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Aguiar R, Bourmpaki E, Bunce C, Coker B, Delaney F, de Jongh L, Oliveira G, Weir A, Higgins F, Spiridou A, Hasan S, Smith J, Mulla A, Glampson B, Mercuri L, Montero R, Hernandez-Fuentes M, Roufosse CA, Simmonds N, Clatworthy M, McLean A, Ploeg R, Davies J, Várnai KA, Woods K, Lord G, Pruthi R, Breen C, Chowdhury P. Incidence, Risk Factors, and Effect on Allograft Survival of Glomerulonephritis Post-transplantation in a United Kingdom Population: Cohort Study. FRONTIERS IN NEPHROLOGY 2022; 2:923813. [PMID: 37675026 PMCID: PMC10479671 DOI: 10.3389/fneph.2022.923813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/17/2022] [Indexed: 09/08/2023]
Abstract
Background Post-transplant glomerulonephritis (PTGN) has been associated with inferior long-term allograft survival, and its incidence varies widely in the literature. Methods This is a cohort study of 7,623 patients transplanted between 2005 and 2016 at four major transplant UK centres. The diagnosis of glomerulonephritis (GN) in the allograft was extracted from histology reports aided by the use of text-mining software. The incidence of the four most common GN post-transplantation was calculated, and the risk factors for disease and allograft outcomes were analyzed. Results In total, 214 patients (2.8%) presented with PTGN. IgA nephropathy (IgAN), focal segmental glomerulosclerosis (FSGS), membranous nephropathy (MN), and membranoproliferative/mesangiocapillary GN (MPGN/MCGN) were the four most common forms of post-transplant GN. Living donation, HLA DR match, mixed race, and other ethnic minority groups were associated with an increased risk of developing a PTGN. Patients with PTGN showed a similar allograft survival to those without in the first 8 years of post-transplantation, but the results suggest that they do less well after that timepoint. IgAN was associated with the best allograft survival and FSGS with the worst allograft survival. Conclusions PTGN has an important impact on long-term allograft survival. Significant challenges can be encountered when attempting to analyze large-scale data involving unstructured or complex data points, and the use of computational analysis can assist.
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Affiliation(s)
- Rute Aguiar
- Department of Transplantation and Renal Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Elli Bourmpaki
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Catey Bunce
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Bola Coker
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Guy’s & St Thomas’ National Health Service (NHS) Foundation Trust and King’s College London, London, United Kingdom
| | - Florence Delaney
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Guy’s & St Thomas’ National Health Service (NHS) Foundation Trust and King’s College London, London, United Kingdom
| | - Leonardo de Jongh
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Guy’s & St Thomas’ National Health Service (NHS) Foundation Trust and King’s College London, London, United Kingdom
| | - Giovani Oliveira
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Guy’s & St Thomas’ National Health Service (NHS) Foundation Trust and King’s College London, London, United Kingdom
| | - Alistair Weir
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Guy’s & St Thomas’ National Health Service (NHS) Foundation Trust and King’s College London, London, United Kingdom
| | - Finola Higgins
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Guy’s & St Thomas’ National Health Service (NHS) Foundation Trust and King’s College London, London, United Kingdom
| | - Anastasia Spiridou
- Data Research, Innovation and Virtual Environments Unit (DRIVE), Great Ormond Street Hospital for Children National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Syed Hasan
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Guy’s & St Thomas’ National Health Service (NHS) Foundation Trust and King’s College London, London, United Kingdom
| | - Jonathan Smith
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Guy’s & St Thomas’ National Health Service (NHS) Foundation Trust and King’s College London, London, United Kingdom
| | - Abdulrahim Mulla
- National Institute for Health and Care Research (NIHR) Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare National Health Service (NHS) Trust, Hammersmith Hospital, London, United Kingdom
| | - Ben Glampson
- Research Informatics Team, Imperial College Healthcare National Health Service (NHS) Trust, London, United Kingdom
| | - Luca Mercuri
- National Institute for Health and Care Research (NIHR) Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare National Health Service (NHS) Trust, Hammersmith Hospital, London, United Kingdom
| | - Rosa Montero
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Guy’s & St Thomas’ National Health Service (NHS) Foundation Trust and King’s College London, London, United Kingdom
| | | | - Candice A. Roufosse
- Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Naomi Simmonds
- Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Menna Clatworthy
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Adam McLean
- Renal Section, Department of Medicine, Hammersmith Hospital Campus, Imperial College London, London, United Kingdom
| | - Rutger Ploeg
- Nuffield Department of Surgical Sciences, Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Jim Davies
- National Institute for Health and Care Research (NIHR) Oxford Biomedical Research Centre, Big Data Institute, University of Oxford, Oxford, Oxfordshire, United Kingdom
