1
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Batterton KA, Schubert CM, Warr RL. A fiducial-based confidence interval for the linear combination of multinomial probabilities. Biom J 2023; 65:e2300065. [PMID: 37694601 DOI: 10.1002/bimj.202300065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 06/25/2023] [Accepted: 07/17/2023] [Indexed: 09/12/2023]
Abstract
Across a broad set of applications, system outcomes may be summarized as probabilities in confusion or contingency tables. In settings with more than two outcomes (e.g., stages of cancer), these outcomes represent multinomial experiments. Measures to summarize system performance have been presented as linear combinations of the resulting multinomial probabilities. Statistical inference on the linear combination of multinomial probabilities has been focused on large-sample and parametric settings and not small-sample settings. Such inference is valuable, however, especially in settings such as those resulting from pilot or low-cost studies. To address this gap, we leverage the fiducial approach to derive confidence intervals around the linear combination of multinomial parameters with desirable frequentist properties. One of the original arguments against the fiducial approach was its inability to extend to multiparameter settings. Therefore, the great novelty of this work is both the derived interval and the logical framework for applying the fiducial approach in multiparameter settings. Through simulation, we demonstrate that the proposed method maintains a minimum coverage of1 - α $1 - \alpha$ , unlike the bootstrap and large-sample methods, at comparable interval lengths. Finally, we illustrate its use in a medical problem of selecting classifiers for diagnosing chronic allograph nephropathy in postkidney transplant patients.
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Affiliation(s)
- Katherine A Batterton
- Department of Mathematics and Statistics, Air Force Institute of Technology, Ohio, USA
| | - Christine M Schubert
- Department of Mathematics and Statistics, Air Force Institute of Technology, Ohio, USA
| | - Richard L Warr
- Department of Statistics, Brigham Young University, Provo, Utah, USA
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2
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Obi Y, Ichimaru N, Sakaguchi Y, Iwadoh K, Ishii D, Sakai K, Iwami D, Harada H, Sumida K, Sekine A, Masutani K, Akutsu N, Inoue T, Nishihira M, Yoneda T, Ito S, Araki M, Kaimori JY, Yoshida K, Satoh S, Ubara Y, Isaka Y, Yoshida K, Tsubakihara Y, Takahara S, Hamano T. Correcting anemia and native vitamin D supplementation in kidney transplant recipients: a multicenter, 2 × 2 factorial, open-label, randomized clinical trial. Transpl Int 2021; 34:1212-1225. [PMID: 33884674 DOI: 10.1111/tri.13885] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 03/10/2021] [Accepted: 04/03/2021] [Indexed: 12/21/2022]
Abstract
Anemia and vitamin D deficiency are associated with allograft failure, and hence, are potential therapeutic targets among kidney transplant recipients (KTRs). We conducted a multicenter, two-by-two factorial, open-label, randomized clinical trial to examine the effects of anemia correction and vitamin D supplementation on 2-year change in eGFR among KTRs (CANDLE-KIT). We enrolled 153 patients with anemia and >1-year history of transplantation across 23 facilities in Japan, and randomly assigned them to either a high or low hemoglobin target (>12.5 vs. <10.5 g/dl) and to either cholecalciferol 1000 IU/day or control. This trial was terminated early based on the planned interim intention-to-treat analyses (α = 0.034). Among 125 patients who completed the study, 2-year decline in eGFR was smaller in the high vs. low hemoglobin group (i.e., -1.6 ± 4.5 vs. -4.0 ± 6.9 ml/min/1.73 m2 ; P = 0.021), but did not differ between the cholecalciferol and control groups. These findings were supported by the fully adjusted mixed effects model evaluating the rate of eGFR decline among all 153 participants. There were no significant between-group differences in all-cause death or the renal composite outcome in either arm. In conclusion, aggressive anemia correction showed a potential to preserve allograft kidney function.
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Affiliation(s)
- Yoshitsugu Obi
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan.,Obi Clinic, Osaka, Japan.,Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Naotsugu Ichimaru
- Department of Advanced Technology for Transplantation, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yusuke Sakaguchi
- Department of Inter-Organ Communication Research in Kidney Disease, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kazuhiro Iwadoh
- Department of Surgery III, Tokyo Women's Medical University, Tokyo, Japan.,Department of Blood Purification, Tokyo Women's Medical University, Tokyo, Japan
| | - Daisuke Ishii
- Department of Urology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Ken Sakai
- Department of Nephrology, Omori Medical Center, Toho University School of Medicine, Tokyo, Japan
| | - Daiki Iwami
- Department of Urology, Hokkaido University, Sapporo, Japan.,Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Shimotsuke, Japan
| | - Hiroshi Harada
- Department of Kidney Transplant Surgery, Sapporo City General Hospital, Sapporo, Japan
| | - Keiichi Sumida
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Center, Toranomon Hospital Kajigaya, Kawasaki, Japan
| | - Akinari Sekine
- Nephrology Center, Toranomon Hospital Kajigaya, Kawasaki, Japan
| | - Kosuke Masutani
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Naotake Akutsu
- Department of Surgery and Clinical Research Center, Chibahigashi National Hospital, National Hospital Organization, Chiba, Japan
| | - Takamitsu Inoue
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | | | - Tatsuo Yoneda
- Departments of Urology, Nara Medical University, Kashihara, Nara, Japan
| | | | - Motoo Araki
- Department of Urology, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Jun-Ya Kaimori
- Department of Advanced Technology for Transplantation, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Inter-Organ Communication Research in Kidney Disease, Osaka University Graduate School of Medicine, Suita, Japan
| | - Katsunori Yoshida
- Departments of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Shigeru Satoh
- Center for Kidney Disease and Transplantation, Akita University Hospital, Akita, Japan
| | - Yoshifumi Ubara
- Nephrology Center, Toranomon Hospital Kajigaya, Kawasaki, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kazunari Yoshida
- Department of Urology, Kitasato University School of Medicine, Sagamihara, Japan.,Research and Development Center for New Medical Frontiers, Organ Transplant Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Yoshiharu Tsubakihara
- Department of Safety Management in Health Care Sciences, Graduate School of Health Care Sciences, Jikei Institute, Osaka, Japan
| | - Shiro Takahara
- Department of Advanced Technology for Transplantation, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Renal Transplantation, Kansai Medical Hospital, Toyonaka, Japan
| | - Takayuki Hamano
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Inter-Organ Communication Research in Kidney Disease, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Nephrology, Graduate School of Medical Science, Nagoya City University, Nagoya, Japan
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3
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Paul RS, Almokayad I, Collins A, Raj D, Jagadeesan M. Donor-derived Cell-free DNA: Advancing a Novel Assay to New Heights in Renal Transplantation. Transplant Direct 2021; 7:e664. [PMID: 33564715 PMCID: PMC7862009 DOI: 10.1097/txd.0000000000001098] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/09/2020] [Accepted: 10/13/2020] [Indexed: 02/07/2023] Open
Abstract
Despite advances in transplant immunosuppression, long-term renal allograft outcomes remain suboptimal because of the occurrence of rejection, recurrent disease, and interstitial fibrosis with tubular atrophy. This is largely due to limitations in our understanding of allogeneic processes coupled with inadequate surveillance strategies. The concept of donor-derived cell-free DNA as a signal of allograft stress has therefore rapidly been adopted as a noninvasive monitoring tool. Refining it for effective clinical use, however, remains an ongoing effort. Furthermore, its potential to unravel new insights in alloimmunity through novel molecular techniques is yet to be realized. This review herein summarizes current knowledge and active endeavors to optimize cell-free DNA-based diagnostic techniques for clinical use in kidney transplantation. In addition, the integration of DNA methylation and microRNA may unveil new epigenetic signatures of allograft health and is also explored in this report. Directing research initiatives toward these aspirations will not only improve diagnostic precision but may foster new paradigms in transplant immunobiology.
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Affiliation(s)
- Rohan S. Paul
- Division of Kidney Disease & Hypertension, George Washington University, Washington, DC
| | - Ismail Almokayad
- Division of Kidney Disease & Hypertension, George Washington University, Washington, DC
| | - Ashte Collins
- Division of Kidney Disease & Hypertension, George Washington University, Washington, DC
| | - Dominic Raj
- Division of Kidney Disease & Hypertension, George Washington University, Washington, DC
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4
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Dendritic Cells Transfected with MHC Antigenic Determinants of CBA Mice Induce Antigen-Specific Tolerance in C57Bl/6 Mice. J Immunol Res 2020; 2020:9686143. [PMID: 32953894 PMCID: PMC7487104 DOI: 10.1155/2020/9686143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/07/2020] [Accepted: 07/31/2020] [Indexed: 12/12/2022] Open
Abstract
Background Nonspecific immunosuppressive therapy for graft rejection and graft-versus-host disease (GVHD) is often accompanied by severe side effects such as opportunistic infections and cancers. Several approaches have been developed to suppress transplantation reactions using tolerogenic cells, including induction of FoxP3+ Tregs with antigen-loaded dendritic cells (DCs) and induction of CD4+IL-10+ cells with interleukin IL-10-producing DCs. Here, we assessed the effectiveness of both approaches in the suppression of graft rejection and GVHD. Methods IL-10-producing DCs were generated by the transfection of DCs with DNA constructs encoding mouse IL-10. Antigen-loaded DCs from C57BL/6 mice were generated by transfection with DNA constructs encoding antigenic determinants from the H2 locus of CBA mice which differ from the homologous antigenic determinants of C57BL/6 mice. Results We found that both IL-10-producing DCs and antigen-loaded immature DCs could suppress graft rejection and GVHD but through distinct nonspecific and antigen-specific mechanisms, respectively. Discussion. We provide data that the novel approach for DCs antigen loading using DNA constructs encoding distinct homologous determinants derived from major histocompatibility complex genes is effective in antigen-specific suppression of transplantation reactions. Such an approach eliminates the necessity of donor material use and may be useful in immunosuppressive therapy side effects prevention.
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5
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Group IIA Secretory Phospholipase A2 Predicts Graft Failure and Mortality in Renal Transplant Recipients by Mediating Decreased Kidney Function. J Clin Med 2020; 9:jcm9051282. [PMID: 32365505 PMCID: PMC7288094 DOI: 10.3390/jcm9051282] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 04/24/2020] [Accepted: 04/25/2020] [Indexed: 01/14/2023] Open
Abstract
The acute phase protein group IIA secretory phospholipase A2 (sPLA2-IIA) has intrinsic proatherosclerotic properties. The present prospective cohort study investigated whether plasma sPLA2-IIA associates with graft failure, cardiovascular, and all-cause mortality in renal transplant recipients (RTRs), patients with accelerated atherosclerosis formation both systemically and within the graft. In 511 RTRs from a single academic center with stable graft function >1 year, baseline plasma sPLA2-IIA was determined by ELISA. Primary end points were death-censored graft failure and mortality (median follow-up, 7.0 years). Baseline sPLA2-IIA was higher in RTRs than in healthy controls (median 384 ng/dL (range 86–6951) vs. 185 ng/dL (range 104–271), p < 0.001). Kaplan–Meier analysis demonstrated increased risk for graft failure (p = 0.002), as well as cardiovascular (p < 0.001) and all-cause mortality (p < 0.001), with increasing sPLA2-IIA quartiles. Cox regression showed strong associations of sPLA2-IIA with increased risks of graft failure (hazard ratio (HR) = 1.42 (1.11–1.83), p = 0.006), as well as cardiovascular (HR = 1.48 (1.18−1.85), p = 0.001) and all-cause mortality (HR = 1.39 (1.17−1.64), p < 0.001), dependent on parameters of kidney function. Renal function during follow-up declined faster in RTRs with higher baseline sPLA2-IIA levels. In RTRs, sPLA2-IIA is a significant predictive biomarker for chronic graft failure, as well as overall and cardiovascular disease mortality dependent on kidney function. This dependency is conceivably explained by sPLA2-IIA impacting negatively on kidney function.
