidney Failure Risk Equation (KFRE) is a simple widely validated prediction model using age, sex, estimated glomerular filtration rate, and urinary albumin-creatinine ratio to predict the risk for end-stage kidney disease. Data are limited for its applicability to kidney transplant recipients. Study Design Validation study of the KFRE as a post hoc analysis of the Folic Acid for Vascular Outcomes Reduction in Transplantation (FAVORIT) Trial. Setting & Participants Adult kidney transplant recipients with functioning kidney allografts at least 6 months posttransplantation from 30 centers in the United States, Canada, and Brazil. Participants with estimated glomerular filtration rates < 60 mL/min/1.73 m2 at study entry were included. Predictor 2- and 5-year kidney failure risk predicted by the KFRE using variables at study entry. Outcome Graft loss, defined by initiation of dialysis. Analytical Approach Discrimination of the KFRE was assessed using C statistics; calibration was assessed by plotting predicted risk against observed cumulative incidence of graft loss. Results 2,889 participants were included. Within 2 years, 98 participants developed graft loss, 107 participants died with a functioning graft, and 129 participants were lost to follow-up, and by 5 years, 252 had developed graft loss, 265 died with a functioning graft, and 1,543 were lost to follow-up. The KFRE demonstrated accurate calibration and discrimination (C statistic, 0.85 [95% CI, 0.81-0.88] at 2 years and 0.81 [95% CI, 0.78-0.84] at 5 years); performance was similar regardless of donor type (living vs deceased) and graft vintage, with the noted exception of poorer calibration for graft vintage less than 2 years. Limitations Unavailable cause of graft loss. Conclusions The KFRE accurately predicted the risk for graft loss among adult kidney transplant recipients with graft vintage longer than 2 years and may be a useful prognostic tool for nephrologists caring for kidney transplant recipients.
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168
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Organ allocation in the age of the algorithm: avoiding futile transplantation - utility in allocation. Curr Opin Organ Transplant 2020; 25:305-309. [PMID: 32304427 DOI: 10.1097/mot.0000000000000752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW This review describes and questions the evolution of allocation systems from local team decisions in the 20th century to patient-oriented allocation using complex algorithm predicting transplant benefit. RECENT FINDINGS The opening years of the 2000s have seen the implementation of prioritization scores aiming at increasing transparency and reducing waitlist mortality. The 2010s have underlined the necessity of drawing the upper limits of how sick a patient can be while still ensuring acceptable survival. More complex algorithms evaluating transplant benefit have been implemented in allocation systems to take this issue into account. SUMMARY Allocation algorithms are becoming more and more complex, integrating numerous parameters from both donor and recipient to achieve optimal matching. The limitations of implementing these complex algorithms are represented by the evermoving waiting list demography, geographic disparities between recipients and donors, team policy adaptation to rule changes, and implicit biases within the transplant community. Survival as the only metric by which to define benefit may be seen as restrictive; quality of life may be a fruitful measure for better defining benefit in organ transplantation in the future.
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169
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Montero N, Codina S, Cruzado JM. Prediction scores for risk of allograft loss in patients receiving kidney transplants: nil satis nisi optimum. Clin Kidney J 2020; 13:745-748. [PMID: 33125003 PMCID: PMC7577772 DOI: 10.1093/ckj/sfaa081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 04/21/2020] [Indexed: 12/16/2022] Open
Abstract
Long-term graft survival is the main concern of kidney transplantation. Some strategies have been tested to predict graft survival using estimated glomerular filtration rate or proteinuria at different time points, histologic assessment, non-invasive biomarkers or even machine-learning methods. However, the 'magical formulae' for allograft survival prediction does not exist yet.
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Affiliation(s)
- Nuria Montero
- Department of Nephrology, Hospital Universitari de Bellvitge, L’ Hospitalet de Llobregat, Barcelona, Spain
- Biomedical Research Institute (IDIBELL), L’ Hospitalet de Llobregat, University of Barcelona, Barcelona, Spain
| | - Sergi Codina
- Department of Nephrology, Hospital Universitari de Bellvitge, L’ Hospitalet de Llobregat, Barcelona, Spain
| | - Josep M Cruzado
- Department of Nephrology, Hospital Universitari de Bellvitge, L’ Hospitalet de Llobregat, Barcelona, Spain
- Biomedical Research Institute (IDIBELL), L’ Hospitalet de Llobregat, University of Barcelona, Barcelona, Spain
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170
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Tambur AR, Campbell P, Chong AS, Feng S, Ford ML, Gebel H, Gill RG, Kelsoe G, Kosmoliaptsis V, Mannon RB, Mengel M, Reed EF, Valenzuela NM, Wiebe C, Dijke IE, Sullivan HC, Nickerson P. Sensitization in transplantation: Assessment of risk (STAR) 2019 Working Group Meeting Report. Am J Transplant 2020; 20:2652-2668. [PMID: 32342639 PMCID: PMC7586936 DOI: 10.1111/ajt.15937] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 04/01/2020] [Accepted: 04/20/2020] [Indexed: 01/25/2023]
Abstract
The purpose of the STAR 2019 Working Group was to build on findings from the initial STAR report to further clarify the expectations, limitations, perceptions, and utility of alloimmune assays that are currently in use or in development for risk assessment in the setting of organ transplantation. The goal was to determine the precision and clinical feasibility/utility of such assays in evaluating both memory and primary alloimmune risks. The process included a critical review of biologically driven, state-of-the-art, clinical diagnostics literature by experts in the field and an open public forum in a face-to-face meeting to promote broader engagement of the American Society of Transplantation and American Society of Histocompatibility and Immunogenetics membership. This report summarizes the literature review and the workshop discussions. Specifically, it highlights (1) available assays to evaluate the attributes of HLA antibodies and their utility both as clinical diagnostics and as research tools to evaluate the effector mechanisms driving rejection; (2) potential assays to assess the presence of alloimmune T and B cell memory; and (3) progress in the development of HLA molecular mismatch computational scores as a potential prognostic biomarker for primary alloimmunity and its application in research trial design.
