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Ettenger RB, Seifert ME, Blydt-Hansen T, Briscoe DM, Holman J, Weng PL, Srivastava R, Fleming J, Malekzadeh M, Pearl M. Detection of Subclinical Rejection in Pediatric Kidney Transplantation: Current and Future Practices. Pediatr Transplant 2024; 28:e14836. [PMID: 39147695 DOI: 10.1111/petr.14836] [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: 04/18/2024] [Revised: 07/19/2024] [Accepted: 07/22/2024] [Indexed: 08/17/2024]
Abstract
INTRODUCTION The successes in the field of pediatric kidney transplantation over the past 60 years have been extraordinary. Year over year, there have been significant improvements in short-term graft survival. However, improvements in longer-term outcomes have been much less apparent. One important contributor has been the phenomenon of low-level rejection in the absence of clinical manifestations-so-called subclinical rejection (SCR). METHODS Traditionally, rejection has been diagnosed by changes in clinical parameters, including but not limited to serum creatinine and proteinuria. This review examines the shortcomings of this approach, the effects of SCR on kidney allograft outcome, the benefits and drawbacks of surveillance biopsies to identify SCR, and new urine and blood biomarkers that define the presence or absence of SCR. RESULTS Serum creatinine is an unreliable index of SCR. Surveillance biopsies are the method most utilized to detect SCR. However, these have significant drawbacks. New biomarkers show promise. These biomarkers include blood gene expression profiles and donor derived-cell free DNA; urine gene expression profiles; urinary cytokines, chemokines, and metabolomics; and other promising blood and urine tests. CONCLUSION Specific emphasis is placed on studies carried out in pediatric kidney transplant recipients. TRIAL REGISTRATION ClinicalTrials.gov: NCT03719339.
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Affiliation(s)
- Robert B Ettenger
- Division of Nephrology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Michael E Seifert
- Division of Pediatric Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tom Blydt-Hansen
- Multi-Organ Transplant Program, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - David M Briscoe
- Division of Nephrology, Department of Pediatrics Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John Holman
- Transplant Genomics Inc., Framingham, Massachusetts, USA
| | - Patricia L Weng
- Division of Nephrology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Rachana Srivastava
- Division of Nephrology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - James Fleming
- Transplant Genomics Inc., Framingham, Massachusetts, USA
| | - Mohammed Malekzadeh
- Division of Nephrology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Meghan Pearl
- Division of Nephrology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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2
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Laroche C, Engen RM. Immune monitoring in pediatric kidney transplant. Pediatr Transplant 2024; 28:e14785. [PMID: 38766986 DOI: 10.1111/petr.14785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 04/25/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Long-term outcomes in pediatric kidney transplantation remain suboptimal, largely related to chronic rejection. Creatinine is a late marker of renal injury, and more sensitive, early markers of allograft injury are an active area of current research. METHODS This is an educational review summarizing existing strategies for monitoring for rejection in kidney transplant recipients. RESULTS We summarize supporting currently available clinical tests, including surveillance biopsy, donor specific antibodies, and donor-derived cell free DNA, as well as the potential limitations of these studies. In addition, we review the current avenues of active research, including transcriptomics, proteomics, metabolomics, and torque tenovirus levels. CONCLUSION Advancing the use of noninvasive immune monitoring will depend on well-designed multicenter trials that include patients with stable graft function, include biopsy results on all patients, and can demonstrate both association with a patient-relevant clinical endpoint such as graft survival or change in glomerular filtration rate and a potential timepoint for intervention.
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Affiliation(s)
| | - Rachel M Engen
- University of Wisconsin Madison, Madison, Wisconsin, USA
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3
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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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4
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Deville KA, Seifert ME. Biomarkers of alloimmune events in pediatric kidney transplantation. Front Pediatr 2022; 10:1087841. [PMID: 36741087 PMCID: PMC9895094 DOI: 10.3389/fped.2022.1087841] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/28/2022] [Indexed: 01/21/2023] Open
Abstract
Alloimmune events such as the development of de novo donor-specific antibody (dnDSA), T cell-mediated rejection (TCMR), and antibody-mediated rejection (ABMR) are the primary contributors to kidney transplant failure in children. For decades, a creatinine-based estimated glomerular filtration rate (eGFR) has been the non-invasive gold standard biomarker for detecting clinically significant alloimmune events, but it suffers from low sensitivity and specificity, especially in smaller children and older allografts. Many clinically "stable" children (based on creatinine) will have alloimmune events known as "subclinical acute rejection" (based on biopsy) that merely reflect the inadequacy of creatinine-based estimates for alloimmune injury rather than a distinct phenotype from clinical rejection with allograft dysfunction. The poor biomarker performance of creatinine leads to many unnecessary surveillance and for-cause biopsies that could be avoided by integrating non-invasive biomarkers with superior sensitivity and specificity into current clinical paradigms. In this review article, we will present and appraise the current state-of-the-art in monitoring for alloimmune events in pediatric kidney transplantation. We will first discuss the current clinical standards for assessing the presence of alloimmune injury and predicting long-term outcomes. We will review principles of biomarker medicine and the application of comprehensive metrics to assess the performance of a given biomarker against the current gold standard. We will then highlight novel blood- and urine-based biomarkers (with special emphasis on pediatric biomarker studies) that have shown superior diagnostic and prognostic performance to the current clinical standards including creatinine-based eGFR. Finally, we will review some of the barriers to translating this research and implementing emerging biomarkers into common clinical practice, and present a transformative approach to using multiple biomarker platforms at different times to optimize the detection and management of critical alloimmune events in pediatric kidney transplant recipients.
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Affiliation(s)
- Kyle A Deville
- Division of Pediatric Nephrology, Department of Pediatrics, University of Alabama Heersink School of Medicine, Birmingham, AL, United States
| | - Michael E Seifert
- Division of Pediatric Nephrology, Department of Pediatrics, University of Alabama Heersink School of Medicine, Birmingham, AL, United States
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5
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Allred ET, Crane CR, Ingulli EG. Three-month protocol biopsies do not detect subclinical rejection in pediatric kidney transplant recipients at a single center. TRANSPLANTATION REPORTS 2021. [DOI: 10.1016/j.tpr.2021.100082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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6
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Blydt-Hansen TD, Sharma A, Gibson IW, Wiebe C, Sharma AP, Langlois V, Teoh CW, Rush D, Nickerson P, Wishart D, Ho J. Validity and utility of urinary CXCL10/Cr immune monitoring in pediatric kidney transplant recipients. Am J Transplant 2021; 21:1545-1555. [PMID: 33034126 DOI: 10.1111/ajt.16336] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/26/2020] [Accepted: 09/20/2020] [Indexed: 02/06/2023]
Abstract
Individualized posttransplant immunosuppression is hampered by suboptimal monitoring strategies. To validate the utility of urinary CXCL10/Cr immune monitoring in children, we conducted a multicenter prospective observational study in children <21 years with serial and biopsy-associated urine samples (n = 97). Biopsies (n = 240) were categorized as normal (NOR), rejection (>i1t1; REJ), indeterminate (IND), BKV infection, and leukocyturia (LEU). An independent pediatric cohort of 180 urines was used for external validation. Ninety-seven patients aged 11.4 ± 5.5 years showed elevated urinary CXCL10/Cr in REJ (3.1, IQR 1.1, 16.4; P < .001) and BKV nephropathy (median = 5.6, IQR 1.3, 26.9; P < .001) vs. NOR (0.8, IQR 0.4, 1.5). The AUC for REJ vs. NOR was 0.76 (95% CI 0.66-0.86). Low (0.63) and high (4.08) CXCL10/Cr levels defined high sensitivity and specificity thresholds, respectively; validated against an independent sample set (AUC = 0.76, 95% CI 0.66-0.86). Serial urines anticipated REJ up to 4 weeks prior to biopsy and declined within 1 month following treatment. Elevated mean CXCL10/Cr was correlated with first-year eGFR decline (ρ = -0.37, P ≤ .001), particularly when persistently exceeding ≥4.08 (ratio = 0.81; P < .04). Useful thresholds for urinary CXCL10/Cr levels reproducibly define the risk of rejection, immune quiescence, and decline in allograft function for use in real-time clinical monitoring in children.