- Department of Computer Science, University of Oxford, Oxford, Oxfordshire, United Kingdom
| | - Kinga Anna Várnai
- National Institute for Health and Care Research (NIHR) Oxford Biomedical Research Centre, Big Data Institute, University of Oxford, Oxford, Oxfordshire, United Kingdom
- Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, Oxfordshire, United Kingdom
| | - Kerrie Woods
- National Institute for Health and Care Research (NIHR) Oxford Biomedical Research Centre, Big Data Institute, University of Oxford, Oxford, Oxfordshire, United Kingdom
- Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, Oxfordshire, United Kingdom
| | - Graham Lord
- Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Rishi Pruthi
- Department of Transplantation and Renal Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Cormac Breen
- Department of Transplantation and Renal Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Paramit Chowdhury
- Department of Transplantation and Renal Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
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Infante B, Rossini M, Leo S, Troise D, Netti GS, Ranieri E, Gesualdo L, Castellano G, Stallone G. Recurrent Glomerulonephritis after Renal Transplantation: The Clinical Problem. Int J Mol Sci 2020; 21:ijms21175954. [PMID: 32824988 PMCID: PMC7504691 DOI: 10.3390/ijms21175954] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 07/30/2020] [Accepted: 08/17/2020] [Indexed: 12/22/2022] Open
Abstract
Glomerulonephritis (GN) continues to be one of the main causes of end-stage kidney disease (ESKD) with an incidence rating from 10.5% to 38.2%. Therefore, recurrent GN, previously considered to be a minor contributor to graft loss, is the third most common cause of graft failure 10 years after renal transplantation. However, the incidence, pathogenesis, and natural course of recurrences are still not completely understood. This review focuses on the most frequent diseases that recur after renal transplantation, analyzing rate of recurrence, epidemiology and risk factors, pathogenesis and bimolecular mechanisms, clinical presentation, diagnosis, and therapy, taking into consideration the limited data available in the literature. First of all, the risk for recurrence depends on the type of glomerulonephritis. For example, recipient patients with anti-glomerular basement membrane (GBM) disease present recurrence rarely, but often exhibit rapid graft loss. On the other hand, recipient patients with C3 glomerulonephritis present recurrence in more than 50% of cases, although the disease is generally slowly progressive. It should not be forgotten that every condition that can lead to chronic graft dysfunction should be considered in the differential diagnosis of recurrence. Therefore, a complete workup of renal biopsy, including light, immunofluorescence and electron microscopy study, is essential to provide the diagnosis, excluding alternative diagnosis that may require different treatment. We will examine in detail the biomolecular mechanisms of both native and transplanted kidney diseases, monitoring the risk of recurrence and optimizing the available treatment options.
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Affiliation(s)
- Barbara Infante
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto Luigi 251, 71122 Foggia, Italy; (B.I.); (S.L.); (D.T.); (G.S.)
| | - Michele Rossini
- Clinical Pathology Unit and Center of Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto, 71122 Foggia, Italy; (M.R.); (G.S.N.); (E.R.)
| | - Serena Leo
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto Luigi 251, 71122 Foggia, Italy; (B.I.); (S.L.); (D.T.); (G.S.)
| | - Dario Troise
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto Luigi 251, 71122 Foggia, Italy; (B.I.); (S.L.); (D.T.); (G.S.)
| | - Giuseppe Stefano Netti
- Clinical Pathology Unit and Center of Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto, 71122 Foggia, Italy; (M.R.); (G.S.N.); (E.R.)
| | - Elena Ranieri
- Clinical Pathology Unit and Center of Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto, 71122 Foggia, Italy; (M.R.); (G.S.N.); (E.R.)
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, 70124 Bari, Italy;
| | - Giuseppe Castellano
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto Luigi 251, 71122 Foggia, Italy; (B.I.); (S.L.); (D.T.); (G.S.)
- Correspondence: ; Tel.: +39-0881732610; Fax: +39-0881736001
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto Luigi 251, 71122 Foggia, Italy; (B.I.); (S.L.); (D.T.); (G.S.)
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3
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Vale P, Quinino R, Costa K, Júnior T, Araújo S, Fechine L, Cunha R. Post-transplant Lupus Nephritis Recurrence: A Case Report and Review of the Literature. Transplant Proc 2019; 51:1614-1617. [PMID: 31155203 DOI: 10.1016/j.transproceed.2019.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Despite progress in treating lupus nephritis, the incidence of end-stage chronic kidney disease has increased. Renal transplantation is the treatment of choice for these patients and has been successfully performed on systemic lupus erythematosus (SLE) since 1959. The main concern in these patients is post-transplant lupus nephritis recurrence. Several questions remain for SLE patients following transplantation, including fear of lupus nephritis recurrence, choice of immunosuppressive therapy, and how to manage the disease and associated complications to reduce morbidity and risk of death.