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Affiliation(s)
- Anat R. Tambur
- Department of SurgeryComprehensive Transplant CenterNorthwestern UniversityChicagoIllinoisUSA
| | - Patricia Campbell
- Department of Laboratory Medicine & PathologyUniversity of AlbertaEdmontonCanada
| | - Anita S. Chong
- Section of TransplantationDepartment of SurgeryThe University of ChicagoChicagoIllinoisUSA
| | - Sandy Feng
- Department of SurgeryUCSF Medical CenterSan FranciscoCaliforniaUSA
| | - Mandy L. Ford
- Department of Surgery and Emory Transplant CenterEmory UniversityAtlantaGeorgiaUSA
| | - Howard Gebel
- Department of PathologyEmory University School of MedicineAtlantaGeorgiaUSA
| | - Ronald G. Gill
- Department of ImmunologyUniversity of ColoradoDenverColoradoUSA
| | - Garnett Kelsoe
- Department of ImmunologyDuke University School of MedicineDurhamNorth CarolinaUSA
| | | | - Roslyn B. Mannon
- Department of MedicineDivision of NephrologyUniversity of Alabama School of MedicineBirminghamAlabamaUSA
| | - Michael Mengel
- Department of Laboratory Medicine & PathologyUniversity of AlbertaEdmontonCanada
| | - Elaine F. Reed
- Department of Pathology and Laboratory MedicineDavid Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA
| | - Nicole M. Valenzuela
- Department of Pathology and Laboratory MedicineDavid Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA
| | - Chris Wiebe
- Department of MedicineUniversity of ManitobaWinnipegManitobaCanada
| | - I. Esme Dijke
- Department of Laboratory Medicine & PathologyUniversity of AlbertaEdmontonCanada
| | - Harold C. Sullivan
- Department of PathologyEmory University School of MedicineAtlantaGeorgiaUSA
| | - Peter Nickerson
- Department of MedicineUniversity of ManitobaWinnipegManitobaCanada
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Gray JN, Wolf-Doty T, Sulejmani N, Gaber O, Axelrod D, Abdalla B, Danovitch G. KidneyCare Guided Immuno-Optimization in Renal Allografts: The KIRA Protocol. Methods Protoc 2020; 3:E68. [PMID: 33007896 PMCID: PMC7712506 DOI: 10.3390/mps3040068] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 09/20/2020] [Accepted: 09/25/2020] [Indexed: 01/09/2023] Open
Abstract
Immunosuppressant agents are essential in every transplant recipient's care yet walking the fine line of over- or under-immunosuppression is a constant struggle for both patients and transplant providers alike. Optimization and personalization of immunosuppression has been limited by the need for non-invasive graft surveillance methods that are specific enough to identify organ injury in real time. With this in mind, we propose a pilot study protocol utilizing both donor derived cell free DNA (dd-cfDNA, gene expression profiling (GEP), and machine learning (iBox), called KidneyCare, to assess the feasibility and safety in reducing immunosuppressant exposure without increasing the risk of clinical rejection, graft injury, or allograft loss. Patients randomized to the immunominimization arm will be enrolled in one of two protocols designed to eliminate one immunosuppressant and optimize the dose of the Calcineurin Inhibitors (CNIs) using the KidneyCare platform. All patients will be maintained on dual therapy of either steroids and a low dose CNI, or mycophenolate mofetil (MMF) and low dose CNI. Their outcomes will be compared to patients who have their immunosuppressants managed using standard clinical assessment and treatment protocols to determine the impact of immuno-optimization on graft function, complications, and patient reported outcomes.
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Affiliation(s)
- Jennifer N. Gray
- CareDx, 3260 Bayshore Blvd, Brisbane, CA 94005, USA; (T.W.-D.); (N.S.)
| | - Theresa Wolf-Doty
- CareDx, 3260 Bayshore Blvd, Brisbane, CA 94005, USA; (T.W.-D.); (N.S.)
| | - Nimisha Sulejmani
- CareDx, 3260 Bayshore Blvd, Brisbane, CA 94005, USA; (T.W.-D.); (N.S.)
| | - Osama Gaber
- Houston Methodist Hospital, 6565 Fannin St. Houston, TX 77030, USA;
| | - David Axelrod
- Department of Surgery, University of Iowa Medical Center, 200 Hawkins Dr, Iowa City, IA 52242, USA;
| | - Basmah Abdalla
- UCLA Medical Center, 757 Westwood Plaza, Los Angeles, CA 90095, USA; (B.A.); (G.D.)
| | - Gabriel Danovitch
- UCLA Medical Center, 757 Westwood Plaza, Los Angeles, CA 90095, USA; (B.A.); (G.D.)
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172
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Logistic Regression Model in a Machine Learning Application to Predict Elderly Kidney Transplant Recipients with Worse Renal Function One Year after Kidney Transplant: Elderly KTbot. J Aging Res 2020; 2020:7413616. [PMID: 32922997 PMCID: PMC7453245 DOI: 10.1155/2020/7413616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 07/22/2020] [Indexed: 12/22/2022] Open
Abstract
Background Renal replacement therapy (RRT) is a public health problem worldwide. Kidney transplantation (KT) is the best treatment for elderly patients' longevity and quality of life. Objectives The primary endpoint was to compare elderly versus younger KT recipients by analyzing the risk covariables involved in worsening renal function, proteinuria, graft loss, and death one year after KT. The secondary endpoint was to create a robot based on logistic regression capable of predicting the likelihood that elderly recipients will develop worse renal function one year after KT. Method Unicentric retrospective analysis of a cohort was performed with individuals aged ≥60 and <60 years old. We analysed medical records of KT recipients from January to December 2017, with a follow-up time of one year after KT. We used multivariable logistic regression to estimate odds ratios for elderly vs younger recipients, controlled for demographic, clinical, laboratory, data pre- and post-KT, and death. Results 18 elderly and 100 younger KT recipients were included. Pretransplant immune variables were similar between two groups. No significant differences (P > 0.05) between groups were observed after KT on laboratory data means and for the prevalences of diabetes mellitus, hypertension, acute rejection, cytomegalovirus, polyomavirus, and urinary infections. One year after KT, the creatinine clearance was higher (P = 0.006) in youngers (70.9 ± 25.2 mL/min/1.73 m2) versus elderlies (53.3 ± 21.1 mL/min/1.73 m2). There was no difference in death outcome comparison. Multivariable analysis among covariables predisposing chronic kidney disease epidemiology collaboration (CKD-EPI) equation <60 mL/min/1.73 m2 presented a statistical significance for age ≥60 years (P = 0.01) and reduction in serum haemoglobin (P = 0.03). The model presented goodness-fit in the evaluation of artificial intelligence metrics (precision: 90%; sensitivity: 71%; and F 1 score: 0.79). Conclusion Renal function in elderly KT recipients was lower than in younger KT recipients. However, patients aged ≥60 years maintained enough renal function to remain off dialysis. Moreover, a learning machine application built a robot (Elderly KTbot) to predict in the elderly populations the likelihood of worse renal function one year after KT.
