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Frutos MÁ, Crespo M, Valentín MDLO, Alonso-Melgar Á, Alonso J, Fernández C, García-Erauzkin G, González E, González-Rinne AM, Guirado L, Gutiérrez-Dalmau A, Huguet J, Moral JLLD, Musquera M, Paredes D, Redondo D, Revuelta I, Hofstadt CJVD, Alcaraz A, Alonso-Hernández Á, Alonso M, Bernabeu P, Bernal G, Breda A, Cabello M, Caro-Oleas JL, Cid J, Diekmann F, Espinosa L, Facundo C, García M, Gil-Vernet S, Lozano M, Mahillo B, Martínez MJ, Miranda B, Oppenheimer F, Palou E, Pérez-Saez MJ, Peri L, Rodríguez O, Santiago C, Tabernero G, Hernández D, Domínguez-Gil B, Pascual J. Recommendations for living donor kidney transplantation. Nefrologia 2022; 42 Suppl 2:5-132. [PMID: 36503720 DOI: 10.1016/j.nefroe.2022.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/26/2021] [Indexed: 06/17/2023] Open
Abstract
This Guide for Living Donor Kidney Transplantation (LDKT) has been prepared with the sponsorship of the Spanish Society of Nephrology (SEN), the Spanish Transplant Society (SET), and the Spanish National Transplant Organization (ONT). It updates evidence to offer the best chronic renal failure treatment when a potential living donor is available. The core aim of this Guide is to supply clinicians who evaluate living donors and transplant recipients with the best decision-making tools, to optimise their outcomes. Moreover, the role of living donors in the current KT context should recover the level of importance it had until recently. To this end the new forms of incompatible HLA and/or ABO donation, as well as the paired donation which is possible in several hospitals with experience in LDKT, offer additional ways to treat renal patients with an incompatible donor. Good results in terms of patient and graft survival have expanded the range of circumstances under which living renal donors are accepted. Older donors are now accepted, as are others with factors that affect the decision, such as a borderline clinical history or alterations, which when evaluated may lead to an additional number of transplantations. This Guide does not forget that LDKT may lead to risk for the donor. Pre-donation evaluation has to centre on the problems which may arise over the short or long-term, and these have to be described to the potential donor so that they are able take them into account. Experience over recent years has led to progress in risk analysis, to protect donors' health. This aspect always has to be taken into account by LDKT programmes when evaluating potential donors. Finally, this Guide has been designed to aid decision-making, with recommendations and suggestions when uncertainties arise in pre-donation studies. Its overarching aim is to ensure that informed consent is based on high quality studies and information supplied to donors and recipients, offering the strongest possible guarantees.
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Affiliation(s)
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | | | | | - Juana Alonso
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | | | - Esther González
- Nephrology Department, Hospital Universitario 12 Octubre, Spain
| | | | - Lluis Guirado
- Nephrology Department, Fundacio Puigvert, Barcelona, Spain
| | | | - Jorge Huguet
- RT Surgical Team, Fundació Puigvert, Barcelona, Spain
| | | | - Mireia Musquera
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | - David Paredes
- Donation and Transplantation Coordination Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Ignacio Revuelta
- Nephrology and RT Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Antonio Alcaraz
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Manuel Alonso
- Regional Transplantation Coordination, Seville, Spain
| | | | - Gabriel Bernal
- Nephrology Department, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Alberto Breda
- RT Surgical Team, Fundació Puigvert, Barcelona, Spain
| | - Mercedes Cabello
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | - Joan Cid
- Apheresis and Cell Therapy Unit, Haemotherapy and Haemostasis Department, Hospital Clinic Universitari, Barcelona, Spain
| | - Fritz Diekmann
- Nephrology and RT Department, Hospital Clinic Universitari, Barcelona, Spain
| | - Laura Espinosa
- Paediatric Nephrology Department, Hospital La Paz, Madrid, Spain
| | - Carme Facundo
- Nephrology Department, Fundacio Puigvert, Barcelona, Spain
| | | | | | - Miquel Lozano
- Apheresis and Cell Therapy Unit, Haemotherapy and Haemostasis Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | | | | | | | - Eduard Palou
- Immunology Department, Hospital Clinic i Universitari, Barcelona, Spain
| | | | - Lluis Peri
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | | | | | - Domingo Hernández
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | - Julio Pascual
- Nephrology Department, Hospital del Mar, Barcelona, Spain.