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Affiliation(s)
- Pedro Vale
- Division of Nephrology and Kidney Transplantation, Onofre Lopes University Hospital, Natal, Rio Grande do Norte (RN), Brazil.
| | - Raquel Quinino
- Division of Nephrology and Kidney Transplantation, Onofre Lopes University Hospital, Natal, Rio Grande do Norte (RN), Brazil
| | - Kellen Costa
- Division of Nephrology and Kidney Transplantation, Onofre Lopes University Hospital, Natal, Rio Grande do Norte (RN), Brazil
| | - Tomás Júnior
- Division of Nephrology and Kidney Transplantation, Onofre Lopes University Hospital, Natal, Rio Grande do Norte (RN), Brazil
| | - Stanley Araújo
- Nephropathology Institute, Minas Gerais Federal University School of Medicine, Belo Horizonte, Minas Gerais, Brazil
| | - Laíse Fechine
- Division of Nephrology and Kidney Transplantation, Onofre Lopes University Hospital, Natal, Rio Grande do Norte (RN), Brazil
| | - Rinadja Cunha
- Division of Internal Medicine, Onofre Lopes University Hospital, Natal (RN), Brazil
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Allen PJ, Chadban SJ, Craig JC, Lim WH, Allen RDM, Clayton PA, Teixeira-Pinto A, Wong G. Recurrent glomerulonephritis after kidney transplantation: risk factors and allograft outcomes. Kidney Int 2018; 92:461-469. [PMID: 28601198 DOI: 10.1016/j.kint.2017.03.015] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 02/08/2017] [Accepted: 03/02/2017] [Indexed: 12/22/2022]
Abstract
Recurrent glomerulonephritis after kidney transplantation is a feared complication because it is unpredictable and may have a negative impact on graft outcomes. To better understand this we collected data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry accumulated over 30 years. The incidence, risk factors, and outcomes of recurrent glomerulonephritis in transplant recipients were determined using adjusted Cox proportional hazard and competing risk modeling. A total of 6,597 recipients with biopsy-proven glomerulonephritis as the primary cause of end-stage kidney disease were followed for 51,871 person-years (median duration 7.7 years). The four most common types of glomerulonephritis were IgA nephropathy in 2501 patients, focal segmental glomerulosclerosis (FSGS) in 1403, membranous in 376, and membranoproliferative (MPGN) nephropathy in 357 patients. Among these four types, recurrence was reported in 479 of 4637 patients, and of these, 212 lost their allograft due to recurrence. Older age at transplantation (adjusted hazard ratio [per year increase] 0.96 [95% confidence interval 0.95 - 0.97]) was associated with a lower risk of recurrence. Significantly, the five-year graft survival was 30% for recipients with recurrent MPGN and 57-59% for recipients with FSGS, IgA, and membranous nephropathy. Transplant recipients with recurrent disease were twice as likely to lose their allografts compared to those without recurrence (adjusted hazard ratio 2.04 [1.81-2.31]). Thus, recurrent glomerulonephritis remains a significant cause of graft loss in transplant recipients.
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Affiliation(s)
- Penelope J Allen
- Sydney School of Public Health, University of Sydney, New South Wales, Australia; Centre for Kidney Research, Kids Research Institute, The Children's Hospital at Westmead, New South Wales, Australia; ANU College of Medicine, Biology and Environment, Australian National University, Canberra, Australian Capital Territory, Australia.
| | - Steve J Chadban
- Transplantation Services, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Sydney Medical School, University of Sydney, New South Wales, Australia; Australia and New Zealand Dialysis and Transplant Registry, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, University of Sydney, New South Wales, Australia; Centre for Kidney Research, Kids Research Institute, The Children's Hospital at Westmead, New South Wales, Australia
| | - Wai H Lim
- Department of Nephrology, Sir Charles Gardiner Hospital, Perth, Western Australia, Australia
| | - Richard D M Allen
- Transplantation Services, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Sydney Medical School, University of Sydney, New South Wales, Australia; Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia
| | - Philip A Clayton
- Australia and New Zealand Dialysis and Transplant Registry, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Faculty of Health Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | | | - Germaine Wong
- Sydney School of Public Health, University of Sydney, New South Wales, Australia; Centre for Kidney Research, Kids Research Institute, The Children's Hospital at Westmead, New South Wales, Australia; Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia; Department of Renal Medicine, Westmead Hospital, New South Wales, Australia
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5
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Kennard AL, Jiang SH, Walters GD. Increased glomerulonephritis recurrence after living related donation. BMC Nephrol 2017; 18:25. [PMID: 28095803 PMCID: PMC5240239 DOI: 10.1186/s12882-016-0435-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 12/28/2016] [Indexed: 11/29/2022] Open
Abstract
Background Kidney transplantation confers superior outcomes for patients with end stage kidney disease, and live donor kidneys associate with superior outcomes compared to deceased donor kidneys. Modern immunosuppression has improved rejection rates and transplant survival and, as a result, recurrence of glomerulonephritis has emerged as a major cause of allograft loss. However, many glomerulonephritides have significant genetic risk which may manifest through kidney intrinsic or systemic mechanisms. We hypothesise that heritable kidney intrinsic predisposition to glomerulonephritis will result in increased risk of glomerulonephritis recurrence in kidneys transplanted from genetically related donors. Methods We investigated the effect of living related donation on rates of recurrence and subsequent graft outcomes in 7236 patient from 28 years of ANZDATA transplant registry data. Data were analysed in R, using Kaplan Meier Survival analysis and adjusted analyses performed using Cox Proportional Hazards methods. A competing risk model was also analysed. Results Glomerulonephritis recurrence rates were significantly higher in living related donor grafts compared to either living unrelated or deceased donor grafts (p < 0 · 001). In IgA nephropathy, transplantation from living related donor kidneys demonstrated a 10 year recurrence rate of 16 · 7% compared to 7 · 1% in living unrelated donors and 9 · 2% in deceased donors (HR:1 · 7, 95% CI:1 · 26–2 · 26, p = 0 · 0005 for living related vs deceased donors). In focal segmental glomerulosclerosis, risk of recurrence at 10 years was 14 · 6% in living related donors compared to 10 · 8% in living unrelated donors and 6 · 6% in deceased donors (HR:2 · 2, 95% CI 1 · 34–3 · 64, p = 0 · 002) for living related vs deceased donors. Primary glomerulonephritis death censored graft survival was superior for living donor grafts, related or unrelated, compared to deceased donor grafts. Conclusions We identified a significant increase in the risk of glomerulonephritis recurrence in IgA Nephropathy and Focal Segmental Glomerulosclerosis in living related donors compared to a deceased donors.