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6
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Achilonu OJ, Fabian J, Musenge E. Modeling Long-Term Graft Survival With Time-Varying Covariate Effects: An Application to a Single Kidney Transplant Centre in Johannesburg, South Africa. Front Public Health 2019; 7:201. [PMID: 31403039 PMCID: PMC6669915 DOI: 10.3389/fpubh.2019.00201] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 07/08/2019] [Indexed: 12/02/2022] Open
Abstract
Objectives: Patients' characteristics that could influence graft survival may also exhibit non-constant effects over time; therefore, violating the important assumption of the Cox proportional hazard (PH) model. We describe the effects of covariates on the hazard of graft failure in the presence of long follow-ups. Study Design and Settings: We studied 915 adult patients that received kidney transplant between 1984 and 2000, using Cox PH, a variation of the Aalen additive hazard and Accelerated failure time (AFT) models. Selection of important predictors was based on the purposeful method of variable selection. Results: Out of 915 patients under study, 43% had graft failure by the end of the study. The graft survival rate is 81, 66, and 50% at 1, 5, and 10 years, respectively. Our models indicate that donor type, recipient age, donor-recipient gender match, delayed graft function, diabetes and recipient ethnicity are significant predictors of graft survival. However, only the recipient age and donor-recipient gender match exhibit constant effects in the models. Conclusion: Conclusion made about predictors of graft survival in the Cox PH model without adequate assessment of the model fit could over-estimate significant effects. The additive hazard and AFT models offer more flexibility in understanding covariates with non-constant effects on graft survival. Our results suggest that the period of follow-up in this study is long to support the proportionality assumption. Modeling graft survival at different time points may restrain the possibility of important covariates showing time-variant effects in the Cox PH model.
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Affiliation(s)
- Okechinyere J Achilonu
- Division of Biostatistics and Epidemiology, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - June Fabian
- Wits Donald Gordon Medical Centre, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Eustasius Musenge
- Division of Biostatistics and Epidemiology, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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7
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Aktürk S, Erdoğmuş Ş, Kumru G, Elhan AH, Şengül Ş, Tüzüner A, Keven K. Average Tacrolimus Trough Level in the First Month After Transplantation May Predict Acute Rejection. Transplant Proc 2017; 49:430-435. [PMID: 28340806 DOI: 10.1016/j.transproceed.2017.02.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Although tacrolimus is one of the essential drugs used for the prevention of rejection in kidney recipients, target trough levels are not well established. In this study, we aimed to investigate the association between average tacrolimus trough levels (TTLs) of the first month after transplantation and biopsy-proven acute rejection (BPAR) during the first 12 months after transplant. METHODS A total of 274 patients who underwent kidney-alone transplantation between 2002 and 2014 were enrolled in the study. Average TTLs of the first month were assessed by means of receiver operating characteristic (ROC) curve analysis to discriminate patients with and those without BPAR. Univariate and multivariate Cox proportional hazards models were used to determine the effect of average TTLs of the first month on BPAR. RESULTS According to ROC curve analysis, the highest area under the curve (AUC) was obtained from 8 ng/mL (AUC = 0.73 ± 0.11; 95% confidence interval [CI], 0.62-0.84). Forty-two (31.8%) of the 132 patients with average TTLs <8 ng/mL and 13 (9.1%) of 142 patients with ≥8 ng/mL had BPAR during the first 12 months after transplant (P < .001). In univariable analysis, average TTLs of the first month <8 ng/mL were associated with higher risk of BPAR (P < .001), and the significance remained in Cox multivariable analysis (hazard ratio, 2.79; 95% CI, 1.76-3.82; P = .001). No significant differences were observed in the glomerular filtration rate, cytomegalovirus, BK viremia, or BK nephropathy between groups at post-transplant month 12. CONCLUSIONS Keeping the average TTLs of the first month after transplantation at ≥8 ng/mL not only prevents BPAR occurrence but also minimizes the toxic effects of the use of a single-trough level.
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Affiliation(s)
- S Aktürk
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey.
| | - Ş Erdoğmuş
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | - G Kumru
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | - A H Elhan
- Department of Biostatistics, Ankara University School of Medicine, Ankara, Turkey
| | - Ş Şengül
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | - A Tüzüner
- Department of General Surgery, Ankara University School of Medicine, Ankara, Turkey
| | - K Keven
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
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8
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Sayin B, Canver B, Gurlek Demirci B, Colak T, Ozdemir BH, Haberal M. Renin-Angiotensin System Blockage and Avoiding High Doses of Calcineurin Inhibitors Prevent Interstitial Fibrosis and Tubular Atrophy in Kidney Transplant Recipients. EXP CLIN TRANSPLANT 2017; 15:32-36. [PMID: 28260428 DOI: 10.6002/ect.mesot2016.o19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Chronic allograft dysfunction is a complex and multifactorial process characterized by progressive interstitial fibrosis and tubular atrophy. The finding of interstitial fibrosis and tubular atrophy is prevalent among kidney transplant patients receiving a calcineurin inhibitor-based immunosuppressive regimen and may be considered as a surrogate of allograft survival. Both immune (acute rejection episodes, sensitization, and HLA incompatibility) and nonimmune (donor age, delayed graft function, calcineurin inhibitor toxicity, infections, and hypertension) mechanisms play a role in chronic allograft dysfunction, and different causes all lead to similar histologic and clinical final pathways, with the end result of graft loss. In our study, we aimed to compare the outcomes of kidney transplant recipients with or without interstitial fibrosis and tubular atrophy in protocol biopsies to determine the conditions that may affect allograft survival. MATERIALS AND METHODS We divided 192 kidney transplant recipients into 2 groups (96 patients with interstitial fibrosis and tubular atrophy; 96 patients without interstitial fibrosis and tubular atrophy) according to protocol biopsy at 6 months. Patient groups were compared according to their risk factors for chronic allograft dysfunction (cold ischemia time, delayed graft function, donor age, infections, mean blood calcineurin levels, and hypertension). RESULTS Cold ischemia time, delayed graft function, high 24-hour proteinuria levels, and higher mean blood calcineurin levels were found to be major risk factors for poor graft function in kidney transplant recipients with interstitial fibrosis and tubular atrophy. Renin-angiotensin system blockage with either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was found to be preventive for interstitial fibrosis and tubular atrophy after kidney transplant. CONCLUSIONS Preventing prolongation of cold ischemia time, lowering blood cholesterol levels, angiotensin-converting enzyme inhibitors and angiotensin receptor blocker treatment even without existing proteinuria and avoiding higher doses of calcineurin inhibitors should be major approaches in kidney transplant recipients.
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Affiliation(s)
- Burak Sayin
- Department of Nephrology, Baskent University Faculty of Medicine, Ankara, Turkey
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9
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Ali H, Shaaban A, Murtaza A, Howell LE, Ahmed A. Effect of Long-Term, Low-Dose Aspirin Therapy on Renal Graft Function. EXP CLIN TRANSPLANT 2016; 15:400-404. [PMID: 28004997 DOI: 10.6002/ect.2016.0139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Despite improvements in immunosuppressive protocols for renal transplant, long-term success of renal transplant is still limited by the occurrence of interstitial fibrosis and tubular atrophy. Some studies have shown that aspirin decreases the severity of kidney ischemia-reperfusion injury and the development of tubular atrophy in animal models. This study aimed to assess the effects of aspirin therapy started at the time of transplant on long-term graft function. MATERIALS AND METHODS We compared renal graft function of 82 patients on low-dose aspirin 75 mg once daily who underwent renal transplant between 1 January 2000 and 31 December 2010 from a single center with 65 patients not taking aspirin. For each patient, the following measurements were collected: age, sex, creatinine level, type of donor, cold ischemia time, occurrence of acute allograft rejections, number of HLA mismatches, first transplant, intake of statins, number of antihypertensive medications, and number of days posttransplant. Patients were excluded from the study who were on aspirin before transplant or who had coronary artery disease. RESULTS Multilevel modelling was used to compare renal allograft function, as measured by serum creatinine levels, between patients taking and not taking aspirin after kidney transplant. Aspirin was not significantly associated with creatinine levels (P = .59) after adjusting for other relevant variables. CONCLUSIONS Low-dose aspirin started at the time of transplant has a negligible effect on renal allograft function over the 15-year study period posttransplant.
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Affiliation(s)
- Hatem Ali
- From the Renal Department, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
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10
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Wei C, Li L, Menon MC, Zhang W, Fu J, Kidd B, Keung KL, Woytovich C, Greene I, Xiao W, Salem F, Yi Z, He JC, Dudley JT, Murphy B. Genomic Analysis of Kidney Allograft Injury Identifies Hematopoietic Cell Kinase as a Key Driver of Renal Fibrosis. J Am Soc Nephrol 2016; 28:1385-1393. [PMID: 27927780 DOI: 10.1681/asn.2016020238] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 11/01/2016] [Indexed: 11/03/2022] Open
Abstract
Renal fibrosis is the common pathway of progression for patients with CKD and chronic renal allograft injury (CAI), but the underlying mechanisms remain obscure. We performed a meta-analysis in human kidney biopsy specimens with CAI, incorporating data available publicly and from our Genomics of Chronic Renal Allograft Rejection study. We identified an Src family tyrosine kinase, hematopoietic cell kinase (Hck), as upregulated in allografts in CAI. Querying the Kinase Inhibitor Resource database revealed that dasatinib, a Food and Drug Administration-approved drug, potently binds Hck with high selectivity. In vitro, Hck overexpression activated the TGF-β/Smad3 pathway, whereas HCK knockdown inhibited it. Treatment of tubular cells with dasatinib reduced the expression of Col1a1 Dasatinib also reduced proliferation and α-SMA expression in fibroblasts. In a murine model with unilateral ureteric obstruction, pretreatment with dasatinib significantly reduced the upregulation of profibrotic markers, phosphorylation of Smad3, and renal fibrosis observed in kidneys pretreated with vehicle alone. Dasatinib treatment also improved renal function, reduced albuminuria, and inhibited expression of profibrotic markers in animal models with lupus nephritis and folic acid nephropathy. These data suggest that Hck is a key mediator of renal fibrosis and dasatinib could be developed as an antifibrotic drug.