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Affiliation(s)
- Tom D Blydt-Hansen
- Pediatric Nephrology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Atul Sharma
- Biostatistical Consulting Unit, George, Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ian W Gibson
- Pathology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Chris Wiebe
- Nephrology, University of Manitoba, Winnipeg, Manitoba, Canada.,Transplant/Immunology Lab, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ajay P Sharma
- Pediatric Nephrology, University of Western Ontario, London, Ontario, Canada
| | - Valerie Langlois
- Pediatric Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - Chia W Teoh
- Pediatric Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - David Rush
- Nephrology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Peter Nickerson
- Nephrology, University of Manitoba, Winnipeg, Manitoba, Canada.,Transplant/Immunology Lab, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Wishart
- Computing Science, University of Alberta, Edmonton, Alberta, Canada.,The Metabolomics Innovation Center, Edmonton, Alberta, Canada
| | - Julie Ho
- Nephrology, University of Manitoba, Winnipeg, Manitoba, Canada.,Manitoba Centre for Proteomics & Systems Biology, Winnipeg, Manitoba, Canada
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7
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Hoffmann AJ, Gibson IW, Ho J, Nickerson P, Rush D, Sharma A, Wishart D, Blydt-Hansen TD. Early surveillance biopsy utilization and management of pediatric renal allograft acute T cell-mediated rejection in Canadian centers: Observations from the PROBE multicenter cohort study. Pediatr Transplant 2021; 25:e13870. [PMID: 33026135 DOI: 10.1111/petr.13870] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Early TCMR surveillance with protocol kidney biopsy is used differentially among pediatric kidney transplant centers. Little has been reported about actual center-based differences, and this variability may influence TCMR ascertainment, treatment, and monitoring more broadly. METHODS Data from the PROBE multicenter study were used to identify patients from centers conducting ESB or LSIB. ESB was defined as >50% of patients having at least 1 surveillance biopsy in the first 9 months. Patients were compared for number of biopsies, rejection episodes, treatment, and follow-up monitoring. RESULTS A total of 261 biopsies were performed on 97 patients over 1-2 years of follow-up. A total of 228 (87%) of biopsies were performed in ESB centers. Compared to LSIB centers, ESB centers had 7-fold more episodes of TCMR diagnosed on any biopsy [0.8 ± 1.2 vs 0.1 ± 0.4; P < .001] and a 3-fold higher rate from indication biopsies [0.3 ± 0.9 vs 0.1 ± 0.3; P = .04]. The proportion of rejection treatment varied based on severity: Banff borderline i1t1 (40%);>i1t1 and < Banff 1A (86%); and ≥ Banff 1A (100%). Biopsies for follow-up were performed after treatment in 80% of cases (n = 28) of rejection almost exclusively at ESB centers, with 17 (61%) showing persistence of TCMR (≥i1t1). CONCLUSIONS Practice variation exists across Canadian pediatric renal transplant centers with ESB centers identifying more episodes of rejection. Additionally, treatment of Banff borderline is not universal and varies with severity regardless of center type. Lastly, follow-up biopsies are performed inconsistently and invariably show persistence of rejection.
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Affiliation(s)
| | - Ian W Gibson
- Department of Pathology, University of Manitoba, Winnipeg, MB, Canada
| | - Julie Ho
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Nickerson
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Shared Health Services Manitoba, Transplant/Immunology Lab, Winnipeg, MB, Canada
| | - David Rush
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Atul Sharma
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
| | - David Wishart
- The Metabolomics Innovation Centre, University of Alberta, Edmonton, AB, Canada
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8
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Landsberg A, Riazy M, Blydt-Hansen TD. Yield and utility of surveillance kidney biopsies in pediatric kidney transplant recipients at various time points post-transplant. Pediatr Transplant 2021; 25:e13869. [PMID: 33073499 DOI: 10.1111/petr.13869] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/29/2020] [Accepted: 09/09/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Due to a lack of consensus on SB for pediatric kidney transplant recipients, we evaluated the yield and clinical utility of SB findings at various time points post-transplant. METHODS Patients transplanted at a single institution between 2014 and 2020 with at least one SB at 1.5, 3, 6, 12, and 24 months post-transplant were included. Additional biopsies were done for indication (IB). TCMR was classified by Banff criteria (score ≥i1t1). RESULTS Forty-seven patients had 142 biopsies (SB = 113, IB = 29); 19 (40.4%) of whom experienced at least one TCMR episode in the first-year post-transplant. The greatest SB yield of any pathologic abnormality was at 6 months (57.1%; P < .001). Six months also had the highest yield for TCMR (42.9%), compared with 3.3%, 20.8%, 15.0%, and 9.1% at 1.5, 3, 12 months, and 24 months, respectively (P = .003). SB instigated intensification of immunosuppression (28.3% cases), reduction of immunosuppression (2.7% cases), and other non-immunosuppressant changes (1.8% cases). The 6-month SB led to the greatest number of changes in management (53.6%), compared with 1.5, 3, 12, and 24 months (13.3, 20.8, 25.0, and 36.4%, respectively; P = .012). There were no major biopsy-related complications. CONCLUSIONS SBs identify an important burden of subclinical rejection and other pathology leading to changes in clinical management. The greatest yield was at 6 months, whereas the least utility was at the 1.5 months. Selection of SB timing may be tailored such that the optimal yield is balanced against the procedural risk.
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Affiliation(s)
- Adina Landsberg
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Maziar Riazy
- Department of Pathology, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Tom D Blydt-Hansen
- Division of Nephrology, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
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9
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Kanzelmeyer NK, Lerch C, Ahlenstiel-Grunow T, Bräsen JH, Haffner D, Pape L. The role of protocol biopsies after pediatric kidney transplantation. Medicine (Baltimore) 2020; 99:e20522. [PMID: 32502003 PMCID: PMC7306334 DOI: 10.1097/md.0000000000020522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Data on protocol biopsies (PBs) after pediatric kidney transplantation are rare.We evaluated 6-month post-transplantation renal function in 86 children after PB as observational study. Patients were divided into 3 groups:Glomerular filtration rate (GFR) and delta GFR were determined.PBs 6 months post-kidney transplantation did not influence the clinical course in stable pediatric patients and are therefore of questionable value. Decreased kidney function may however be stabilized by therapeutic intervention according to results of PB.
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Affiliation(s)
| | | | | | - Jan H. Bräsen
- Department of Pathology, Hannover Medical School, Hannover, Germany
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10
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Gordillo R, Munshi R, Monroe EJ, Shivaram GM, Smith JM. Benefits and risks of protocol biopsies in pediatric renal transplantation. Pediatr Nephrol 2019; 34:593-598. [PMID: 29725772 DOI: 10.1007/s00467-018-3959-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 03/14/2018] [Accepted: 04/03/2018] [Indexed: 11/30/2022]
Abstract
Protocol biopsies are defined as sampling of allograft tissue at predetermined times regardless of function. This procedure can be justified due to the lack of non-invasive methods to reliably diagnose rejection (acute or subclinical). Changes in creatinine are not seen with subclinical rejection or early acute rejection and do not always correlate with efficacy of treatment. Parents and providers are still hesitant to pursue protocol biopsy due to the potential complications and lack of definitive evidence of a benefit from doing this procedure. Importantly, the rate of transplant renal biopsy complications requiring additional intervention is low. It is unclear if detection and treatment of subclinical rejection detected on protocol biopsy will lead to improved graft survival. Our goal is to review the literature on this topic and share some of the experience in our center. Definition, indications, and complications of diagnostic transplant renal biopsies are not included in this review.
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Affiliation(s)
- Roberto Gordillo
- Division of Nephrology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA.
| | - Raj Munshi
- Division of Nephrology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Eric J Monroe
- Division of Radiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Giridhar M Shivaram
- Division of Radiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Jodi M Smith
- Division of Nephrology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
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11
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Zotta F, Guzzo I, Morolli F, Diomedi-Camassei F, Dello Strologo L. Protocol biopsies in pediatric renal transplantation: a precious tool for clinical management. Pediatr Nephrol 2018; 33:2167-2175. [PMID: 29980849 DOI: 10.1007/s00467-018-4007-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 06/15/2018] [Accepted: 06/18/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Kidney transplantation is the best treatment for children with end-stage kidney disease. Early results have improved, but late graft loss is still a major problem. Non-invasive, fully reliable early biomarkers of acute rejection are currently missing. METHODS Our aim was to evaluate the efficacy of protocol biopsies (PBXs) in a pediatric population. During 11 years, 209 renal transplantations were performed in 204 pediatric patients. Biopsies were performed 3-6 months, 1 year, and 5 years after transplantation. Procedure-related complications were systematically looked for by means of ultrasound scans. RESULTS Unexpected findings (mainly subclinical rejections) requiring therapeutic intervention were found in 19.3% biopsies performed at 3-6 months, in 18.4% in 12-month biopsies and in none of those performed after 5 years. The 13.6% patients at 12-month biopsies and 23.6% at 5-year biopsies showed calcineurin inhibitor (CNI) toxicity. Interstitial fibrosis and tubular atrophy (IF/TA) was found in 17.6 and 83.6% of patients at 12-month and 5-year biopsies, respectively. Complications of the PBX were infrequent. Five-year estimated glomerular filtration rate (GFR) was not significantly different in patients who received treatment for any cause and patients with normal histology. CONCLUSIONS Although we do not have a control group, we may speculate that patients who received treatment returned to a "standard" condition possibly improving final outcome. Protocol biopsies are a powerful diagnostic tool for the management of pediatric renal transplant recipients. In view of the lack of evidence that biopsies taken 5 years after transplantation lead to any therapeutic change, their use should be reconsidered.