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Guy P, Delas A, Esposito L, Cointault O, Colombat M, Congy-Jolivet N, Raynaud M, Kamar N, Del Bello A. Progression of histological lesions after ABO incompatible kidney transplantation. Front Immunol 2022; 13:969998. [PMID: 36275771 PMCID: PMC9582152 DOI: 10.3389/fimmu.2022.969998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/06/2022] [Indexed: 11/22/2022] Open
Abstract
Recent large meta-analyses suggested a poorer long-term patients’ and grafts’ outcomes after ABO incompatible (ABOi) living-donor kidney transplantation (LDKT) compared to ABO compatible LDKT. However, little is known about the long-term histological pattern after ABOi LDKT. We compared the histological features observed on protocol biopsies from 03/11 to 11/19 in 94 ABOi LDKT (including 14 with preformed Donor Specific Antibodies, pDSAs), 27 LDKT ABO compatible (ABOc) with pDSAs, and 21 ABOc without pDSAs) during the first five years post transplantation. During the first 5 years post-transplantation, a progression of chronic lesions (patients with a ci >0 raised from 11% to 65%, p<0.0001, patients with a ct >0 raised from 29% to 78%, p<0.0001) was observed in ABOi LDKT without pDSAs. Histological patterns of evolution were comparable to those observed in ABOc kidney transplant patients. Microvascular inflammation was lower in ABOi LDKT without pDSAs compared to those with pDSAs (ABOi or ABOc). At last follow-up, 28 months, IQR (15-48) post-transplantation, 29 patients (36%) had a severe graft dysfunction (defined by a CKD-epi eGFR < 30 mL/min/1.73m²). The donor age was a predictive factor for the development of severe kidney allograft dysfunction at last follow-up (HR= 1.05, 95% CI [1.05-1.10], p= 0.03). Hence, long-term histological analysis of ABOi LDKT shows only an increase of chronic interstitial and tubular atrophy changes, without active lesions. These data confirm that ABOi LDKT programs can be securely developed.
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Affiliation(s)
- Pierre Guy
- Department of Nephrology and Organ Transplantation, Centre Hospitalier et Universitaire (CHU), Toulouse, France
| | - Audrey Delas
- Department of Pathology, Toulouse University Hospital, Toulouse, France
| | - Laure Esposito
- Department of Nephrology and Organ Transplantation, Centre Hospitalier et Universitaire (CHU), Toulouse, France
| | - Olivier Cointault
- Department of Nephrology and Organ Transplantation, Centre Hospitalier et Universitaire (CHU), Toulouse, France
| | - Magali Colombat
- Department of Pathology, Toulouse University Hospital, Toulouse, France
- Centre Hospitalier et Universitaire, Université Paul Sabatier Toulouse III, Toulouse, France
| | - Nicolas Congy-Jolivet
- Laboratory of Immunology, Biology Department, Centre Hospitalier et Universitaire (CHU) de Toulouse, Toulouse, France
| | - Marc Raynaud
- Paris Translational Research Epidemiology and Biostatistics Department, Université de Paris, INSERM U970, PARCC, Paris, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Centre Hospitalier et Universitaire (CHU), Toulouse, France
- Centre Hospitalier et Universitaire, Université Paul Sabatier Toulouse III, Toulouse, France
- Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), INSERM UMR1043-CNRS 5282, Toulouse, France
| | - Arnaud Del Bello
- Department of Nephrology and Organ Transplantation, Centre Hospitalier et Universitaire (CHU), Toulouse, France
- Centre Hospitalier et Universitaire, Université Paul Sabatier Toulouse III, Toulouse, France
- Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), INSERM UMR1043-CNRS 5282, Toulouse, France
- *Correspondence: Arnaud Del Bello,
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Heo EJ, Hong S, Chun Y. Efficient use of immunosuppressants for kidney transplants. JOURNAL OF HEALTH ECONOMICS 2022; 85:102650. [PMID: 35810567 DOI: 10.1016/j.jhealeco.2022.102650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/23/2022] [Accepted: 06/26/2022] [Indexed: 06/15/2023]
Abstract
A recent development of immunosuppressive protocols (or simply, suppressants) offers a new option to patients suffering from end-stage renal disease: transplants from biologically incompatible donors. Suppressants are currently being used for direct transplants within patient-donor pairs, but they can be utilized more efficiently when combined with kidney exchanges. To assess the welfare gains from doing so, we introduce the "minimum chains algorithms" for different sizes of feasible exchanges. Using these algorithms, we calculate the minimal number of suppressants needed for transplants for a group of patient-donor pairs. Our simulation results show that (i) a significant reduction of suppressants can be achieved by implementing this proposal, (ii) it suffices to arrange 2-way exchanges for the best use of suppressants, and (iii) the welfare gain varies with the ABO blood-type distribution, and the gain in Korea appears to be larger than that in the United States. Finally, we assess the value (or cost) of each patient-donor pair by comparing the outcomes of the pools with and without the pair.