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Affiliation(s)
| | - Li Li
- Departments of Genetics and Genomic Sciences and
| | | | | | - Jia Fu
- Divisions of *Nephrology and
| | - Brian Kidd
- Departments of Genetics and Genomic Sciences and
| | - Karen L Keung
- Department of Renal Medicine, Westmead Hospital, Westmead, New South Wales, Australia; and
| | | | | | | | | | | | - John Cijiang He
- Divisions of *Nephrology and .,Renal Section, Department of Medicine, James J. Peter Veterans Affairs Medical Center, New York, New York
| | - Joel T Dudley
- Departments of Genetics and Genomic Sciences and .,Health Policy and Research, Icahn School of Medicine at Mount Sinai, New York, New York
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11
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Abstract
Objective To review the pharmacology, pharmacokinetics, efficacy, and safety of mycophenolate sodium, everolimus, and FTY720. Study Selection and Data Extraction Clinical trials and abstracts evaluating mycophenolate sodium, everolimus, and FTY720 in solid-organ transplantation were considered for evaluation. English-language studies and published abstracts were selected for inclusion. Data Synthesis Mycophenolate sodium has recently been approved by the Food and Drug Adminstration for marketing in the United States; everolimus and FTY720 are immunosuppressive agents that may soon be available in the United States. These agents have proven efficacy in reducing the incidence of acute rejection in solid-organ transplantation. Clinical trials have shown that these newer agents are relatively well tolerated. The most common adverse events associated with these agents were gastrointestinal and hematologic effects (mycophenolate sodium); hyperlipidemia, increased serum creatinine, and hematologic effects (everolimus); and gastrointestinal effects, headache, and bradycardia (FTY720). Conclusion Mycophenolate sodium has been approved in some European countries and the United States. Everolimus has been approved in some European countries and a new drug application has been submitted to the Food and Drug Administration. FTY720 is currently in phase III clinical trials and submission to the Food and Drug Administration for approval is a few years away. The approval of these agents will furnish the transplant practitioner with even more options for immunosuppression.
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12
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Rekers NV, de Fijter J, Claas FH, Eikmans M. Mechanisms and risk assessment of steroid resistance in acute kidney transplant rejection. Transpl Immunol 2016; 38:3-14. [DOI: 10.1016/j.trim.2016.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 07/28/2016] [Indexed: 12/15/2022]
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13
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Akhtar MZ, Huang H, Kaisar M, Lo Faro ML, Rebolledo R, Morten K, Heather LC, Dona A, Leuvenink HG, Fuggle SV, Kessler BM, Pugh CW, Ploeg RJ. Using an Integrated -Omics Approach to Identify Key Cellular Processes That Are Disturbed in the Kidney After Brain Death. Am J Transplant 2016; 16:1421-40. [PMID: 26602379 DOI: 10.1111/ajt.13626] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 10/26/2015] [Accepted: 11/12/2015] [Indexed: 01/25/2023]
Abstract
In an era where we are becoming more reliant on vulnerable kidneys for transplantation from older donors, there is an urgent need to understand how brain death leads to kidney dysfunction and, hence, how this can be prevented. Using a rodent model of hemorrhagic stroke and next-generation proteomic and metabolomic technologies, we aimed to delineate which key cellular processes are perturbed in the kidney after brain death. Pathway analysis of the proteomic signature of kidneys from brain-dead donors revealed large-scale changes in mitochondrial proteins that were associated with altered mitochondrial activity and morphological evidence of mitochondrial injury. We identified an increase in a number of glycolytic proteins and lactate production, suggesting a shift toward anaerobic metabolism. Higher amounts of succinate were found in the brain death group, in conjunction with increased markers of oxidative stress. We characterized the responsiveness of hypoxia inducible factors and found this correlated with post-brain death mean arterial pressures. Brain death leads to metabolic disturbances in the kidney and alterations in mitochondrial function and reactive oxygen species generation. This metabolic disturbance and alteration in mitochondrial function may lead to further cellular injury. Conditioning the brain-dead organ donor by altering metabolism could be a novel approach to ameliorate this brain death-induced kidney injury.
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Affiliation(s)
- M Z Akhtar
- Centre for Cellular and Molecular Physiology, Oxford University, Oxford, UK.,Oxford Transplant Centre, Nuffield Department of Surgical Sciences, Churchill Hospital, Oxford, UK
| | - H Huang
- Oxford Transplant Centre, Nuffield Department of Surgical Sciences, Churchill Hospital, Oxford, UK.,Target Discovery Institute, Oxford University, Oxford, UK
| | - M Kaisar
- Oxford Transplant Centre, Nuffield Department of Surgical Sciences, Churchill Hospital, Oxford, UK.,Target Discovery Institute, Oxford University, Oxford, UK
| | - M L Lo Faro
- Centre for Cellular and Molecular Physiology, Oxford University, Oxford, UK.,Oxford Transplant Centre, Nuffield Department of Surgical Sciences, Churchill Hospital, Oxford, UK
| | - R Rebolledo
- Surgical Research Laboratory, University of Groningen, Groningen, the Netherlands
| | - K Morten
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK
| | - L C Heather
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
| | - A Dona
- Department of Surgery, Imperial College, London, UK.,Kolling Institute for Medical Research, The University of Sydney, New South Wales, Australia
| | - H G Leuvenink
- Surgical Research Laboratory, University of Groningen, Groningen, the Netherlands
| | - S V Fuggle
- Oxford Transplant Centre, Nuffield Department of Surgical Sciences, Churchill Hospital, Oxford, UK
| | - B M Kessler
- Target Discovery Institute, Oxford University, Oxford, UK
| | - C W Pugh
- Centre for Cellular and Molecular Physiology, Oxford University, Oxford, UK
| | - R J Ploeg
- Oxford Transplant Centre, Nuffield Department of Surgical Sciences, Churchill Hospital, Oxford, UK
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14
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Spatola L, Andrulli S. Doppler ultrasound in kidney diseases: a key parameter in clinical long-term follow-up. J Ultrasound 2016; 19:243-250. [PMID: 27965714 DOI: 10.1007/s40477-016-0201-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 03/10/2016] [Indexed: 02/07/2023] Open
Abstract
Doppler ultrasound has been extensively used in detecting reno-vascular diseases, showing to be a non-invasive, safe, low cost and repeatable tool. The Renal Resistive Index (RRI) [(peak systolic velocity - end diastolic velocity)/peak systolic velocity] is a semi-quantitative index derived by Doppler evaluation of renal vascular bed. Normally RRI is in the range of 0.47-0.70, it increases with aging and, usually, it shows a difference between the two kidneys less than 5-8 %. RRI is an important prognostic marker in chronic kidney diseases (CKD), both in diabetic and non-diabetic kidney diseases, because, in longitudinal prospective studies, it significantly correlated with hemodynamic (ABPM, SBP, DBP, pulse pressure) and histopathological parameters (glomerular sclerosis, arteriolosclerosis, interstitial fibrosis/tubular atrophy, interstitial infiltration). In acute kidney injury (AKI) RI is a valid tool in differentiating between pre-renal and renal failure and in predicting renal response to vaso-active agents. In addition a RRI >0.74 can predict the onset of AKI in septic patients. Renal Resistive Index is a useful marker in allograft diseases because it has been widely showed a correlation with histological lesions during worsening of renal function, both in acute rejection and in chronic allograft nephropathy. Recent studies suggest its role in the risk of new onset diabetes after transplantation and it could be one of the parameters to evaluate to shift or withdrawal immunological and/or hypertensive therapy.
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Affiliation(s)
- Leonardo Spatola
- Internal Medicine Unit, Hospital San Pellegrino srl, Castiglione delle Stiviere, Mantua, MN Italy
| | - Simeone Andrulli
- Renal Unit, Hospital "A. Manzoni", via Dell'Eremo, Lecco, LC Italy
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15
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BK Virus Load Associated with Serum Levels of sCD30 in Renal Transplant Recipients. Int J Microbiol 2016; 2016:9752097. [PMID: 27051424 PMCID: PMC4804059 DOI: 10.1155/2016/9752097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 02/10/2016] [Accepted: 02/15/2016] [Indexed: 12/19/2022] Open
Abstract
Background. Rejection is the main drawback facing the renal transplant operations. Complicated and overlapping factors, mainly related to the immune system, are responsible for this rejection. Elevated serum levels of sCD30 were frequently recorded as an indicator for renal allograft rejection, while BV virus is considered as one of the most serious consequences for immunosuppressive treatment of renal transplant recipients (RTRs). Aims. This study aimed to determine the association of BK virus load with serum levels of sCD30 in RTRs suffering from nephropathy. Patients and Methods. A total of 50 RTRs with nephropathy and 30 age-matched apparently healthy individuals were recruited for this study. Serum samples were obtained from each participant. Real-time PCR was used to quantify BK virus load in RTRs serum, while ELISA technique was employed to estimate serum levels of sCD30. Results. Twenty-two percent of RTRs had detectable BKV with mean viral load of 1.094E + 06 ± 2.291E + 06. RTRs showed higher mean serum level of sCD30 (20.669 ± 18.713 U/mL) than that of controls (5.517 ± 5.304 U/mL) with significant difference. BK virus load had significant positive correlation with the serum levels of sCD30 in RTRs group. Conclusion. These results suggest that serum levels of sCD30 could be used as an indicator of BK viremia, and accordingly the immunosuppressive regime should be adjusted.
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16
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Cassidy H, Slyne J, O'Kelly P, Traynor C, Conlon PJ, Johnston O, Slattery C, Ryan MP, McMorrow T. Urinary biomarkers of chronic allograft nephropathy. Proteomics Clin Appl 2016; 9:574-85. [PMID: 25951805 DOI: 10.1002/prca.201400200] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 04/23/2015] [Accepted: 05/05/2015] [Indexed: 12/21/2022]
Abstract
PURPOSE Chronic allograft nephropathy (CAN) is widely accepted as the leading cause of renal allograft loss after the first year post transplantation. This study aimed to identify urinary biomarkers that could predict CAN in transplant patients. EXPERIMENTAL DESIGN The study included 34 renal transplant patients with histologically proven CAN and 36 renal transplant patients with normal renal function. OrbiTrap MS was utilized to analysis a urinary fraction in order to identify other members of a previously identified biomarker tree . This novel biomarker pattern offers the potential to distinguish between transplant recipients with CAN and those with normal renal function. RESULTS The primary node of the biomarker pattern was reconfirmed as β2 microglobulin. Three other members of this biomarker pattern were identified: neutrophil gelatinase-associated lipocalin, clusterin, and kidney injury biomarker 1. Significantly higher urinary concentrations of these proteins were found in patients with CAN compared to those with normal kidney function. CONCLUSIONS AND CLINICAL RELEVANCE While further validation in a larger more-diverse patient population is required to determine if this biomarker pattern provides a potential means of diagnosing CAN by noninvasive methods in a clinical setting, this study clearly demonstrates the biomarkers' ability to stratify patients based on transplant function.
