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Masset C, Danger R, Degauque N, Dantal J, Giral M, Brouard S. Blood Gene Signature as a Biomarker for Subclinical Kidney Allograft Rejection: Where Are We? Transplantation 2024:00007890-990000000-00787. [PMID: 38867352 DOI: 10.1097/tp.0000000000005105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
The observation decades ago that inflammatory injuries because of an alloimmune response might be present even in the absence of concomitant clinical impairment in allograft function conduced to the later definition of subclinical rejection. Many studies have investigated the different subclinical rejections defined according to the Banff classification (subclinical T cell-mediated rejection and antibody-mediated rejection), overall concluding that these episodes worsened long-term allograft function and survival. These observations led several transplant teams to perform systematic protocolar biopsies to anticipate treatment of rejection episodes and possibly prevent allograft loss. Paradoxically, the invasive characteristics and associated logistics of such procedures paved the way to investigate noninvasive biomarkers (urine and blood) of subclinical rejection. Among them, several research teams proposed a blood gene signature developed from cohort studies, most of which achieved excellent predictive values for the occurrence of subclinical rejection, mainly antibody-mediated rejection. Interestingly, although all identified genes relate to immune subsets and pathways involved in rejection pathophysiology, very few transcripts are shared among these sets of genes, highlighting the heterogenicity of such episodes and the difficult but mandatory need for external validation of such tools. Beyond this, their application and value in clinical practice remain to be definitively demonstrated in both biopsy avoidance and prevention of clinical rejection episodes. Their combination with other biomarkers, either epidemiological or biological, could contribute to a more accurate picture of a patient's risk of rejection and guide clinicians in the follow-up of kidney transplant recipients.
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Affiliation(s)
- Christophe Masset
- Institut de Transplantation-Urologie-Néphrologie (ITUN), Nantes University Hospital, Nantes, France
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, Nantes, France
| | - Richard Danger
- Institut de Transplantation-Urologie-Néphrologie (ITUN), Nantes University Hospital, Nantes, France
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, Nantes, France
| | - Nicolas Degauque
- Institut de Transplantation-Urologie-Néphrologie (ITUN), Nantes University Hospital, Nantes, France
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, Nantes, France
| | - Jacques Dantal
- Institut de Transplantation-Urologie-Néphrologie (ITUN), Nantes University Hospital, Nantes, France
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, Nantes, France
| | - Magali Giral
- Institut de Transplantation-Urologie-Néphrologie (ITUN), Nantes University Hospital, Nantes, France
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, Nantes, France
| | - Sophie Brouard
- Institut de Transplantation-Urologie-Néphrologie (ITUN), Nantes University Hospital, Nantes, France
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, Nantes, France
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2
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Koo BJ, Huh H, Ye BM, Kim Y, Choi BH, Lee HJ, Kang MS, Lee DW, Lee SB, Kim YH, Kim IY, Kim T, Kim SR. Impact of nonspecific allograft biopsy findings in symptomatic kidney transplant recipients. Sci Rep 2024; 14:4002. [PMID: 38369626 PMCID: PMC10874932 DOI: 10.1038/s41598-024-54596-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 02/14/2024] [Indexed: 02/20/2024] Open
Abstract
A for-cause biopsy is performed to diagnose the cause of allograft dysfunction in kidney transplantation. We occasionally encounter ambiguous biopsy results in symptomatic kidney transplant recipients. Yet, the allograft survival outcome in symptomatic recipients with nonspecific allograft biopsy findings remains unclear. The purpose of this study was to analyze the impact of nonspecific for-cause biopsy findings in symptomatic kidney transplant recipients. We retrospectively collected records from 773 kidney transplant recipients between January 2008 and October 2021. The characteristics of transplant recipients with nonspecific findings in the first for-cause biopsy were analyzed. Nonspecific allograft biopsy findings were defined as other biopsy findings excluding rejection, borderline rejection, calcineurin inhibitor toxicity, infection, glomerulonephritis, and diabetic nephropathy. The graft outcome was compared between recipients who had never undergone a for-cause biopsy and those who had a first for-cause biopsy with nonspecific findings. The graft survival in recipients with nonspecific for-cause biopsy findings was comparable to that in recipients who did not require the for-cause biopsy before and after propensity score matching. Even in symptomatic kidney transplant recipients, nonspecific allograft biopsy findings might not be a poor prognostic factor for allograft survival compared to recipients who did not require the for-cause biopsy.
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Affiliation(s)
- Bon Jin Koo
- Division of Nephrology, Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Hyuk Huh
- Department of Internal Medicine-Nephrology, Inje University Busan Paik Hospital, Busan, South Korea
| | - Byung Min Ye
- Division of Nephrology, Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Yunmi Kim
- Department of Internal Medicine-Nephrology, Inje University Busan Paik Hospital, Busan, South Korea
| | - Byung Hyun Choi
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
- Department of Surgery, Pusan National University School of Medicine, Yangsan, South Korea
| | - Hyun Jeong Lee
- Department of Pathology, Pusan National University School of Medicine, Yangsan, South Korea
| | - Mi Seon Kang
- Department of Pathology, Inje University Busan Paik Hospital, Busan, South Korea
| | - Dong Won Lee
- Division of Nephrology, Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Soo Bong Lee
- Division of Nephrology, Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Yeong Hoon Kim
- Department of Internal Medicine-Nephrology, Inje University Busan Paik Hospital, Busan, South Korea
| | - Il Young Kim
- Division of Nephrology, Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Taehee Kim
- Department of Internal Medicine-Nephrology, Inje University Busan Paik Hospital, Busan, South Korea
| | - Seo Rin Kim
- Division of Nephrology, Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea.
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea.
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3
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Carraro A, De Gaspari P, Antoniello B, Marzenta D, Vianello E, Bussolati B, Tritta S, Collino F, Bertoldi L, Benvenuto G, Vedovelli L, Benetti E, Negrisolo S. New Insights into Pediatric Kidney Transplant Rejection Biomarkers: Tissue, Plasma and Urine MicroRNAs Compared to Protocol Biopsy Histology. Int J Mol Sci 2024; 25:1911. [PMID: 38339187 PMCID: PMC10856071 DOI: 10.3390/ijms25031911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/26/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
The early identification of a subclinical rejection (SCR) can improve the long-term outcome of the transplanted kidney through intensified immunosuppression. However, the only approved diagnostic method is the protocol biopsy, which remains an invasive method and not without minor and/or major complications. The protocol biopsy is defined as the sampling of allograft tissue at pre-established times even in the absence of an impaired renal function; however, it does not avoid histological damage. Therefore, the discovery of new possible biomarkers useful in the prevention of SCR has gained great interest. Among all the possible candidates, there are microRNAs (miRNAs), which are short, noncoding RNA sequences, that are involved in mediating numerous post-transcriptional pathways. They can be found not only in tissues, but also in different biological fluids, both as free particles and contained in extracellular vesicles (EVs) released by different cell types. In this study, we firstly performed a retrospective miRNA screening analysis on biopsies and serum EV samples of 20 pediatric transplanted patients, followed by a second screening on another 10 pediatric transplanted patients' urine samples at one year post-transplant. In both cohorts, we divided the patients into two groups: patients with histological SCR and patients without histological SCR at one year post-transplantation. The isolated miRNAs were analyzed in an NGS platform to identify different expressions in the two allograft states. Although no statistical data were found in sera, in the tissue and urinary EVs, we highlighted signatures of miRNAs associated with the histological SCR state.