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Affiliation(s)
- Federica Zotta
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Isabella Guzzo
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Federica Morolli
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | | | - Luca Dello Strologo
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
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12
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Seifert ME, Yanik MV, Feig DI, Hauptfeld-Dolejsek V, Mroczek-Musulman EC, Kelly DR, Rosenblum F, Mannon RB. Subclinical inflammation phenotypes and long-term outcomes after pediatric kidney transplantation. Am J Transplant 2018; 18:2189-2199. [PMID: 29766640 PMCID: PMC6436389 DOI: 10.1111/ajt.14933] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/02/2018] [Accepted: 05/06/2018] [Indexed: 01/25/2023]
Abstract
The implementation of surveillance biopsies in pediatric kidney transplantation remains controversial. Surveillance biopsies detect subclinical injury prior to clinical dysfunction, which could allow for early interventions that prolong allograft survival. We conducted a single-center retrospective cohort study of 120 consecutive pediatric kidney recipients, of whom 103 had surveillance biopsies ≤6 months posttransplant. We tested the hypothesis that subclinical inflammation (borderline or T cell-mediated rejection without clinical dysfunction) is associated with a 5-year composite endpoint of acute rejection and allograft failure. Overall, 36% of subjects had subclinical inflammation, which was associated with increased hazard for the composite endpoint (adjusted hazard ratio 2.89 [1.27, 6.57]; P < .01). Subjects with treated vs untreated subclinical borderline rejection had a lower incidence of the composite endpoint (41% vs 67%; P < .001). Subclinical vascular injury (subclinical inflammation with Banff arteritis score > 0) had a 78% incidence of the composite endpoint vs 11% in subjects with no major surveillance abnormalities (P < .001). In summary, we showed that subclinical inflammation phenotypes were prevalent in pediatric kidney recipients without clinical dysfunction and were associated with increased acute rejection and allograft failure. Once prospectively validated, our data would support implementation of surveillance biopsies as standard of care in pediatric kidney transplantation.
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Affiliation(s)
- Michael E. Seifert
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham, Alabama
| | - Megan V. Yanik
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham, Alabama
| | - Daniel I. Feig
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham, Alabama
| | - Vera Hauptfeld-Dolejsek
- Department of Surgery, University of Alabama School of Medicine, Birmingham, Alabama,Comprehensive Transplant Institute, University of Alabama School of Medicine, Birmingham, Alabama
| | - Elizabeth C. Mroczek-Musulman
- Children’s of Alabama, Birmingham, Alabama,Department of Pathology, University of Alabama School of Medicine, Birmingham, Alabama
| | - David R. Kelly
- Children’s of Alabama, Birmingham, Alabama,Department of Pathology, University of Alabama School of Medicine, Birmingham, Alabama
| | - Frida Rosenblum
- Department of Pathology, University of Alabama School of Medicine, Birmingham, Alabama
| | - Roslyn B. Mannon
- Department of Surgery, University of Alabama School of Medicine, Birmingham, Alabama,Comprehensive Transplant Institute, University of Alabama School of Medicine, Birmingham, Alabama,Department of Medicine, University of Alabama School of Medicine, Birmingham, Alabama
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13
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Landsberg A, Sharma A, Gibson IW, Rush D, Wishart DS, Blydt-Hansen TD. Non-invasive staging of chronic kidney allograft damage using urine metabolomic profiling. Pediatr Transplant 2018; 22:e13226. [PMID: 29855144 DOI: 10.1111/petr.13226] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2018] [Indexed: 01/06/2023]
Abstract
Chronic kidney allograft damage is characterized by IFTA and GS. We sought to identify urinary metabolite signatures associated with severity of IFTA and GS in pediatric kidney transplant recipients. Urine samples (n = 396) from 60 pediatric transplant recipients were obtained at the time of kidney biopsy and assayed for 133 metabolites by mass spectrometry. Metabolite profiles were quantified via PLS-DA. We used mixed-effects regression to identify laboratory and clinical predictors of histopathology. Urine samples (n = 174) without rejection or AKI were divided into training/validation sets (75:25%). Metabolite classifiers trained on IFTA severity and %GS showed strong statistical correlation (r = .73, P < .001 and r = .72; P < .001, respectively) and remained significant on the validation sets. Regression analysis identified additional clinical features that improved prediction: months post-transplant (GS, IFTA); and proteinuria, GFR, and age (GS only). Addition of clinical variables improved performance of the %GS classifier (AUC = 0.9; 95% CI = 0.85-0.96) but not for IFTA (AUC = 0.82; 95% CI = 0.71-0.92). Despite the presence of potentially confounding phenotypes, these findings were further validated in samples withheld for rejection or AKI. We identify urine metabolite classifiers for IFTA and GS, which may prove useful for non-invasive assessment of histopathological damage.
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Affiliation(s)
- Adina Landsberg
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Atul Sharma
- Department of Pediatrics and Child Health, Children's Hospital at Health Sciences Center, University of Manitoba, Winnipeg, MB, Canada
| | - Ian W Gibson
- Department of Pathology, Health Sciences Center, University of Manitoba, Winnipeg, MB, Canada
| | - David Rush
- Department of Medicine, Health Sciences Center, University of Manitoba, Winnipeg, MB, Canada
| | - David S Wishart
- The Metabolomics Innovation Center, University of Alberta, Edmonton, AB, Canada
| | - Tom D Blydt-Hansen
- Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
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14
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Mockler C, Sharma A, Gibson IW, Gao A, Wong A, Ho J, Blydt-Hansen TD. The prognostic value of urinary chemokines at 6 months after pediatric kidney transplantation. Pediatr Transplant 2018; 22:e13205. [PMID: 29733487 DOI: 10.1111/petr.13205] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2018] [Indexed: 11/29/2022]
Abstract
Pediatric kidney transplantation is lifesaving, but long-term allograft survival is still limited by injury processes mediated by alloimmune inflammation that may otherwise be clinically silent. Chemokines associated with alloimmune inflammation may offer prognostic value early post-transplant by identifying patients at increased risk of poor graft outcomes. We conducted a single-center prospective cohort study of consecutive pediatric kidney transplant recipients (<19 years). Urinary CCL2 and CXCL10 measured at 6 months post-transplant were evaluated for association with long-term eGFR decline, allograft survival, and concomitant acute cellular rejection histology. Thirty-eight patients with a mean age of 12.4 ± 4.6 years were evaluated. Urinary CCL2 was associated with eGFR decline until 6 months (ρ -0.43; P < .01), but not at later time points. Urinary CXCL10 was associated with eGFR decline at 36 months (ρ -0.49; P < .01), risk of 50% eGFR decline (HR = 1.04; P = .02), risk of allograft loss (HR = 1.05; P = .01), borderline rejection or rejection episodes 6-12 months post-transplant (r .41; P = .02), and Banff i + t score (r .47, P < .01). CCL2 and CXCL10 were also correlated with one another (ρ 0.54; P < .01). CCL2 and CXCL10 provide differing, but complementary, information that may be useful for early non-invasive prognostic testing in pediatric kidney transplant recipients.
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Affiliation(s)
- Claire Mockler
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Atul Sharma
- Department of Pediatrics and Child Health, Children's Hospital at Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Ian W Gibson
- Department of Pathology, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Ang Gao
- Manitoba Centre for Proteomics and Systems Biology, University of Manitoba, Winnipeg, MB, Canada
| | - Alexander Wong
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julie Ho
- Manitoba Centre for Proteomics and Systems Biology, University of Manitoba, Winnipeg, MB, Canada.,Section of Nephrology, Department of Internal Medicine, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada.,Department of Immunology, University of Manitoba, Winnipeg, MB, Canada
| | - Tom D Blydt-Hansen
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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15
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Mincham CM, Gibson IW, Sharma A, Wiebe C, Mandal R, Rush D, Nickerson P, Ho J, Wishart DS, Blydt-Hansen TD. Evolution of renal function and urinary biomarker indicators of inflammation on serial kidney biopsies in pediatric kidney transplant recipients with and without rejection. Pediatr Transplant 2018; 22:e13202. [PMID: 29696778 DOI: 10.1111/petr.13202] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2018] [Indexed: 01/06/2023]
Abstract
Urinary CXCL10 and metabolites are biomarkers independently associated with TCMR. We sought to test whether these biomarkers fluctuate in association with histological severity of TCMR over short time frames. Forty-nine pairs of renal biopsies obtained 1-3 months apart from 40 pediatric renal transplant recipients were each scored for TCMR acuity score (i + t; Banff criteria). Urinary CXCL10:Cr and TCMR MDS were obtained at each biopsy and were tested for association with changes between biopsies in acuity, estimated GFR (ΔeGFR), and 12-month ΔeGFR. Sequential biopsies were obtained 1.8 ± 0.8 months apart. Biopsy 1 was usually obtained under protocol (75%), and 62% percent had evidence of TCMR. Using each biopsy pair for comparison, ΔeGFR did not predict change in acuity. By contrast, change in acuity was significantly correlated with change in urinary CXCL10:Cr (ρ 0.45, P = .003) and MDS (ρ 0.29, P = .04) between biopsies. The 12-month ΔeGFR was not predicted by TCMR acuity or CXCL10:Cr at Biopsy 2; however, an inverse correlation was seen with urinary MDS (ρ -0.35; P = .02). Changes in eGFR correlate poorly with evolving TCMR acuity on histology. Urinary biomarkers may be superior for non-invasive monitoring of rejection, including histological response to therapy, and may be prognostic for medium-term function.