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173
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Gupta G, Raynaud M, Kumar D, Sanghi P, Chang J, Kimball P, Kang L, Levy M, Sharma A, Bhati CS, Kamal L, Yakubu I, Massey HD, Kidd C, King AL, Halloran PF. Impact of belatacept conversion on kidney transplant function, histology, and gene expression - a single-center study. Transpl Int 2020; 33:1458-1471. [PMID: 32790889 DOI: 10.1111/tri.13718] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/28/2020] [Accepted: 08/07/2020] [Indexed: 11/28/2022]
Abstract
Prior studies on belatacept conversion from calcineurin inhibitor (CNI) have been limited by an absence of postconversion surveillance biopsies that could underestimate subclinical rejection, or a case-controlled design. A total of 53 adult patients with allograft dysfunction underwent belatacept conversion (median: 6 months) post-transplant. At a median follow-up = 2.5 years, patient survival was 94% with a death-censored graft survival of 85%. Seven (13%) patients had acute rejection (including 3 subclinical) at median 6 months postconversion. Overall, eGFR improved (P = <0.001) from baseline = 31±15 to 40.2 ± 17.6 ml/min/1.73m2 by 6 months postconversion, but then stayed stable. This improvement was also observed (P < 0.001) in comparison with a propensity matched control cohort on CNI, where eGFR stayed stable (mean ~ 32ml/min/1.72m2 ) over 2-year follow-up. Patients converted < 6 months post-transplant were more likely to have a long-term improvement in kidney function. Paired gene expression analysis of 30 (of 53) consecutive pre- and postconversion surveillance biopsies did not reveal changes in inflammation/acute injury; although atrophy-fibrosis score worsened (mean = 0.28 to 0.44; P = 0.005). Thus, improvement in renal function with belatacept conversion occurred early and then sustained in comparison with controls where renal function remained unchanged overtime. We were unable to show molecular signals that could be related to CNI administration and regressed after withdrawal.
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Affiliation(s)
- Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Dhiren Kumar
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | - Pooja Sanghi
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | - Jessica Chang
- Alberta Transplant Applied Genomics Center, Edmonton, AB, Canada
| | - Pam Kimball
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Le Kang
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Marlon Levy
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Amit Sharma
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Chandra S Bhati
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Layla Kamal
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | - Idris Yakubu
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Hugh D Massey
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Chelsea Kidd
- Department of Pathology, Virginia Commonwealth University, Richmond, VA, USA
| | - Anne L King
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
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174
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Advances and New Insights in Post-Transplant Care: From Sequencing to Imaging. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00828-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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175
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Loupy A, Haas M, Roufosse C, Naesens M, Adam B, Afrouzian M, Akalin E, Alachkar N, Bagnasco S, Becker JU, Cornell LD, Clahsen‐van Groningen MC, Demetris AJ, Dragun D, Duong van Huyen J, Farris AB, Fogo AB, Gibson IW, Glotz D, Gueguen J, Kikic Z, Kozakowski N, Kraus E, Lefaucheur C, Liapis H, Mannon RB, Montgomery RA, Nankivell BJ, Nickeleit V, Nickerson P, Rabant M, Racusen L, Randhawa P, Robin B, Rosales IA, Sapir‐Pichhadze R, Schinstock CA, Seron D, Singh HK, Smith RN, Stegall MD, Zeevi A, Solez K, Colvin RB, Mengel M. The Banff 2019 Kidney Meeting Report (I): Updates on and clarification of criteria for T cell- and antibody-mediated rejection. Am J Transplant 2020; 20:2318-2331. [PMID: 32463180 PMCID: PMC7496245 DOI: 10.1111/ajt.15898] [Citation(s) in RCA: 426] [Impact Index Per Article: 106.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/24/2020] [Accepted: 03/10/2020] [Indexed: 01/25/2023]
Abstract
The XV. Banff conference for allograft pathology was held in conjunction with the annual meeting of the American Society for Histocompatibility and Immunogenetics in Pittsburgh, PA (USA) and focused on refining recent updates to the classification, advances from the Banff working groups, and standardization of molecular diagnostics. This report on kidney transplant pathology details clarifications and refinements to the criteria for chronic active (CA) T cell-mediated rejection (TCMR), borderline, and antibody-mediated rejection (ABMR). The main focus of kidney sessions was on how to address biopsies meeting criteria for CA TCMR plus borderline or acute TCMR. Recent studies on the clinical impact of borderline infiltrates were also presented to clarify whether the threshold for interstitial inflammation in diagnosis of borderline should be i0 or i1. Sessions on ABMR focused on biopsies showing microvascular inflammation in the absence of C4d staining or detectable donor-specific antibodies; the potential value of molecular diagnostics in such cases and recommendations for use of the latter in the setting of solid organ transplantation are presented in the accompanying meeting report. Finally, several speakers discussed the capabilities of artificial intelligence and the potential for use of machine learning algorithms in diagnosis and personalized therapeutics in solid organ transplantation.
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176
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Wiebe C, Rush DN, Gibson IW, Pochinco D, Birk PE, Goldberg A, Blydt‐Hansen T, Karpinski M, Shaw J, Ho J, Nickerson PW. Evidence for the alloimmune basis and prognostic significance of Borderline T cell-mediated rejection. Am J Transplant 2020; 20:2499-2508. [PMID: 32185878 PMCID: PMC7496654 DOI: 10.1111/ajt.15860] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/05/2020] [Accepted: 03/07/2020] [Indexed: 02/06/2023]
Abstract
Prognostic biomarkers of T cell-mediated rejection (TCMR) have not been adequately studied in the modern era. We evaluated 803 renal transplant recipients and correlated HLA-DR/DQ molecular mismatch alloimmune risk categories (low, intermediate, high) with the severity, frequency, and persistence of TCMR. Allograft survival was reduced in recipients with Banff Borderline (hazard ratio [HR] 2.4, P = .003) and Banff ≥ IA TCMR (HR 4.3, P < .0001) including a subset who never developed de novo donor-specific antibodies (P = .002). HLA-DR/DQ molecular mismatch alloimmune risk categories were multivariate correlates of Banff Borderline and Banff ≥ IA TCMR and correlated with the severity and frequency of rejection episodes. Recipient age, HLA-DR/DQ molecular mismatch category, and cyclosporin vs tacrolimus immunosuppression were independent correlates of Banff Borderline and Banff ≥ IA TCMR. In the subset treated with tacrolimus (720/803) recipient age, HLA-DR/DQ molecular mismatch category, and tacrolimus coefficient of variation were independent correlates of TCMR. The correlation of HLA-DR/DQ molecular mismatch category with TCMR, including Borderline, provides evidence for their alloimmune basis. HLA-DR/DQ molecular mismatch may represent a precise prognostic biomarker that can be applied to tailor immunosuppression or design clinical trials based on individual patient risk.