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Affiliation(s)
- A L Kennard
- Department of Renal Medicine, The Canberra Hospital, PO Box 11, Woden, ACT, 2605, Australia
| | - S H Jiang
- Department of Renal Medicine, The Canberra Hospital, PO Box 11, Woden, ACT, 2605, Australia.,Department of Immunology and Infectious Diseases, John Curtin School of Medical Research, Australian National University, Canberra, Australia
| | - G D Walters
- Department of Renal Medicine, The Canberra Hospital, PO Box 11, Woden, ACT, 2605, Australia. .,Department of Immunology and Infectious Diseases, John Curtin School of Medical Research, Australian National University, Canberra, Australia. .,Australian National University Medical School, Garran, Australia. .,ANZDATA Registry, Adelaide 5000, Australia.
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An JN, Lee JP, Oh YJ, Oh YK, Ha JW, Chae DW, Kim YS, Lim CS. Incidence of post-transplant glomerulonephritis and its impact on graft outcome. Kidney Res Clin Pract 2012; 31:219-26. [PMID: 26889425 PMCID: PMC4716107 DOI: 10.1016/j.krcp.2012.09.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 06/14/2012] [Accepted: 07/18/2012] [Indexed: 01/18/2023] Open
Abstract
Background Herein, the significance of post-transplant glomerulonephritis (PTGN) has been revisited to investigate whether PTGN induces allograft failure. The aim of this study was to identify the incidence of PTGN and its association with allograft failure, as well as to analyze the risk factors for PTGN. Methods Among the 996 Korean patients who underwent kidney transplantation in a multicenter cohort from 1995 to 2010, 764 patients were enrolled in this study. Results The incidence rate of PTGN was 9.7% and 17.0% at 5 and 10 years of follow-up, respectively. PTGN was diagnosed in 17.8% of the recipients with results of biopsy tests or clinical diagnosis identifying glomerular diseases as the underlying cause, compared with 0.0%, 4.4%, 4.9%, 5.5%, and 5.7% of the recipients with renal vascular diseases, renal interstitial diseases/pyelonephritis/uropathy, diabetic renal disease, hereditary renal diseases, and diseases with unknown etiologies, respectively. Allograft survival was significantly decreased in patients with PTGN. PTGN was associated with a fourfold increase in graft failure with a hazard ratio of 7.11 for both acute rejection and PTGN. Results of the risk factor analysis for PTGN revealed that the underlying glomerular renal diseases and treatment methods using drugs such as tacrolimus and basiliximab significantly increased PTGN development, after adjusting for other risk factors. Conclusion We conclude that PTGN is strongly associated with poor kidney allograft survival. Therefore, optimal management of recurrent or de novo GN should be the critical focus of post-transplant care.