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Affiliation(s)
- Eun Jeong Heo
- Department of Economics, University of Seoul, Seoul 02504, South Korea.
| | - Sunghoon Hong
- Department of Science in Taxation, University of Seoul, Seoul 02504, South Korea.
| | - Youngsub Chun
- Department of Economics, Seoul National University, Seoul 08826, South Korea.
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Achram R, Zerra PE, Delvadia B, Thompson L, Badell IR, Roback JD, Sullivan HC. Indeterminate group A subtyping for prospective renal transplant donor. Transfusion 2022; 62:1927-1928. [PMID: 36084206 DOI: 10.1111/trf.17047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/05/2022] [Accepted: 07/05/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Robert Achram
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Patricia E Zerra
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Louisa Thompson
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - I Raul Badell
- Emory Transplant Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - John D Roback
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - H Cliff Sullivan
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, Emory University School of Medicine, Atlanta, Georgia, USA
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Recomendaciones para el trasplante renal de donante vivo. Nefrologia 2022. [DOI: 10.1016/j.nefro.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Manook M, Flores WJ, Schmitz R, Fitch Z, Yoon J, Bae Y, Shaw B, Kirk A, Harnois M, Permar S, Farris AB, Magnani DM, Kwun J, Knechtle S. Measuring the Impact of Targeting FcRn-Mediated IgG Recycling on Donor-Specific Alloantibodies in a Sensitized NHP Model. Front Immunol 2021; 12:660900. [PMID: 34149698 PMCID: PMC8207189 DOI: 10.3389/fimmu.2021.660900] [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: 01/29/2021] [Accepted: 05/17/2021] [Indexed: 11/13/2022] Open
Abstract
Background In transplantation, plasmapheresis and IVIg provide the mainstay of treatment directed at reducing or removing circulating donor-specific antibody (DSA), yet both have limitations. We sought to test the efficacy of targeting the IgG recycling mechanism of the neonatal Fc receptor (FcRn) using anti-FcRn mAb therapy in a sensitized non-human primate (NHP) model, as a pharmacological means of lowering DSA. Methods Six (6) rhesus macaque monkeys, previously sensitized by skin transplantation, received a single dose of 30mg/kg anti-RhFcRn IV, and effects on total IgG, as well as DSA IgG, were measured, in addition to IgM and protective immunity. Subsequently, 60mg/kg IV was given in the setting of kidney transplantation from skin graft donors. Kidney transplant recipients received RhATG, and tacrolimus, MMF, and steroid for maintenance immunosuppression. Results Circulating total IgG was reduced from a baseline 100% on D0 to 32.0% (mean, SD ± 10.6) on d4 post infusion (p<0.05), while using a DSA assay. T-cell flow cross match (TFXM) was reduced to 40.6±12.5% of baseline, and B-cell FXCM to 52.2±19.3%. Circulating total IgM and DSA IgM were unaffected by treatment. Pathogen-specific antibodies (anti-gB and anti-tetanus toxin IgG) were significantly reduced for 14d post infusion. Post-transplant, circulating IgG responded to anti-FcRn mAb treatment, but DSA increased rapidly. Conclusion Targeting the FcRn-mediated recycling of IgG is an effective means of lowering circulating donor-specific IgG in the sensitized recipient, although in the setting of organ transplantation mechanisms of rapid antibody rise post-transplant remains unaffected.