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Affiliation(s)
- Chris Wiebe
- Department of MedicineUniversity of ManitobaWinnipegCanada
- Shared Health Services ManitobaWinnipegCanada
- Department of ImmunologyUniversity of ManitobaWinnipegCanada
| | - David N. Rush
- Department of MedicineUniversity of ManitobaWinnipegCanada
| | - Ian W. Gibson
- Shared Health Services ManitobaWinnipegCanada
- Department of PathologyUniversity of ManitobaWinnipegCanada
| | | | - Patricia E. Birk
- Department of Pediatrics and Child HealthUniversity of ManitobaWinnipegCanada
| | - Aviva Goldberg
- Department of Pediatrics and Child HealthUniversity of ManitobaWinnipegCanada
| | - Tom Blydt‐Hansen
- Department of PediatricsUniversity of British ColumbiaWinnipegCanada
| | | | - Jamie Shaw
- Department of MedicineUniversity of ManitobaWinnipegCanada
| | - Julie Ho
- Department of MedicineUniversity of ManitobaWinnipegCanada
- Department of ImmunologyUniversity of ManitobaWinnipegCanada
| | - Peter W. Nickerson
- Department of MedicineUniversity of ManitobaWinnipegCanada
- Shared Health Services ManitobaWinnipegCanada
- Department of ImmunologyUniversity of ManitobaWinnipegCanada
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177
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Farris AB, Moghe I, Wu S, Hogan J, Cornell LD, Alexander MP, Kers J, Demetris AJ, Levenson RM, Tomaszewski J, Barisoni L, Yagi Y, Solez K. Banff Digital Pathology Working Group: Going digital in transplant pathology. Am J Transplant 2020; 20:2392-2399. [PMID: 32185875 PMCID: PMC7496838 DOI: 10.1111/ajt.15850] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/25/2020] [Accepted: 02/27/2020] [Indexed: 01/25/2023]
Abstract
The Banff Digital Pathology Working Group (DPWG) was formed in the time leading up to and during the joint American Society for Histocompatibility and Immunogenetics/Banff Meeting, September 23-27, 2019, held in Pittsburgh, Pennsylvania. At the meeting, the 14th Banff Conference, presentations directly and peripherally related to the topic of "digital pathology" were presented; and discussions before, during, and after the meeting have resulted in a list of issues to address for the DPWG. Included are practice standardization, integrative approaches for study classification, scoring of histologic parameters (eg, interstitial fibrosis and tubular atrophy and inflammation), algorithm classification, and precision diagnosis (eg, molecular pathways and therapeutics). Since the meeting, a survey with international participation of mostly pathologists (81%) was conducted, showing that whole slide imaging is available at the majority of centers (71%) but that artificial intelligence (AI)/machine learning was only used in ≈12% of centers, with a wide variety of programs/algorithms employed. Digitalization is not just an end in itself. It also is a necessary precondition for AI and other approaches. Discussions at the meeting and the survey highlight the unmet need for a Banff DPWG and point the way toward future contributions that can be made.
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Affiliation(s)
| | | | - Simon Wu
- University of AlbertaEdmontonCanada
| | | | | | | | - Jesper Kers
- Amsterdam University Medical CentersAmsterdamthe Netherlands,Leiden University Medical CenterLeidenthe Netherlands
| | | | | | - John Tomaszewski
- University at BuffaloState University of New YorkBuffaloNew York
| | | | - Yukako Yagi
- Memorial Sloan Kettering Cancer CenterNew YorkNew York
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178
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Mengel M, Loupy A, Haas M, Roufosse C, Naesens M, Akalin E, Clahsen‐van Groningen MC, Dagobert J, Demetris AJ, Duong van Huyen J, Gueguen J, Issa F, Robin B, Rosales I, Von der Thüsen JH, Sanchez‐Fueyo A, Smith RN, Wood K, Adam B, Colvin RB. Banff 2019 Meeting Report: Molecular diagnostics in solid organ transplantation-Consensus for the Banff Human Organ Transplant (B-HOT) gene panel and open source multicenter validation. Am J Transplant 2020; 20:2305-2317. [PMID: 32428337 PMCID: PMC7496585 DOI: 10.1111/ajt.16059] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/19/2020] [Accepted: 04/27/2020] [Indexed: 02/06/2023]
Abstract
This meeting report from the XV Banff conference describes the creation of a multiorgan transplant gene panel by the Banff Molecular Diagnostics Working Group (MDWG). This Banff Human Organ Transplant (B-HOT) panel is the culmination of previous work by the MDWG to identify a broadly useful gene panel based on whole transcriptome technology. A data-driven process distilled a gene list from peer-reviewed comprehensive microarray studies that discovered and validated their use in kidney, liver, heart, and lung transplant biopsies. These were supplemented by genes that define relevant cellular pathways and cell types plus 12 reference genes used for normalization. The 770 gene B-HOT panel includes the most pertinent genes related to rejection, tolerance, viral infections, and innate and adaptive immune responses. This commercially available panel uses the NanoString platform, which can quantitate transcripts from formalin-fixed paraffin-embedded samples. The B-HOT panel will facilitate multicenter collaborative clinical research using archival samples and permit the development of an open source large database of standardized analyses, thereby expediting clinical validation studies. The MDWG believes that a pathogenesis and pathway based molecular approach will be valuable for investigators and promote therapeutic decision-making and clinical trials.