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Affiliation(s)
- Jung Nam An
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea; Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Yun Jung Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yun Kyu Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea; Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jong-Won Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Wan Chae
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea; Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Chun Soo Lim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea; Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
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7
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Thiyagarajan UM, Bagul A, Frost J, Horsburgh T, Nicholson M. Role of Human Leukocyte Antigen, Donor-Specific Antibodies, and Their Impact in Renal Transplantation. Transplant Proc 2012; 44:1231-5. [DOI: 10.1016/j.transproceed.2011.10.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Accepted: 10/27/2011] [Indexed: 10/28/2022]
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8
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The Effect of Recurrent Glomerulonephritis and Acute Rejection Episodes in Zero Human Leukocyte Antigen-Mismatched Kidney Transplantation. Transplant Proc 2012; 44:600-6. [DOI: 10.1016/j.transproceed.2011.11.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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9
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van de Wetering J, Gerrits JH, van Besouw NM, Ijzermans JNM, Weimar W. Successful tapering of immunosuppression to low-dose monotherapy steroids after living-related human leukocyte antigen-identical renal transplantation. Transplantation 2009; 87:740-4. [PMID: 19295320 DOI: 10.1097/tp.0b013e31819634eb] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Living-related (LR) human leukocyte antigen (HLA)-identical renal transplant (RTx) recipients often receive standard immunosuppression, despite the absence of mismatched major HLA-antigens and the known complications of long-term use of immunosuppression. No data are available on the need for immunosuppression for these specific patients. We wondered whether their immunosuppressive load could be radically reduced. METHOD Between November 1982 and November 2005, 83 LR HLA-identical RTx were performed in our center. Their unadjusted graft survival was 74% at 10 years. In 29 patients (median time after transplantation 5.6 [range 1.0-21.4] years) with stable uncompromised renal function, we tapered their immunosuppression from triple or dual therapy to prednisolone 5 mg/day. Follow up on prednisolone monotherapy was at least 24 months. RESULTS In 27 of 29 patients reduction of immunosuppression to prednisolone monotherapy was uneventful. One patient, using dual therapy, developed JC-virus nephropathy resulting in graft loss. One refused further discontinuation of his medication. Four (15%) of the 27 patients on monotherapy developed biopsy-proven recurrence of their original disease. Only one of them showed a transient decline in renal function. One additional patient developed minor proteinuria and a rise in serum creatinine level, as a result of chronic urinary tract infections. The remaining 23 of 27 patients (85%) had an uneventful follow up during 24 months prednisolone monotherapy. CONCLUSION We conclude that HLA-identical LR RTx recipients who are at least 1 year after transplantation might be treated with low-dose steroid monotherapy. Close surveillance of patients for recurrence of their original disease is recommended to allow for potential early therapeutic intervention.
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Affiliation(s)
- Jacqueline van de Wetering
- Department of Internal Medicine and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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Chailimpamontree W, Dmitrienko S, Li G, Balshaw R, Magil A, Shapiro RJ, Landsberg D, Gill J, Keown PA. Probability, predictors, and prognosis of posttransplantation glomerulonephritis. J Am Soc Nephrol 2009; 20:843-51. [PMID: 19193778 DOI: 10.1681/asn.2008050454] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Glomerulonephritis (GN) is the leading cause of chronic kidney disease among recipients of renal transplants. Because modern immunosuppressive regimens have reduced the incidence of rejection-related graft loss, the probability and clinical significance of posttransplantation GN (PTGN) requires reevaluation. In this Canadian epidemiologic study, we monitored 2026 sequential renal transplant recipients whose original renal disease resulted from biopsy-proven GN (36%), from presumed GN (7.8%), or from disorders other than GN (56%) for 15 yr without loss to follow-up. Kaplan-Meier estimates of PTGN in the whole population were 5.5% at 5 yr, 10.1% at 10 yr, and 15.7% at 15 yr. PTGN was diagnosed in 24.3% of patients whose original renal disease resulted from biopsy-proven GN, compared with 11.8% of those with presumed GN and 10.5% of those with disorders other than GN. Biopsy-proven GN in the native kidney, male gender, younger age, and nonwhite ethnicity predicted PTGN. Current immunosuppressive regimens did not associate with a reduced frequency of PTGN. Patients who developed PTGN had significantly reduced graft survival (10.2 versus 69.7%; P < 0.0001). In summary, in the Canadian population, PTGN is a common and serious complication that causes accelerated graft failure, despite the use of modern immunosuppressive regimens.
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Affiliation(s)
- Worawon Chailimpamontree
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Abstract
We describe the case of a 24-year-old female with end-stage renal disease from focal segmental glomerulosclerosis (FSGS) diagnosed at age 16, who underwent monozygotic triplet transplantation at age 21 from her sister. Monozygosity was established by buccal smear DNA PCR amplification using short tandem repeat (1) profiling for 16 genetic alleles. All immunosuppression was discontinued by 1 month posttransplant. To evaluate the use of immunosuppression in HLA identical monozygotic transplantation, we interrogated the OPTN (Organ Procurement Transplant Network) database for all transplants conducted from 1987 to 2006. We identified 194 probable identical twin transplantations based on age, gender, race, ethnic category, blood type and HLA match. We evaluated the use of various immunosuppressive agents at discharge, 6 months and 1, 2 and 3 years after transplantation. Seventy-one percent of these patients at discharge and 34% at the end of 1 year were on immunosuppression. At discharge 61% received steroids and 30% received calcineurin inhibitors and 66% of these remained on calcineurin inhibitors at 1 year. Renal function was superior among those not maintained on immunosuppression. Thus, monozygotic transplantation confers an immunologic advantage that allows immunosuppression elimination despite a risk of recurrent glomerular disease such as FSGS with appropriate evaluation and management.