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Affiliation(s)
- Hilary Cassidy
- School of Biomolecular and Biomedical Science, Conway Institute, University College Dublin, Belfield, Dublin, Ireland
| | - Jennifer Slyne
- School of Biomolecular and Biomedical Science, Conway Institute, University College Dublin, Belfield, Dublin, Ireland
| | - Patrick O'Kelly
- Department of Nephrology & Transplantation, Beaumont Hospital, Beaumont, Dublin, Ireland
| | - Carol Traynor
- Nephrology Department, Mater Misercordiae University Hospital, Dublin, Ireland
| | - Peter J Conlon
- Department of Nephrology & Transplantation, Beaumont Hospital, Beaumont, Dublin, Ireland
| | - Olwyn Johnston
- Gordon & Leslie Diamond Centre, Division of Nephrology, University of British Columbia, Vancouver, Canada
| | - Craig Slattery
- School of Biomolecular and Biomedical Science, Conway Institute, University College Dublin, Belfield, Dublin, Ireland
| | - Michael P Ryan
- School of Biomolecular and Biomedical Science, Conway Institute, University College Dublin, Belfield, Dublin, Ireland
| | - Tara McMorrow
- School of Biomolecular and Biomedical Science, Conway Institute, University College Dublin, Belfield, Dublin, Ireland
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17
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Batterton KA, Schubert CM. A nonparametric fiducial interval for the Youden index in multi-state diagnostic settings. Stat Med 2016; 35:78-96. [PMID: 26278275 DOI: 10.1002/sim.6613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 06/10/2015] [Accepted: 07/14/2015] [Indexed: 12/27/2022]
Abstract
The Youden index is a commonly employed metric to characterize the performance of a diagnostic test at its optimal point. For tests with three or more outcome classes, the Youden index has been extended; however, there are limited methods to compute a confidence interval (CI) about its value. Often, outcome classes are assumed to be normally distributed, which facilitates computational formulas for the CI bounds; however, many scenarios exist for which these assumptions cannot be made. In addition, many of these existing CI methods do not work well for small sample sizes. We propose a method to compute a nonparametric interval about the Youden index utilizing the fiducial argument. This fiducial interval ensures that CI coverage is met regardless of sample size, underlying distributional assumptions, or use of a complex classifier for diagnosis. Two alternate fiducial intervals are also considered. A simulation was conducted, which demonstrates the coverage and interval length for the proposed methods. Comparisons were made using no distributional assumptions on the outcome classes and for when outcomes were assumed to be normally distributed. In general, coverage probability was consistently met, and interval length was reasonable. The proposed fiducial method was also demonstrated in data examining biomarkers in subjects to predict diagnostic stages ranging from normal kidney function to chronic allograph nephropathy. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.
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Affiliation(s)
| | - Christine M Schubert
- Department of Mathematics and Statistics, Graduate School of Engineering and Management, Air Force Institute of Technology, 2950 Hobson Way, Wright-Patterson AFB, OH, 45433-7765, U.S.A
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18
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Bamoulid J, Staeck O, Halleck F, Dürr M, Paliege A, Lachmann N, Brakemeier S, Liefeldt L, Budde K. Advances in pharmacotherapy to treat kidney transplant rejection. Expert Opin Pharmacother 2015; 16:1627-48. [PMID: 26159444 DOI: 10.1517/14656566.2015.1056734] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Current immunosuppressive combination therapy provides excellent prevention of T-cell-mediated rejection following renal transplantation; however, antibody-mediated rejection remains of high concern and accounts for a large number of long-term allograft losses. The recent development of protocol biopsies resulted in the definition of subclinical rejection (SCR), showing histologic evidence for rejection but unremarkable clinical course. AREAS COVERED This review describes the current knowledge and evidence of pharmacotherapy to treat kidney allograft rejections and covers SCR treatment options. Each substance is analyzed with regard to its classical indication and further discussed for the treatment of other forms of rejection. EXPERT OPINION Despite a lack of randomized trials, early acute T-cell-mediated rejection can be treated effectively in most cases without graft loss. The necessity to treat SCR is currently unclear. Due to a lack of effective therapies, new treatment approaches for antibody-mediated rejection are an urgent medical need to improve long-term outcomes. Future research should aim to better define pathophysiology and histology, stratify risk, and develop rational treatment strategies from randomized controlled trials, in order to establish the value of novel therapies in the arsenal of rejection pharmacotherapy. However, the effective prevention of rejection with minimal side effects still remains the goal in immunosuppression.
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Affiliation(s)
- Jamal Bamoulid
- Charité Universitätsmedizin Berlin, Department of Nephrology , Berlin , Germany +49 30 450 514002 ; +49 30 450 514902 ;
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19
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Bhatti AB, Usman M. Chronic Renal Transplant Rejection and Possible Anti-Proliferative Drug Targets. Cureus 2015; 7:e376. [PMID: 26677426 PMCID: PMC4671911 DOI: 10.7759/cureus.376] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 11/06/2015] [Indexed: 12/17/2022] Open
Abstract
The global prevalence of renal transplants is increasing with time, and renal transplantation is the only definite treatment for end-stage renal disease. We have limited the acute and late acute rejection of kidney allografts, but the long-term survival of renal tissues still remains a difficult and unanswered question as most of the renal transplants undergo failure within a decade of their transplantation. Among various histopathological changes that signify chronic allograft nephropathy (CAN), tubular atrophy, fibrous thickening of the arteries, fibrosis of the kidney interstitium, and glomerulosclerosis are the most important. Moreover, these structural changes are followed by a decline in the kidney function as well. The underlying mechanism that triggers the long-term rejection of renal transplants involves both humoral and cell-mediated immunity. T cells, with their related cytokines, cause tissue damage. In addition, CD 20+ B cells and their antibodies play an important role in the long-term graft rejection. Other risk factors that predispose a recipient to long-term graft rejection include HLA-mismatching, acute episodes of graft rejection, mismatch in donor-recipient age, and smoking. The purpose of this review article is the analyze current literature and find different anti-proliferative agents that can suppress the immune system and can thus contribute to the long-term survival of renal transplants. The findings of this review paper can be helpful in understanding the long-term survival of renal transplants and various ways to improve it.
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Affiliation(s)
- Adnan Bashir Bhatti
- Department of Medicine, Capital Development Authority Hospital, Islamabad, Pakistan
| | - Muhammad Usman
- Department of Medicine, Jinnah Hospital Lahore (JHL)/Allama Iqbal Medical College (AIMC), Lahore, Pakistan
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20
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Annema W, Dikkers A, de Boer JF, Dullaart RPF, Sanders JSF, Bakker SJL, Tietge UJF. HDL Cholesterol Efflux Predicts Graft Failure in Renal Transplant Recipients. J Am Soc Nephrol 2015; 27:595-603. [PMID: 26319244 DOI: 10.1681/asn.2014090857] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 03/31/2015] [Indexed: 01/14/2023] Open
Abstract
High-density lipoprotein (HDL) particles are involved in the protection against cardiovascular disease by promoting cholesterol efflux, in which accumulated cholesterol is removed from macrophage foam cells. We investigated whether HDL cholesterol efflux capacity is associated with cardiovascular mortality, all-cause mortality, and graft failure in a cohort of renal transplant recipients (n=495, median follow-up 7.0 years). Cholesterol efflux capacity at baseline was quantified using incubation of human macrophage foam cells with apolipoprotein B-depleted plasma. Baseline efflux capacity was not different in deceased patients and survivors (P=0.60 or P=0.50 for cardiovascular or all-cause mortality, respectively), whereas recipients developing graft failure had lower efflux capacity than those with functioning grafts (P<0.001). Kaplan-Meier analysis demonstrated a lower risk for graft failure (P=0.004) but not cardiovascular (P=0.30) or all-cause mortality (P=0.31) with increasing gender-stratified tertiles of efflux capacity. Cox regression analyses adjusted for age and gender showed that efflux capacity was not associated with cardiovascular mortality (hazard ratio [HR], 0.89; 95% confidence interval [95% CI], 0.67 to 1.19; P=0.43). Furthermore, the association between efflux capacity and all-cause mortality (HR, .79; 95% CI, 0.63 to 0.98; P=0.031) disappeared after further adjustment for potential confounders. However, efflux capacity at baseline significantly predicted graft failure (HR, 0.43; 95% CI, 0.29 to 0.64; P<0.001) independent of apolipoprotein A-I, HDL cholesterol, or creatinine clearance. In conclusion, this prospective study shows that cholesterol efflux capacity from macrophage foam cells is not associated with cardiovascular or all-cause mortality but is a strong predictor of graft failure independent of plasma HDL cholesterol levels in renal transplant recipients.
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Affiliation(s)
- Wijtske Annema
- Department of Pediatrics, Center for Liver, Digestive, and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Top Institute Food and Nutrition, Wageningen, The Netherlands
| | - Arne Dikkers
- Department of Pediatrics, Center for Liver, Digestive, and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan Freark de Boer
- Department of Pediatrics, Center for Liver, Digestive, and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robin P F Dullaart
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; and
| | - Jan-Stephan F Sanders
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Stephan J L Bakker
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Uwe J F Tietge
- Department of Pediatrics, Center for Liver, Digestive, and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Top Institute Food and Nutrition, Wageningen, The Netherlands;
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21
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Zhang K, Gao B, Wang Y, Wang G, Wang W, Zhu Y, Yao L, Gu Y, Chen M, Zhou H, Fu Y. Serum Uric Acid and Renal Transplantation Outcomes: At Least 3-Year Post-transplant Retrospective Multivariate Analysis. PLoS One 2015. [PMID: 26208103 PMCID: PMC4514650 DOI: 10.1371/journal.pone.0133834] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Since the association of serum uric acid and kidney transplant graft outcome remains disputable, we sought to evaluate the predictive value of uric acid level for graft survival/function and the factors could affect uric acid as time varies. A consecutive cohort of five hundred and seventy three recipients transplanted during January 2008 to December 2011 were recruited. Data and laboratory values of our interest were collected at 1, 3, 6, 12, 24 and 36 months post-transplant for analysis. Cox proportional hazard model, and multiple regression equation were built to adjust for the possible confounding variables and meet our goals as appropriate. The current cohort study lasts for 41.86 ± 15.49 months. Uric acid level is proven to be negatively associated with eGFR at different time point after adjustment for age, body mass index and male gender (standardized β ranges from -0.15 to -0.30 with all P<0.001).Males with low eGFR but high level of TG were on CSA, diuretics and RAS inhibitors and experienced at least one episode of acute rejection and diabetic issue were associated with a higher mean uric acid level. Hyperuricemia was significantly an independent predictor of pure graft failure (hazard ratio=4.01, 95% CI: 1.25-12.91, P=0.02) after adjustment. But it was no longer an independent risk factor for graft loss after adjustment. Interestingly, higher triglyceride level can make incidence of graft loss (hazard ratio=1.442, for each unit increase millimoles per liter 95% CI: 1.008-2.061, P=0.045) and death (hazard ratio=1.717, 95% CI: 1.105-2.665, P=0.016) more likely. The results of our study suggest that post-transplant elevated serum uric acid level is an independent predictor of long-term graft survival and graft function. Together with the high TG level impact on poor outcomes, further investigations for therapeutic effect are needed.
