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Wu Q, Ni X, Chen J, Cheng D, Zhang M, Xie K, Li X, Wen J. Similar incidence of graft glomerulonephritis in recipients with definitively diagnosed glomerulonephritis and those with unknown etiology: a retrospective observational study. Ren Fail 2024; 46:2325644. [PMID: 38445391 PMCID: PMC10919306 DOI: 10.1080/0886022x.2024.2325644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/26/2024] [Indexed: 03/07/2024] Open
Abstract
OBJECTIVE In China, most of the patients who underwent kidney transplants have unknown causes of end-stage renal disease (uESRD). However, little is known regarding the incidence of graft glomerulonephritis (GN) and graft survival in kidney transplant recipients (KTRs) with uESRD. METHODS In this retrospective cohort study, 473 of the 565 KTRs who underwent kidney transplantation (KTx) from 2015 to 2020 were included. We mainly observed the occurrence of graft GN between uESRD group and definitively diagnosed GN group, and repeatedly compared after propensity score matching (PSM). RESULTS The median follow-up was 50 months in 473 KTRs, and about 75% of KTRs of native kidney disease of unknown etiology. The total cumulative incidence of graft GN was 17%, and no difference was observed between the definitively diagnosed GN group and the uESRD group (p = 0.76). Further, PSM analysis also showed no difference in the incidence of graft GN between the 2 groups. Multivariable analysis disclosed males (p = 0.001), younger age (p = 0.03), and anti-endothelial cell anti-body (AECA) positive pre-KTx (p = 0.001) were independent risk factors for graft GN. CONCLUSIONS The incidence of graft GN was similar between uESRD and definitively diagnosed GN group. The allograft survival was also similar between two groups.
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Affiliation(s)
- Qianqian Wu
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China
| | - Xuefeng Ni
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China
| | - Jingsong Chen
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China
| | - Dongrui Cheng
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China
| | - Mingchao Zhang
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China
| | - Kenan Xie
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China
| | - Xue Li
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China
| | - Jiqiu Wen
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China
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2
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Dessaix K, Bontoux C, Aubert O, Grünenwald A, Sberro Soussan R, Zuber J, Duong Van Huyen JP, Anglicheau D, Legendre C, Fremeaux Bacchi V, Rabant M. De novo thrombotic microangiopathy after kidney transplantation in adults: Interplay between complement genetics and multiple endothelial injury. Am J Transplant 2024; 24:1205-1217. [PMID: 38320731 DOI: 10.1016/j.ajt.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 01/26/2024] [Accepted: 01/30/2024] [Indexed: 02/24/2024]
Abstract
De novo thrombotic microangiopathy (dnTMA), after renal transplantation may significantly alter graft outcomes. However, its pathogenesis and the role of complement alternative pathway dysregulation remain elusive. We studied all consecutive adult patients with a kidney allograft biopsy performed between January 2004 and March 2016 displaying dnTMA. Ninety-two patients were included. The median time of occurrence was 166 (IQR 25-811) days. The majority (82.6 %) had TMA localized only in the graft. Calcineurin inhibitor toxicity and antibody-mediated rejection (ABMR) were the 2 most frequent causes (54.3% and 37.0%, respectively). However, etiological factors were multiple in 37% patients. Interestingly, pathogenic variants in the genes of complement alternative pathway were significantly more frequent in the 42 tested patients than in healthy controls (16.7% vs 3.7% respectively, P < .008). The overall graft survival after biopsy was 66.0% at 5 years and 23.4% at 10 years, significantly worse than a matched cohort without TMA. Moreover, graft survival of patients with TMA and ABMR was worse than a matched cohort with ABMR without TMA. The 2 main prognostic factors were a positive C4d staining and a lower estimated glomerular filtration rate at diagnosis. DnTMA is a severe and multifactorial disease, induced by 1 or several endothelium-insulting conditions, mostly calcineurin inhibitor toxicity and ABMR.
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Affiliation(s)
- Kathleen Dessaix
- Service des Maladies du Rein et du Métabolisme, Transplantation et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France
| | - Christophe Bontoux
- Laboratoire d'Anatomie et Cytologie Pathologiques, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France; Laboratory of Clinical and Experimental Pathology, Hospital-Integrated Biobank (BB-0033-00025), Team 4, Institute of Research on Cancer and Aging of Nice, InsermU1081, CNRS UMR7284, FHU OncoAge, Institut Hospitalo-Universitaire RespirERA, Université Côte d'Azur, Hôpital Pasteur, CHU de Nice, CEDEX 1, Nice, France
| | - Olivier Aubert
- Service des Maladies du Rein et du Métabolisme, Transplantation et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France; INSERM, PARCC, Paris Translational Reseach for Organ Transplantation, Université Paris Cité, Paris, France
| | - Anne Grünenwald
- INSERM, UMRS 1138, Inflammation, Complement and Cancer Team, Centre de recherche des Cordeliers, Sorbonne Universités, Université Paris Cité, Paris, France
| | - Rebecca Sberro Soussan
- Service des Maladies du Rein et du Métabolisme, Transplantation et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France
| | - Julien Zuber
- Service des Maladies du Rein et du Métabolisme, Transplantation et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France
| | - Jean-Paul Duong Van Huyen
- Laboratoire d'Anatomie et Cytologie Pathologiques, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France; INSERM, PARCC, Paris Translational Reseach for Organ Transplantation, Université Paris Cité, Paris, France
| | - Dany Anglicheau
- Service des Maladies du Rein et du Métabolisme, Transplantation et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France; Necker-Enfants Malades Institute, INSERM U1151, Université de Paris Cité, Paris, France
| | - Christophe Legendre
- Service des Maladies du Rein et du Métabolisme, Transplantation et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France
| | - Veronique Fremeaux Bacchi
- INSERM, UMRS 1138, Inflammation, Complement and Cancer Team, Centre de recherche des Cordeliers, Sorbonne Universités, Université Paris Cité, Paris, France; Service d'Immunologie, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Université Paris Cité, Paris, France
| | - Marion Rabant
- Laboratoire d'Anatomie et Cytologie Pathologiques, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France; Necker-Enfants Malades Institute, INSERM U1151, Université de Paris Cité, Paris, France.