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Affiliation(s)
- Christine M Mincham
- Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Ian W Gibson
- Department of Pathology, University of Manitoba, Health Sciences Center, Winnipeg, MB, Canada
| | - Atul Sharma
- Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital at Health Sciences Center, Winnipeg, MB, Canada
| | - Chris Wiebe
- Department of Internal Medicine, Section of Nephrology, University of Manitoba, Health Sciences Center, Winnipeg, MB, Canada
| | - Rupasri Mandal
- Department of Immunology, University of Manitoba, Winnipeg, MB, Canada
| | - David Rush
- Department of Internal Medicine, Section of Nephrology, University of Manitoba, Health Sciences Center, Winnipeg, MB, Canada
| | - Peter Nickerson
- Department of Internal Medicine, Section of Nephrology, University of Manitoba, Health Sciences Center, Winnipeg, MB, Canada
| | - Julie Ho
- Department of Internal Medicine, Section of Nephrology, University of Manitoba, Health Sciences Center, Winnipeg, MB, Canada.,Department of Immunology, University of Manitoba, Winnipeg, MB, Canada
| | - David S Wishart
- The Metabolomics Innovation Center, University of Alberta, Edmonton, AB, Canada
| | - Tom D Blydt-Hansen
- Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
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16
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Nazario M, Nicoara O, Becton L, Self S, Hill J, Mack E, Evans M, Twombley K. Safety and utility of surveillance biopsies in pediatric kidney transplant patients. Pediatr Transplant 2018; 22:e13178. [PMID: 29582530 DOI: 10.1111/petr.13178] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/05/2018] [Indexed: 01/04/2023]
Abstract
There is currently no way to diagnose a rejection before a change in serum creatinine. This had led some to start doing SB, but little data exist on the utility and safety of SB in pediatric patients. There is also little known on practice patterns of pediatric nephrologists. A retrospective review of pediatric kidney transplant SB between January 2013 and January 2017 at a single center was performed. A survey went to the PedNeph email list. There were 47 SB; 15 at 6 months, 12 at 1 year, 13 at 2 years, and 7 at 3 years. There were 3 minor (1 gross hematuria and 2 hematomas) and no major complications. On 6-month SB, 1 had SC 1A ACR (6.7%) with no BR ACR. On the 12-month SB, there were 5 with SCBR ACR (41.7%) and 1 with SC AMR (8.3%). On the 2-year SB, there were 4 that had SCBR ACR (30.8%), and 1 with SC AMR (7.7%). On the 3-year SB, 1 had chronic transplant glomerulitis (14.3%). The survey showed that 34.3% of pediatric nephrologists perform SB. SB can be performed safely. By early identification of histological lesions, SB gives us an opportunity for individualized immunosuppressive regimens that may prevent chronic allograft dysfunction and improve long-term graft outcome.
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Affiliation(s)
- Maritere Nazario
- Medical University of South Carolina, Charleston, SC, USA.,Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Oana Nicoara
- Medical University of South Carolina, Charleston, SC, USA.,Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA.,Division of Pediatric Nephrology, Medical University of South Carolina, Charleston, SC, USA
| | - Lauren Becton
- Medical University of South Carolina, Charleston, SC, USA.,Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA.,Division of Pediatric Nephrology, Medical University of South Carolina, Charleston, SC, USA
| | - Sally Self
- Medical University of South Carolina, Charleston, SC, USA.,Department of Pathology, Medical University of South Carolina, Charleston, SC, USA
| | - Jeanne Hill
- Medical University of South Carolina, Charleston, SC, USA.,Department of Radiology, Medical University of South Carolina, Charleston, SC, USA
| | - Elizabeth Mack
- Medical University of South Carolina, Charleston, SC, USA.,Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA.,Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Melissa Evans
- Medical University of South Carolina, Charleston, SC, USA.,Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA.,Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Katherine Twombley
- Medical University of South Carolina, Charleston, SC, USA.,Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA.,Division of Pediatric Nephrology, Medical University of South Carolina, Charleston, SC, USA
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17
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Gupta C, Moudgil A. Renal transplantation in children: Current status and challenges. APOLLO MEDICINE 2017. [DOI: 10.1016/j.apme.2017.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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18
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Pilot Study of Renal Diffusion Tensor Imaging as a Correlate to Histopathology in Pediatric Renal Allografts. AJR Am J Roentgenol 2017; 208:1358-1364. [PMID: 28379715 DOI: 10.2214/ajr.16.17418] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Fractional anisotropy (FA) is a measure of molecular motion obtained from diffusion tensor imaging (DTI). The objective of this study was to assess the use of FA as a noninvasive correlate of renal allograft histopathology. SUBJECTS AND METHODS Sixteen pediatric renal allograft recipients were imaged using DTI in a prospective study, between October 2014 and January 2016, before a same-day renal allograft biopsy. The Kendall tau correlation coefficient was used to assess the relationship between cortical and medullary FA values and several clinically important Banff renal allograft histopathology scores. The Mann-Whitney U test was also used to compare cortical and medullary FA values in the region of biopsy in patients whose biopsy results did and in those whose biopsy results did not change clinical management. RESULTS Medullary FA values had direct inverse correlation with several histopathology scores: tubulitis (designated "t" score in Banff pathologic classification, p < 0.04), interstitial inflammation (i score, p < 0.005), tubular atrophy (ct score, p < 0.002), and interstitial fibrosis (ci score, p < 0.007). Cortical FA values inversely correlated with peritubular capillaritis (ptc score, p < 0.02). Neither medullary nor cortical FA values correlated with glomerulitis (g score). At a b value of 800 s/mm2, medullary FA values of pediatric renal allograft recipients whose renal biopsies prompted a change in clinical management (mean ± SD at a b value of 800 s/mm2 = 0.262 ± 0.07; n = 9) were statistically different compared with the group whose biopsy results did not change clinical management (mean ± SD at a b value of 800 s/mm2 = 0.333 ± 0.06; n = 7) (p < 0.006). CONCLUSION FA is a noninvasive correlate of several important renal allograft histopathology scores and a potential noninvasive method of assessing renal allograft health in pediatric allograft recipients.
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19
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Rose EM, Kennedy SE, Mackie FE. Surveillance biopsies after paediatric kidney transplantation: A review. Pediatr Transplant 2016; 20:748-55. [PMID: 27306873 DOI: 10.1111/petr.12733] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/11/2016] [Indexed: 11/28/2022]
Abstract
Kidney transplantation is the most effective means of treating children with end-stage kidney disease, and yet, there continues to be a limited "life span" of transplanted kidneys in paediatric recipients. Early graft monitoring, using the surveillance biopsy, has the potential to extend renal allograft survival in paediatric recipients. The surveillance biopsy provides important and timely information about acute and chronic graft pathology, particularly SCR and calcineurin inhibitor-induced nephrotoxicity, which can subsequently guide management decisions and improve long-term graft survival. The ostensible value of the surveillance biopsy is furthered by the limitations of conventional renal functional studies. However, there is still much debate surrounding the surveillance biopsy in paediatric recipients, particularly in regard to its overall utility, safety and timing. This review discusses the current literature regarding the utility, safety, and potential predictive value of surveillance biopsies for guiding post-transplant management in paediatric renal allograft recipients, as well as the viability of other potentially newer non-invasive strategies for renal allograft monitoring.
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Affiliation(s)
- Edward M Rose
- School of Women's & Children's Health, UNSW Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Sean E Kennedy
- School of Women's & Children's Health, UNSW Medicine, University of New South Wales, Sydney, NSW, Australia.,Nephrology, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Fiona E Mackie
- School of Women's & Children's Health, UNSW Medicine, University of New South Wales, Sydney, NSW, Australia.,Nephrology, Sydney Children's Hospital, Randwick, NSW, Australia
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20
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Elevated urinary CXCL10-to-creatinine ratio is associated with subclinical and clinical rejection in pediatric renal transplantation. Transplantation 2015; 99:797-804. [PMID: 25222013 DOI: 10.1097/tp.0000000000000419] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Subclinical and clinical T cell-mediated rejection (TCMR) has significant prognostic implications in pediatric renal transplantation. The goal of this study was to independently validate urinary CXCL10 as a noninvasive biomarker for detecting acute rejection in children and to extend these findings to subclinical rejection. METHODS Urines (n = 140) from 51 patients with surveillance or indication biopsies were assayed for urinary CXCL10 using enzyme-linked immunosorbent assay and corrected with urinary creatinine. RESULTS Median urinary CXCL10-to-creatinine (Cr) ratio (ng/mmol) was significantly elevated in subclinical TCMR (4.4 [2.6, 25.4], P < 0.001, n = 17); clinical TCMR (24.3 [11.2, 44.8], P < 0.001, n = 9); and antibody-mediated rejection (6.0 [3.3, 13.7], P = 0.002, n = 9) compared to noninflamed histology (1.4 [0.4, 4.2], normal and interstitial fibrosis and tubular atrophy, n = 52), and borderline tubulitis (3.3, [1.3, 4.9], n = 36). Elevated urinary CXCL10:Cr was independently associated with t scores (P < 0.001) and g scores (P = 0.006) on multivariate analysis. The area under receiver operating curve for subclinical and clinical TCMR was 0.81 (P = 0.045) and 0.88 (P = 0.019), respectively. This corresponded to a sensitivity-specificity of 0.59-0.67 and 0.77-0.60 for subclinical and clinical TCMR at cutoffs of 4.82 and 4.72 ng/mmol, respectively. CONCLUSION This study demonstrates that urinary CXCL10:Cr corresponds with microvascular inflammation and is a sensitive and specific biomarker for subclinical and clinical TCMR in children. This may provide a noninvasive monitoring tool for posttransplant immune surveillance for pediatric renal transplant recipients.