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Affiliation(s)
- Kun Zhang
- Department of Urology/Transplant Center, First Hospital of Jilin University, Changchun, Jilin, China
| | - Baoshan Gao
- Department of Urology/Transplant Center, First Hospital of Jilin University, Changchun, Jilin, China
| | - Yuantao Wang
- Department of Urology/Transplant Center, First Hospital of Jilin University, Changchun, Jilin, China
| | - Gang Wang
- Department of Urology/Transplant Center, First Hospital of Jilin University, Changchun, Jilin, China
| | - Weigang Wang
- Department of Urology/Transplant Center, First Hospital of Jilin University, Changchun, Jilin, China
| | - Yaxiang Zhu
- Department of Urology/Transplant Center, First Hospital of Jilin University, Changchun, Jilin, China
| | - Liyu Yao
- Department of Urology/Transplant Center, First Hospital of Jilin University, Changchun, Jilin, China
| | - Yiming Gu
- Department of Urology/Transplant Center, First Hospital of Jilin University, Changchun, Jilin, China
| | - Mo Chen
- Department of Urology/Transplant Center, First Hospital of Jilin University, Changchun, Jilin, China
| | - Honglan Zhou
- Department of Urology/Transplant Center, First Hospital of Jilin University, Changchun, Jilin, China
- * E-mail: (YWF); (HLZ)
| | - Yaowen Fu
- Department of Urology/Transplant Center, First Hospital of Jilin University, Changchun, Jilin, China
- * E-mail: (YWF); (HLZ)
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22
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Safety and Efficacy Endpoints for Mesenchymal Stromal Cell Therapy in Renal Transplant Recipients. J Immunol Res 2015; 2015:391797. [PMID: 26258149 PMCID: PMC4518147 DOI: 10.1155/2015/391797] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 05/26/2015] [Indexed: 02/07/2023] Open
Abstract
Despite excellent short-term graft survival after renal transplantation, the long-term graft outcome remains compromised. It has become evident that a combination of sustained alloreactivity and calcineurin-inhibitor- (CNI-) related nephrotoxicity results in fibrosis and consequently dysfunction of the graft. New immunosuppressive regimens that can minimize or eliminate side effects, while maintaining efficacy, are required to improve long-term graft survival. In this perspective mesenchymal stromal cells (MSCs) are an interesting candidate, since MSCs have immunosuppressive and regenerative properties. The first clinical trials with MSCs in renal transplantation showed safety and feasibility and displayed promising results. Recently, the first phase II studies have been started. One of the most difficult and challenging aspects in those early phase trials is to define accurate endpoints that can measure safety and efficacy of MSC treatment. Since both graft losses and acute rejection rates declined, alternative surrogate markers such as renal function, histological findings, and immunological markers are used to measure efficacy and to provide mechanistic insight. In this review, we will discuss the current status of MSCs in renal transplantation with a focus on the endpoints used in the different experimental and clinical studies.
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23
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Zaza G, Masola V, Granata S, Bellin G, Dalla Gassa A, Onisto M, Gambaro G, Lupo A. Sulodexide alone or in combination with low doses of everolimus inhibits the hypoxia-mediated epithelial to mesenchymal transition in human renal proximal tubular cells. J Nephrol 2015; 28:431-40. [DOI: 10.1007/s40620-015-0216-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 05/26/2015] [Indexed: 12/13/2022]
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Nanoparticle enhanced MRI scanning to detect cellular inflammation in experimental chronic renal allograft rejection. INTERNATIONAL JOURNAL OF MOLECULAR IMAGING 2015; 2015:507909. [PMID: 25954516 PMCID: PMC4411452 DOI: 10.1155/2015/507909] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 03/12/2015] [Accepted: 03/12/2015] [Indexed: 01/06/2023]
Abstract
Objectives. We investigated whether ultrasmall paramagnetic particles of iron oxide- (USPIO-) enhanced magnetic resonance imaging (MRI) can detect experimental chronic allograft damage in a murine renal allograft model. Materials and Methods. Two cohorts of mice underwent renal transplantation with either a syngeneic isograft or allograft kidney. MRI scanning was performed prior to and 48 hours after USPIO infusion using T2∗-weighted protocols. R2∗ values were calculated to indicate the degree of USPIO uptake. Native kidneys and skeletal muscle were imaged as reference tissues and renal explants analysed by histology and electron microscopy. Results. R2∗ values in the allograft group were higher compared to the isograft group when indexed to native kidney (median 1.24 (interquartile range: 1.12 to 1.36) versus 0.96 (0.92 to 1.04), P < 0.01). R2∗ values were also higher in the allograft transplant when indexed to skeletal muscle (6.24 (5.63 to 13.51)) compared to native kidney (2.91 (1.11 to 6.46) P < 0.05). Increased R2∗ signal in kidney allograft was associated with macrophage and iron staining on histology. USPIO were identified within tissue resident macrophages on electron microscopy. Conclusion. USPIO-enhanced MRI identifies macrophage.
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Viero RM, da Silva MG, dos Santos DC, de Carvalho MFC, de Andrade LGM. The role of renin-angiotensin system in the chronic allograft nephropathy: an immunohistochemical study. Ren Fail 2015; 37:827-34. [PMID: 25782922 DOI: 10.3109/0886022x.2015.1024563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Evidences suggest a role of renin-angiotensin system (RAS) in the development of chronic allograft injury. METHODS We correlated intrarenal angiotensin-converting enzyme, angiotensin II (Angio II) and transforming growth factor β1 (TGFβ1) expression in 58 biopsies-proven chronic allograft nephropathy (CAN) with tissue injury and allograft survival. RESULTS The biopsies with CAN were graded according to Banff classification as I (22 cases), II (17) and III (19); 27 biopsies also showed a mononuclear inflammatory infiltrate in scarred areas. There were increased expression of angiotensin converting-enzyme (ACE), Angio II and TGFβ1 mainly in tubulointerstitial compartment in the group with CAN; there was no association of Angio II and TGFβ1 expression with interstitial fibrosis. There were no significant differences of ACE, Angio II and TGFβ1 expression between the patients treated and untreated with RAS blockade, and with the graft outcome. Interstitial inflammatory infiltrate had positive correlation with interstitial fibrosis and significant impact on graft survival at 8 years. CONCLUSIONS Our study showed in a group of cases with CAN a high percentage of inflammatory infiltrate that correlated with interstitial fibrosis and graft outcome. The chronic inflammatory changes in these cases did not show significant association with local RAS expression.
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Affiliation(s)
- Rosa Marlene Viero
- a Department of Pathology , Botucatu Medical School, São Paulo State University (UNESP) , Botucatu , São Paulo , Brazil and
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Rossi AP, Vella JP. Hypertension, living kidney donors, and transplantation: where are we today? Adv Chronic Kidney Dis 2015; 22:154-64. [PMID: 25704353 DOI: 10.1053/j.ackd.2015.01.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 01/05/2015] [Indexed: 02/08/2023]
Abstract
Hypertension is a prevalent problem in kidney transplant recipients that is known to be a "traditional" risk factor for atherosclerotic cardiovascular disease leading to premature allograft failure and death. Donor, peritransplant, and recipient factors affect hypertension risk. Blood pressure control after transplantation is inversely associated with glomerular filtration rate (GFR). Calcineurin inhibitors, the most commonly used class of immunosuppressives, cause endothelial dysfunction, increase vascular tone, and sodium retention via the renin-angiotensin-aldosterone system resulting in systemic hypertension. Steroid withdrawal seems to have little impact on blood pressure control. Newer agents like belatacept appear to be associated with less hypertension. Transplant renal artery stenosis is an important, potentially treatable cause of hypertension. Dihydropyridine calcium channel blockers mitigate calcineurin inhibitor nephrotoxicity and may be associated with improved estimated GFR. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are not recommended in the first 3 to 6 months given their effects on reduced estimated GFR, anemia, and hyperkalemia. The use of ß-blockers may be associated with improved patient survival, even for patients without cardiovascular disease. Living donation may increase blood pressure by 5 mm Hg or more. Some transplant centers accept Caucasian living donors with well-controlled hypertension on a single agent if they agree to close follow-up.
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27
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Sibunruang C, Ingsathit A, Kantachuvesiri P, Radinahamed P, Rattanasiri S, Pootracool P, Kijvikai K, Sumethkul V, Kantachuvesiri S. Increased urine transforming growth factor β1 (TGF-β1) and serum uric acid are associated with an early decline of glomerular filtration rate in kidney transplant recipients. Transplant Proc 2015; 47:304-8. [PMID: 25769564 DOI: 10.1016/j.transproceed.2014.11.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 10/23/2014] [Accepted: 11/19/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND The renin-angiotensin system (RAS) and transforming growth factor β1 (TGF-β1) may play a role in the pathogenesis of fibrosis in kidney allografts. Experimental hyperuricemia shows activation of intrarenal RAS. However, the association between uric acid (UA), RAS, and TGF-β1 in allograft recipients has not been demonstrated. Therefore we investigated the association between serum UA levels, RAS, and TGF-β1 in kidney transplant recipients during the 1st year after transplantation. METHODS Sixty-two transplant recipients were included in the study. Serum UA level, plasma renin activity (PRA), and urine TGF-β1 concentration were studied at 3, 6, and 12 months after transplantation. Statistical correlation was demonstrated with the use of Spearman rank correlation coefficient. Receiver operating characteristic curve analysis and area under the curve were performed to assess the diagnostic performance to discriminate between estimated glomerular filtration rate (eGFR) <60 and ≥ 60 mL/min/1.73 m(2). RESULTS For all 62 patients, urine TGF-β1 and serum UA had a tendency to increase during the 1-year follow-up period, despite no statistically significant change in eGFR. We found that increased urine TGF-β1 was correlated with rising serum UA levels and a decrease of the eGFR (r = 0.27 [P = .01]; r = -0.38 [P = .0003]). In contrast, there was no significant change in PRA and it was not correlated with eGFR or TGF-β1 (r = -0.01; P = .93). CONCLUSIONS Increased urine TGF-β1 and serum UA level during the 1st year after transplantation correlated with a decline in eGFR. The evaluation of these parameters in the early post-transplantation period may identify patients at risk of allograft dysfunction.
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Affiliation(s)
- C Sibunruang
- Renal Division, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - A Ingsathit
- Renal Division, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Clinical Epidemiology and Biostatistics, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - P Kantachuvesiri
- Renal Division, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - P Radinahamed
- Renal Division, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - S Rattanasiri
- Clinical Epidemiology and Biostatistics, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - P Pootracool
- Vascular and Organ Transplantation Division, Department of Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - K Kijvikai
- Urology Division, Department of Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - V Sumethkul
- Renal Division, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - S Kantachuvesiri
- Renal Division, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
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Goubella A, Broeders N, Racapé J, Hamade A, Massart A, Hougardy JM, Hoang AD, Mikhalski D, Baudoux T, Gankam F, Madhoun P, Janssen F, Moine AL, Nortier J, Vereerstraeten P. Patient and graft outcome in current era of immunosuppression: a single centre pilot study. Acta Clin Belg 2015; 70:23-9. [PMID: 25257447 DOI: 10.1179/2295333714y.0000000078] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES The present single centre study aims at analyzing the impact on renal allograft outcome of the important changes which occurred in the transplant population and immunosuppressive therapy during the last two decades. METHODS From 2000 to 2013, 779 single kidney transplantations were performed on 635 patients who all received on an intent-to-treat basis steroids, a calcineurin inhibitor, mycophenolate mofetil and an induction therapy with either antithymocyte globulin or an antagonist directed to the interleukin (IL)-2 receptor. Uni- and multivariate analyses of patient and immunologic graft survival were conducted. RESULTS The sole factor predicting patient survival is recipient's age: 10-year survival rates are 94·7, 81·6 and 57·9% for the <45, 45-60 and >60 years age groups, respectively (P<0·001). Peak (>50% panel reactive antibodies) anti-human leucocyte antigens (HLA) sensitization, cold ischaemia time and HLA-B and -DR mismatches (MM) influence graft outcome: at 10 years, the difference in 10-year survival rates is 5·9% between grafts from sensitized and not sensitized patients (90·9 vs 96·8%, P = 0·002), 3·8% between grafts with <18 and ≧18 hours cold ischaemia (96·6 vs 92·8%, P = 0·003), 7·3% between grafts with no MM and either B or DR MM versus those with B and DR MM (96·8 vs 89·5%, P = 0·002). CONCLUSION In our single centre experience, graft survival was most strongly determined by HLA matching, offering excellent long term graft outcome to most patients.