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Affiliation(s)
- Krishnan N
- University of Massachusetts, Worcester, MA
| | - Buchanan PM
- Center for Outcomes Research, Saint Louis University; Renal Division
| | - Dzebisashvili N
- Center for Outcomes Research, Saint Louis University; Renal Division
| | - Xiao H
- Center for Outcomes Research, Saint Louis University; Renal Division
| | - Schnitzler MA
- Center for Outcomes Research, Saint Louis University; Renal Division
| | - Brennan DC
- Washington University School of Medicine
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12
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Requião-Moura LR, Moscoso-Solorzano GT, Franco MF, Ozaki KS, Pacheco-Silva A, Kirsztajn GM, Câmara NOS. Prognostic factors associated with poor graft outcomes in renal recipients with post-transplant glomerulonephritis. Clin Transplant 2007; 21:363-70. [PMID: 17488386 DOI: 10.1111/j.1399-0012.2007.00650.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Little data are available concerning post-transplantation glomerulonephritis (PTx-GN) and its prognostic factors associated with graft outcomes. METHODS We retrospectively evaluated patients with de novo and recurrent PTx-GN to identify the factors associated with their negative impact on graft and patient outcomes. PTx-GN was diagnosed in 55 patients, wherein 17 (31%) had recurrent glomerulonephritis (GN) and 16 (29%) had de novo. RESULTS Our enrolled population consisted of 34 +/- 13.7-yr-old male patients (72%), on hemodialysis for a median of 18 months (0-204) and mainly grafted from living donors (76%). The median onset time of proteinuria and hematuria was 50 d (10-2160) and 30 d (4-1170), respectively. One-yr graft survival rates after PTx-GN diagnosis was 64%. The most frequent de novo GN was membranous GN (26%), while focal segmental glomerulosclerosis was the most frequent recurrent GN (41%), with a very early onset (median of three months). One-yr graft survival was better in the recurrent disease than in the de novo patients, 76% vs. 55% (p = 0.24). The best predictor factors that correlated with graft survival were: proteinuria <3.5 g [relative risk (RR) = 0.24, p = 0.017], serum creatinine below 2.0 mg/dL (RR = 0.06, p = 0.016) at the time of biopsy and the use of angiotensin-converting enzyme inhibitors (ACEI) (RR = 0.12, p = 0.005). The use of ACEI markedly improved one-yr graft survival rates (92% vs. 47%, p < 0.001). CONCLUSION PTx-GN has a strong negative impact on kidney graft survival. De novo GN appears to have a poorer prognosis than the recurrent type. Patients who used ACEI showed a better survival rate in the follow-up.
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Affiliation(s)
- Lúcio R Requião-Moura
- Laboratory of Clinical and Experimental Immunology, Nephrology Division, Universidade Federal de São Paulo, UNIFESP, São Paulo, Brazil
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13
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Requião-Moura LR, Mastroianni-Kirsztajn G, Moscoso-Solorzano GT, Franco MF, Ozaki KS, Pacheco-Silva A, Câmara NOS. Impact of Therapeutic Changes on Renal Graft Survival With Posttransplant Glomerulonephritis. Transplant Proc 2007; 39:453-6. [PMID: 17362757 DOI: 10.1016/j.transproceed.2007.01.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Posttransplant glomerulonephritis (GN) is the third cause of graft loss after 1 year of transplant follow-up; few approaches have been efficient in reversing this outcome. The aim of this study was to evaluate whether the modification of the immunosuppressive therapy for treating posttransplant GN had an impact on allograft survival. PATIENTS AND METHODS Forty-nine patients who underwent renal transplantation and developed posttransplant GN were divided into two groups: group 1, 22 patients with modified immunosuppressive treatment (72.3%, pulse of methylprednisolone; 13.6%, high-dose oral corticosteroid), and group 2, where it was maintained. Additionally, the impact of the concomitant use of drugs that promote the renin-angiotensin-aldosterone system blockade (RAASB) was analyzed in terms of graft survival. RESULTS We established the diagnosis of GN at 17.9 months (range, 0.57 to 153.4) after transplantation, when serum creatinine (Cr) was 2.2 mg/dL (range, 0.8 to 12.5) and proteinuria 3.2 g/L (range, 0.2 to 24.2). Graft survivals at 1 and 3 years after diagnosis were 69.2% and 52.9%, respectively. The patients of group 1 showed a lower prevalence of graft loss (27.2% versus 48.1%, P = .40) and better survival at the end of 1 year (73.2% versus 60.4%) and 3 years (62.5% versus 38.0%, P = .26), but the differences were not significant. RAASB showed a positive impact on survival at the end of 3 years in both groups: for group 1, 83.8% with RAASB, 41.4% without RAASB; and for group 2, 75% with RAASB and 14.8% without RAASB (P < .001). CONCLUSION Although treatment of posttransplant GN with modification of immunosuppression seemed to improve graft survival in the first 3 years after diagnosis, RAASB improved this effect.
