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Wiebe C, Balshaw R, Gibson IW, Ho J, Shaw J, Karpinski M, Trachtenberg A, Pochinco D, Goldberg A, Birk P, Pinsk M, Rush DN, Nickerson PW. A rational approach to guide cost-effective de novo donor-specific antibody surveillance with tacrolimus immunosuppression. Am J Transplant 2023; 23:1882-1892. [PMID: 37543094 DOI: 10.1016/j.ajt.2023.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/07/2023]
Abstract
De novo donor-specific antibody (dnDSA) after renal transplantation has been shown to correlate with antibody-mediated rejection and allograft loss. However, the lack of proven interventions and the time and cost associated with annual screening for dnDSA are difficult to justify for all recipients. We studied a well-characterized consecutive cohort (n = 949) with over 15 years of prospective dnDSA surveillance to identify risk factors that would help institute a resource-responsible surveillance strategy. Younger recipient age and HLA-DR/DQ molecular mismatch were independent predictors of dnDSA development. Combining both risk factors into recipient age molecular mismatch categories, we found that 52% of recipients could be categorized as low-risk for dnDSA development (median subclinical dnDSA-free survival at 5 and 10 years, 98% and 97%, respectively). After adjustment, multivariate correlates of dnDSA development included tacrolimus versus cyclosporin maintenance immunosuppression (hazard ratio [HR], 0.37; 95% CI, 0.2-0.6; P < .0001) and recipient age molecular mismatch category: intermediate versus low (HR, 2.48; 95% CI, 1.5-4.2; P = .0007), high versus intermediate (HR, 2.56; 95% CI, 1.6-4.2; P = .0002), and high versus low (HR, 6.36; 95% CI, 3.7-10.8; P < .00001). When combined, recipient age and HLA-DR/DQ molecular mismatch provide a novel data-driven approach to reduce testing by >50% while selecting those most likely to benefit from dnDSA surveillance.
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Affiliation(s)
- Chris Wiebe
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Immunology, University of Manitoba, Winnipeg, Manitoba, Canada; Shared Health Services Manitoba, Winnipeg, Manitoba, Canada.
| | - Rob Balshaw
- George and Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ian W Gibson
- Shared Health Services Manitoba, Winnipeg, Manitoba, Canada; Department of Pathology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Julie Ho
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Immunology, University of Manitoba, Winnipeg, Manitoba, Canada; Shared Health Services Manitoba, Winnipeg, Manitoba, Canada
| | - Jamie Shaw
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Martin Karpinski
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Aaron Trachtenberg
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Aviva Goldberg
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Patricia Birk
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Maury Pinsk
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David N Rush
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Shared Health Services Manitoba, Winnipeg, Manitoba, Canada
| | - Peter W Nickerson
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Immunology, University of Manitoba, Winnipeg, Manitoba, Canada; Shared Health Services Manitoba, Winnipeg, Manitoba, Canada
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Fukuhara H, Nawano T, Kanda A, Tomosugi T, Okada M, Futamura K, Hiramitsu T, Takeda A, Tsuchiya N, Goto N, Narumi S, Watarai Y. Short-term outcomes of second kidney transplantation compared with those of first transplantation in Japanese patients: a single-center, retrospective, observational study. Clin Exp Nephrol 2023; 27:188-196. [PMID: 36318396 DOI: 10.1007/s10157-022-02290-1] [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: 03/22/2022] [Accepted: 10/16/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Among patients who undergo kidney transplantation, a subsequent second kidney transplantation (TX2) is often necessary. The TX2 outcomes remain controversial, however, and only limited data are available on clinical outcomes of TX2 in Japanese patients. This study aimed to assess graft and patient survival rates of TX2 and compared these rates with those of first kidney transplantation (TX1) in Japanese patients. METHODS Of the 898 kidney transplantations performed between 2010 and 2019 at our institution, 33 were TX2. We performed survival analysis using weighted Kaplan-Meier analysis and Cox proportional hazards analysis with propensity score matching, specifically inverse probability of treatment weighting (IPTW). RESULTS Death-censored graft survival (DCGS) rates at 1, 3, and 5 years for the TX1 versus TX2 groups were 99.3, 97.9, and 95.0% versus 100, 96.0, and 91.2%, respectively. Overall survival (OS) rates at 1, 3, and 5 years for the TX1 versus TX2 groups were 99.4, 98.9, and 97.8% versus 100, 100, and 94.4%, respectively. Using the log-rank test, IPTW-weighted Kaplan-Meier curves showed no significant differences for TX1 versus TX2 in DCGS (p = 0.535) and OS (p = 0.302). On Cox proportional hazards analysis for TX2 versus TX1, the IPTW-adjusted hazard ratio (HR) for DCGS was 1.75 (95% CI, 0.28-10.9; p = 0.550) and for OS was 2.71 (95% CI, 0.40-18.55; p = 0.311). CONCLUSIONS For patients who require TX2, this treatment is an acceptable option based on the short-term outcomes data for DCGS and OS.