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21
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Bruel A, Allain-Launay E, Humbert J, Ryckewaert A, Champion G, Moreau A, Renaudin K, Karam G, Roussey-Kesler G. Early protocol biopsies in pediatric renal transplantation: interest for the adaptation of immunosuppression. Pediatr Transplant 2014; 18:142-9. [PMID: 24341571 DOI: 10.1111/petr.12197] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2013] [Indexed: 12/21/2022]
Abstract
GPB are often performed in PRT to detect subclinical acute rejection or IF/TA. Reducing immunosuppression side effects without increasing rejection is a major concern in PRT. We report the results of GPB in children transplanted with a steroid-sparing protocol adapted to immunological risk. Children under 18 yr who received a renal transplantation between April 1, 2009 and May 31, 2012 were included. Immunosuppression consisted of an antibody induction therapy, tacrolimus, and MMF for all recipients. CSs were administered to children under five yr old, or receiving a second allograft. Twenty-eight children were included, 50% were CSs free. GPB were performed between three and six months. IF/TA was documented in seven biopsies; four of these seven children were CS free. One child, with CSs, presented a borderline rejection, and another child, steroid free, with significant inflammatory interstitial infiltrate, considered as a subclinical rejection, was treated with CSs pulses. The median eGFR was stable (74, 67.5, and 82 mL/min/1.73 m² at, respectively, seven days, three months, and one yr). Patient and graft survival were 100%. These results have to be confirmed in a larger cohort, with long-term follow-up.
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Affiliation(s)
- Alexandra Bruel
- Department of Pediatrics, Nantes University Hospital, Nantes, France
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22
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Protocol biopsies in pediatric renal transplant recipients on cyclosporine versus tacrolimus-based immunosuppression. Pediatr Nephrol 2013; 28:493-8. [PMID: 23111894 DOI: 10.1007/s00467-012-2330-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 09/15/2012] [Accepted: 09/17/2012] [Indexed: 01/07/2023]
Abstract
BACKGROUND Protocol biopsies can detect subclinical rejection and early signs of calcineurin inhibitor-induced nephrotoxicity. METHODS In a prospective study, protocol biopsies 3 and 12 months after transplant in transplanted children from two centers were studied. One center used cyclosporine (CsA)-based immunosuppression and the other center used tacrolimus. Patients were on CsA (n = 26, group 1) or on tacrolimus (n = 10, group 2). Patients received basiliximab induction, mycophenolate mofetil, and prednisone. RESULTS In patients on CsA, 26 kidney biopsies were performed during the 6 months after transplantation. Eighteen protocol biopsies were performed at 3 months post transplant; 13 were normal and five showed rejection (two borderline and three Banff II rejections). Eight biopsies were motivated by an increase of serum creatinine; four were normal and four revealed signs of acute rejection (two borderline and two Banff II). Twelve protocol biopsies were performed after 12 months; all were normal. For patients on tacrolimus (n = 10), ten protocol transplant biopsies were performed at 3 months post-transplant; none showed signs of rejection. No biopsy was performed for an increase of serum creatinine. There were no differences in patient age, number of human leukocyteantigen (HLA) incompatibilities, or other patient characteristics. CONCLUSIONS Patients on tacrolimus had less acute rejection episodes detected on protocol biopsies 3 months after transplant. Protocol biopsies seem to play an important role in the detection of subclinical rejection in patients on CsA.
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23
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Chatterjee P, Mathur SR, Dinda AK, Guleria S, Mahajan S, Iyer V, Arora V. Analysis of urine sediment for cytology and antigen expression in acute renal allograft rejection: an alternative to renal biopsy. Am J Clin Pathol 2012; 137:816-24. [PMID: 22523222 DOI: 10.1309/ajcpqfz0gelh5zpn] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Acute rejection in renal transplant recipients is diagnosed by renal biopsy at an advanced disease stage. There is no modality for sequential monitoring of graft status. We studied the role of urine cytology in predicting acute cellular rejection (ACR) and its ability to correctly diagnose ACR and differentiate it from drug toxicity (DT). Urine samples from 203 renal transplant recipients were studied to determine the cellular composition using cytology and immunocytochemistry for HLA-DR, intercellular adhesion molecule (ICAM)-1, and interleukin (IL)-2R. In a 3-month follow-up period, there were 36 episodes of graft dysfunction, of which 28 occurred due to ACR and 8 due to DT. The cytology results showed a significantly increased percentage of lymphocytes and polymorphonuclear cells in samples obtained before and during the clinical manifestations of ACR. A greater level of expression of antigens was observed before and during ACR. The use of IL2-R-, ICAM-1-, and HLA class II-specific monoclonal antibodies gave very high specificity, sensitivity, and positive predictive values in diagnosing rejection through urine cytology, suggesting that routine cytology along with immunocytochemistry of urine sediment has clinical potential for early diagnosis and management of ACR and DT.
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24
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Surveillance biopsies in children post-kidney transplant. Pediatr Nephrol 2012; 27:753-60. [PMID: 21792611 PMCID: PMC3315641 DOI: 10.1007/s00467-011-1969-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 06/29/2011] [Accepted: 07/05/2011] [Indexed: 01/05/2023]
Abstract
Surveillance biopsies are increasingly used in the post-transplant monitoring of pediatric renal allograft recipients. The main justification for this procedure is to diagnose early and presumably modifiable acute and chronic renal allograft injury. Pediatric recipients are theoretically at increased risk for subclinical renal allograft injury due to their relatively large adult-sized kidneys and their higher degree of immunological responsiveness. The safety profile of this procedure has been well investigated. Patient morbidity is low, with macroscopic hematuria being the most common adverse event. No patient deaths have been attributed to this procedure. Longitudinal surveillance biopsy studies have revealed a substantial burden of subclinical immunological and non-immunological injury, including acute cellular rejection, interstitial fibrosis and tubular atrophy, microvascular lesions and transplant glomerulopathy. The main impediment to the implementation of surveillance biopsies as the standard of care is the lack of demonstrable benefit of early histological detection on long-term outcome. The considerable debate surrounding this issue highlights the need for multicenter, prospective, and randomized studies.
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25
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26
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Kanzelmeyer NK, Ahlenstiel T, Drube J, Froede K, Kreuzer M, Broecker V, Ehrich JHH, Melk A, Pape L. Protocol biopsy-driven interventions after pediatric renal transplantation. Pediatr Transplant 2010; 14:1012-8. [PMID: 20846241 DOI: 10.1111/j.1399-3046.2010.01399.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The therapeutic value of protocol biopsies (PBs) in renal transplant recipients remains unclear. We performed protocol biopsies in 57 children six months after transplantation. We increased the CNI dose in patients with borderline findings. In cases of Banff grade Ia, six prednisolone IV-pulses were given and the CNI dose was increased. CNI toxicity and polyomavirus nephropathy led to a reduction in the CNI dose. GFR was compared with a control group of 51 children with no PBs transplanted in the same period. Forty-two percent of PBs had no pathological changes, 24% IF/TA. Borderline findings were detected in 11%, Banff grade Ia in 15% (CNI), toxicity in 8%, and one case showed polyomavirus nephropathy. GFR after 1.5 and 2.5 yr was similar in both groups. GFR 3.5 yr after transplantation was significantly higher in the intervention group (57 ± 17 vs. 46 ± 20). Patients treated with low-dose CNI and everolimus had a significantly lower number of pathological findings in PBs. The performance of protocol biopsies followed by a standardized treatment algorithm led to better graft function 3.5 yr after transplantation. Prospective randomized studies to confirm our findings are needed.
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Affiliation(s)
- N K Kanzelmeyer
- Department of Pediatrics, Hannover Medical School, Hannover, Germany.
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27
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Birk PE, Gill JS, Blydt-Hansen TD, Gibson IW. Enhanced resolution of interstitial fibrosis in pediatric renal allograft biopsies using image analysis of trichrome stain. Pediatr Transplant 2010; 14:925-30. [PMID: 20946518 DOI: 10.1111/j.1399-3046.2010.01376.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The Banff classification is ill suited to detect subtle histologic progression in renal allografts. We present image analysis methodology to precisely quantify IF in pediatric renal allograft biopsies routinely stained with MT. The mean area %IF was determined in 105 pediatric renal allograft biopsies. Associations between %IF or Banff ci scores and estimated GFR were determined using GEE modeling. Logistic regression was used to estimate IF progression. Percent IF (mean ± s.d.) was 6.83% ± 3.94, 10.39 ± 5.23%, and 20.53 ± 8.74 in patients with ci0, ci1, and ci2, respectively. The difference in %IF between biopsies with ci0, ci1, and ci2 was not proportionately incremental: compared to ci2, ci0 had 67% less IF (p < 0.0001), while ci1 had 48% less IF (p < 0.0001). AR had no impact on the precision of %IF measurements. Each 0.5% decrement in %IF was associated with a 1 mL/min per 1.73 m² increase in GFR (p < 0.004). Histologic progression was demonstrated by increasing %IF values (p < 0.0001) and could be estimated by IF = 2.61 × (months) + 6.43. This readily adaptable methodology may be used for the longitudinal assessment of IF in pediatric protocol renal allograft biopsies.