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Affiliation(s)
- Andrea Carraro
- Laboratory of Immunopathology and Molecular Biology of the Kidney, Department of Women’s and Children’s Health, University of Padova, 35127 Padua, Italy
| | - Piera De Gaspari
- Laboratory of Immunopathology and Molecular Biology of the Kidney, Department of Women’s and Children’s Health, University of Padova, 35127 Padua, Italy
- Laboratory Reference, Euroimmun Italy, 35127 Padua, Italy
| | - Benedetta Antoniello
- Laboratory of Immunopathology and Molecular Biology of the Kidney, Department of Women’s and Children’s Health, University of Padova, 35127 Padua, Italy
| | - Diana Marzenta
- Laboratory of Immunopathology and Molecular Biology of the Kidney, Department of Women’s and Children’s Health, University of Padova, 35127 Padua, Italy
- Pediatric Nephrology, Department of Women’s and Children’s Health, Padua University Hospital, 35128 Padua, Italy
| | - Emanuele Vianello
- Pediatric Nephrology, Department of Women’s and Children’s Health, Padua University Hospital, 35128 Padua, Italy
| | - Benedetta Bussolati
- Department of Molecular Biotechnology and Health Sciences, University of Turin, 10124 Torino, Italy
| | - Stefania Tritta
- Department of Molecular Biotechnology and Health Sciences, University of Turin, 10124 Torino, Italy
| | - Federica Collino
- Department of Clinical Sciences and Community Health, University of Milano, 20126 Milan, Italy
- Paediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | | | | | - Luca Vedovelli
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Elisa Benetti
- Laboratory of Immunopathology and Molecular Biology of the Kidney, Department of Women’s and Children’s Health, University of Padova, 35127 Padua, Italy
- Pediatric Nephrology, Department of Women’s and Children’s Health, Padua University Hospital, 35128 Padua, Italy
- Pediatric Research Institute “IRP Città della Speranza”, 35127 Padua, Italy
| | - Susanna Negrisolo
- Laboratory of Immunopathology and Molecular Biology of the Kidney, Department of Women’s and Children’s Health, University of Padova, 35127 Padua, Italy
- Pediatric Research Institute “IRP Città della Speranza”, 35127 Padua, Italy
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4
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Landsberg A, Raza SS, Seifert ME, Blydt-Hansen TD. Follow-up biopsies identify high rates of persistent rejection in pediatric kidney transplant recipients after treatment of T cell-mediated rejection. Pediatr Transplant 2024; 28:e14617. [PMID: 37750353 PMCID: PMC10872996 DOI: 10.1111/petr.14617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/07/2023] [Accepted: 09/13/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Incomplete resolution of T cell-mediated rejection (TCMR) after treatment may not be detected with serum creatinine monitoring and is associated with donor-specific antibodies and chronic rejection. We evaluate the utility of follow-up biopsies (FUB) to identify and characterize rates of persistent TCMR after treatment in pediatric kidney transplant patients. METHODS Patients from two pediatric transplant centers performing standard of care FUB at 1.5-2 months after treatment for TCMR were included. FUB were evaluated for extent of rejection resolution (complete vs. incomplete) and grade. Clinical data at time of FUB and later were reported, where available. RESULTS Fifty-eight patients underwent FUB, at mean of 1.7 months (SD 0.7) post-index biopsy. Rejection grade on index biopsy was Banff borderline (≥i1t1 and CONCLUSIONS FUB were effective at detecting persistent rejection, which was common among pediatric transplant patients after standard TCMR treatment. Until more effective rejection treatments or sensitive biomarkers are available, FUB may be effectively utilized to identify patients with ongoing rejection who would benefit from further treatment.
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Affiliation(s)
- Adina Landsberg
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - S. Sikandar Raza
- Department of Pediatrics, University of Alabama Heersink School of Medicine, Birmingham, AL, United States
| | - Michael E. Seifert
- Department of Pediatrics, University of Alabama Heersink School of Medicine, Birmingham, AL, United States
| | - Tom D. Blydt-Hansen
- BC Children’s Hospital, Division of Nephrology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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5
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Vazquez-Sanchez T, Sanchez-Niño MD, Ruiz-Esteban P, López V, León M, Caballero A, Ruiz-Escalera JF, Ortiz A, Torres A, Rodriguez M, Hernandez D. Time-Dependent Changes of Klotho and FGF-23 Levels after Kidney Transplantation: Role of Cold Ischemia Time, Renal Function and Graft Inflammation. J Clin Med 2023; 12:4486. [PMID: 37445521 DOI: 10.3390/jcm12134486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/23/2023] [Accepted: 06/30/2023] [Indexed: 07/15/2023] Open
Abstract
We investigated the evolution of serum klotho (s-Kl) and FGF-23 during the first two years post-kidney transplantation (KT), considering the cold ischemia time (CIT), glomerular filtration rate (GFR) and graft subclinical inflammation (SCI). We undertook a prospective, cohort, multicenter study of consecutive patients between April 2018 and January 2021 (with follow-up at 24 months). Subgroups were analyzed according to the median CIT (<14 vs. ≥14 h), the median GFR (≤40 vs. >40 mL/min/1.73 m2) and the presence of SCI at month 3. A total of 147 patients were included. s-Kl and fibroblast growth factor-23 (FGF-23) levels were measured at baseline and at months 3, 12 and 24. Graft biopsies (n = 96) were performed at month 3. All patients had low s-Kl levels at month 3. Patients with CIT < 14 h exhibited a significant increase in s-Kl at month 24. In patients with CIT ≥ 14 h, s-Kl at month 3 fell and lower s-Kl levels were seen at month 24. Patients with a GFR > 40 had a lesser decrease in s-Kl at month 3. FGF-23 fell significantly at months 3 and 12 in both GFR groups, a reduction maintained during follow-up. There were significant inter-group differences in s-Kl from months 3 to 24. CIT, GFR at 3 months and SCI were significantly associated with s-KI at month 3. A reduction in s-Kl at month 3 post-KT could be explained by longer CIT and delayed graft function as well as by impaired graft function. Early SCI may regulate s-Kl increase post-KT.
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Affiliation(s)
- Teresa Vazquez-Sanchez
- Nephrology Department, Hospital Universitario Regional de Málaga, Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma BIONAND, RICORS2040 (RD21/0005/0012), E-29010 Malaga, Spain
| | - Maria Dolores Sanchez-Niño
- Pharmacology Department, IIS-Fundacion Jimenez Diaz, Universidad Autonoma de Madrid, RICORS2040 (RD21/0005/0001), E-28040 Madrid, Spain
| | - Pedro Ruiz-Esteban
- Nephrology Department, Hospital Universitario Regional de Málaga, Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma BIONAND, RICORS2040 (RD21/0005/0012), E-29010 Malaga, Spain
| | - Veronica López
- Nephrology Department, Hospital Universitario Regional de Málaga, Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma BIONAND, RICORS2040 (RD21/0005/0012), E-29010 Malaga, Spain
| | - Myriam León
- Pathology Department, Hospital Universitario Regional de Málaga, Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma BIONAND, RICORS2040 (RD21/0005/0012), E-29010 Málaga, Spain
| | - Abelardo Caballero
- Immunology Department, Hospital Universitario Regional de Málaga, Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma BIONAND, RICORS2040 (RD21/0005/0012), E-29010 Malaga, Spain
| | - Juan Francisco Ruiz-Escalera
- Clinical Analysis Department, Hospital Universitario Regional de Málaga, Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma BIONAND, RICORS2040 (RD21/0005/0012), E-29010 Malaga, Spain
| | - Alberto Ortiz
- Nephrology Department, IIS-Fundacion Jimenez Diaz, Universidad Autonoma de Madrid, RICORS2040 (RD21/0005/0001), E-28040 Madrid, Spain
| | - Armando Torres
- Nephrology Department, Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas, Universidad La Laguna, REDinREN (RD16/0009/0031), E-38320 Tenerife, Spain
| | - Mariano Rodriguez
- Nephrology Department, Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, RICORS2040 (RD21/0005/0008), E-14004 Cordoba, Spain
| | - Domingo Hernandez
- Nephrology Department, Hospital Universitario Regional de Málaga, Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma BIONAND, RICORS2040 (RD21/0005/0012), E-29010 Malaga, Spain
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6
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Hernández D, Caballero A. Kidney transplant in the next decade: Strategies, challenges and vision of the future. Nefrologia 2023; 43:281-292. [PMID: 37635014 DOI: 10.1016/j.nefroe.2022.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 04/24/2022] [Indexed: 08/29/2023] Open
Abstract
Although the results of kidney transplantation (KT) have improved substantially in recent years, a chronic and inexorable loss of grafts mainly due to the death of the patient and chronic dysfunction of the KT, continues to be observed. The objectives, thus, to optimize this situation in the next decade are fundamentally focused on minimizing the rate of kidney graft loss, improving patient survival, increasing the rate of organ procurement and its distribution, promoting research and training in health professionals and the development of scientific registries providing clinical and reliable information that allow us to optimize our clinical practice in the field of KT. With this perspective, this review will deep into: (1) strategies to avoid chronic dysfunction and graft loss in the medium and long term; (2) to prolong patient survival; (3) strategies to increase the donation, maintenance and allocation of organs; (4) promote clinical and basic research and training activity in KT; and (5) the analysis of the results in KT by optimizing and merging scientific registries.
