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Transplant glomerulopathy. Mod Pathol 2018; 31:235-252. [PMID: 29027535 DOI: 10.1038/modpathol.2017.123] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/28/2017] [Accepted: 08/10/2017] [Indexed: 12/13/2022]
Abstract
In the renal allograft, transplant glomerulopathy represents a morphologic lesion and not a specific diagnosis. The hallmark pathologic feature is glomerular basement membrane reduplication by light microscopy or electron microscopy in the absence of immune complex deposits. Transplant glomerulopathy results from chronic, recurring endothelial cell injury that can be mediated by HLA alloantibodies (donor-specific antibodies), various autoantibodies, cell-mediated immune injury, thrombotic microangiopathy, or chronic hepatitis C. Clinically, transplant glomerulopathy may be silent, detectable on protocol biopsy, or present with overt manifestations, including up to nephrotic range proteinuria, hypertension, and declining glomerular filtration rate. In either case, transplant glomerulopathy is associated with reduced graft survival. This review details the morphologic features of transplant glomerulopathy found on light microscopy, immunofluorescence microscopy, and electron microscopy. The pathophysiology of the causes and risk factors are discussed. Clinical manifestations are emphasized and potential therapeutic modalities are examined.
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Lin MV, Sise ME, Pavlakis M, Amundsen BM, Chute D, Rutherford AE, Chung RT, Curry MP, Hanifi JM, Gabardi S, Chandraker A, Heher EC, Elias N, Riella LV. Efficacy and Safety of Direct Acting Antivirals in Kidney Transplant Recipients with Chronic Hepatitis C Virus Infection. PLoS One 2016; 11:e0158431. [PMID: 27415632 PMCID: PMC4945034 DOI: 10.1371/journal.pone.0158431] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 06/15/2016] [Indexed: 02/06/2023] Open
Abstract
The prevalence of Hepatitis C Virus (HCV) infection is significantly higher in patients with end-stage renal disease compared to the general population and poses important clinical challenges in patients who undergo kidney transplantation. Historically, interferon-based treatment options have been limited by low rates of efficacy and significant side effects, including risk of precipitating rejection. Limited data exist on the use of all-oral, interferon-free direct-acting antiviral (DAA) therapies in kidney transplant recipients. In this study, we performed a retrospective chart review with prospective clinical follow-up of post-kidney transplant patients treated with DAA therapies at three major hospitals in Boston, MA. A total of 24 kidney recipients with HCV infection received all-oral DAA therapy post-transplant. Patients were predominantly male (79%) with a median age of 60 years (range 34–70 years), median creatinine of 1.2 mg/dL (0.66–1.76), and 42% had advanced fibrosis or cirrhosis. The majority had HCV genotype 1a infection (58%). All patients received full-dose sofosbuvir; it was paired with simeprevir (9 patients without and 3 patients with ribavirin), ledipasvir (7 patients without and 1 patient with ribavirin) or ribavirin alone (4 patients). The overall sustained virologic response (SVR12) was 91% (21 out of 23 patients). One patient achieved SVR4 but demised prior to SVR12 check point due to treatment unrelated cause. Two treatment failures were successfully retreated with alternative DAA regimens and achieved SVR. Both initials failures occurred in patients with advanced fibrosis or cirrhosis, with genotype 1a infection, and prior HCV treatment failure. Adverse events were reported in 11 patients (46%) and were managed clinically without discontinuation of therapy. Calcineurin inhibitor trough levels did not significantly change during therapy. In this multi-center series of patients, all-oral DAA therapy appears to be safe and effective in post-kidney transplant patients with chronic HCV infection.
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Affiliation(s)
- Ming V. Lin
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
- * E-mail: (LVR); (MVL)
| | - Meghan E. Sise
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Martha Pavlakis
- Division of Nephrology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States of America
| | - Beth M. Amundsen
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Donald Chute
- Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Anna E. Rutherford
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Raymond T. Chung
- Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Michael P. Curry
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States of America
| | - Jasmine M. Hanifi
- Department of Internal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Steve Gabardi
- Transplantation Research Center, Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Anil Chandraker
- Transplantation Research Center, Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Eliot C. Heher
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Nahel Elias
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Leonardo V. Riella
- Transplantation Research Center, Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, United States of America
- * E-mail: (LVR); (MVL)
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