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Affiliation(s)
- Patricia E Birk
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada.
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28
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Goldsmith PJ, Asthana S, Fitzpatrick M, Finlay E, Attia MS, Menon KV, Pollard SG, Ridgway DM, Ahmad N. Transplantation of adult-sized kidneys in low-weight pediatric recipients achieves short-term outcomes comparable to size-matched grafts. Pediatr Transplant 2010; 14:919-24. [PMID: 20840437 DOI: 10.1111/j.1399-3046.2010.01375.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Low-weight pediatric recipients are disadvantaged by scarcity of size-matched donors. ASK have been successfully used for pediatric recipients. We report the results of renal transplantation using ASK in low-weight pediatric recipients and compare outcomes in weight-matched and unmatched donor-recipient pairs. The outcomes of renal transplants using ASK grafts in low-weight (<20 kg) recipients from a single center over a 10-yr period were reviewed. Two groups, comprising recipients of grafts from weight-matched and mismatched donors, were compared. Primary outcome was one-yr graft survival. Secondary outcomes were one- and two-yr calculated eGFR, changes in recipient body weight, perioperative cardiovascular stability, rates of AR and DGF. Twenty-three low-weight recipients were transplanted. Eleven received ASK grafts from high-weight donors and 12 grafts from low-weight donors. One patient in each group had early graft loss. No significant difference was observed in rates of DGF, AR, one-yr graft or patient survival and perioperative cardiovascular parameters. ASK with considerable donor:recipient weight discrepancies can be safely transplanted into small pediatric recipients with comparable outcomes to grafts with less weight discrepancy.
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Affiliation(s)
- P J Goldsmith
- Division of Surgery, Department of Transplant Surgery, St James's University Hospital, Leeds, UK
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29
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Knoll GA, Blydt-Hansen TD, Campbell P, Cantarovich M, Cole E, Fairhead T, Gill JS, Gourishankar S, Hebert D, Hodsman A, House AA, Humar A, Karpinski M, Kim SJ, Mainra R, Prasad GVR. Canadian Society of Transplantation and Canadian Society of Nephrology commentary on the 2009 KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Kidney Dis 2010; 56:219-46. [PMID: 20659623 DOI: 10.1053/j.ajkd.2010.05.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Accepted: 05/14/2010] [Indexed: 01/26/2023]
Affiliation(s)
- Greg A Knoll
- Division of Nephrology, Clinical Epidemiology Program, The Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, USA
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30
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Abstract
PURPOSE OF REVIEW Transplantation is the preferred method of treatment for end-stage renal disease in children. The rate of pediatric kidney transplantation has been steadily rising over the past decade. The use of increasingly potent immunosuppressive drugs has lessened the risk for acute rejection substantially and improved short-term outcomes; however, the long-term outcomes have remained inadequate. RECENT FINDINGS The follow-up of pediatric cohorts and the encouraging results from data registries prompt us to revisit our practices in transplantation so as to devise additional strategies to improve long-term outcomes. SUMMARY This review presents a comprehensive discussion of the major issues in pediatric renal transplantation, the newer immunosuppression approaches to limit toxicities of therapies in children and some critical issues that remain to be addressed, specific to the care of the transplanted child. The ultimate goal of designing optimum conditions for equating graft survival to patient survival still remains a major goal for pediatric organ transplantation.
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Abstract
BACKGROUND In pediatric recipients, the pathophysiology of chronic renal allograft injury is poorly understood. METHODS We studied the evolution and determinants of tubulointerstitial, vascular, and glomerular injury in 240 pediatric protocol renal allograft biopsies during the first 5 years posttransplant. RESULTS Chronic tubulointerstitial injury (ci, ct) developed predominantly during the first 12 months posttransplant, whereas chronic vascular damage (cv, and arteriolar hyalinosis [ah]) and global glomerulosclerosis (gs) became increasingly prevalent at 25 to 36 months and beyond. Chronic interstitial lesions were associated with acute rejection and borderline histology (odds ratio [OR] 2.3, P<0.04), recipient body surface area less than 1.0 m2 (OR 3.6, P<0.05), and obesity (OR 2.0, P<0.03). Determinants of ct were acute rejection (OR 2.6, P=0.02) and acute tubular necrosis (OR 2.8, P<0.04). Vascular fibrous intimal thickening and ah were associated with donor hypertension (OR 3.6, P=0.001) and recipient body surface area less than 1.0 m (OR 2.6, P=0.02), respectively. The severity of ah correlated with the incidence of gs (r=0.32, P<0.0001), with 7.8% gs for ah0, 14.3% gs for ah1, 60.0% gs for ah2, and 95.5% gs for ah3 (median values). Antibody induction conferred protection from ci (OR 0.31, P=0.008), ct (OR 0.33, P=0.002), and ah (OR 0.12, P<0.001) progression. CONCLUSIONS By 5 years posttransplant, pediatric renal allografts manifest a substantial burden of tubulointerstitial and microvascular injury. These lesions are associated with donor hypertension, acute inflammation, renal hypoperfusion, obesity, and calcineurin inhibitor toxicity. The pervasiveness and rapid progression of microvascular lesions at 25 to 36 months suggest that attempts at reducing calcineurin inhibitor exposure should be made before two years posttransplant.
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Hymes LC, Warshaw BL, Hennigar RA, Amaral SG, Greenbaum LA. Prevalence of clinical rejection after surveillance biopsies in pediatric renal transplants: does early subclinical rejection predispose to subsequent rejection episodes? Pediatr Transplant 2009; 13:823-6. [PMID: 19515080 DOI: 10.1111/j.1399-3046.2009.01200.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We analyzed rates of both SCR and CR in children receiving SB at three months post-transplant to determine if SCR predisposed patients to acute CR. Acute rejection was defined according to Banff criteria to include borderline classification or higher. All cases of SCR and CR were treated with anti-rejection protocols. Between October 2004 and July 2008, 89 SB were performed at three months post-transplant. Twenty-six cases of SCR were detected (29%). Sixteen patients experienced 22 episodes of biopsy-proven CR occurring after SB, including seven episodes following SCR and 15 after normal SB. The onset of CR varied from one to 27 months after SB and occurred at similar intervals for cases with SCR and normal SB. The percentage of patients remaining free of CR at 30 months post-transplant was similar in patients with SCR and normal SB. Renal function and graft survival at 30 months also were no different between patients with SCR and those with normal SB. Early-SCR, when treated with rejection protocols, is not a prognostic indicator for subsequent CR episodes.
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Affiliation(s)
- Leonard C Hymes
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Noninvasive detection of acute and chronic injuries in human renal transplant by elevation of multiple cytokines/chemokines in urine. Transplantation 2009; 87:1814-20. [PMID: 19543058 DOI: 10.1097/tp.0b013e3181a66b3e] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Injuries in kidney transplant is currently diagnosed by needle biopsy. A noninvasive test that sensitively detects these injuries would benefit the patients. METHODS Urine samples were collected from healthy controls and kidney transplant recipients. Urine samples were screened first with an antibody array consisting of 120 chemokines and cytokines and then with a multiplex beads assay. Representative parameters, including macrophage inflammatory protein-1Delta, osteoprotegerin, monokine induced by interferon-gamma (IFN), and IFN-gamma-induced protein of 10 kDa, were simultaneously determined by a quadruplex assay in urine samples from 84 patients with renal allograft injury, 29 patients with stable graft function, and 19 healthy individuals. RESULTS Twenty-three cytokines/chemokines were found to be elevated in urine samples of patients with acute rejection by the antibody array. The second round of screening confirmed that 11 of the 23 parameters were elevated in the patients but not in the healthy controls. Induced protein of 10 kDa and monokine induced by IFN-gamma were significantly elevated in urine samples of patients with acute renal injury, and macrophage inflammatory protein-1Delta and osteoprotegerin were significantly elevated in patients with both acute and chronic renal injuries. The combination of the four parameters had a high positive detection rate (97.6%) for renal transplant injury and could differentiate between acute and chronic injury. CONCLUSION These results might indicate that the present multiplex assay provides a basis to establish a noninvasive method for the diagnosis and monitoring of renal transplant injury.