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Affiliation(s)
- Domingo Hernández
- Unidad de Gestión Clínica de Nefrología, Hospital Regional Universitario Carlos Haya, Instituto Biomédico de Investigación de Málaga (IBIMA), Universidad de Málaga, REDinREN, Málaga, Spain.
| | - Abelardo Caballero
- Sección de Inmunología, Hospital Regional Universitario Carlos Haya, Instituto Biomédico de Investigación de Málaga (IBIMA), Universidad de Málaga, REDinREN, Málaga, Spain
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7
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Cherukuri A, Abou-Daya KI, Chowdhury R, Mehta RB, Hariharan S, Randhawa P, Rothstein DM. Transitional B cell cytokines risk stratify early borderline rejection after renal transplantation. Kidney Int 2023; 103:749-761. [PMID: 36436679 PMCID: PMC10038876 DOI: 10.1016/j.kint.2022.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 11/27/2022]
Abstract
Borderline rejection (BL) in renal transplantation is associated with decreased allograft survival, yet many patients with BL maintain stable graft function. Identifying patients with early BL at risk for shortened allograft survival would allow for timely targeted therapeutic intervention aimed at improving outcomes. 851/1187 patients transplanted between 2013-18 underwent early biopsy (0-4 mos). 217/851 (25%) had BL and were compared to 387/851 without significant inflammation (NI). Serial surveillance and for-cause biopsies and seven-year follow-up were used to evaluate histological and clinical progression. To identify high-risk patients, we examined clinical/histological parameters using regression and non-linear dimensionality reduction (tSNE) and a biomarker based on peripheral blood transitional-1 B cell (T1B) IL-10/TNFα ratio. Compared to NI, early BL was associated with increased progression to late acute rejection (AR; 5-12 mos), premature interstitial fibrosis and tubular atrophy (IFTA) and decreased seven-year graft survival. However, decreased graft survival was limited to BL patients who progressed to late AR or IFTA, and was not influenced by treatment. Although tSNE clustered patients into groups based on clinical factors, the ability of these factors to risk stratify BL patients was modest. In contrast, a low T1B IL-10/TNFα ratio at 3 months identified BL patients at high risk for progression to AR (ROC AUC 0.87) and poor 7-yr graft survival (52% vs. 92%, p=0.003), while BL patients with a high ratio had similar graft survival to patients with NI (91%, p=NS). Thus, progressive early allograft inflammation manifested as BL that progresses to late AR in the first post-transplant year represents a high-risk clinical state for poor allograft outcomes. Such high-risk status can be predicted by the T1B IL-10/TNFα ratio before irreversible scarring sets in, thus allowing timely risk stratification.
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Affiliation(s)
- Aravind Cherukuri
- Thomas E. Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
| | - Khodor I Abou-Daya
- Thomas E. Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Raad Chowdhury
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rajil B Mehta
- Thomas E. Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sundaram Hariharan
- Thomas E. Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Parmjeet Randhawa
- Thomas E. Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Transplantation Pathology, Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David M Rothstein
- Thomas E. Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Immunology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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8
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The Histological Spectrum and Clinical Significance of T Cell-mediated Rejection of Kidney Allografts. Transplantation 2022; 107:1042-1055. [PMID: 36584369 DOI: 10.1097/tp.0000000000004438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
T cell-mediated rejection (TCMR) remains a significant cause of long-term kidney allograft loss, either indirectly through induction of donor-specific anti-HLA alloantibodies or directly through chronic active TCMR. Whether found by indication or protocol biopsy, Banff defined acute TCMR should be treated with antirejection therapy and maximized maintenance immunosuppression. Neither isolated interstitial inflammation in the absence of tubulitis nor isolated tubulitis in the absence of interstitial inflammation results in adverse outcomes, and neither requires antirejection treatment. RNA gene expression analysis of biopsy material may supplement conventional histology, especially in ambiguous cases. Lesser degrees of tubular and interstitial inflammation (Banff borderline) may portend adverse outcomes and should be treated when found on an indication biopsy. Borderline lesions on protocol biopsies may resolve spontaneously but require close follow-up if untreated. Following antirejection therapy of acute TCMR, surveillance protocol biopsies should be considered. Minimally invasive blood-borne assays (donor-derived cell-free DNA and gene expression profiling) are being increasingly studied as a means of following stable patients in lieu of biopsy. The clinical benefit and cost-effectiveness require confirmation in randomized controlled trials. Treatment of acute TCMR is not standardized but involves bolus corticosteroids with lymphocyte depleting antibodies for severe, refractory, or relapsing cases. Arteritis may be found with acute TCMR, active antibody-mediated rejection, or mixed rejections and should be treated accordingly. The optimal treatment ofchronic active TCMR is uncertain. Randomized controlled trials are necessary to optimally define therapy.
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9
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Mehta RB, Melgarejo I, Viswanathan V, Zhang X, Pittappilly M, Randhawa P, Puttarajappa C, Sood P, Wu C, Sharma A, Molinari M, Hariharan S. Long-term immunological outcomes of early subclinical inflammation on surveillance kidney allograft biopsies. Kidney Int 2022; 102:1371-1381. [PMID: 36049641 DOI: 10.1016/j.kint.2022.07.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 07/07/2022] [Accepted: 07/26/2022] [Indexed: 01/12/2023]
Abstract
The long-term impact of early subclinical inflammation (SCI) through surveillance biopsy has not been well studied. To do this, we recruited a prospective observational cohort that included 1000 sequential patients who received a kidney transplant from 2013-2017 at our center. A total of 586 patients who underwent a surveillance biopsy in their first year post-transplant were included after excluding those with clinical rejections, and those who were unable to undergo a surveillance biopsy. Patients were classified based on their biopsy findings: 282 with NSI (No Significant Inflammation) and 304 with SCI-T (SCI and Tubulitis) which was further subdivided into 182 with SC-BLR (Subclinical Borderline Changes) and 122 with SC-TCMR (Subclinical T Cell Mediated Rejection, Banff 2019 classification of 1A or more). We followed the clinical and immunological events including Clinical Biopsy Proven Acute Rejection [C-BPAR], long-term kidney function and death-censored graft loss over a median follow-up of five years. Episodes of C-BPAR were noted at a median of two years post-transplant. Adjusted odds of having a subsequent C-BPAR was significantly higher in the SCI-T group [SC-BLR and SC-TCMR] compared to NSI 3.8 (2.1-7.5). The adjusted hazard for death-censored graft loss was significantly higher with SCI-T compared to NSI [1.99 (1.04-3.84)]. Overall, SCI detected through surveillance biopsy within the first year post-transplant is a harbinger for subsequent immunological events and is associated with a significantly greater hazard for subsequent C-BPAR and death-censored graft loss. Thus, our study highlights the need for identifying patients with SCI through surveillance biopsy and develop strategies to prevent further alloimmune injuries.
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Affiliation(s)
- Rajil B Mehta
- Division of Transplant Nephrology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Ivy Melgarejo
- Division of Transplant Nephrology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Vignesh Viswanathan
- Division of Transplant Nephrology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Xingyu Zhang
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Matthew Pittappilly
- Division of Transplant Nephrology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Parmjeet Randhawa
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Chethan Puttarajappa
- Division of Transplant Nephrology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Puneet Sood
- Division of Transplant Nephrology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Christine Wu
- Division of Transplant Nephrology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Akhil Sharma
- Division of Transplant Nephrology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michele Molinari
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sundaram Hariharan
- Division of Transplant Nephrology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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10
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Thanukrishnan H, Venkataramanan R, Mehta RB, Jorgensen D, Sood P. The combination of exposure to Tacrolimus, mycophenolic acid, Inosine 5'-Monophosphate Dehydrogenase activity and inhibition in the first week define early histological outcomes in renal transplant recipients. Clin Transplant 2022; 36:e14830. [PMID: 36177865 DOI: 10.1111/ctr.14830] [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: 09/06/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 12/27/2022]
Abstract
Therapeutic drug monitoring is routine for Tacrolimus, while levels are not routinely monitored for mycophenolic acid (MPA). This study investigated the effect of early post-transplant pharmacokinetics (PK) of MPA and Tacrolimus along with the pharmacodynamics (PD) of MPA on biopsy-proven acute rejection (BPAR) after renal transplantation. A prospective PK/PD study with limited sampling (three blood samples) was conducted in renal transplant recipients on week 1, around Day 6 (n = 42) and at the 3rd-month biopsy on Day 90 (n = 23). The partial exposures (area under curve [AUC]0-3.5 h ) of both MPA and Tacrolimus obtained during the first week were more predictive of rejection (combined clinical and subclinical rejection) by Day 90 than their trough concentrations or Day 90 exposures. Patients with rejection had significantly worse renal function (eGFR) and a comparatively lower exposure to MPA during the first post-transplant week. The lower MPA exposure was also associated with sub-optimal inosine monophosphate dehydrogenase (IMPDH) inhibition in patients with rejection, and the probability of rejection was higher in the presence of an increased pre-transplant IMPDH activity. A composite of parameters, including MPA exposure and IMPDH activity was found to predict acute rejection and may be beneficial along with tacrolimus monitoring early after renal transplantation.