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Affiliation(s)
- L R Requião-Moura
- Laboratory of Clinical and Experimental Immunology, Universidade Federal de São Paulo, UNIFESP, São Paulo, Brazil
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14
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Shimmura H, Tanabe K, Ishida H, Miyamoto N, Tokumoto T, Ishikawa N, Toma H. Long-term results of living kidney transplantation from HLA-identical sibling donors under calcineurin inhibitor immunosuppression. Int J Urol 2006; 13:502-8. [PMID: 16771716 DOI: 10.1111/j.1442-2042.2006.01350.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Recently, it has been revealed that alloantigen-independent causes are important factors for late graft loss in kidney transplantation. We compared the results of living kidney transplantation from HLA-identical siblings with those from HLA-non-identical siblings to analyse the impact of alloantigen-independent factors on long-term graft survival. METHODS Two hundred and sixty-six recipients who were grafted from their siblings between 1983 and 2002 were subdivided into those transplanted from HLA-identical donors (n=86) and those from HLA-non-identical donors (n=180). RESULTS The incidence of acute rejection was significantly lower in the HLA-identical group than in the HLA-non-identical group (9.3% vs 53.9%, respectively; P<0.0001). Graft survival was significantly higher in the HLA-identical group than in the HLA-non-identical group (91.3% vs 79.2% at 5 years, 80.3% vs 66.8% at 10 years and 59.1% vs 51.7% at 15 years, respectively; P=0.0372). Although acute rejection was not seen as a cause of graft loss in the HLA-identical group, death with functioning graft, recurrence of the original disease or chronic allograft nephropathy were observed as the major causes of graft loss in the late period of the HLA-identical group. CONCLUSION We concluded that alloantigen-independent causes constitute a crucial factor for graft loss in the late period of HLA-identical kidney transplantation.
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Affiliation(s)
- Hiroaki Shimmura
- Department of Urology, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan.
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15
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Takemoto S, Port FK, Claas FHJ, Duquesnoy RJ. HLA matching for kidney transplantation. Hum Immunol 2005; 65:1489-505. [PMID: 15603878 DOI: 10.1016/j.humimm.2004.06.008] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2004] [Accepted: 06/17/2004] [Indexed: 12/24/2022]
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Ozdemir BH, Ozdemir FN, Demirhan B, Turan M, Haberal M. Renal transplantation in amyloidosis: effects of HLA matching and donor type on recurrence of primary disease. Transpl Int 2004; 17:241-6. [PMID: 15175852 DOI: 10.1111/j.1432-2277.2004.tb00437.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2003] [Revised: 09/30/2003] [Accepted: 03/11/2004] [Indexed: 11/28/2022]
Abstract
The aim of this study is to evaluate the effect of HLA-matching and donor type on recurrence of amyloidosis after renal transplantation. The study includes 30 patients with systemic amyloidosis who received kidney transplants between 1985 and 2001. Donor source and HLA tissue typing of the donor and recipient were evaluated in each case. Of the 30 patients, 20 developed a recurrence of amyloidosis in their allografts, as confirmed by biopsy. The time from transplantation to diagnosis of amyloidosis in the graft ranged from 18 months to 10 years. Of the 20 patients with recurrence, 18 had received their grafts from living related donors (LRDs), and 2 had received their grafts from cadaveric donors (P < 0.01). There was a strong correlation between amyloidosis recurrence and degree of HLA-DR matching (P < 0.05). Furthermore, in the recipients of LRD grafts, the risk of amyloidosis recurrence was much higher if the donor-recipient pair were HLA-identical than if they were not perfectly matched (P < 0.01). The incidence of amyloidosis recurrence in our patients was significantly higher than the rates reported for other series. Most of the cases in previous reports involved cadaveric grafts. The higher rate of amyloidosis recurrence in our patients may be explained by the high proportion of LRD grafts and by genetic susceptibility.
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Floege J. Recurrent glomerulonephritis following renal transplantation: an update. Nephrol Dial Transplant 2003; 18:1260-5. [PMID: 12808159 DOI: 10.1093/ndt/gfg102] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jürgen Floege
- Division of Nephrology and Immunology, University of Aachen, Germany.
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18
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Baltzan MA, Shoker AS, Baltzan MA. Relative contribution of HLA disparity to chronic allograft nephropathy. Transplant Proc 2002; 34:3125-7. [PMID: 12493395 DOI: 10.1016/s0041-1345(02)03693-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- M A Baltzan
- Department of Medicine Saskatoon District Health, Saskatoon, Canada.
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Abstract
In transplantation the risk of acute rejection decreases with recipient age. This is clearly illustrated in transplantation of a non-vascularised tissue, such as the cornea. In vascularised transplants, such as kidneys, acute rejection decreases with recipient age, but the phenomenon is obscured by the fact that chronic allograft nephropathy increases with age, and is further confounded by increased death from infectious disease and drug-related causes. The underlying cellular mechanisms responsible for this weakening of rejection are discussed, as is defective signal transduction leading to decreased activation of cells and decreased resistance to immunosuppressive drugs. This supports a view that less intensive immunosuppressive drug therapy is desirable in elderly recipients. Although pharmacokinetic studies are documented, there are no routine assays to measure efficacy of these drugs in individual patients. In summary, the decline in acute rejection with increasing recipient age may be due both to immunosenescence and decreased resistance to immunosuppressive drugs. Future assays to test these mechanisms could be used to tailor therapy to individual needs.
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Affiliation(s)
- Benjamin A Bradley
- University of Bristol Department of Transplantation Sciences, Paul O'Gorman Lifeline Centre, Southmead Hospital, UK.