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Sharma AP, Filler G. Monitoring kidney function and renal disease in children following transplant. ACTA ACUST UNITED AC 2009. [DOI: 10.2217/phe.09.12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This article reviews the currently available tools for measuring glomerular filtration rate (GFR) and early detection of chronic kidney disease in pediatric transplant recipients. GFR measurement remains the mainstay to detect renal dysfunction. Inulin clearance formed the earlier gold standard method to measure GFR. In current clinical practice, it has been replaced by nuclear medicine techniques (51Cr EDTA and 99Tc DTPA isotope clearance studies). GFR estimation based on surrogate markers allows more frequent GFR monitoring in a clinical setting. Serum creatinine has a low sensitivity to detect early renal dysfunction and its muscle mass dependency hampers its clinical utility. The Schwartz formula accounts for age-dependent muscle changes in children, but requires center-specific constants. Cystatin C offers the advantage of a constant production and a higher sensitivity in diagnosing renal dysfunction. Microalbuminuria has been an established screening tool in diabetic renal disease. It offers the advantage of detecting underlying renal damage even before a decrease in GFR. Its diagnostic value in other conditions needs evaluation. Hypertension is known to accelerate the progression of chronic kidney disease. A 24-h ambulatory blood pressure is a useful tool to diagnose hypertension, to quantify blood pressure load and to characterize nocturnal blood pressure dipping. GFR scans, serum creatinine and cystatin C form the cornerstone of currently used tools to evaluate kidney dysfunction.
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Affiliation(s)
- Ajay Parkash Sharma
- Department of Paediatrics, Children’s Hospital at London Health Science Centre, University of Western Ontario, London, Ontario, Canada
| | - Guido Filler
- Department of Paediatrics, University of Western Ontario, Children’s Hospital, London Health Science Centre, 800 Commissioners Road East, London, Ontario, Canada, N6A 5W9
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Abstract
Chronic allograft nephropathy (CAN) is the leading cause of renal allograft loss in paediatric renal transplant recipients. CAN is the result of immunological and nonimmunological injury, including acute rejection episodes, hypoperfusion, ischaemia reperfusion, calcineurin toxicity, infection and recurrent disease. The development of CAN is often insidious and may be preceded by subclinical rejection in a well-functioning allograft. Classification of CAN is histological using the Banff classification of renal allograft pathology with classic findings of interstitial fibrosis, tubular atrophy, glomerulosclerosis, fibrointimal hyperplasia and arteriolar hyalinosis. Although improvement in immunosuppression has led to greater 1-year graft survival rates, chronic graft loss remains relatively unchanged and opportunistic infectious complications remain a problem. Protocol biopsy monitoring is not current practice in paediatric transplantation for CAN monitoring but may have a place if new treatment options become available. Newer immunosuppression regimens, closer monitoring of the renal allograft and management of subclinical rejection may lead to reduced immune injury leading to CAN in the paediatric population but must be weighed against the risk of increased immunosuppression and calcineurin inhibitor nephrotoxicity.
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Feasibility of Diagnosing Subclinical Renal Allograft Rejection in Children By Whole Blood Gene Expression Analysis. Transplantation 2008; 86:1222-8. [DOI: 10.1097/tp.0b013e3181883fb0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Qvist E, Their M, Krogerus L, Holmberg C, Jalanko H. Early treatment of acute rejections gives favorable long-term function after renal transplantation in small children. Pediatr Transplant 2007; 11:895-900. [PMID: 17976125 DOI: 10.1111/j.1399-3046.2007.00761.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AR is considered as a risk factor for CAN after kidney TX. We combined data on AR with long-term graft function and histopathology to assess whether early treatment of AR is beneficial for long-term graft outcome in small children. Seventy-seven children with a mean age of 4.7 yr were studied. Early AR were diagnosed with FNAB and treated with methylprednisolone already before clinical signs occurred. The children were grouped into three groups (clinical, subclinical, and no AR) and then followed prospectively up to seven yr after TX with measured GFR and core needle biopsies to assess histopathological findings with the CADI score. Early AR, whether clinical or subclinical, did not affect long-term graft survival (80% with AR vs. 83% without AR, at 10 yr). Late AR, more than one yr after TX, had an inferior graft survival 50% vs. 84% (p = 0.02). GFR declined and the CADI scores increased with time, but there were no significant differences between the three groups. Prompt and early treatment of post-operative AR gives favorable long-term graft function compared with children without AR. Late AR is a risk factor for inferior long-term graft function.
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Affiliation(s)
- Erik Qvist
- Hospital for Children and Adolescents, Pediatric Nephrology and Transplantation, University of Helsinki, Helsinki, Finland.
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41
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Naesens M, Kambham N, Concepcion W, Salvatierra O, Sarwal M. The evolution of nonimmune histological injury and its clinical relevance in adult-sized kidney grafts in pediatric recipients. Am J Transplant 2007; 7:2504-14. [PMID: 17725681 DOI: 10.1111/j.1600-6143.2007.01949.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To describe the evolution, risk factors and impact of nonimmune histological injury after pediatric kidney transplantation, we analyzed 245 renal allograft protocol biopsies taken regularly from the time of transplantation to 2 years thereafter in 81 consecutive rejection-free pediatric recipients of an adult-sized kidney. Isometric tubular vacuolization was present early after transplantation was not progressive, and was associated with higher tacrolimus pre-dose trough levels. Chronic tubulo-interstitial damage and tubular microcalcifications were already noted at 3 months, were progressive and had a greater association with small recipient size, male donor gender, higher donor age and female recipient gender, but not with tacrolimus exposure. Renal function assessment showed that older recipients had a significant increase in absolute glomerular filtration rate with time after transplantation, which differed from small recipients who showed no increase. It is concluded that progressive, functionally relevant, nonimmune injury is detected early after adult-sized kidney transplantation in pediatric recipients. Renal graft ischemia associated with the donor-recipient size discrepancy appears to be a greater risk factor for this chronic histological injury, suggesting that the exploration of additional therapeutic approaches to increase allograft perfusion could further extend the graft survival benefit of adult-sized kidneys transplanted into small children.
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Affiliation(s)
- M Naesens
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
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Hymes LC, Greenbaum L, Amaral SG, Warshaw BL. Surveillance renal transplant biopsies and subclinical rejection at three months post-transplant in pediatric recipients. Pediatr Transplant 2007; 11:536-9. [PMID: 17631023 DOI: 10.1111/j.1399-3046.2007.00705.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
UNLABELLED Subclinical acute rejection (SCR) has been increasingly recognized in adult renal transplant recipients with the advent of surveillance biopsies. However, in children, surveillance biopsies are not routinely performed at most centers. Therefore, the incidence, predisposing factors, treatment, and clinical outcomes of SCR remain unclear in children. From August 2004 to December 2005, we performed 36 protocol biopsies at three months post-transplantation. All patients had received induction therapy with basiliximab and were maintained on prednisone, MMF, and tacrolimus. Sixteen cases of SCR were detected by biopsy (44%). Age, gender, race, donor source, or serum creatinine did not discriminate between children with SCR and those with normal biopsies. All cases of SCR were treated with high doses of methylprednisolone. At one yr post-transplant, renal function was similar in children with SCR to those with normal surveillance biopsies (p = 0.62). Because of the high incidence of SCR, the maintenance dose of MMF was increased by 50% in 20 children transplanted after December 2005. This resulted in a significant decline in the incidence of SCR from 44 to 15% (p < 0.05). However, the incidence of polyomavirus (BK) viremia also increased significantly in these children (p < 0.005). CONCLUSION A high incidence of SCR was found on surveillance biopsies at three months post-transplant and could not be predicted by age, gender, race, donor source, or serum creatinine. The occurrence of SCR declined significantly by increasing the dose of MMF, but resulted in an increase in BK viremia. We conclude that surveillance biopsies provide valuable information in the management of pediatric renal transplant recipients. Increasing immunosuppression to avoid SCR should be weighed against the risk for infection.
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Affiliation(s)
- Leonard C Hymes
- Department of Pediatrics, Division of Nephrology, Emory University, 2015 Uppergate Drive, Atlanta, GA 30322, USA.
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Serón D, Moreso F. Protocol biopsies in renal transplantation: prognostic value of structural monitoring. Kidney Int 2007; 72:690-7. [PMID: 17597702 DOI: 10.1038/sj.ki.5002396] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The natural history of renal allograft damage has been characterized in serial protocol biopsies. The prevalence of subclinical rejection (SCR) is maximal during the first months and it is associated with the progression of interstitial fibrosis/tubular atrophy (IF/TA) and a decreased graft survival. IF/TA rapidly progress during the first months and constitutes an independent predictor of graft survival. IF/TA associated with transplant vasculopathy, SCR, or transplant glomerulopathy implies a poorer prognosis than IF/TA without additional lesions. These observations suggest that protocol biopsies could be considered a surrogate of graft survival. Preliminary data suggest that the predictive value of protocol biopsies is not inferior to acute rejection or renal function. Additionally, protocol biopsies have been employed as a secondary efficacy variable in clinical trials. This strategy has been useful to demonstrate a decrease in the progression of IF/TA in some calcineurin-free regimens. Quantification of renal damage is associated with graft survival suggesting that quantitative parameters might improve the predictive value of protocol biopsies. Validation of protocol biopsies as a surrogate of graft survival is actively pursued, as the utility of classical surrogates of graft outcome such as acute rejection has become less useful because of its decreased prevalence with actual immunosuppression.
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Affiliation(s)
- D Serón
- Nephrology Department, Hospital Universitari de Bellvitge, Barcelona, Spain.