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Affiliation(s)
| | - Raman Venkataramanan
- School of Pharmacy and Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rajil B Mehta
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dana Jorgensen
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Puneet Sood
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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11
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Hernández D, Vázquez-Sánchez T, Sola E, Lopez V, Ruiz-Esteban P, Caballero A, Salido E, Leon M, Rodriguez A, Serra N, Rodriguez C, Facundo C, Perello M, Silva I, Marrero-Miranda D, Cidraque I, Moreso F, Guirado L, Serón D, Torres A. Treatment of early borderline lesions in low immunological risk kidney transplant patients: a Spanish multicenter, randomized, controlled parallel-group study protocol: the TRAINING study. BMC Nephrol 2022; 23:357. [PMCID: PMC9639260 DOI: 10.1186/s12882-022-02989-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 10/24/2022] [Indexed: 11/09/2022] Open
Abstract
Abstract
Background
Subclinical inflammation, including borderline lesions (BL), is very common (30–40%) after kidney transplantation (KT), even in low immunological risk patients, and can lead to interstitial fibrosis/tubular atrophy (IFTA) and worsening of renal function with graft loss. Few controlled studies have analyzed the therapeutic benefit of treating these BL on renal function and graft histology. Furthermore, these studies have only used bolus steroids, which may be insufficient to slow the progression of these lesions. Klotho, a transmembrane protein produced mainly in the kidney with antifibrotic properties, plays a crucial role in the senescence-inflammation binomial of kidney tissue. Systemic and local inflammation decrease renal tissue expression and soluble levels of α-klotho. It is therefore important to determine whether treatment of BL prevents a decrease in α-klotho levels, progression of IFTA, and loss of kidney function.
Methods
The TRAINING study will randomize 80 patients with low immunological risk who will receive their first KT. The aim of the study is to determine whether the treatment of early BL (3rd month post-KT) with polyclonal rabbit antithymocyte globulin (Grafalon®) (6 mg/kg/day) prevents or decreases the progression of IFTA and the worsening of graft function compared to conventional therapy after two years post-KT, as well as to analyze whether treatment of BL with Grafalon® can modify the expression and levels of klotho, as well as the pro-inflammatory cytokines that regulate its expression.
Discussion
This phase IV investigator-driven, randomized, placebo-controlled clinical trial will examine the efficacy and safety of Grafalon® treatment in low-immunological-risk KT patients with early BL.
Trial registration
clinicaltrials.gov: NCT04936282. Registered June 23, 2021, https://clinicaltrials.gov/ct2/show/NCT04936282?term=NCT04936282&draw=2&rank=1. Protocol Version 2 of 21 January 2022. Sponsor: Canary Isles Institute for Health Research Foundation, Canary Isles (FIISC). mgomez@fciisc.org.
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12
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Randhawa P. The MMDx ® diagnostic system: A critical re-appraisal of its knowledge gaps and a call for rigorous validation studies. Clin Transplant 2022; 36:e14747. [PMID: 35678044 DOI: 10.1111/ctr.14747] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 05/31/2022] [Accepted: 06/04/2022] [Indexed: 12/15/2022]
Abstract
Transcriptomics generates pathogenetic insights not obtainable by histology, but translation of these insights into diagnostic tests is not a trivial task. This opinion-piece critically appraises declarative MMDx statements, such as the infallibility of machine learning algorithms, measurements of gene expression with >99% precision, and "unambiguous reclassifications" of contentious biopsies such as those with borderline change, polyomavirus nephropathy, chronic active T-cell or mixed rejection, isolated intimal arteritis, and renal medullary pathology. It is shown that molecular diagnoses that do not agree with histology cannot be attributed primarily to pathology reading errors. Neither can all molecular calls derived from arbitrary binary thresholds be automatically accepted as the ground truth. Important other sources of discrepancies between clinico-pathologic and molecular calls include: (a) organ being studied, (b) disease definition, (c) clinical histologic, and gene expression heterogeneity within the same diagnostic label, (d) size and composition of comparator groups, (e) molecular noise, (f) variability in output of different machine learning algorithms, and (g) the nonavailability of a molecular classifier for chronic active TCMR. Carefully designed clinical trials are needed to determine which of the proposed indications of MMDx provide incremental value over existing standard of care protocols.
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Affiliation(s)
- Parmjeet Randhawa
- Division of Transplantation Pathology, Department of Pathology, The Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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13
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Tang D, Cao F, Yan C, Fang K, Ma J, Gao L, Sun B, Wang G. Extracellular Vesicle/Macrophage Axis: Potential Targets for Inflammatory Disease Intervention. Front Immunol 2022; 13:705472. [PMID: 35769456 PMCID: PMC9234271 DOI: 10.3389/fimmu.2022.705472] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 05/18/2022] [Indexed: 11/13/2022] Open
Abstract
Extracellular vesicles (EVs) can regulate the polarization of macrophages in a variety of inflammatory diseases by mediating intercellular signal transduction and affecting the occurrence and development of diseases. After macrophages are regulated by EVs, they mainly show two phenotypes: the proinflammatory M1 type and the anti-inflammatory M2 type. A large number of studies have shown that in diseases such as mastitis, inflammatory bowel disease, Acute lung injury, and idiopathic pulmonary fibrosis, EVs promote the progression of the disease by inducing the M1-like polarization of macrophages. In diseases such as liver injury, asthma, and myocardial infarction, EVs can induce M2-like polarization of macrophages, inhibit the inflammatory response, and reduce the severity of the disease, thus indicating new pathways for treating inflammatory diseases. The EV/macrophage axis has become a potential target for inflammatory disease pathogenesis and comprehensive treatment. This article reviews the structure and function of the EV/macrophage axis and summarizes its biological functions in inflammatory diseases to provide insights for the diagnosis and treatment of inflammatory diseases.
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Affiliation(s)
- Desheng Tang
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Central Laboratory, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Feng Cao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
| | - Changsheng Yan
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Central Laboratory, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Kun Fang
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Central Laboratory, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jiamin Ma
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Central Laboratory, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Lei Gao
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Central Laboratory, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Bei Sun
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Central Laboratory, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Gang Wang
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Central Laboratory, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- *Correspondence: Gang Wang,
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14
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Trasplante renal en la próxima década: estrategias, retos y visión de futuro. Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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15
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Seron D, Rabant M, Becker JU, Roufosse C, Bellini MI, Böhmig GA, Budde K, Diekmann F, Glotz D, Hilbrands L, Loupy A, Oberbauer R, Pengel L, Schneeberger S, Naesens M. Proposed Definitions of T Cell-Mediated Rejection and Tubulointerstitial Inflammation as Clinical Trial Endpoints in Kidney Transplantation. Transpl Int 2022; 35:10135. [PMID: 35669975 PMCID: PMC9163314 DOI: 10.3389/ti.2022.10135] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/11/2022] [Indexed: 12/14/2022]
Abstract
The diagnosis of acute T cell-mediated rejection (aTCMR) after kidney transplantation has considerable relevance for research purposes. Its definition is primarily based on tubulointerstitial inflammation and has changed little over time; aTCMR is therefore a suitable parameter for longitudinal data comparisons. In addition, because aTCMR is managed with antirejection therapies that carry additional risks, anxieties, and costs, it is a clinically meaningful endpoint for studies. This paper reviews the history and classifications of TCMR and characterizes its potential role in clinical trials: a role that largely depends on the nature of the biopsy taken (indication vs protocol), the level of inflammation observed (e.g., borderline changes vs full TCMR), concomitant chronic lesions (chronic active TCMR), and the therapeutic intervention planned. There is ongoing variability—and ambiguity—in clinical monitoring and management of TCMR. More research, to investigate the clinical relevance of borderline changes (especially in protocol biopsies) and effective therapeutic strategies that improve graft survival rates with minimal patient morbidity, is urgently required. The present paper was developed from documentation produced by the European Society for Organ Transplantation (ESOT) as part of a Broad Scientific Advice request that ESOT submitted to the European Medicines Agency for discussion in 2020. This paper proposes to move toward refined definitions of aTCMR and borderline changes to be included as primary endpoints in clinical trials of kidney transplantation.