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Affiliation(s)
- Miriam Manook
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Walter J Flores
- Massbiologics of the University of Massachusetts Medical School, Boston, MA, United States
| | - Robin Schmitz
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Zachary Fitch
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Janghoon Yoon
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Yeeun Bae
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Brian Shaw
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Allan Kirk
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Melissa Harnois
- Human Vaccine Institute, Duke University Medical Center, Durham, NC, United States
| | - Sallie Permar
- Human Vaccine Institute, Duke University Medical Center, Durham, NC, United States
| | - Alton B Farris
- Department of Pathology, Emory School of Medicine, Atlanta, GA, United States
| | - Diogo M Magnani
- Massbiologics of the University of Massachusetts Medical School, Boston, MA, United States
| | - Jean Kwun
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Stuart Knechtle
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
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May FNJ, Rees MT, Griffin S, Fildes JE. Understanding immunological response to desensitisation strategies in highly sensitised potential kidney transplant patients. Transplant Rev (Orlando) 2021; 35:100596. [DOI: 10.1016/j.trre.2021.100596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 01/18/2023]
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8
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de Klerk M, Kal-van Gestel JA, van de Wetering J, Kho ML, Middel-de Sterke S, Betjes MGH, Zuidema WC, Roelen D, Glorie K, Roodnat JI. Creating Options for Difficult-to-match Kidney Transplant Candidates. Transplantation 2021; 105:240-248. [PMID: 32101984 DOI: 10.1097/tp.0000000000003203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Most transplantation centers recognize a small patient population that unsuccessfully participates in all available, both living and deceased donor, transplantation programs for many years: the difficult-to-match patients. This population consists of highly immunized and/or ABO blood group O or B patients. METHODS To improve their chances, Computerized Integration of Alternative Transplantation programs (CIAT) were developed to integrate kidney paired donation, altruistic/unspecified donation, and ABO and HLA desensitization. To compare CIAT with reality, a simulation was performed, including all patients, donors, and pairs who participated in our programs in 2015-2016. Criteria for inclusion as difficult-to-match, selected-highly immunized (sHI) patient were as follows: virtual panel reactive antibody >85% and participating for 2 years in Eurotransplant Acceptable Mismatch program. sHI patients were given priority, and ABO blood group incompatible (ABOi) and/or HLA incompatible (HLAi) matching with donor-specific antigen-mean fluorescence intensity (MFI) <8000 were allowed. For long-waiting blood group O or B patients, ABOi matches were allowed. RESULTS In reality, 90 alternative program transplantations were carried out: 73 compatible, 16 ABOi, and 1 both ABOi and HLAi combination. Simulation with CIAT resulted in 95 hypothetical transplantations: 83 compatible (including 1 sHI) and 5 ABOi combinations. Eight sHI patients were matched: 1 compatible, 6 HLAi with donor-specific antigen-MFI <8000 (1 also ABOi), and 1 ABOi match. Six/eight combinations for sHI patients were complement-dependent cytotoxicity cross-match negative. CONCLUSIONS CIAT led to 8 times more matches for difficult-to-match sHI patients. This offers them better chances because of a more favorable MFI profile against the new donor. Besides, more ABO compatible matches were found for ABOi couples, while total number of transplantations was not hampered. Prioritizing difficult-to-match patients improves their chances without affecting the chances of regular patients.
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Affiliation(s)
- Marry de Klerk
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | | | - Marcia L Kho
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - Michiel G H Betjes
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Willij C Zuidema
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Dave Roelen
- Department of Immunohaematology and Blood Transfusion LUMC, Leiden, The Netherlands
| | - Kristiaan Glorie
- Erasmus Q-Intelligence, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Joke I Roodnat
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
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IdeS (Imlifidase): A Novel Agent That Cleaves Human IgG and Permits Successful Kidney Transplantation Across High-strength Donor-specific Antibody. Ann Surg 2018; 268:488-496. [DOI: 10.1097/sla.0000000000002924] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Purpose of review Polyomavirus nephropathy (PVN) mainly caused by BK virus (BKV) remains the most common productive viral infection of the kidney. Over the past decade, clinical interest often focused on BK viremia and viruria as the diagnostic mainstays of patient management. The purpose of this review is to discuss viral nephropathy in the context of BK viremia and viruria and new strategies to optimize diagnostic accuracy and patient management. The emerging roles of polyomaviruses in oncogenesis, salivary gland disease, and post-bone marrow transplantation as well as novel Polyomavirus strains are highlighted. Recent findings Areas of investigation include proposals by the Banff working group on the classification of PVN and studies on PVN progression and resolution, including the role cellular immune responses may play during reconstitution injury. New noninvasive strategies to optimize the diagnosis of PVN, that is, the urinary ‘polyomavirus-haufen’ test and mRNA expression levels for BKV in the urine, hold great promise to accurately identify patients with viral nephropathy. Tools are now available to separate ‘presumptive’ from ‘definitive’ disease in various patient cohorts including individuals post-bone marrow transplantation. Recent observations also point to a currently underrecognized role of polyomaviruses in oncogenesis post-transplantation and salivary gland disease in patients with HIV-AIDS. Summary This review summarizes recent studies on PVN and the significance of the BKV strain in disease. Current paradigms for patient management post-(renal) transplantation are discussed in the setting of new observations. Issues that still require clarification and further validation are highlighted.