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Affiliation(s)
- A. Goubella
- Department of NephrologyDialysis and Transplantation and Department of Abdominal Surgery, Cliniques Universitaires de Bruxelles, Hôpital Erasme
| | - N. Broeders
- Department of NephrologyDialysis and Transplantation and Department of Abdominal Surgery, Cliniques Universitaires de Bruxelles, Hôpital Erasme
| | - J. Racapé
- Research Center of BiostatisticsEpidemiology and Clinical Research, School of Public Health, Université libre de Bruxelles, Brussels, Belgium
| | - A. Hamade
- Department of NephrologyDialysis and Transplantation and Department of Abdominal Surgery, Cliniques Universitaires de Bruxelles, Hôpital Erasme
| | - A. Massart
- Department of NephrologyDialysis and Transplantation and Department of Abdominal Surgery, Cliniques Universitaires de Bruxelles, Hôpital Erasme
| | - J.-M. Hougardy
- Department of NephrologyDialysis and Transplantation and Department of Abdominal Surgery, Cliniques Universitaires de Bruxelles, Hôpital Erasme
| | - A. D. Hoang
- Department of NephrologyDialysis and Transplantation and Department of Abdominal Surgery, Cliniques Universitaires de Bruxelles, Hôpital Erasme
| | - D. Mikhalski
- Department of NephrologyDialysis and Transplantation and Department of Abdominal Surgery, Cliniques Universitaires de Bruxelles, Hôpital Erasme
| | - T. Baudoux
- Department of NephrologyDialysis and Transplantation and Department of Abdominal Surgery, Cliniques Universitaires de Bruxelles, Hôpital Erasme
| | - F. Gankam
- Department of NephrologyDialysis and Transplantation and Department of Abdominal Surgery, Cliniques Universitaires de Bruxelles, Hôpital Erasme
| | - P. Madhoun
- Department of NephrologyDialysis and Transplantation and Department of Abdominal Surgery, Cliniques Universitaires de Bruxelles, Hôpital Erasme
| | - F. Janssen
- Department of NephrologyDialysis and Transplantation and Department of Abdominal Surgery, Cliniques Universitaires de Bruxelles, Hôpital Erasme
| | - A. Le Moine
- Department of NephrologyDialysis and Transplantation and Department of Abdominal Surgery, Cliniques Universitaires de Bruxelles, Hôpital Erasme
| | - J. Nortier
- Department of NephrologyDialysis and Transplantation and Department of Abdominal Surgery, Cliniques Universitaires de Bruxelles, Hôpital Erasme
| | - P. Vereerstraeten
- Department of NephrologyDialysis and Transplantation and Department of Abdominal Surgery, Cliniques Universitaires de Bruxelles, Hôpital Erasme
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Kellenberger T, Marcussen N, Nyengaard JR, Wogensen L, Jespersen B. Expression of hypoxia-inducible factor-1α and hepatocyte growth factor in development of fibrosis in the transplanted kidney. Transpl Int 2014; 28:180-90. [DOI: 10.1111/tri.12475] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 06/21/2014] [Accepted: 10/02/2014] [Indexed: 01/30/2023]
Affiliation(s)
- Terese Kellenberger
- Research Laboratory for Biochemical Pathology; Department of Clinical Medicine; Aarhus University; Aarhus C Denmark
| | - Niels Marcussen
- Department of Pathology; Odense University Hospital; Odense C Denmark
| | - Jens R. Nyengaard
- Stereology and Electron Microscopy Laboratory; Centre for Stochastic Geometry and Advanced Bioimaging; Department of Clinical Medicine; Aarhus University; Aarhus C Denmark
| | - Lise Wogensen
- Research Laboratory for Biochemical Pathology; Department of Clinical Medicine; Aarhus University; Aarhus C Denmark
| | - Bente Jespersen
- Department of Renal Medicine; Aarhus University Hospital; Skejby Denmark
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30
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Chen W, Peng W, Huang J, Yu X, Tan K, Chen Y, Lin X, Chen D, Dai Y. Microarray analysis of long non-coding RNA expression in human acute rejection biopsy samples following renal transplantation. Mol Med Rep 2014; 10:2210-6. [PMID: 25198465 DOI: 10.3892/mmr.2014.2420] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Accepted: 06/10/2014] [Indexed: 11/05/2022] Open
Abstract
Rejection is still a major obstacle in long-term allograft survival of renal transplant recipients. Long non‑coding RNAs (lncRNAs) are an important class of pervasive RNAs involved in a variety of biological functions, and which are often found to be differentially expressed between healthy and pathological conditions. The aim of this study was to compare the expression profiles of lncRNAs between samples from acute rejection following kidney transplantation and control samples. Three patients were enrolled, diagnosed by renal biopsy with acute rejection upon kidney transplantation. We used lncRNA microarrays to study the lncRNA expression profiles in the kidney biopsies of these patients and in kidneys from healthy donors. Reverse transcription‑quantitative polymerase chain reaction (RT-qPCR) was used to validate the microarray results. In addition, potential functions of the identified lncRNAs were further explored by searching the UCSC, RNAdb, RefSeq and NRED databases. Five candidate lncRNAs displaying differential expression in acute rejection samples were validated by RT-qPCR. The results were in agreement with the microarray data. Among the identified lncRNAs, certain have been previously identified in relevant conditions, thereby supporting previous evidence, but certain may constitute novel biomarker candidates. This is the first report to date using lncRNA microarrays to identify unique expression signatures of acute rejection in transplant biopsies. Our data indicate that lncRNAs are potentially involved in the pathogenesis of acute rejection. Our results may have important implications in the identification of diagnostic biomarkers, as well as in the understanding and treatment of acute rejection following renal transplantation.
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Affiliation(s)
- Wenbiao Chen
- Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, Guangdong 518020, P.R. China
| | - Wujian Peng
- Third People's Hospital of Shenzhen, Guangdong Medical College, Shenzhen, Guangdong 518112, P.R. China
| | - Jianrong Huang
- Third People's Hospital of Shenzhen, Guangdong Medical College, Shenzhen, Guangdong 518112, P.R. China
| | - Xiangqi Yu
- Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, Guangdong 518020, P.R. China
| | - Kuibi Tan
- Ningbo Second Hospital, Ningbo, Zhejiang 315100, P.R. China
| | - Yuyu Chen
- Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, Guangdong 518020, P.R. China
| | - Xiaocong Lin
- Institute of Biochemistry and Molecular Biology, Guangdong Medical College, Zhanjiang, Guangdong 524000, P.R. China
| | - Deheng Chen
- Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, Guangdong 518020, P.R. China
| | - Yong Dai
- Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, Guangdong 518020, P.R. China
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31
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Mathis AS, Egloff G, Ghin HL. Calcineurin inhibitor sparing strategies in renal transplantation, part one: Late sparing strategies. World J Transplant 2014; 4:57-80. [PMID: 25032096 PMCID: PMC4094953 DOI: 10.5500/wjt.v4.i2.57] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Revised: 03/25/2014] [Accepted: 05/14/2014] [Indexed: 02/05/2023] Open
Abstract
Kidney transplantation improves quality of life and reduces the risk of mortality. A majority of the success of kidney transplantation is attributable to the calcineurin inhibitors (CNIs), cyclosporine and tacrolimus, and their ability to reduce acute rejection rates. However, long-term graft survival rates have not improved over time, and although controversial, evidence does suggest a role of chronic CNI toxicity in this failure to improve outcomes. Consequently, there is interest in reducing or removing CNIs from immunosuppressive regimens in an attempt to improve outcomes. Several strategies exist to spare calcineurin inhibitors, including use of agents such as mycophenolate mofetil (MMF), mycophenolate sodium (MPS), sirolimus, everolimus or belatacept to facilitate late calcineurin inhibitor withdrawal, beyond 6 mo post-transplant; or using these agents to plan early withdrawal within 6 mo; or to avoid the CNIs all together using CNI-free regimens. Although numerous reviews have been written on this topic, practice varies significantly between centers. This review organizes the data based on patient characteristics (i.e., the baseline immunosuppressive regimen) as a means to aid the practicing clinician in caring for their patients, by matching up their situation with the relevant literature. The current review, the first in a series of two, examines the potential of immunosuppressive agents to facilitate late CNI withdrawal beyond 6 mo post-transplant, and has demonstrated that the strongest evidence resides with MMF/MPS. MMF or MPS can be successfully introduced/maintained to facilitate late CNI withdrawal and improve renal function in the setting of graft deterioration, albeit with an increased risk of acute rejection and infection. Additional benefits may include improved blood pressure, lipid profile and serum glucose. Sirolimus has less data directly comparing CNI withdrawal to an active CNI-containing regimen, but modest improvement in short-term renal function is possible, with an increased risk of proteinuria, especially in the setting of baseline renal dysfunction and/or proteinuria. Renal outcomes may be improved when sirolimus is used in combination with MMF. Although data with everolimus is less robust, results appear similar to those observed with sirolimus.
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Shrestha BM, Haylor J. Biological pathways and potential targets for prevention and therapy of chronic allograft nephropathy. BIOMED RESEARCH INTERNATIONAL 2014; 2014:482438. [PMID: 24971332 PMCID: PMC4058292 DOI: 10.1155/2014/482438] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 05/04/2014] [Indexed: 02/08/2023]
Abstract
Renal transplantation (RT) is the best option for patients with end-stage renal disease, but the half-life is limited to a decade due to progressive deterioration of renal function and transplant failure from chronic allograft nephropathy (CAN), which is the leading cause of transplant loss. Extensive research has been done to understand the pathogenesis, the biological pathways of fibrogenesis, and potential therapeutic targets for the prevention and treatment of CAN. Despite the advancements in the immunosuppressive agents and patient care, CAN continues to remain an unresolved problem in renal transplantation. The aim of this paper is to undertake a comprehensive review of the literature on the pathogenesis, biological pathways of RT fibrogenesis, and potential therapeutic targets for the prevention and therapy of CAN.
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Affiliation(s)
- Badri Man Shrestha
- Division of Renal Transplantation, Sheffield Kidney Institute, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK
| | - John Haylor
- Division of Renal Transplantation, Sheffield Kidney Institute, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK
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Thomas B, Taber DJ, Srinivas TR. Hypertension after kidney transplantation: a pathophysiologic approach. Curr Hypertens Rep 2014; 15:458-69. [PMID: 23933793 DOI: 10.1007/s11906-013-0381-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Post-transplant hypertension is associated with decreased graft and patient survival and cardiovascular morbidity. Unfortunately, post-transplant hypertension is often poorly controlled. Important risk factors include immunosuppressive medications, complications of the transplant surgery, delayed graft function, rejection, and donor and recipient risk factors. The effects of immunosuppressive medications are multifactorial including increased vascular and sympathetic tone and salt and fluid retention. The immunosuppressive agents most commonly associated with hypertension are glucocorticoids and calcineurin inhibitors. Drug therapy for hypertension should be based on the comorbidities and pathophysiology. Evidence-based approaches to defining and treating hypertension in renal transplant recipients are predominantly extrapolated from large-scale studies performed in the general population. Thus, there continues to be a need for larger studies examining the pathophysiology, diagnosis and treatment of hypertension in renal transplant recipients.