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Affiliation(s)
- Michael Mengel
- Department of Laboratory Medicine and PathologyUniversity of AlbertaEdmontonCanada
| | - Alexandre Loupy
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity of ParisParisFrance
| | - Mark Haas
- Department of Pathology and Laboratory MedicineCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Candice Roufosse
- Department of Immunology and InflammationImperial College London and North West London PathologyLondonUK
| | - Maarten Naesens
- Department of Microbiology, Immunology and TransplantationKU LeuvenLeuvenBelgium,Department of NephrologyUniversity Hospitals LeuvenLeuvenBelgium
| | - Enver Akalin
- Montefiore‐Einstein Center for TransplantationMontefiore Medical CenterBronxNew YorkUSA
| | | | - Jessy Dagobert
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity of ParisParisFrance
| | - Anthony J. Demetris
- Department of PathologyUniversity of Pittsburgh Medical CenterMontefiore, PittsburghPennsylvaniaUSA
| | - Jean‐Paul Duong van Huyen
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity of ParisParisFrance
| | - Juliette Gueguen
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity of ParisParisFrance
| | - Fadi Issa
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Blaise Robin
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity of ParisParisFrance
| | - Ivy Rosales
- Department of PathologyMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | | | | | - Rex N. Smith
- Department of PathologyMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Kathryn Wood
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Benjamin Adam
- Department of Laboratory Medicine and PathologyUniversity of AlbertaEdmontonCanada
| | - Robert B. Colvin
- Department of PathologyMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
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179
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Trajectories of glomerular filtration rate and progression to end stage kidney disease after kidney transplantation. Kidney Int 2020; 99:186-197. [PMID: 32781106 DOI: 10.1016/j.kint.2020.07.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/09/2020] [Accepted: 07/02/2020] [Indexed: 12/11/2022]
Abstract
Although the gold standard of monitoring kidney transplant function relies on glomerular filtration rate (GFR), little is known about GFR trajectories after transplantation, their determinants, and their association with outcomes. To evaluate these parameters we examined kidney transplant recipients receiving care at 15 academic centers. Patients underwent prospective monitoring of estimated GFR (eGFR) measurements, with assessment of clinical, functional, histological and immunological parameters. Additional validation took place in seven randomized controlled trials that included a total of 14,132 patients with 403,497 eGFR measurements. After a median follow-up of 6.5 years, 1,688 patients developed end-stage kidney disease. Using unsupervised latent class mixed models, we identified eight distinct eGFR trajectories. Multinomial regression models identified seven significant determinants of eGFR trajectories including donor age, eGFR, proteinuria, and several significant histological features: graft scarring, graft interstitial inflammation and tubulitis, microcirculation inflammation, and circulating anti-HLA donor specific antibodies. The eGFR trajectories were associated with progression to end stage kidney disease. These trajectories, their determinants and respective associations with end stage kidney disease were similar across cohorts, as well as in diverse clinical scenarios, therapeutic eras and in the seven randomized control trials. Thus, our results provide the basis for a trajectory-based assessment of kidney transplant patients for risk stratification and monitoring.
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180
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Kumar D, Yakubu I, Safavi F, Levy M, Moinuddin I, Kimball P, Kamal L, King A, Massey D, Halloran P, Gupta G. Lack of Histological and Molecular Signature Response to Tocilizumab in Kidney Transplants with Chronic Active Antibody Mediated Rejection: A Case Series. KIDNEY360 2020; 1:663-670. [PMID: 35372943 DOI: 10.34067/kid.0000182019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 04/21/2020] [Indexed: 02/08/2023]
Abstract
Background Traditional therapies for caAbMR have unclear efficacy with significant side effects in recipients of kidney transplants (KTs). A recent single-center case series suggested tocilizumab (TCZ) could stabilize renal function and improve microvascular inflammation. Here we report our findings of the use of TCZ in patients with caAbMR. Methods Ten adult recipients of KTs with biopsy-proven caAbMR were treated with TCZ at 8 mg/kg per month. Patients were monitored for adverse events, and therapy was interrupted in the setting of serious infections. Six patients (60%) underwent post-treatment biopsies. Results Patients (mean age of 43 years) were initiated on TCZ at a median of 36 months post-KT. A majority of patients were black (70%), underwent regrafts (40%), and were sensitized (mean cPRA=41%). Patients received a median of six doses of TCZ (range=3-10). At a median follow-up of 12 months (range=8-24 months), renal function did not show improvement (mean eGFR, 42±18 ml/min per 1.73 m2 to 37±24 ml/min per 1.73 m2; P=0.27). The slope of decline in eGFR remained unchanged (-0.14±0.9 to -0.33±1.1; P=0.25). There was no improvement in mean MVI (g+ptc) (4.8±1.4 to 4.2±2.0; P=0.39) scores or Molecular Microscope Diagnostic System (MMDx) AbMR scores (0.79±0.17 to 0.78±0.26; P=0.86). There was a numeric worsening of chronicity (ci+ct) scores (2.5±0.8 to 3.3±1.7; P=0.38) and MMDx atrophy fibrosis scores (0.36±0.24 to 0.58±0.15; P=0.21). Patient survival was 90%, with one patient death due to complications from a hip infection. Overall death-censored graft survival was 80%, with two graft losses in patients who had recurrent infections requiring hospitalization. Conclusions In this early experience, we report a lack of efficacy and toxicity with the use of TCZ for caAbMR. Prospective clinical trials are needed to clarify the role of IL-6 blockade and the possibility of increased incidence of infections in patients with caAbMR who are treated with TCZ.