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Nath J, Field M, Ebbs S, Smith T, McGrogan D, Al-Shakarchi J, Hodson J, Mellor S, Ready A. Evolution of Renal Transplant Practice Over the Past Decade: A U.K. Center Experience. Transplant Proc 2015; 47:1700-4. [DOI: 10.1016/j.transproceed.2015.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 05/09/2015] [Accepted: 06/02/2015] [Indexed: 12/19/2022]
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Kornberg A. Intravenous immunoglobulins in liver transplant patients: Perspectives of clinical immune modulation. World J Hepatol 2015; 7:1494-1508. [PMID: 26085909 PMCID: PMC4462688 DOI: 10.4254/wjh.v7.i11.1494] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 04/19/2015] [Accepted: 05/08/2015] [Indexed: 02/06/2023] Open
Abstract
Shortage of appropriate donor grafts is the foremost current problem in organ transplantation. As a logical consequence, waiting times have extended and pretransplant mortality rates were significantly increasing. The implementation of a priority-based liver allocation system using the model of end-stage liver disease (MELD) score helped to reduce waiting list mortality in liver transplantation (LT). However, due to an escalating organ scarcity, pre-LT MELD scores have significantly increased and liver recipients became more complex in recent years. This has finally led to posttransplant decreasing survival rates, attributed mainly to elevated rates of infectious and immunologic complications. To meet this challenging development, an increasing number of extended criteria donor grafts are currently accepted, which may, however, aggravate the patients’ infectious and immunologic risk profiles. The administration of intravenous immunoglobulins (IVIg) is an established treatment in patients with immune deficiencies and other antibody-mediated diseases. In addition, IVIg was shown to be useful in treatment of several disorders caused by deterioration of the cellular immune system. It proved to be effective in preventing hyperacute rejection in highly sensitized kidney and heart transplants. In the liver transplant setting, the administration of specific Ig against hepatitis B virus is current standard in post-LT antiviral prophylaxis. The mechanisms of action of IVIg are complex and not fully understood. However, there is increasing experimental and clinical evidence that IVIg has an immuno-balancing impact by a combination of immuno-supporting and immuno-suppressive properties. It may be suggested that, especially in the context of a worsening organ shortage with all resulting clinical implications, liver transplant patients should benefit from immuno-regulatory capabilities of IVIg. In this review, perspectives of immune modulation by IVIg and impact on outcome in liver transplant patients are described.