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Vogler C, Wang Y, Brink DS, Wood E, Belsha C, Walker PD. Renal pathology in the pediatric transplant patient. Adv Anat Pathol 2007; 14:202-16. [PMID: 17452817 DOI: 10.1097/pap.0b013e3180504927] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Renal transplantation is a therapeutic goal for children with advanced chronic kidney disease. There are many causes of renal dysfunction in children with allografts--the transplanted kidney can develop a variety of morphologic alterations leading to dysfunction. Evaluation of the kidney biopsy is one of the best methods of determining the cause of graft dysfunction. Rejection is a major cause of renal allograft failure in children. The morphologic hallmarks of acute antibody-mediated and cell-mediated rejection and chronic allograft nephropathy have been codified in classification strategies that are useful in adults and children. Viral infection and Epstein-Barr virus-driven posttransplant lymphoproliferative disease also occur in the pediatric transplanted kidney. Drug toxicity from immunosuppressive agents also causes characteristic morphologic alterations in the renal allograft. As the survival of pediatric heart and liver transplant patients improves, the incidence of immunosuppression therapy-related disease in the native kidney in these patients will likely become more important clinically. In addition to renal lesions related to the allograft state, glomerular disease can recur or occur de novo in renal allografts. Here, we describe the pathology of the more common morphologic lesions in kidneys of children with a renal allograft.
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Affiliation(s)
- Carole Vogler
- Department of Pathology, Saint Louis University School of Medicine, St Louis, MO 63104, USA.
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45
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Birk PE, Blydt-Hansen TD, Dart AB, Kaita LM, Proulx C, Taylor G. Low incidence of adverse events in outpatient pediatric renal allograft biopsies. Pediatr Transplant 2007; 11:196-200. [PMID: 17300500 DOI: 10.1111/j.1399-3046.2006.00659.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In 1999, our center implemented a policy of outpatient protocol biopsies as standard practice for the clinical management of pediatric renal allograft recipients. In order to determine the safety of this procedure, we conducted a retrospective chart audit of all outpatient renal allograft biopsies performed at our center. Biopsies were performed under conscious (midazolam) or procedural (propofol/fentanyl) sedation. Localization of the lower pole of the renal allograft was achieved with renal ultrasound. Using a Biopty gun with a 16-gauge needle, two cores were obtained. Patients were discharged four h post-biopsy. Patient demographics, hospital length of stay (LOS), specimen adequacy (per Banff criteria) and major and minor adverse events were recorded in a central database. Data were expressed as mean +/- SD. From June 1999 to July 2004, we performed 162 biopsies in 43 pediatric renal allograft recipients. Most patients underwent extraperitoneal transplantation (42/43, 97.7%) and were greater than five yr of age at biopsy (129/131 biopsies, 98.5%). The majority of these procedures (131/162, 80.9%) were conducted in the outpatient department, with 113 of 131 (86.3%) being obtained for protocol (n = 89) and one-month follow-up acute rejection therapy (n = 24) indications. Patients underwent 3.7 +/- 2.7 biopsies (range = 1-11). Specimen adequacy was achieved in 119 of 124 (96.0%) of documented cases. The overall incidence of adverse events was 12 of 131 (9.2%) biopsies, all of which were minor in severity. Macroscopic hematuria was the most common minor adverse event, occurring after 11 of 131 (8.4%) biopsies. While macroscopic hematuria prolonged LOS (adverse events vs. no adverse events: 23.0 +/- 26.0 vs. 8.6 +/- 4.1 h, p = 0), none of these episodes required major surgical or radiographic interventions. We conclude that in patients greater than five yr of age with extraperitoneal renal allografts, outpatient protocol biopsies using a 16-gauge needle are sufficiently safe to justify their inclusion in the routine clinical management of pediatric renal allograft recipients and in pediatric clinical trials.
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Affiliation(s)
- Patricia E Birk
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada.
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Alexander SI, Fletcher JT, Nankivell B. Chronic allograft nephropathy in paediatric renal transplantation. Pediatr Nephrol 2007; 22:17-23. [PMID: 16944214 DOI: 10.1007/s00467-006-0219-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Revised: 05/11/2006] [Accepted: 05/12/2006] [Indexed: 01/05/2023]
Abstract
Chronic allograft nephropathy (CAN) is now the leading cause of renal transplant loss in paediatric transplant recipients. Despite improvements in immunosuppression, which have significantly reduced the incidence of acute rejection, the rates of chronic kidney loss have remained unchanged in paediatric transplant patients over the last 20 years. Chronic allograft nephropathy is a pathological diagnosis of which the key features are tubular atrophy and interstitial fibrosis. More consistent definitions and grading of these through the Banff classification have allowed more rigorous study of the development of chronic allograft nephropathy along with further identification of specific lesions associated with the underlying aetiologies. While initially thought to be primarily due to immune injury, it is now evident that CAN is the end result of a variety of immune and non-immune injuries including ischaemia reperfusion injury, calcineurin inhibitor (CNI) toxicity and infections. Protocol biopsy studies have demonstrated rates of CAN development in children similar to those in adults with comparable underlying pathological processes. This review outlines the current knowledge of CAN within the context of paediatric renal transplantation.
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Affiliation(s)
- Stephen I Alexander
- Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, 2145, Australia.
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Shapiro R, Starzl TE. Protocol biopsies should not (yet) be the standard of care in pediatric renal transplant recipients. Pediatr Transplant 2006; 10:766-7. [PMID: 17032420 PMCID: PMC2975442 DOI: 10.1111/j.1399-3046.2006.00572.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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49
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Nankivell BJ, Chapman JR. The significance of subclinical rejection and the value of protocol biopsies. Am J Transplant 2006; 6:2006-12. [PMID: 16796717 DOI: 10.1111/j.1600-6143.2006.01436.x] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Subclinical rejection (SCR) is diagnosed by protocol histology with a maximal prevalence occurring early after transplantation, falling to low levels by 1 year. Needle-core biopsy is safe, and the histology obtained fairly reflects subclinical immune activity. Several studies have consistently shown that SCR is associated with chronic tubulointerstitial damage, subsequent renal dysfunction and reduced graft survival. SCR is effectively treated by pulse corticosteroid therapy, although increased baseline immunosuppression may be necessary. A single randomized clinical trial of biopsy and corticosteroid therapy demonstrated significantly improved early structural and functional outcomes, and a (nonsignificant) 17% risk reduction in 4-year graft survival. Three possible approaches include: no protocol biopsies (usually accompanied by powerful immunosuppression); biopsies only in high-risk recipients (who may be difficult to reliably predict) or universal screening protocol biopsy (comprehensive but limited by cost and resource utilization). The appropriate screening methodology for a transplant unit is both a clinical and an economic decision; influenced by the SCR prevalence and potential gains of treatment, against costs and resource utilization. Further trials to quantify the cost-benefit balance in a typical, heterogeneous recipient population using modern immunosuppression are required.
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Affiliation(s)
- B J Nankivell
- Department of Renal Medicine, University of Sydney, Westmead Hospital, Sydney, Australia.
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Harmon W, Meyers K, Ingelfinger J, McDonald R, McIntosh M, Ho M, Spaneas L, Palmer JA, Hawk M, Geehan C, Tinckam K, Hancock WW, Sayegh MH. Safety and efficacy of a calcineurin inhibitor avoidance regimen in pediatric renal transplantation. J Am Soc Nephrol 2006; 17:1735-45. [PMID: 16687625 DOI: 10.1681/asn.2006010049] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Thirty-four children were entered into a pilot trial of calcineurin inhibitor avoidance after living-donor kidney transplantation, the CN-01 study. Patients were treated with anti-CD25 mAb, prednisone, mycophenolate mofetil, and sirolimus. Twenty patients were maintained on the protocol for up to 3 yr of follow-up. One enrolled patient did not receive the transplant because of a donor problem, eight terminated because of one or more rejection episodes, four terminated because of adverse events, and one was lost to follow-up. Two grafts were lost, one as a result of chronic rejection and the other as a result of posttransplantation lymphoproliferative disorder. There were no deaths. The 6- and 12-mo acute rejection rates were 21.8 and 31.5%, respectively. GFR were stable throughout the course of the study, with a slight downward trend by 6 mo after transplantation followed by a slight upward trend to a mean of 70 ml/min thereafter. Early surveillance graft biopsies frequently showed focal interstitial mononuclear cellular infiltrates without overt vasculitis or tubulitis, but these infiltrates disappeared without treatment. Anti-HLA class I and II antibodies were detected in three patients before transplantation, and all three had acute rejections, including the two patients who lost their grafts. De novo anti-HLA Ab production occurred in only one patient after transplantation. There were two episodes of Epstein Barr virus-related posttransplantation lymphoproliferative disorder, one of which developed after the patient had been terminated from the study. It is concluded that calcineurin inhibitor-free immunosuppression can be safe and effective in pediatric living-donor renal transplantation. However, further modifications that are designed to lessen early rejection rates and decrease complications should be tested before this approach is used routinely.
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Affiliation(s)
- William Harmon
- Transplantation Research Center, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA.
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