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Affiliation(s)
- Dhiren Kumar
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - Idris Yakubu
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - Frough Safavi
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - Marlon Levy
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - Irfan Moinuddin
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - Pamela Kimball
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - Layla Kamal
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - Anne King
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - Davis Massey
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - Philip Halloran
- Alberta Transplant Applied Genomics Center, Edmonton, Alberta, Canada
| | - Gaurav Gupta
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
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181
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Huang E, Gillespie M, Ammerman N, Vo A, Lim K, Peng A, Najjar R, Sethi S, Jordan SC, Mirocha J, Haas M. Donor-derived Cell-free DNA Combined With Histology Improves Prediction of Estimated Glomerular Filtration Rate Over Time in Kidney Transplant Recipients Compared With Histology Alone. Transplant Direct 2020; 6:e580. [PMID: 33134504 PMCID: PMC7581058 DOI: 10.1097/txd.0000000000001027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/22/2020] [Indexed: 12/11/2022] Open
Abstract
Higher Banff inflammation and chronicity scores on kidney transplant biopsies are associated with poorer graft survival, although histology alone has limitations in predicting outcomes. We investigated if integrating donor-derived cell-free DNA (dd-cfDNA, Allosure; CareDx, Inc.) with Banff biopsy scores into a predictive model for estimated glomerular filtration rate over time can improve prognostic assessment versus histology alone. Methods We identified 180 kidney transplant patients with dd-cfDNA assessed within 1 mo of biopsy. Using linear mixed-effects models, a prediction model of Banff histology scores and dd-cfDNA on estimated glomerular filtration rate over time was derived. Nested models were compared using the likelihood-ratio test, Akaike Information Criterion, and Bayesian Information Criterion to assess if inclusion of dd-cfDNA into a model consisting of Banff biopsy scores would improve model fit. Results Univariate models identified significant covariate-by-time interactions for cg = 3 versus <3 (coefficient: -1.3 mL/min/1.73 m2/mo; 95% confidence interval [CI], -2.4 to -0.2; P = 0.02) and ci + ct ≥ 3 versus <3 (coefficient: -0.7 mL/min/1.73 m2/mo; 95% CI, -1.3 to -0.1; P = 0.03) and a trend toward significant covariate-by-time interaction for dd-cfDNA (coefficient: -0.5 mL/min/1.73 m2/mo; 95% CI, -1.0 to 0.1; P = 0.08). Addition of acute inflammation (i, t, and v), microvascular inflammation (g and ptc), and inflammation in area of interstitial fibrosis and tubular atrophy scores to chronicity scores (cg ≥ 3 and ci + ct ≥ 3) did not improve model fit. However, a model including dd-cfDNA with cg and ci + ct with covariate-by-time interactions had a better model fit compared with cg and ci + ct alone (likelihood-ratio test statistic = 21.1; df = 2; P < 0.001). Conclusions Addition of dd-cfDNA to Banff biopsy scores provided better prognostic assessment over biopsy characteristics alone.
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Affiliation(s)
- Edmund Huang
- Department of Medicine, Division of Nephrology, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Matthew Gillespie
- Department of Medicine, Division of Nephrology, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Noriko Ammerman
- Department of Medicine, Division of Nephrology, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ashley Vo
- Department of Medicine, Division of Nephrology, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Kathlyn Lim
- Department of Medicine, Division of Nephrology, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Alice Peng
- Department of Medicine, Division of Nephrology, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Reiad Najjar
- Department of Medicine, Division of Nephrology, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Supreet Sethi
- Department of Medicine, Division of Nephrology, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Stanley C Jordan
- Department of Medicine, Division of Nephrology, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - James Mirocha
- Biostatistics Core, Research Institute and General Clinical Research Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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182
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Kotla SK, Tanriover B. Recurrent antibody-mediated rejection in renal allograft: physician's dilemma. J Nephrol 2020; 33:661-665. [PMID: 32557204 DOI: 10.1007/s40620-020-00780-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 06/08/2020] [Indexed: 11/29/2022]
Abstract
Antibody-mediated rejection is the primary cause of renal allograft failure, and the molecular mechanistic is relatively less known in comparison to cell-mediated rejection. With the advent of new immunological agents, the short-term graft survival outcomes have improved, but the long-term outcomes are still unchanged. We present a case of 47-year-old with end-stage renal disease due to presumed lupus status post deceased donor renal transplantation. The patient developed recurrent (a total of five) antibody-mediated rejections (donor-specific antibody and C4d staining negative) spanning within a year of transplant despite the standard of care therapies. The present case draws attention to the importance of non-HLA antibodies in antibody-mediated rejection and diagnostic tools we can rely on when the histology is inconclusive and the role of new immunological agents.
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Affiliation(s)
- Suman Krishna Kotla
- Division of Nephrology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5939, Harry Hines Blvd, HP5, POB 1, Dallas, TX, 75390-8516, USA.
| | - Bekir Tanriover
- Division of Nephrology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5939, Harry Hines Blvd, HP5, POB 1, Dallas, TX, 75390-8516, USA
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183
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Nickerson PW. What have we learned about how to prevent and treat antibody-mediated rejection in kidney transplantation? Am J Transplant 2020; 20 Suppl 4:12-22. [PMID: 32538535 DOI: 10.1111/ajt.15859] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/26/2020] [Accepted: 03/09/2020] [Indexed: 02/06/2023]
Abstract
Antibody-mediated rejection (ABMR) in kidney transplantation is a major cause of late graft loss, and despite all efforts to date the "standard of care" remains plasmapheresis, IVIg, and steroids, which itself is based on low quality evidence. This review focuses on the risk factors leading to memory and de novo donor-specific antibody (DSA)-associated ABMR, the optimal prevention strategies for ABMR, and advances in adjunctive and emerging therapies for ABMR. Because new agents require regulatory approval via a Phase 3 randomized control trial (RCT), an overview of progress in innovative trial design for ABMR is provided. Finally, based on the insights gained in the biology of ABMR, current knowledge gaps are identified for future research that could significantly affect our understanding of how to optimally treat ABMR.
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Affiliation(s)
- Peter W Nickerson
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada.,Department of Immunology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
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184
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Mannon RB, Morris RE, Abecassis M, Axelrod D, Bala S, Friedman GS, Heeger PS, Lentine KL, Loupy A, Murphy B, Nickerson P, Sarwal M, O'Doherty I, Spear N, Karpen SR. Use of biomarkers to improve immunosuppressive drug development and outcomes in renal organ transplantation: A meeting report. Am J Transplant 2020; 20:1495-1502. [PMID: 32090461 DOI: 10.1111/ajt.15833] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 02/07/2020] [Accepted: 02/12/2020] [Indexed: 01/25/2023]
Abstract
On September 27-28, 2018 the Food and Drug Administration (FDA) and the Critical Path Institute's Transplant Therapeutics Consortium convened a public workshop titled "Evidence-Based Treatment Decisions in Transplantation: The Right Dose & Regimen for the Right Patient/Individualized Treatment." The workshop facilitated cooperative engagement of transplant community stakeholders, including pharmaceutical industry, academic researchers, clinicians, patients, and regulators to discuss methods to advance the development of novel immunosuppressive drugs for use in solid organ transplantation. Day 1 focused on the utility of biomarkers in drug development, with considerations for seeking regulatory endorsement for use in clinical trials. Biomarkers add value to drug development by improving patient selection criteria, safety monitoring, endpoint selection, and more. Regulatory endorsement through the FDA Biomarker Qualification Program encourages the use of biomarkers in drug development by instilling confidence and consistency in biomarker interpretation across trials. Public-private partnerships or consortia allow stakeholders to share expertise, resources, and data in pursuit of biomarker qualification. Biomarkers relevant to pretransplant risk assessment, early posttransplant care, and assessment of immune response, immunosuppressive drug efficacy, and graft function as discussed on day 1 of the workshop are described.