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Affiliation(s)
- Beje Thomas
- Division of Nephrology, Medical University of South Carolina, 96 Jonathan Lucas Street CSB 829, Charleston, SC, 29425, USA,
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Abstract
PURPOSE OF REVIEW Kidney transplantation has improved the life expectancy and quality of life for patients with end-stage renal failure. However, despite the impressive improvements in short-term outcome parameters because of better and more potent immunosuppressive drugs, the long-term survival of renal allografts has changed little over the last decades. Sustained inflammation in the areas of interstitial fibrosis and tubular atrophy (IFTA) is a strong predictor of allograft failure. Mesenchymal stromal cells (MSCs) have potent anti-inflammatory and reparative properties, and could thus play a role in controlling these processes. RECENT FINDINGS Local resident MSCs and exogenous MSCs have been implicated in the repair of the injured kidney, mostly by their paracrine functions. In the experimental models and clinical trials, first results with MSCs for the treatment of inflammation and IFTA suggest beneficial effects. SUMMARY Endogenously and exogenously administered MSCs might enhance the intrinsic reparative capabilities of the kidney in transplant recipients and maybe developed as a tool to control both inflammation and fibrosis.
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Phelan PJ, Conlon PJ, Sparks MA. Genetic determinants of renal transplant outcome: where do we stand? J Nephrol 2014; 27:247-56. [DOI: 10.1007/s40620-014-0053-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 11/05/2013] [Indexed: 01/07/2023]
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Alpay N, Ozkok A, Caliskan Y, Akagun T, Cinar SA, Deniz G, Sariyar M, Yildiz A. Influence of conversion from calcineurin inhibitors to everolimus on fibrosis, inflammation, tubular damage and vascular function in renal transplant patients. Clin Exp Nephrol 2014; 18:961-7. [PMID: 24515306 DOI: 10.1007/s10157-014-0939-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 01/17/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND Conversion from calcineurin inhibitor (CNI) to mTOR inhibitors may reduce and even halt the progression of chronic allograft dysfunction (CAD) which is the most important cause of renal allograft loss. We aimed to investigate the effects of conversion from CNI to everolimus on parameters of fibrosis, inflammation, glomerulotubular damage and vascular functions in renal transplant recipients. METHODS Fifteen stable renal transplant recipients who were under CNI treatment (male/female 13/2, mean age 41 ± 10 years) were enrolled and switched to everolimus. Serum and urinary transforming growth factor-β (TGF-β), urinary neutrophil gelatinase-associated lipocalin (NGAL) and monocyte chemoattractant protein-1 (MCP-1) were measured as markers of fibrosis, tubular damage and inflammation. As parameters of vascular functions, pulse wave velocity (PWV), augmentation index (AIx), serum asymmetric dimethyl-arginine and fibroblast growth factor-23 (FGF-23) were measured. All these measurements were repeated at the 3rd month of conversion. RESULTS Estimated GFR (52 ± 7-57 ± 11 ml/min/l.73 m(2), p = 0.02) (was increased after conversion to everolimus. However, serum uric acid levels were significantly decreased (6.21 ± 1.21-5.50 ± 1.39 mg/dL, p = 0.01). Serum TGF-β levels (8727 ± 2897-1943 ± 365 pg/mL, p = 0.03) and urinary NGAL levels (26 ± 10-12 ± 2 ng/mg creatinine, p = 0.05) were significantly decreased. However, urinary MCP-1, FGF-23, PWV and AIx did not change. Urinary TGF-β was associated with urinary NGAL (r = 0.62, p = 0.01), urinary MCP-1 (r = 0.68, p = 0.005) and proteinuria (r = 0.50, p = 0.05). CONCLUSION Conversion from CNI to everolimus resulted in significant decreases of serum TGF-β and urinary NGAL which may represent less fibrosis and tubular damage. Association of urinary TGF-β with NGAL and MCP-1 suggests that tubular damage, fibrosis and inflammation may act together for progression of CAD.
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Affiliation(s)
- Nadir Alpay
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul School of Medicine, Istanbul University, Fatih, 34093, Istanbul, Turkey
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Srinivas TR, Schold JD, Meier-Kriesche HU. Mycophenolate mofetil: long-term outcomes in solid organ transplantation. Expert Rev Clin Immunol 2014; 2:495-518. [DOI: 10.1586/1744666x.2.4.495] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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38
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Zhao H, Luo X, Zhou Z, Liu J, Tralau-Stewart C, George AJ, Ma D. Early treatment with xenon protects against the cold ischemia associated with chronic allograft nephropathy in rats. Kidney Int 2014; 85:112-23. [DOI: 10.1038/ki.2013.334] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 06/01/2013] [Accepted: 06/20/2013] [Indexed: 11/09/2022]
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Gökceoğlu AU, Akman S, Köksoy S, Şahin E, Koyun M, Çomak E, Doğan ÇS, Akbaş H, Dinçkan A. Circulating endothelial cells in pediatric renal transplant recipients. Pediatr Nephrol 2013; 28:2377-82. [PMID: 24018796 DOI: 10.1007/s00467-013-2588-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 07/15/2013] [Accepted: 07/23/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND An increase in the number of circulating endothelial cells (CEC) indicates endothelial damage and the risk of cardiovascular disease. The aim of our study was to investigate the association of CEC with various clinical parameters in pediatric renal transplant recipients. METHODS CEC, defined as CD45(-)CD146(+), were enumerated by flow cytometry from the peripheral blood of 50 pediatric renal transplant recipients and 20 healthy controls. Clinical parameters, including renal function tests, fasting blood glucose, serum cholesterol and triglyceride, cyclosporine A (CsA) (trough and 2nd-hour) and tacrolimus (tac) trough blood levels and their association with CEC numbers were analyzed. RESULTS CEC numbers of patients were higher than those of controls (respectively, 128 ± 89 cells/ml (42-468 cells/ml), 82 ± 33 cells/ml (32-137 cells/ml), p = 0.024). There was a statistically significant negative correlation between CEC numbers and glomerular filtration rate (GFR) (r = -0.300, p = 0.012). There was also a statistically positive association between CEC numbers and transplant duration as well as cyclosporine trough level (respectively, r = 0.397, p = 0.004, r = 0.714, p = 0.004). CEC numbers in patients on tac and CsA were similar (p = 0.716). CONCLUSIONS Our results demonstrate that renal transplant recipients with high CsA trough blood level, longer transplant duration, and lower GFR, are at greater risk of developing endothelial damage.
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Affiliation(s)
- Arife Uslu Gökceoğlu
- Department of Pediatric Nephrology, Akdeniz University Medical Faculty, Antalya, Turkey,
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Basu S, Meisert I, Eggensperger E, Krieger E, Krenn CG. Time course and attenuation of ischaemia-reperfusion induced oxidative injury by propofol in human renal transplantation. Redox Rep 2013; 12:195-202. [DOI: 10.1179/135100007x200281] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Comprehensive investigation of the caveolin 2 gene: resequencing and association for kidney transplant outcomes. PLoS One 2013; 8:e63358. [PMID: 23667606 PMCID: PMC3646761 DOI: 10.1371/journal.pone.0063358] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 04/01/2013] [Indexed: 12/05/2022] Open
Abstract
Caveolae are plasma membrane structures formed from a complex of the proteins caveolin-1 and caveolin-2. Caveolae interact with pro-inflammatory cytokines and are dysregulated in fibrotic disease. Although caveolae are present infrequently in healthy kidneys, they are abundant during kidney injury. An association has been identified between a CAV1 gene variant and long term kidney transplant survival. Chronic, gradual decline in transplant function is a persistent problem in kidney transplantation. The aetiology of this is diverse but fibrosis within the transplanted organ is the common end point. This study is the first to investigate the association of CAV2 gene variants with kidney transplant outcomes. Genomic DNA from donors and recipients of 575 kidney transplants performed in Belfast was investigated for common variation in CAV2 using a tag SNP approach. The CAV2 SNP rs13221869 was nominally significant for kidney transplant failure. Validation was sought in an independent group of kidney transplant donors and recipients from Dublin, Ireland using a second genotyping technology. Due to the unexpected absence of rs13221869 from this cohort, the CAV2 gene was resequenced. One novel SNP and a novel insertion/deletion in CAV2 were identified; rs13221869 is located in a repetitive region and was not a true variant in resequenced populations. CAV2 is a plausible candidate gene for association with kidney transplant outcomes given its proximity to CAV1 and its role in attenuating fibrosis. This study does not support an association between CAV2 variation and kidney transplant survival. Further analysis of CAV2 should be undertaken with an awareness of the sequence complexities and genetic variants highlighted by this study.
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Arias M, Hernández D, Guirado L, Campistol JM, Sánchez Plumed JA, Gómez E, Gentil MA, de Santiago C. Clinical profile and post-transplant anaemia in renal transplant recipients restarting dialysis after a failed graft: changing trends between 2001 and 2009. Clin Kidney J 2013; 6:156-63. [PMID: 26019844 PMCID: PMC4432436 DOI: 10.1093/ckj/sfs181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 12/11/2012] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The aim of this study was to compare the clinical profile, outcome and the prevalence and management of anaemia between two cohorts of renal transplant patients with graft failure restarting dialysis in 2001 and 2009. METHODS Cross-sectional, observational, retrospective and multicentre study of 397 patients in the 2001 cohort and 222 in the 2009 cohort. Data were recorded at 0, 3, 6, 9 and 12 months before the onset of dialysis resumption and during the first 90 days after restarting dialysis (mortality and hospital admission). RESULTS Patients in the 2009 cohort were older at the time of inclusion in the study and transplantation, and restarted dialysis therapy with a significantly better glomerular filtration rate. In both cohorts, there was a rapid deterioration of renal function with statistically significant differences in serum creatinine and glomerular filtration rate between the monthly intervals -12 and 0. The mean haemoglobin value at -12 months was 11.6 g/dL [7.2 mmol/L] in the 2001 cohort when compared with 12.3 g/dL [7.6 mmol/L] in the 2009 cohort, and at the time of restarting dialysis 9.6 g/dL [6.0 mmol/L] versus 10.6 g/dL [6.6 mmol/L]. The percentage of patients treated with erythropoiesis-stimulating agents, at any time during the 12 months before readmission to dialysis, increased significantly from 61.5% in the 2001 cohort to 96% in the 2009 cohort. There were no significant differences between the 2001 and 2009 cohorts in mortality rate (8.8 versus 9.0%) or hospital admission (31.5 versus 31.1%) during the study time. CONCLUSIONS At restarting dialysis, the proportion of patients with anaemia (and its severity) due to progressive graft nephropathy decreased over the past 8 years, increasing significantly the percentage of patients treated with erythropoietin. Differences in morbimortality after dialysis resumption were not observed, this is probably due to an increase in the age of donors and recipients.