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Affiliation(s)
- Daniel Seron
- Department of Nephrology and Kidney Transplantation, Vall d’Hebrón University Hospital, Barcelona, Spain
| | - Marion Rabant
- Department of Pathology, Hôpital Necker–Enfants Malades, Paris, France
| | - Jan Ulrich Becker
- Institute of Pathology, University Hospital Cologne, Cologne, Germany
| | - Candice Roufosse
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | | | - Georg A. Böhmig
- Division of Nephrology and Dialysis, Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Fritz Diekmann
- Department of Nephrology and Kidney Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
| | - Denis Glotz
- Paris Translational Research Center for Organ Transplantation, Hôpital Saint Louis, Paris, France
| | - Luuk Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, Hôpital Necker, Paris, France
| | - Rainer Oberbauer
- Department of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Liset Pengel
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Stefan Schneeberger
- Department of General, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- *Correspondence: Maarten Naesens,
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16
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Noninvasive Diagnosis of Acute Rejection in Renal Transplant Patients Using Mass Spectrometric Analysis of Urine Samples: A Multicenter Diagnostic Phase III Trial. Transplant Direct 2022; 8:e1316. [PMID: 35434282 PMCID: PMC9005257 DOI: 10.1097/txd.0000000000001316] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 02/14/2022] [Indexed: 12/14/2022] Open
Abstract
Timely recognition and treatment of acute kidney graft rejection is important to prevent premature graft failure. A predefined urinary marker set for acute T cell–mediated rejection (TCMR) containing 14 peptides was tested for this purpose in a multicenter in-place validation study.
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17
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Rampersad C, Balshaw R, Gibson IW, Ho J, Shaw J, Karpinski M, Goldberg A, Birk P, Rush DN, Nickerson PW, Wiebe C. The negative impact of T cell-mediated rejection on renal allograft survival in the modern era. Am J Transplant 2022; 22:761-771. [PMID: 34717048 PMCID: PMC9299170 DOI: 10.1111/ajt.16883] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 10/19/2021] [Accepted: 10/22/2021] [Indexed: 01/25/2023]
Abstract
The prevalence and long-term impact of T cell-mediated rejection (TCMR) is poorly defined in the modern era of tacrolimus/mycophenolate-based maintenance therapy. This observational study evaluated 775 kidney transplant recipients with serial histology and correlated TCMR events with the risk of graft loss. After a ~30% incidence of a first Banff Borderline or greater TCMR detected on for-cause (17%) or surveillance (13%) biopsies, persistent (37.4%) or subsequent (26.3%) TCMR occurred in 64% of recipients on follow-up biopsies. Alloimmune risk categories based on the HLA-DR/DQ single molecule eplet molecular mismatch correlated with the number of TCMR events (p = .002) and Banff TCMR grade (p = .007). Both a first and second TCMR event correlated with death-censored and all-cause graft loss when adjusted for baseline covariates and other significant time-dependent covariates such as DGF and ABMR. Therefore, a substantial portion of kidney transplant recipients, especially those with intermediate and high HLA-DR/DQ molecular mismatch scores, remain under-immunosuppressed, which in turn identifies the need for novel agents that can more effectively prevent or treat TCMR.
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Affiliation(s)
| | - Robert Balshaw
- George and Fay Yee Centre for Healthcare InnovationUniversity of ManitobaWinnipegManitobaCanada
| | - Ian W. Gibson
- Shared Health Services ManitobaWinnipegManitobaCanada,Department of PathologyUniversity of ManitobaWinnipegManitobaCanada
| | - Julie Ho
- Department of MedicineUniversity of ManitobaWinnipegManitobaCanada,Shared Health Services ManitobaWinnipegManitobaCanada,Department of ImmunologyUniversity of ManitobaWinnipegManitobaCanada
| | - Jamie Shaw
- Department of MedicineUniversity of ManitobaWinnipegManitobaCanada
| | - Martin Karpinski
- Department of MedicineUniversity of ManitobaWinnipegManitobaCanada
| | - Aviva Goldberg
- Department of Pediatrics and Child HealthUniversity of ManitobaWinnipegManitobaCanada
| | - Patricia Birk
- Department of Pediatrics and Child HealthUniversity of ManitobaWinnipegManitobaCanada
| | - David N. Rush
- Department of MedicineUniversity of ManitobaWinnipegManitobaCanada,Shared Health Services ManitobaWinnipegManitobaCanada
| | - Peter W. Nickerson
- Department of MedicineUniversity of ManitobaWinnipegManitobaCanada,Shared Health Services ManitobaWinnipegManitobaCanada,Department of ImmunologyUniversity of ManitobaWinnipegManitobaCanada
| | - Chris Wiebe
- Department of MedicineUniversity of ManitobaWinnipegManitobaCanada,Shared Health Services ManitobaWinnipegManitobaCanada,Department of ImmunologyUniversity of ManitobaWinnipegManitobaCanada
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18
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Ho J, Okoli GN, Rabbani R, Lam OLT, Reddy V, Askin N, Rampersad C, Trachtenberg A, Wiebe C, Nickerson P, Abou‐Setta AM. Effectiveness of T cell-mediated rejection therapy: A systematic review and meta-analysis. Am J Transplant 2022; 22:772-785. [PMID: 34860468 PMCID: PMC9300092 DOI: 10.1111/ajt.16907] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/22/2021] [Accepted: 11/26/2021] [Indexed: 01/25/2023]
Abstract
The effectiveness of T cell-mediated rejection (TCMR) therapy for achieving histological remission remains undefined in patients on modern immunosuppression. We systematically identified, critically appraised, and summarized the incidence and histological outcomes after TCMR treatment in patients on tacrolimus (Tac) and mycophenolic acid (MPA). English-language publications were searched in MEDLINE (Ovid), Embase (Ovid), Cochrane Central (Ovid), CINAHL (EBSCO), and Clinicaltrials.gov (NLM) up to January 2021. Study quality was assessed with the National Institutes of Health Study Quality Tool. We pooled results using an inverse variance, random-effects model and report the binomial proportions with associated 95% confidence intervals (95% CI). Statistical heterogeneity was explored using the I2 statistic. From 2875 screened citations, we included 12 studies (1255 participants). Fifty-eight percent were good/high quality while the rest were moderate quality. Thirty-nine percent of patients (95% CI 0.26-0.53, I2 77%) had persistent ≥Banff Borderline TCMR 2-9 months after anti-rejection therapy. Pulse steroids and augmented maintenance immunosuppression were mainstays of therapy, but considerable practice heterogeneity was present. A high proportion of biopsy-proven rejection exists after treatment emphasizing the importance of histology to characterize remission. Anti-rejection therapy is foundational to transplant management but well-designed clinical trials in patients on Tac/MPA immunosuppression are lacking to define the optimal therapeutic approach.