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Affiliation(s)
- Hiroki Fukuhara
- Transplant Nephrology and Surgery, Kidney Disease Center, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myouken-Cho, Nagoya City, Aichi, Japan. .,Department of Urology, Faculty of Medicine, Yamagata University, 2-2-2 Iida-Nishi, Yamagata, Japan.
| | - Takaaki Nawano
- Transplant Nephrology and Surgery, Kidney Disease Center, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myouken-Cho, Nagoya City, Aichi, Japan
| | - Akiko Kanda
- Transplant Nephrology and Surgery, Kidney Disease Center, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myouken-Cho, Nagoya City, Aichi, Japan
| | - Toshihide Tomosugi
- Transplant Nephrology and Surgery, Kidney Disease Center, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myouken-Cho, Nagoya City, Aichi, Japan
| | - Manabu Okada
- Transplant Nephrology and Surgery, Kidney Disease Center, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myouken-Cho, Nagoya City, Aichi, Japan
| | - Kenta Futamura
- Transplant Nephrology and Surgery, Kidney Disease Center, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myouken-Cho, Nagoya City, Aichi, Japan
| | - Takahisa Hiramitsu
- Transplant Nephrology and Surgery, Kidney Disease Center, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myouken-Cho, Nagoya City, Aichi, Japan
| | - Asami Takeda
- Department of Nephrology, Kidney Disease Center, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myouken-Cho, Nagoya City, Aichi, Japan
| | - Norihiko Tsuchiya
- Department of Urology, Faculty of Medicine, Yamagata University, 2-2-2 Iida-Nishi, Yamagata, Japan
| | - Norihiko Goto
- Transplant Nephrology and Surgery, Kidney Disease Center, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myouken-Cho, Nagoya City, Aichi, Japan
| | - Shunji Narumi
- Transplant Nephrology and Surgery, Kidney Disease Center, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myouken-Cho, Nagoya City, Aichi, Japan
| | - Yoshihiko Watarai
- Transplant Nephrology and Surgery, Kidney Disease Center, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myouken-Cho, Nagoya City, Aichi, Japan
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Urzykowska A, Piątosa B, Grycuk U, Kowalewski G, Kułaga Z, Grenda R. Evaluation of Cumulative Effect of Standard Triple Immunosuppression on Prevention of De Novo Donor Specific Antibodies (dnDSA) Production in Children after Kidney Transplantation—A Retrospective and Prospective Study. CHILDREN 2021; 8:children8121162. [PMID: 34943360 PMCID: PMC8700537 DOI: 10.3390/children8121162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/06/2021] [Accepted: 12/07/2021] [Indexed: 11/23/2022]
Abstract
De novo Donor Specific Antibodies (dnDSA) are associated with inferior graft outcomes. Standard immunosuppression is expected to prevent dnDSA production in low-risk patients. We have evaluated a cumulative effect of a triple immunosuppression (CNI/MMF/Pred), as well as TAC concentration and coefficient of variation on the incidence of dnDSA production. Overall, 67 transplanted patients were evaluated in retrospective (dnDSA for-cause; n = 29) and prospective (dnDSA by protocol; n = 38) groups. In the retrospective group, the eGFR value at first dnDSA detection (median interval—4.0 years post-transplant) was 41 mL/min/1.73 m2; 55% of patients presented biopsy-proven cAMR, and 41% lost the graft within next 2.4 years. Patients from the prospective group presented 97% graft survival and eGFR of 76 mL/min/1.73 m2 at 2 years follow-up, an overall incidence of 21% of dnDSA and 18% of acute (T cell) rejection. None of the patients from the prospective group developed cAMR. Median value of Vasudev score within 2 years of follow-up was not significantly higher in dsDSA negative patients, while median value of TAC C0 > 1–24 months post-transplant was 7.9 in dnDSA negative vs. 7.1 ng/mL in dnDSA positive patients (p = 0.008). Conclusion: dnDSA-negative patients presented a higher exposure to tacrolimus, while not to the combined immunosuppression.
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Affiliation(s)
- Agnieszka Urzykowska
- Department of Nephrology, Kidney Transplantation & Hypertension, Children’s Memorial Health Institute, 04-730 Warsaw, Poland;
| | - Barbara Piątosa
- Histocompatibility Laboratory, Children’s Memorial Health Institute, 04-730 Warsaw, Poland; (B.P.); (U.G.)
| | - Urszula Grycuk
- Histocompatibility Laboratory, Children’s Memorial Health Institute, 04-730 Warsaw, Poland; (B.P.); (U.G.)
| | - Grzegorz Kowalewski
- Department of Surgery and Organ Transplantation, Children’s Memorial Health Institute, 04-730 Warsaw, Poland;
| | - Zbigniew Kułaga
- Department of Public Health, Children’s Memorial Health Institute, 04-730 Warsaw, Poland;
| | - Ryszard Grenda
- Department of Nephrology, Kidney Transplantation & Hypertension, Children’s Memorial Health Institute, 04-730 Warsaw, Poland;
- Correspondence:
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