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Affiliation(s)
- Roslyn B Mannon
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Randall E Morris
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | | | - David Axelrod
- University of Iowa School of Medicine, Iowa City, Iowa, USA
| | - Shukal Bala
- Food and Drug Administration, Silver Spring, MD, USA
| | | | - Peter S Heeger
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Krista L Lentine
- Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | | | - Barbara Murphy
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Minnie Sarwal
- University of California, San Francisco, San Francisco, California, USA
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185
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Tangri N, Ferguson TW, Wiebe C, Eng F, Nash M, Astor BC, Lam NN, Ye F, Shin JI, Whitlock R, Yuen DA. Validation of the Kidney Failure Risk Equation in Kidney Transplant Recipients. Can J Kidney Health Dis 2020; 7:2054358120922627. [PMID: 32549052 PMCID: PMC7249550 DOI: 10.1177/2054358120922627] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/27/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Predicting allograft failure in kidney transplant recipients can help plan
renal replacement therapy and guide patient-provider communication. The
kidney failure risk equation (KFRE) accurately predicts the need for
dialysis in patients with chronic kidney disease (CKD), but has not been
validated in kidney transplant recipients. Objective: We sought to validate the 4-variable KFRE (age, sex, estimated glomerular
filtration rate [eGFR], and urine albumin-to-creatinine ratio [ACR]) for
prediction of 2- and 5-year death-censored allograft failure. Design: Retrospective cohort study. Setting: Four independent North American Cohorts from Ontario, Canada; Alberta,
Canada; Manitoba, Canada; and Wisconsin, United States, between January 1999
and December 2017. Patients: Adult kidney transplant patients at 1-year posttransplantation. Measurements: Kidney failure risk as measured by the KFRE (eGFR, urine ACR, age, and
sex). Methods: We included all adult patients who had at least 1 serum creatinine and at
least 1 urine ACR measurement approximately 1 year following kidney
transplantation. The performance of the KFRE was evaluated using the area
under the receiver operating characteristic curve (C-statistic).
C-statistics from the 4 cohorts were meta-analyzed using random-effects
models. Results: A total of 3659 patients were included. Pooled C-statistics were good in the
entire population, at 0.81 (95% confidence interval: 0.72-0.91) for the
2-year KFRE and 0.73 (0.67-0.80) for the 5-year KFRE. Discrimination
improved among patients with poorer kidney function (eGFR < 45
mL/min/1.73 m2), with a C-statistic of 0.88 (0.78-0.98) for the
2-year KFRE and 0.83 (0.74-0.91) for the 5-year KFRE. Limitations: The KFRE does not predict episodes of acute rejection and there was
heterogeneity between cohorts. Conclusions: The KFRE accurately predicts kidney failure in kidney transplant recipients
at 1-year posttransplantation. Further validation in larger cohorts with
longer follow-up times can strengthen the case for clinical
implementation.
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Affiliation(s)
- Navdeep Tangri
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada.,Seven Oaks Hospital Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Thomas W Ferguson
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada.,Seven Oaks Hospital Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Chris Wiebe
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Frederick Eng
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada.,Seven Oaks Hospital Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Michelle Nash
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Brad C Astor
- Population Health Sciences, University of Wisconsin-Madison, USA
| | - Ngan N Lam
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Feng Ye
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Jung-Im Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Reid Whitlock
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada.,Seven Oaks Hospital Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Darren A Yuen
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, ON, Canada
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186
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Mottola C, Girerd N, Duarte K, Aarnink A, Giral M, Dantal J, Garrigue V, Mourad G, Buron F, Morelon E, Ladrière M, Kessler M, Frimat L, Girerd S. Prognostic value for long-term graft survival of estimated glomerular filtration rate and proteinuria quantified at 3 months after kidney transplantation. Clin Kidney J 2020; 13:791-802. [PMID: 33125000 PMCID: PMC7577768 DOI: 10.1093/ckj/sfaa044] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 03/10/2020] [Indexed: 12/22/2022] Open
Abstract
Background The estimated glomerular filtration rate (eGFR) measured at 1 year is the usual benchmark applied in kidney transplantation (KT). However, acting on earlier eGFR values could help in managing KT during the first post-operative year. We aimed to assess the prognostic value for long-term graft survival of the early (3 months) quantification of eGFR and proteinuria following KT. Methods The 3-, 6- and 12-month eGFR using the Modified Diet in Renal Disease equation (eGFRMDRD) was determined and proteinuria was measured in 754 patients who underwent their first KT between 2000 and 2010 (with a mean follow-up of 8.3 years) in our centre. Adjusted associations with graft survival were estimated using a multivariable Cox model. The predictive accuracy was estimated using the C-index and net reclassification index. These same analyses were measured in a multicentre validation cohort of 1936 patients. Results Both 3-month eGFRMDRD and proteinuria were independent predictors of return to dialysis (all P < 0.05) and there was a strong correlation between eGFR at 3 and 12 months (Spearman’s ρ = 0.76). The predictive accuracy of the 3-month eGFR was within a similar range and did not differ significantly from the 12-month eGFR in either the derivation cohort [C-index 62.6 (range 57.2–68.1) versus 66.0 (range 60.1–71.9), P = 0.41] or the validation cohort [C-index 69.3 (range 66.4–72.1) versus 71.7 (range 68.7–74.6), P = 0.25]. Conclusion The 3-month eGFR was a valuable predictor of the long-term return to dialysis whose predictive accuracy was not significantly less than that of the 12-month eGFR in multicentre cohorts totalling >2500 patients. Three-month outcomes may be useful in randomized controlled trials targeting early therapeutic interventions.