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Affiliation(s)
- Julie Ho
- Department of Internal MedicineMax Rady College of MedicineRady Faculty of Health SciencesUniversity of ManitobaWinnipegManitobaCanada
| | - George N. Okoli
- George and Fay Yee Centre for Healthcare InnovationMax Rady College of MedicineRady Faculty of Health SciencesUniversity of ManitobaWinnipegManitobaCanada
| | - Rasheda Rabbani
- George and Fay Yee Centre for Healthcare InnovationMax Rady College of MedicineRady Faculty of Health SciencesUniversity of ManitobaWinnipegManitobaCanada,Department of Community Health SciencesMax Rady College of MedicineRady Faculty of Health SciencesUniversity of ManitobaWinnipegManitobaCanada
| | - Otto L. T. Lam
- George and Fay Yee Centre for Healthcare InnovationMax Rady College of MedicineRady Faculty of Health SciencesUniversity of ManitobaWinnipegManitobaCanada
| | - Viraj K. Reddy
- George and Fay Yee Centre for Healthcare InnovationMax Rady College of MedicineRady Faculty of Health SciencesUniversity of ManitobaWinnipegManitobaCanada
| | - Nicole Askin
- Neil John Maclean Health Sciences LibraryUniversity of ManitobaWinnipegManitobaCanada
| | - Christie Rampersad
- Department of Internal MedicineMax Rady College of MedicineRady Faculty of Health SciencesUniversity of ManitobaWinnipegManitobaCanada
| | - Aaron Trachtenberg
- Department of Internal MedicineMax Rady College of MedicineRady Faculty of Health SciencesUniversity of ManitobaWinnipegManitobaCanada
| | - Chris Wiebe
- Department of Internal MedicineMax Rady College of MedicineRady Faculty of Health SciencesUniversity of ManitobaWinnipegManitobaCanada
| | - Peter Nickerson
- Department of Internal MedicineMax Rady College of MedicineRady Faculty of Health SciencesUniversity of ManitobaWinnipegManitobaCanada
| | - Ahmed M. Abou‐Setta
- George and Fay Yee Centre for Healthcare InnovationMax Rady College of MedicineRady Faculty of Health SciencesUniversity of ManitobaWinnipegManitobaCanada,Department of Community Health SciencesMax Rady College of MedicineRady Faculty of Health SciencesUniversity of ManitobaWinnipegManitobaCanada
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19
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Mehta RB, Shimko K, Zhang X, Puttarajappa C, Wu C, Sharma A, Molinari M, Tevar AD, Hariharan S, Sood P. Rabbit antithymocyte globulin dose and early subclinical and clinical rejections in kidney transplantation. Clin Transplant 2022; 36:e14582. [PMID: 35000234 DOI: 10.1111/ctr.14582] [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: 11/11/2021] [Revised: 12/12/2021] [Accepted: 12/30/2021] [Indexed: 11/28/2022]
Abstract
Antithymocyte globulin (ATG) is a commonly used induction agent in kidney transplant recipients. However, the optimal dosing has not been well defined. Our protocol aims for a 5-6 mg/kg cumulative dose. It is unclear if a dose lower than 5 mg/kg is associated with more rejection. We performed a retrospective cohort study of patients who received a kidney transplant at our center between January 1, 2013 and December 31, 2016. Primary outcome was biopsy proven acute rejection (clinical and subclinical) in the first six months after kidney transplant. CMV viremia in high risk(D+/R-) recipients and BK viremia was compared as a secondary endpoint. Of the 543 patients, the Low Dose (LD) group (n = 56) received <5 mg/kg ATG and Regular Dose (RD) group (n = 487) received ≧5 mg/kg. Patients in RD were more sensitized (higher PRA and CPRA). LD received a dose of 4 ± 1.1 mg/kg ATG whereas RD received 5.6 ± 0.3 mg/kg ATG (p < 0.001). TCMR(Banff 1A or greater) was present in 34% of patients in LD vs. 22% in RD (p = 0.04) (OR 2.1;95%CI 1.12-3.81;p = 0.019). There was no difference in the incidence of CMV or BK viremia. ATG doses lower than 5 mg/kg may be associated with a heightened risk of rejection despite a low degree of sensitization. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Rajil B Mehta
- University of Pittsburgh Medical Center, Division of Transplant Nephrology.,University of Pittsburgh, Division of Transplant Surgery
| | - Kristen Shimko
- University of Pittsburgh Medical Center, Department of Pharmacy
| | - Xingyu Zhang
- University of Pittsburgh, Division of Transplant Surgery
| | | | - Christine Wu
- University of Pittsburgh Medical Center, Division of Transplant Nephrology
| | - Akhil Sharma
- University of Pittsburgh Medical Center, Division of Transplant Nephrology
| | | | - Amit D Tevar
- University of Pittsburgh, Division of Transplant Surgery
| | - Sundaram Hariharan
- University of Pittsburgh Medical Center, Division of Transplant Nephrology
| | - Puneet Sood
- University of Pittsburgh Medical Center, Division of Transplant Nephrology
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20
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Loupy A, Mengel M, Haas M. 30 years of the International Banff Classification for Allograft Pathology: The Past, Present and Future of Kidney Transplant Diagnostics. Kidney Int 2021; 101:678-691. [DOI: 10.1016/j.kint.2021.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/06/2021] [Accepted: 11/05/2021] [Indexed: 10/19/2022]
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21
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Park S, Guo K, Heilman RL, Poggio ED, Taber DJ, Marsh CL, Kurian SM, Kleiboeker S, Weems J, Holman J, Zhao L, Sinha R, Brietigam S, Rebello C, Abecassis MM, Friedewald JJ. Combining Blood Gene Expression and Cellfree DNA to Diagnose Subclinical Rejection in Kidney Transplant Recipients. Clin J Am Soc Nephrol 2021; 16:1539-1551. [PMID: 34620649 PMCID: PMC8499014 DOI: 10.2215/cjn.05530421] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/11/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Subclinical acute rejection is associated with poor outcomes in kidney transplant recipients. As an alternative to surveillance biopsies, noninvasive screening has been established with a blood gene expression profile. Donor-derived cellfree DNA (cfDNA) has been used to detect rejection in patients with allograft dysfunction but not tested extensively in stable patients. We hypothesized that we could complement noninvasive diagnostic performance for subclinical rejection by combining a donor-derived cfDNA and a gene expression profile assay. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a post hoc analysis of simultaneous blood gene expression profile and donor-derived cfDNA assays in 428 samples paired with surveillance biopsies from 208 subjects enrolled in an observational clinical trial (Clinical Trials in Organ Transplantation-08). Assay results were analyzed as binary variables, and then, their continuous scores were combined using logistic regression. The performance of each assay alone and in combination was compared. RESULTS For diagnosing subclinical rejection, the gene expression profile demonstrated a negative predictive value of 82%, a positive predictive value of 47%, a balanced accuracy of 64%, and an area under the receiver operating curve of 0.75. The donor-derived cfDNA assay showed similar negative predictive value (84%), positive predictive value (56%), balanced accuracy (68%), and area under the receiver operating curve (0.72). When both assays were negative, negative predictive value increased to 88%. When both assays were positive, positive predictive value increased to 81%. Combining assays using multivariable logistic regression, area under the receiver operating curve was 0.81, significantly higher than the gene expression profile (P<0.001) or donor-derived cfDNA alone (P=0.006). Notably, when cases were separated on the basis of rejection type, the gene expression profile was significantly better at detecting cellular rejection (area under the receiver operating curve, 0.80 versus 0.62; P=0.001), whereas the donor-derived cfDNA was significantly better at detecting antibody-mediated rejection (area under the receiver operating curve, 0.84 versus 0.71; P=0.003). CONCLUSIONS A combination of blood-based biomarkers can improve detection and provide less invasive monitoring for subclinical rejection. In this study, the gene expression profile detected more cellular rejection, whereas donor-derived cfDNA detected more antibody-mediated rejection.
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Affiliation(s)
- Sookhyeon Park
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois,Division of Nephrology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Kexin Guo
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois,Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Raymond L. Heilman
- Department of Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic, Phoenix, Arizona
| | - Emilio D. Poggio
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio
| | - David J. Taber
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Christopher L. Marsh
- Department of Medicine and Surgery, Scripps Clinic and Green Hospital, La Jolla, California
| | - Sunil M. Kurian
- Bio-Repository and Bio-Informatics Core, Scripps Health, La Jolla, California
| | | | - Juston Weems
- Eurofins US Clinical Diagnostics, Lee’s Summit, Missouri
| | - John Holman
- Transplant Genomics, Inc., Mansfield, Massachusetts
| | - Lihui Zhao
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois,Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rohita Sinha
- Eurofins US Clinical Diagnostics, Lee’s Summit, Missouri
| | - Susan Brietigam
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Christabel Rebello
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Michael M. Abecassis
- Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona,Department of Immunobiology, University of Arizona College of Medicine, Tucson, Arizona
| | - John J. Friedewald
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois,Division of Nephrology, Department of Medicine, Northwestern University, Chicago, Illinois
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22
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Maanaoui M, Kerr-Conte J. Pushing the boundaries of organs before it's too late: pre-emptive regeneration. Transpl Int 2021; 34:1761-1769. [PMID: 34532871 DOI: 10.1111/tri.13969] [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: 04/13/2021] [Revised: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 11/28/2022]
Abstract
Solid organ transplantation is marked by accelerated aging and inexorable fibrosis. It is crucial to promote strategies to attenuate, or to reverse, damage before organ failure. Hence, the objective of this article is to provide insight into strategies, which aim to regenerate or rejuvenate the transplanted organs. Cell therapy with mesenchymal stromal cells is currently under investigation because of their antifibrotic properties. Their ability to promote mitochondrial biogenesis, and to transfer mitochondria to wounded cells, is another approach to boost the organ regeneration. Other teams have investigated bioengineered organs, which consists of decellularization of the damaged organ followed by recellularization. Lastly, the development of CAR-T cell-based technologies may revolutionize the field of transplantation, as recent preclinical studies showed that CAR-T cells could efficiently clear senescent cells from an organ and reverse fibrosis. Ultimately, these cutting-edge strategies may bring the holy grail of a pre-emptive regenerated organ closer to reality.