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Budding K, van de Graaf E, Otten H. Humoral immunity and complement effector mechanisms after lung transplantation. Transpl Immunol 2014; 31:260-5. [DOI: 10.1016/j.trim.2014.08.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 08/29/2014] [Accepted: 08/29/2014] [Indexed: 11/28/2022]
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Histologic phenotype on 1-year posttransplantation biopsy and allograft survival in HLA-incompatible kidney transplants. Transplantation 2014; 97:541-7. [PMID: 24521779 DOI: 10.1097/01.tp.0000442513.27641.7e] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The correlation between histopathologic phenotypes and allograft outcomes among patients desensitized for donor-specific antibody (HLA-incompatible) is unknown. METHODS We analyzed 1-year biopsies from desensitized recipients transplanted between 1999 and 2010 and estimated graft survival for each histologic phenotype identified. Median time posttransplant for the 1-year biopsy was 367 days (interquartile range 357-388 days) and median follow-up of all patients post-1-year biopsy was 42 months (interquartile range 19.5-65 months). RESULTS Transplant glomerulopathy was present in 25.0% of biopsies and resulted in worse graft survival (66.7% vs. 96.7%, P<0.001). C4d positivity and transplant glomerulopathy together portended exceptionally poor graft survival (33.3% vs. 97.2%, P<0.001). Microcirculation inflammation was prevalent, with glomerulitis and peritubular capillaritis found in 60.0% and 47.6% of 1-year biopsies, respectively. Glomerulitis was associated with worse graft survival (82.1% vs. 98.1%, P=0.004), whereas capillaritis was not (88.1% vs. 97.7% respectively, P=0.091). Among C4d-negative HLA-incompatible recipients (82.6% of biopsies), no difference in graft survival was observed between patients with or without microcirculation inflammation in contrast to previous reports by other investigators. Patients who had no C4d deposition, transplant glomerulopathy, or microcirculation inflammation had a 100.0% graft survival. On Cox regression analysis, no independent histopathological parameter was associated with graft survival. CONCLUSIONS We have identified several histopathologic phenotypes in HLA-incompatible kidney recipients that correlate with allograft outcomes. Characterization of these phenotypes is the first step towards better understanding the pathophysiologic basis of chronic antibody-mediated allograft injury and individualizing therapeutic intervention.
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Fadeyi EA, Stratta RJ, Farney AC, Pomper GJ. Successful unintentional ABO-incompatible renal transplantation: Blood group A1B donor into an A2B recipient. Am J Clin Pathol 2014; 141:724-6. [PMID: 24713746 DOI: 10.1309/ajcpbgw81hqwbozo] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES To report a successful unintentional transplantation of a deceased donor kidney from an "incompatible" A1B donor into a recipient who was blood group A2B with unsuspected preformed anti-A1 antibodies. METHODS The donor and recipient were both typed for ABO antigens. The recipient was tested for ABO and non-ABO antibodies. The recipient was typed for HLA class I and class II antigens, including HLA antibody screen. The T-and B-flow cytometry crossmatch test was performed using standard protocol. RESULTS The donor-recipient pair was a complete six-antigen human leukocyte antigen mismatch, but final T- and B-flow cytometry cross-match tests were compatible. The recipient was a 65-year-old woman with a medical history of end-stage renal disease secondary to diabetic nephropathy who underwent kidney transplantation from a 46-year-old brain-dead standard criteria donor. The recipient's RBCs were negative with A1 lectin, and the recipient was thus typed as an A2 subgroup. Anti-A1 could be demonstrated in the recipient's plasma. The donor's RBCs were positive with A1 lectin, thereby conferring an A1 blood type. CONCLUSIONS It is safe to transplant across the A1/A2 blood group barrier provided that the preformed antibodies are not reactive at 37°C and with anti-human globulin.
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Affiliation(s)
- Emmanuel A. Fadeyi
- Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Robert J. Stratta
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Alan C. Farney
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Gregory J. Pomper
- Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, NC
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Glorie K, Haase-Kromwijk B, van de Klundert J, Wagelmans A, Weimar W. Allocation and matching in kidney exchange programs. Transpl Int 2013; 27:333-43. [PMID: 24112284 DOI: 10.1111/tri.12202] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 07/21/2013] [Accepted: 09/15/2013] [Indexed: 12/14/2022]
Abstract
Living donor kidney transplantation is the preferred treatment for patients suffering from end-stage renal disease. To alleviate the shortage of kidney donors, many advances have been made to improve the utilization of living donors deemed incompatible with their intended recipient. The most prominent of these advances is kidney paired donation (KPD), which matches incompatible patient-donor pairs to facilitate a kidney exchange. This review discusses the various approaches to matching and allocation in KPD. In particular, it focuses on the underlying principles of matching and allocation approaches, the combination of KPD with other strategies such as ABO incompatible transplantation, the organization of KPD, and important future challenges. As the transplant community strives to balance quantity and equity of transplants to achieve the best possible outcomes, determining the right long-term allocation strategy becomes increasingly important. In this light, challenges include making full use of the various modalities that are now available through integrated and optimized matching software, encouragement of transplant centers to fully participate, improving transplant rates by focusing on the expected long-run number of transplants, and selecting uniform allocation criteria to facilitate international pools.
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Affiliation(s)
- Kristiaan Glorie
- Econometric Institute, Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, The Netherlands
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