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Affiliation(s)
- Manuel Arias
- Nephrology Service, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Domingo Hernández
- Nephrology Service, Complejo Hospitalario Universitario Carlos Haya, Málaga, Spain
| | - Luis Guirado
- Nephrology Service, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Josep M. Campistol
- Nephrology Service, Hospital Clínic i Provincial, Universitat de Barcelona, Barcelona, Spain
| | | | - Ernesto Gómez
- Nephrology Service, Hospital Central de Asturias, Oviedo, Spain
| | | | - Carlos de Santiago
- Nephrology Service, Hospital General Universitario de Alicante, Alicante, Spain
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Gois PHF, Rivelli GG, Pereira LM, Mazzali M. Sirolimus in renal transplantation: analysis of safety and efficacy in a nonprotocol conversion group. Transplant Proc 2013; 44:2348-51. [PMID: 23026590 DOI: 10.1016/j.transproceed.2012.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Conversion to sirolimus (SRL)-based immunosuppression in renal transplant recipients is an alternative for chronic allograft dysfunction (CAD), cancer and viral infections. We sought to analyze the indications for and safety and efficacy of conversion to SRL among renal transplant patients. METHODS/MATERIALS We examined a retrospective cohort, using medical records of renal transplant recipients >18 years old who had their immunosuppressive regimen converted to a SRL-based treatment. Data analysis included the indication for conversion, time posttransplant, as well as urine protein and serum creatinine at conversion and 6 months thereafter. The end points included death, graft loss and/or discontinuation of SRL. RESULTS We included 112 patients in this series who had indications for conversion: fungal, polyomavirus, or cytomegalovirus infection (n = 32), CAD (n = 30), cancer (n = 21), immunologic (n = 3), and other reasons (n = 26). Changes in immunosuppression were performed at 41 ± 57 months posttransplant or later in cancer patients. SRL was discontinued in 9 patients owing to adverse events such as edema, proteinuria, mucositis, or pneumonitis. Graft loss was observed in 19 patients, and death in 6. In 87 patients with functioning grafts, protein/creatinine ratios increased from 0.28 ± 0.03 (conversion) to 0.63 ± 0.09 (after 6 months; P < .001). Serum creatinine decreased from 2.24 ± 0.13 (conversion) to 1.89 ± 0.75 mg/dL (after 6 months; P < .001). Graft survival was 88% at 1 and 80% at 3 years after conversion. CONCLUSION In, SRL was well tolerated; conversion to SRL improved graft function with a slight increase in proteinuria.
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Affiliation(s)
- P H F Gois
- Division of Nephrology, Department of Medicine, School of Medical Sciences, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
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De Novo Donor-Specific HLA Antibody Development and Peripheral CD4(+)CD25(high) Cells in Kidney Transplant Recipients: A Place for Interaction? J Transplant 2012; 2012:302539. [PMID: 22970343 PMCID: PMC3432543 DOI: 10.1155/2012/302539] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Revised: 07/03/2012] [Accepted: 07/11/2012] [Indexed: 01/05/2023] Open
Abstract
The aim of this study was to determine whether the abundance of regulatory T cells (Tregs) (CD4+CD25high) affects the de novo development of anti-HLA donor-specific antibodies (DSAs) in kidney transplant recipients (KTRs). Methods. Unsensitized (PRA ≤ 10%, no DSA) adult primary KTRs who received a living (83%) or deceased (17%) KT in our Institution during 2004/2005 were included. DSA testing was performed monthly, and Tregs were quantified by flow cytometry every 3 months, during the 1st year after KT. All patients received triple drug immunosuppressive therapy (CNI + MMF or AZA + PDN); 83% received anti-CD25. Results. 53 KTRs were included; 32% developed DSA during the 1st year after KT. Significantly lower 7-year graft survival was observed in those who developed DSA. No difference was observed in Treg numbers up to 9 months after KT, between DSA positive and negative. However, at 12 months after KT, DSA-negative patients had significantly higher numbers of Treg. Conclusions. Early development of DSA was not associated to variations in Treg abundance. The differences in Treg numbers observed at the late time point may reflect better immune acceptance of the graft and may be associated to long-term effects. Additional inhibitory mechanisms participating earlier in DSA development after KT deserve to be sought.
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Deetman PE, Zelle DM, Homan van der Heide JJ, Navis GJ, Gans ROB, Bakker SJL. Plasma bilirubin and late graft failure in renal transplant recipients. Transpl Int 2012; 25:876-81. [DOI: 10.1111/j.1432-2277.2012.01515.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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46
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Ripoll È, Nacher V, Vidal A, Herrero E, Bolaños N, Torras J, Grinyó JM, Ruberte J, Herrero-Fresneda I. Cold ischaemia, innate immunity and deterioration of the glomerular filtration barrier in antibody-mediated acute rejection. Nephrol Dial Transplant 2012; 27:3296-305. [DOI: 10.1093/ndt/gfs003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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47
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Gelens MACJ, Steegh FMEG, van Hooff JP, van Suylen RJ, Nieman FHM, van Heurn LWE, Peutz-Kootstra CJ, Christiaans MHL. Immunosuppressive regimen and interstitial fibrosis and tubules atrophy at 12 months postrenal transplant. Clin J Am Soc Nephrol 2012; 7:1010-7. [PMID: 22490875 DOI: 10.2215/cjn.09030911] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Chronic renal transplant dysfunction is histopathologically characterized by interstitial fibrosis and tubular atrophy. This study investigated the relative contribution of baseline donor, recipient, and transplant characteristics to interstitial fibrosis and tubular atrophy score at month 12 after renal transplantation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This retrospective study includes all 109 consecutive recipients with adequate implantation and month 12 biopsies transplanted between April of 2003 and February of 2007. Immunosuppression regimen was tacrolimus and steroids (10 days) plus either sirolimus or mycophenolate mofetil. RESULTS Average interstitial fibrosis and tubular atrophy score increased from 0.70 to 1.65 (P<0.001). In an adjusted multiple linear regression analysis, interstitial fibrosis and tubular atrophy score at month 12 was significantly related to donor type (donors after cardiac death versus living donor had interstitial fibrosis and tubular atrophy score+0.41, 95% confidence interval=0.05-0.76, P=0.02), baseline interstitial fibrosis and tubular atrophy, and immunosuppression regimen. Because of interaction between the latter two variables (P=0.002), results are given separately: recipients with a baseline interstitial fibrosis and tubular atrophy score of zero had a 0.60 higher score at month 12 (95% confidence interval=0.09-1.10, P=0.02) when mycophenolate mofetil-treated, whereas recipients with a baseline interstitial fibrosis and tubular atrophy score more than zero had a 0.38 higher score at month 12 (95% confidence interval=0.01-0.74, P=0.04) when sirolimus-treated. A higher score at month 12 correlated with a lower estimated GFR (ρ=-0.45, P<0.001). CONCLUSIONS These findings suggest that histologic assessment of a preimplantation biopsy may guide choice of immunosuppresion to maximize transplant survival and its interaction with type of immunosuppression.
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Affiliation(s)
- Mariëlle A C J Gelens
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Centre, Maastricht, The Netherlands.
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Huang ST, Shu KH, Cheng CH, Wu MJ, Yu TM, Chuang YW, Chen CH. Serum Total p-Cresol and Indoxyl Sulfate Correlated With Stage of Chronic Kidney Disease in Renal Transplant Recipients. Transplant Proc 2012; 44:621-4. [DOI: 10.1016/j.transproceed.2011.11.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Ai D, Chen C, Han S, Ganda A, Murphy AJ, Haeusler R, Thorp E, Accili D, Horton JD, Tall AR. Regulation of hepatic LDL receptors by mTORC1 and PCSK9 in mice. J Clin Invest 2012; 122:1262-70. [PMID: 22426206 DOI: 10.1172/jci61919] [Citation(s) in RCA: 129] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Accepted: 02/01/2012] [Indexed: 12/26/2022] Open
Abstract
Individuals with type 2 diabetes have an increased risk of atherosclerosis. One factor underlying this is dyslipidemia, which in hyperinsulinemic subjects with early type 2 diabetes is typically characterized by increased VLDL secretion but normal LDL cholesterol levels, possibly reflecting enhanced catabolism of LDL via hepatic LDLRs. Recent studies have also suggested that hepatic insulin signaling sustains LDLR levels. We therefore sought to elucidate the mechanisms linking hepatic insulin signaling to regulation of LDLR levels. In WT mice, insulin receptor knockdown by shRNA resulted in decreased hepatic mTORC1 signaling and LDLR protein levels. It also led to increased expression of PCSK9, a known post-transcriptional regulator of LDLR expression. Administration of the mTORC1 inhibitor rapamycin caused increased expression of PCSK9, decreased levels of hepatic LDLR protein, and increased levels of VLDL/LDL cholesterol in WT but not Pcsk9-/- mice. Conversely, mice with increased hepatic mTORC1 activity exhibited decreased expression of PCSK9 and increased levels of hepatic LDLR protein levels. Pcsk9 is regulated by the transcription factor HNF1α, and our further detailed analyses suggest that increased mTORC1 activity leads to activation of PKCδ, reduced activity of HNF4α and HNF1α, decreased PCSK9 expression, and ultimately increased hepatic LDLR protein levels, which result in decreased circulating LDL levels. We therefore suggest that PCSK9 inhibition could be an effective way to reduce the adverse side effect of increased LDL levels that is observed in transplant patients taking rapamycin as immunosuppressive therapy.
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Affiliation(s)
- Ding Ai
- Department of Medicine, Columbia University, New York, New York 10032, USA.
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Khalkhali HR, Ghafari A. Prediction of long-term kidney failure in renal transplant with chronic allograft dysfunction using stage-specific hazard rates. EXP CLIN TRANSPLANT 2012; 10:8-13. [PMID: 22309413 DOI: 10.6002/ect.2011.0049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES The process of kidney failure in renal transplant recipients with chronic allograft dysfunction is characterized by a progressive decline in glomerular filtration rate over time that it is determined by the 5-stage model. This study used stage-based statistical survival analysis to predict graft survival in renal transplant recipients with chronic allograft dysfunction. MATERIALS AND METHODS In a single-center, retrospective study, 214 renal transplant recipients with chronic allograft dysfunction were investigated at a university hospital in Iran from 1997 to 2005. At each patient visit, kidney function was assessed using glomerular filtration rate and stage of disease. RESULTS The estimated stage-specific hazard rates of disease progression are stage one, 453.936; stage two, 485.040; stage three, 545.808; and stage four; 649.488 per 1000 person-years. The estimated mean times in each stage were as follows: kidney damage with normal or increased glomerular filtration rate, 26.43 months; kidney damage with mildly decreased glomerular filtration rate, 24.74 months; moderate kidney disease, 21.98 months; and severe kidney disease; 18.48 months. These estimates yield a mean time from stage 1 to kidney failure of 91.63 months. The probability of graft survival was predicted using estimated stage-specific hazard rates. The 18th, 58th, 118th, and 155th months death-censored graft survival probabilities were 0.99, 0.75, 0.25, and 0.10. CONCLUSIONS In this method of survival analysis, we can determine a statistical model according to a real clinical model in renal transplant recipients with chronic allograft dysfunction. It enables us to determine the stage-specific hazard rates of disease progression. These findings can help nephrologists to understand the kidney disease process and better predict graft survival.
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Affiliation(s)
- Hamid Reza Khalkhali
- Department of Epidemiology and Biostatistics, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran.
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