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Affiliation(s)
- Mehdi Maanaoui
- Department of Nephrology, CHU Lille, Lille, France.,Inserm, CHU Lille, Institut Pasteur Lille, U1190 - EGID, Univ. Lille, Lille, France
| | - Julie Kerr-Conte
- Inserm, CHU Lille, Institut Pasteur Lille, U1190 - EGID, Univ. Lille, Lille, France
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23
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Doberer K, Haupenthal F, Nackenhorst M, Bauernfeind F, Dermuth F, Eigenschink M, Schiemann M, Kläger J, Görzer I, Eskandary F, Reindl-Schwaighofer R, Kikić Ž, Böhmig G, Strassl R, Regele H, Puchhammer-Stöckl E, Bond G. Torque Teno Virus Load Is Associated With Subclinical Alloreactivity in Kidney Transplant Recipients: A Prospective Observational Trial. Transplantation 2021; 105:2112-2118. [PMID: 33587432 PMCID: PMC8376270 DOI: 10.1097/tp.0000000000003619] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Nonpathogenic torque teno viruses (TTVs) are highly prevalent in transplant recipients and associated with immunosuppression. Studies in kidney transplant patients have proposed assessment of TTV load for risk stratification of clinically overt graft rejection. The value of TTV quantification in the context of subclinical rejection has not been evaluated. METHODS In this prospective trial, 307 consecutive kidney transplant recipients were subjected to per-protocol monitoring of plasma TTV. TTV was analyzed in the context of protocol biopsies (n = 82), scheduled 1 year posttransplantation. RESULTS TTV load at the time of biopsy was lower in recipients with rejection (n = 19; according to Banff, including borderline changes suspicious for acute T cell-mediated rejection) than those without rejection (n = 63) whereby each log increase in TTV copies/mL decreased the risk for rejection by 9% (risk ratio 0.91, 95% confidence interval, 0.85-0.97; P = 0.004). Development of chronic lesions (cg, cv, ci, ct, ah, ptcml) was associated with the number of days with a TTV load <1 × 106 copies/mL between months 3 and 12 posttransplant (β 0.07, 95% confidence interval, 0.01-0.14; P = 0.02). CONCLUSIONS This trial demonstrates an association between TTV and subclinical graft rejection in kidney transplant recipients. A TTV load <1 × 106 copies/mL suggests suboptimal immunosuppression.
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Affiliation(s)
- Konstantin Doberer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Frederik Haupenthal
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Maja Nackenhorst
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Florian Bauernfeind
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Florentina Dermuth
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Eigenschink
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Martin Schiemann
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Johannes Kläger
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Irene Görzer
- Center for Virology, Medical University of Vienna, Vienna, Austria
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Roman Reindl-Schwaighofer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Željko Kikić
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Georg Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Robert Strassl
- Division of Clinical Virology, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Heinz Regele
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | | | - Gregor Bond
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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24
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Affiliation(s)
- Sundaram Hariharan
- From the University of Pittsburgh Medical Center, Pittsburgh (S.H.); Hennepin Healthcare, the University of Minnesota, and the Scientific Registry of Transplant Recipients - all in Minneapolis (A.K.I.); and the University of California, Los Angeles, Los Angeles (G.D.)
| | - Ajay K Israni
- From the University of Pittsburgh Medical Center, Pittsburgh (S.H.); Hennepin Healthcare, the University of Minnesota, and the Scientific Registry of Transplant Recipients - all in Minneapolis (A.K.I.); and the University of California, Los Angeles, Los Angeles (G.D.)
| | - Gabriel Danovitch
- From the University of Pittsburgh Medical Center, Pittsburgh (S.H.); Hennepin Healthcare, the University of Minnesota, and the Scientific Registry of Transplant Recipients - all in Minneapolis (A.K.I.); and the University of California, Los Angeles, Los Angeles (G.D.)
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25
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Clinical Relevance of Corticosteroid Withdrawal on Graft Histological Lesions in Low-Immunological-Risk Kidney Transplant Patients. J Clin Med 2021; 10:jcm10092005. [PMID: 34067039 PMCID: PMC8125434 DOI: 10.3390/jcm10092005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/30/2021] [Accepted: 05/03/2021] [Indexed: 12/14/2022] Open
Abstract
The impact of corticosteroid withdrawal on medium-term graft histological changes in kidney transplant (KT) recipients under standard immunosuppression is uncertain. As part of an open-label, multicenter, prospective, phase IV, 24-month clinical trial (ClinicalTrials.gov, NCT02284464) in low-immunological-risk KT recipients, 105 patients were randomized, after a protocol-biopsy at 3 months, to corticosteroid continuation (CSC, n = 52) or corticosteroid withdrawal (CSW, n = 53). Both groups received tacrolimus and MMF and had another protocol-biopsy at 24 months. The acute rejection rate, including subclinical inflammation (SCI), was comparable between groups (21.2 vs. 24.5%). No patients developed dnDSA. Inflammatory and chronicity scores increased from 3 to 24 months in patients with, at baseline, no inflammation (NI) or SCI, regardless of treatment. CSW patients with SCI at 3 months had a significantly increased chronicity score at 24 months. HbA1c levels were lower in CSW patients (6.4 ± 1.2 vs. 5.7 ± 0.6%; p = 0.013) at 24 months, as was systolic blood pressure (134.2 ± 14.9 vs. 125.7 ± 15.3 mmHg; p = 0.016). Allograft function was comparable between groups and no patients died or lost their graft. An increase in chronicity scores at 2-years post-transplantation was observed in low-immunological-risk KT recipients with initial NI or SCI, but CSW may accelerate chronicity changes, especially in patients with early SCI. This strategy did, however, improve the cardiovascular profiles of patients.
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26
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Impact of HLA Mismatching on Early Subclinical Inflammation in Low-Immunological-Risk Kidney Transplant Recipients. J Clin Med 2021; 10:jcm10091934. [PMID: 33947168 PMCID: PMC8125522 DOI: 10.3390/jcm10091934] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/20/2021] [Accepted: 04/27/2021] [Indexed: 01/17/2023] Open
Abstract
The impact of human leukocyte antigen (HLA)-mismatching on the early appearance of subclinical inflammation (SCI) in low-immunological-risk kidney transplant (KT) recipients is undetermined. We aimed to assess whether HLA-mismatching (A-B-C-DR-DQ) is a risk factor for early SCI. As part of a clinical trial (Clinicaltrials.gov, number NCT02284464), a total of 105 low-immunological-risk KT patients underwent a protocol biopsy on the third month post-KT. As a result, 54 presented SCI, showing a greater number of total HLA-mismatches (p = 0.008) and worse allograft function compared with the no inflammation group (48.5 ± 13.6 vs. 60 ± 23.4 mL/min; p = 0.003). Multiple logistic regression showed that the only risk factor associated with SCI was the total HLA-mismatch score (OR 1.32, 95%CI 1.06-1.64, p = 0.013) or class II HLA mismatching (OR 1.51; 95%CI 1.04-2.19, p = 0.032) after adjusting for confounder variables (recipient age, delayed graft function, transfusion prior KT, and tacrolimus levels). The ROC curve illustrated that the HLA mismatching of six antigens was the optimal value in terms of sensitivity and specificity for predicting the SCI. Finally, a significantly higher proportion of SCI was seen in patients with >6 vs. ≤6 HLA-mismatches (62.3 vs. 37.7%; p = 0.008). HLA compatibility is an independent risk factor associated with early SCI. Thus, transplant physicians should perhaps be more aware of HLA mismatching to reduce these early harmful lesions.