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20
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Ponticelli C, Traversi L, Feliciani A, Cesana BM, Banfi G, Tarantino A. Kidney transplantation in patients with IgA mesangial glomerulonephritis. Kidney Int 2001; 60:1948-54. [PMID: 11703614 DOI: 10.1046/j.1523-1755.2001.00006.x] [Citation(s) in RCA: 125] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Strategies for treating IgA glomerulonephritis (IgAGN) are controversial, particularly with regards to the long-term results of kidney transplantation, including the risk of recurrence of IgAGN post-transplant and the impact of this recurrence on graft survival. METHODS The outcomes of 106 adults transplanted because of a biopsy-proven IgAGN and of 212 patients without IgAGN transplanted during the same period were analyzed. To evaluate the risk of recurrence, patients with hematuria, proteinuria, or an increase in plasma creatinine were submitted to allograft biopsy. Factors influencing recurrence and the impact of recurrence on graft survival were analyzed. RESULTS The ten-year patient (0.93 vs. 0.92) and graft survival (0.75 vs. 0.82) probabilities were not significantly different between IgAGN patients and controls. Only plasma creatinine and proteinuria at six months were associated with an increased relative risk (RR) of graft failure (RR 2.79 and 5.94, respectively). Histological recurrence of IgA glomerulonephritis was diagnosed in 37 patients. Younger age (RR 2.63), increased plasma creatinine (RR 2.39), and proteinuria (RR 6.02) at six months were associated with the risk of recurrence. If proteinuria and plasma creatinine at six months were considered in the Cox model, IgA recurrence per se was not associated with an increased risk of graft failure (P = 0.181). The main causes of graft failure were glomerulonephritis in patients with recurrence of IgAGN and chronic rejection in patients without recurrence. CONCLUSIONS The ten-year graft survival rate was similar in patients with IgAGN or other renal diseases. At least 35% IgAGN patients had biopsy-proven recurrence, and younger patients were more prone to the risk of recurrence. Recurrence did not affect the ten-year graft survival.
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Affiliation(s)
- C Ponticelli
- Department of Nephro-Urology and Kidney Transplantation, IRCCS Ospedale Maggiore, Via Della Commenda 15, 20122 Milan, Italy.
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Nankivell BJ, Fenton-Lee CA, Kuypers DR, Cheung E, Allen RD, O'Connell PJ, Chapman JR. Effect of histological damage on long-term kidney transplant outcome. Transplantation 2001; 71:515-23. [PMID: 11258430 DOI: 10.1097/00007890-200102270-00006] [Citation(s) in RCA: 206] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Chronic renal allograft failure remains a major challenge to overcome. Factors such as donor quality, delayed graft function (DGF), acute rejection, and immunosuppression are known to affect long-term outcome, but their relationship to histological damage to graft outcome is unclear. METHODS Protocol kidney biopsies (n=112) obtained at 3 months after transplantation yielded 102 with adequate tissue. Histology was scored by the Banff schema, and compared with implantation biopsies (n=91), repeat 12-month histology (n=39), decline in serum creatinine and serial isotopic glomerular filtration rate, onset of chronic allograft nephropathy (CAN), and actuarial graft survival censored for death with a functioning graft. RESULTS At a median follow-up of 9.3 years, 20 patients had graft failure and 26 died with a functioning graft. Banff chronic nephropathy was present in 24% of 3-month biopsies, and was predicted by microvascular disease in the donor, cold ischemia, DGF, and acute vascular rejection (P<0.001). Acute glomerulitis at 3 months correlated with segmental glomerulosclerosis at 12 months, subsequent recurrent glomerulonephritis, and graft failure (P<0.01). Subclinical rejection at 3 months occurred in 29% of biopsies, correlated with prior acute rejection and HLA mismatch, and led to chronic histological damage by 12 months (r=0.25-0.67, P<0.05-0.001). Subclinical rejection, arteriolar hyalinosis, and tubulitis present at 3 months had resolved by 12 months. The 10-year survival rates for Banff chronic nephropathy were 90.4% for grade 0, 81.0% grade 1, and 57.9% for grades 2 or greater (P<0.01). Early tubulointerstitial damage at 3 months profoundly influenced graft survival beyond 10 years. CAN was predicted by kidney ischemia, 3-month chronic intimal vascular thickening, tubular injury, proteinuria, and late rejection. Chronic fibrointimal thickening of the small arteries and chronic interstitial fibrosis at 3 months independently predicted graft loss and decline in renal function (P<0.05-0.001). CONCLUSIONS Early transplant damage occurs in the tubulointerstitial compartment from preexisting donor kidney injury and discrete events such as vascular rejection and DGF. Subsequent chronic damage and graft failure reflect accumulated previous injury and chronic interstitial fibrosis, vascular impairment, subclinical rejection, and injury from late rejection. CAN may be conceptualized as the sequelae of incremental and cumulative damage to the transplanted kidney. The duration of graft survival is dependent and predicted by the quality of the transplanted donor kidney combined with the intensity, frequency, and irreversibility of these damaging insults.
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Affiliation(s)
- B J Nankivell
- Department of Renal Medicine, University of Sydney, Westmead Hospital, New South Wales, Australia
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