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Affiliation(s)
- Clément Mottola
- Department of Nephrology and Kidney Transplantation, Nancy University Hospital, Vandoeuvre-lès-Nancy, France
| | - Nicolas Girerd
- INSERM U1116, Clinical Investigation Centre, Lorraine University, Vandoeuvre-lès-Nancy, France.,Cardiovascular and Renal Clinical Trialists (INI-CRCT) F-CRIN Network, Nancy, France
| | - Kevin Duarte
- INSERM U1116, Clinical Investigation Centre, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Alice Aarnink
- Department of Immunology and Histocompatibility, Nancy University Hospital, Vandoeuvre-lès-Nancy, France
| | - Magali Giral
- CRTI UMR 1064, Inserm, Nantes University, Nantes, France.,ITUN, Nantes University Hospital, RTRS Centaure, Nantes, France
| | - Jacques Dantal
- CRTI UMR 1064, Inserm, Nantes University, Nantes, France.,ITUN, Nantes University Hospital, RTRS Centaure, Nantes, France
| | - Valérie Garrigue
- Department of Nephrology and Kidney Transplantation, Montpellier University Hospital, Montpellier, France
| | - Georges Mourad
- Department of Nephrology and Kidney Transplantation, Montpellier University Hospital, Montpellier, France
| | - Fanny Buron
- Department of Nephrology and Kidney Transplantation, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Emmanuel Morelon
- Department of Nephrology and Kidney Transplantation, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Marc Ladrière
- Department of Nephrology and Kidney Transplantation, Nancy University Hospital, Vandoeuvre-lès-Nancy, France
| | - Michèle Kessler
- Department of Nephrology and Kidney Transplantation, Nancy University Hospital, Vandoeuvre-lès-Nancy, France
| | - Luc Frimat
- Department of Nephrology and Kidney Transplantation, Nancy University Hospital, Vandoeuvre-lès-Nancy, France.,Cardiovascular and Renal Clinical Trialists (INI-CRCT) F-CRIN Network, Nancy, France
| | - Sophie Girerd
- Department of Nephrology and Kidney Transplantation, Nancy University Hospital, Vandoeuvre-lès-Nancy, France.,INSERM U1116, Clinical Investigation Centre, Lorraine University, Vandoeuvre-lès-Nancy, France.,Cardiovascular and Renal Clinical Trialists (INI-CRCT) F-CRIN Network, Nancy, France
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187
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Talwar M, Balaraman V, Bhalla A, Cseprekal O, Yazawa M, Podila PSB, Azhar A, Cossey LN, Eason JD, Molnar MZ. Validation of Prognostic Index for Allograft Outcome in Kidney Transplant Recipients With Transplant Glomerulopathy. Kidney Int Rep 2020; 5:915-920. [PMID: 32518874 PMCID: PMC7271004 DOI: 10.1016/j.ekir.2020.03.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/02/2020] [Accepted: 03/30/2020] [Indexed: 11/23/2022] Open
Affiliation(s)
- Manish Talwar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Vasanthi Balaraman
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Anshul Bhalla
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Orsolya Cseprekal
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Masahiko Yazawa
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Divison of Nephrology and Hypertension, St. Marianna University School of Medicine, Tokyo, Japan
| | - Pradeep S B Podila
- Faith & Health Division, Methodist Le Bonheur Healthcare, Memphis, Tennessee, USA.,Division of Health Systems Management & Policy, School of Public Health, The University of Memphis, Memphis, Tennessee, USA
| | - Ambreen Azhar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - James D Eason
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Miklos Z Molnar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary.,Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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188
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Artificial intelligence and machine learning in nephropathology. Kidney Int 2020; 98:65-75. [PMID: 32475607 DOI: 10.1016/j.kint.2020.02.027] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/03/2020] [Accepted: 02/12/2020] [Indexed: 12/15/2022]
Abstract
Artificial intelligence (AI) for the purpose of this review is an umbrella term for technologies emulating a nephropathologist's ability to extract information on diagnosis, prognosis, and therapy responsiveness from native or transplant kidney biopsies. Although AI can be used to analyze a wide variety of biopsy-related data, this review focuses on whole slide images traditionally used in nephropathology. AI applications in nephropathology have recently become available through several advancing technologies, including (i) widespread introduction of glass slide scanners, (ii) data servers in pathology departments worldwide, and (iii) through greatly improved computer hardware to enable AI training. In this review, we explain how AI can enhance the reproducibility of nephropathology results for certain parameters in the context of precision medicine using advanced architectures, such as convolutional neural networks, that are currently the state of the art in machine learning software for this task. Because AI applications in nephropathology are still in their infancy, we show the power and potential of AI applications mostly in the example of oncopathology. Moreover, we discuss the technological obstacles as well as the current stakeholder and regulatory concerns about developing AI applications in nephropathology from the perspective of nephropathologists and the wider nephrology community. We expect the gradual introduction of these technologies into routine diagnostics and research for selective tasks, suggesting that this technology will enhance the performance of nephropathologists rather than making them redundant.
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189
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Abstract
Introduction: Lung transplantation remains an important treatment for patients with end stage lung disease. Chronic lung allograft dysfunction (CLAD) remains the greatest limiting factor for long term survival. As the diagnosis of CLAD is based on pulmonary function tests, significant lung injury is required before a diagnosis is feasible, likely when irreversible damage has already occurred. Therefore, research is ongoing for early CLAD recognition, with biomarkers making up a substantial amount of this research.Areas covered: The purpose of this review is to describe available biomarkers, focusing on those which aid in predicting CLAD and distinguishing between different CLAD phenotypes. We describe biomarkers presenting in bronchial alveolar lavage (BAL) as well as circulating in peripheral blood, both of which offer an appealing alternative to lung biopsy.Expert opinion: Development of CLAD involves complex, multiple immune and nonimmune mechanisms. Therefore, evaluation of potential CLAD biomarkers serves a dual purpose: clinically, the goal remains early detection and identification of patients at increased risk. Simultaneously, biomarkers offer insight into the different mechanisms involved in the pathophysiology of CLAD, leading to the development of possible interventions. The ultimate goal is the development of both preventive and early intervention strategies for CLAD to improve the overall survival of our lung transplant recipients.
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Affiliation(s)
- Osnat Shtraichman
- Division of Pulmonary, Allergy & Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Pulmonary institute, Rabin Medical Center, Petach Tikva, Israel; Sackler School of Medicine, Tel Aviv, Israel
| | - Joshua M Diamond
- Division of Pulmonary, Allergy & Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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190
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Clinical News. Br J Hosp Med (Lond) 2019; 80:564-567. [DOI: 10.12968/hmed.2019.80.10.564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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