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27
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Sood P, Cherikh WS, Toll AE, Mehta RB, Hariharan S. Kidney allograft rejection: Diagnosis and treatment practices in USA- A UNOS survey. Clin Transplant 2021; 35:e14225. [PMID: 33455009 DOI: 10.1111/ctr.14225] [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: 09/22/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 12/11/2022]
Abstract
We studied diverse rejection management strategies across centers by conducting a UNOS survey of kidney transplant program directors in 2017. There were 104 total responses from 235 kidney transplant programs representing 88 unique transplant programs (response rate 37%). Information was collected on center-specific management practices. Pertinent center-specific data were obtained from the OPTN database. Of the respondents, 33% were considered large centers (>100 transplants/year). Thymoglobulin was the most commonly used induction agent at 84%, 72% responders do rapid steroid withdrawal, and mycophenolic acid (MPA) is the major antimetabolite (100%). For diagnosing TCMR, 100% used indication biopsy, 28% used protocol biopsy, 2% used serum biomarkers, and none used urine cytokines. For ABMR, 99% used indication biopsy, 34% used protocol biopsy, 72% used DSA, 21% used C1q positive DSA, and none used gene profiling (ENDATS). The treatment of subclinical and clinical TCMR included iv/PO steroids. PP/IVIG were the commonest treatments for ABMR. The use of rituximab, bortezomib, and eculizumab increased from C4D-ABMR to recurrent ABMR. There are diverse management practices for diagnosing and treating rejection. An effort to harmonize these diverse practices for management of TCMR and ABMR will give an opportunity to pool data for evaluating clinical outcomes.
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Affiliation(s)
- Puneet Sood
- Department of Medicine and Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Alice E Toll
- United Network for Organ Sharing, Richmond, VA, USA
| | - Rajil B Mehta
- Department of Medicine and Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sundaram Hariharan
- Department of Medicine and Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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28
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Chamoun B, Torres IB, Gabaldón A, Sellarés J, Perelló M, Castellá E, Guri X, Salcedo M, Toapanta NG, Cidraque I, Moreso F, Seron D. Progression of Interstitial Fibrosis and Tubular Atrophy in Low Immunological Risk Renal Transplants Monitored by Sequential Surveillance Biopsies: The Influence of TAC Exposure and Metabolism. J Clin Med 2021; 10:jcm10010141. [PMID: 33406589 PMCID: PMC7796060 DOI: 10.3390/jcm10010141] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/21/2020] [Accepted: 12/30/2020] [Indexed: 02/06/2023] Open
Abstract
The combination of tacrolimus (TAC) and mycophenolate is the most widely employed maintenance immunosuppression in renal transplants. Different surrogates of tacrolimus exposure or metabolism such as tacrolimus trough levels (TAC-C0), coefficient of variation of tacrolimus (CV-TAC-C0), time in therapeutic range (TTR), and tacrolimus concentration dose ratio (C/D) have been associated with graft outcomes. We explore in a cohort of low immunological risk renal transplants (n = 85) treated with TAC, mycophenolate mofetil (MMF), and steroids and then monitored by paired surveillance biopsies the association between histological lesions and TAC-C0 at the time of biopsy as well as CV-TAC-C0, TTR, and C/D during follow up. Interstitial inflammation (i-Banff score ≥ 1) in the first surveillance biopsy was associated with TAC-C0 (odds ratio (OR): 0.69, 95% confidence interval (CI): 0.50–0.96; p = 0.027). In the second surveillance biopsy, inflammation was associated with time below the therapeutic range (OR: 1.05 and 95% CI: 1.01–1.10; p = 0.023). Interstitial inflammation in scarred areas (i-IFTA score ≥ 1) was not associated with surrogates of TAC exposure/metabolism. Progression of interstitial fibrosis/tubular atrophy (IF/TA) was observed in 35 cases (41.2%). Multivariate regression logistic analysis showed that mean C/D (OR: 0.48; 95% CI: 0.25–0.92; p = 0.026) and IF/TA in the first biopsy (OR: 0.43, 95% CI: 0.24–0.77, p = 0.005) were associated with IF/TA progression between biopsies. A low C/D ratio is associated with IF/TA progression, suggesting that TAC nephrotoxicity may contribute to fibrosis progression in well immunosuppressed patients. Our data support that TAC exposure is associated with inflammation in healthy kidney areas but not in scarred tissue.
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Affiliation(s)
- Betty Chamoun
- Nephrology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (B.C.); (I.B.T.); (J.S.); (M.P.); (N.G.T.); (I.C.); (D.S.)
| | - Irina B. Torres
- Nephrology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (B.C.); (I.B.T.); (J.S.); (M.P.); (N.G.T.); (I.C.); (D.S.)
| | - Alejandra Gabaldón
- Pathology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (A.G.); (M.S.)
| | - Joana Sellarés
- Nephrology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (B.C.); (I.B.T.); (J.S.); (M.P.); (N.G.T.); (I.C.); (D.S.)
| | - Manel Perelló
- Nephrology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (B.C.); (I.B.T.); (J.S.); (M.P.); (N.G.T.); (I.C.); (D.S.)
| | - Eva Castellá
- Radiology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (E.C.); (X.G.)
| | - Xavier Guri
- Radiology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (E.C.); (X.G.)
| | - Maite Salcedo
- Pathology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (A.G.); (M.S.)
| | - Nestor G. Toapanta
- Nephrology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (B.C.); (I.B.T.); (J.S.); (M.P.); (N.G.T.); (I.C.); (D.S.)
| | - Ignacio Cidraque
- Nephrology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (B.C.); (I.B.T.); (J.S.); (M.P.); (N.G.T.); (I.C.); (D.S.)
| | - Francesc Moreso
- Nephrology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (B.C.); (I.B.T.); (J.S.); (M.P.); (N.G.T.); (I.C.); (D.S.)
- Department of Medicine, Autonomous University of Barcelona, 08035 Barcelona, Spain
- Correspondence: ; Tel.: +34-93-274-46-66
| | - Daniel Seron
- Nephrology Departments, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (B.C.); (I.B.T.); (J.S.); (M.P.); (N.G.T.); (I.C.); (D.S.)
- Department of Medicine, Autonomous University of Barcelona, 08035 Barcelona, Spain
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29
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Molecular patterns of isolated tubulitis differ from tubulitis with interstitial inflammation in early indication biopsies of kidney allografts. Sci Rep 2020; 10:22220. [PMID: 33335257 PMCID: PMC7746707 DOI: 10.1038/s41598-020-79332-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/02/2020] [Indexed: 11/09/2022] Open
Abstract
The Banff 2019 kidney allograft pathology update excluded isolated tubulitis without interstitial inflammation (ISO-T) from the category of borderline (suspicious) for acute T cell-mediated rejection due to its proposed benign clinical outcome. In this study, we explored the molecular assessment of ISO-T. ISO-T or interstitial inflammation with tubulitis (I + T) was diagnosed in indication biopsies within the first 14 postoperative days. The molecular phenotype of ISO-T was compared to I + T either by using RNA sequencing (n = 16) or by Molecular Microscope Diagnostic System (MMDx, n = 51). RNA sequencing showed lower expression of genes related to interferon-y (p = 1.5 *10-16), cytokine signaling (p = 2.1 *10-20) and inflammatory response (p = 1.0*10-13) in the ISO-T group than in I + T group. Transcripts with increased expression in the I + T group overlapped significantly with previously described pathogenesis-based transcript sets associated with cytotoxic and effector T cell transcripts, and with T cell-mediated rejection (TCMR). MMDx classified 25/32 (78%) ISO-T biopsies and 12/19 (63%) I + T biopsies as no-rejection. ISO-T had significantly lower MMDx scores for interstitial inflammation (p = 0.014), tubulitis (p = 0.035) and TCMR (p = 0.016) compared to I + T. Fewer molecular signals of inflammation in isolated tubulitis suggest that this is also a benign phenotype on a molecular level.
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30
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The meaning of borderline rejection in kidney transplantation. Kidney Int 2020; 98:278-280. [PMID: 32709286 DOI: 10.1016/j.kint.2020.04.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/02/2020] [Indexed: 11/21/2022]
Abstract
Borderline T cell-mediated rejection is a diagnostic category of the Banff schema that uses a lower diagnostic threshold. Subclinical borderline T cell-mediated rejection detected by surveillance sampling is not entirely benign. Studies demonstrate increased rates of late rejection, progressive nephron loss, functional impairment, donor-specific antibody formation, and allograft failure. It can be conceptualized as a failure to control the cellular alloimmune response. Mixed results are reported for its treatment, and randomized controlled trials are needed.
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