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3
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Matarneh AS, Salameh O, Sardar S, Karasinski A, Channapragada T, Abdulbasit M, Washburn E, Ghahramani N. A rare case of non-lupus full house nephropathy in a transplanted kidney, case report. Clin Case Rep 2024; 12:e8886. [PMID: 38707603 PMCID: PMC11066189 DOI: 10.1002/ccr3.8886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/22/2024] [Accepted: 03/27/2024] [Indexed: 05/07/2024] Open
Abstract
Key Clinical Message Non-lupus full house nephropathy is a rare entity that is still poorly understood. It can complicate post-transplant kidneys and result in a de novo process. Treatment is difficult but can be possibly achieved with optimization of immune suppression. Abstract Non-lupus full house nephropathy is a rare entity with an unclear incidence. It describes the kidney biopsy findings of positive deposits for IgG, IgA, IgM, C3, and C1q on immunofluorescence in the absence of the classical diagnostic features of systemic lupus nephritis. This disease entity is becoming more recognized but further studies are still needed to evaluate the incidence, etiologies, and management of this condition. Transplant glomerulopathy is a major cause for renal graft loss. It can present with a wide variety of manifestations; it can cause AKI, CKD, or glomerular inflammations through an immune complex or autoimmune-mediated damage.
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Affiliation(s)
- Ahmad Samir Matarneh
- Department of NephrologyPenn State Milton S Hershey Medical CenterHersheyPennsylvaniaUSA
| | - Omar Salameh
- Department of Internal MedicinePenn State Milton S Hershey Medical CenterHersheyPennsylvaniaUSA
| | - Sundus Sardar
- Department of NephrologyPenn State Milton S Hershey Medical CenterHersheyPennsylvaniaUSA
| | - Amanda Karasinski
- Department of NephrologyPenn State Milton S Hershey Medical CenterHersheyPennsylvaniaUSA
| | - Theja Channapragada
- Department of Internal MedicinePenn State Milton S Hershey Medical CenterHersheyPennsylvaniaUSA
| | - Muhammad Abdulbasit
- Department of NephrologyPenn State Milton S Hershey Medical CenterHersheyPennsylvaniaUSA
| | - Erik Washburn
- Department of PathologyPenn State Milton S Hershey Medical CenterHersheyPennsylvaniaUSA
| | - Nasrollah Ghahramani
- Department of NephrologyPenn State Milton S Hershey Medical CenterHersheyPennsylvaniaUSA
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4
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Panagakis A, Bellos I, Grigorakos K, Panagoutsos S, Passadakis P, Marinaki S. Recurrence of Idiopathic Membranous Nephropathy in the Kidney Allograft: A Systematic Review. Biomedicines 2024; 12:739. [PMID: 38672095 PMCID: PMC11048506 DOI: 10.3390/biomedicines12040739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/10/2024] [Accepted: 03/12/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION The recurrence of idiopathic membranous nephropathy (iMN) after kidney transplantation is common, although its exact clinical significance remains unclear. This systematic review aims to elucidate the effects of iMN recurrence on graft survival. MATERIALS AND METHODS A literature search was performed by systematically searching Medline, Scopus, Web of Science, and Google Scholar from inception. Cohort studies examining iMN recurrence after kidney transplantation were deemed eligible. Meta-analysis was performed by fitting random-effects models. RESULTS Twelve (12) articles published from 1995 to 2016 reporting on 139 transplant patients with recurrent iMN were included. The median time of the diagnosis of recurrent iMN was 18 months during follow-up from 35 to 120 months. Risk factors for iMN recurrence in the renal allograft are a positive serum test for anti-PLA2R antibodies pretransplant, female sex, younger age, high proteinuria pretransplant, the longest interval from initial disease to end-stage chronic kidney disease, and the combination of alleles HLA DQA1 05:01 and HLA DQB1 02:01. In the pretransplant period, 37 (26.61%) patients had a positive serum test and 18 (12.94%) patients had a positive biopsy stain for anti-PLA2R antibodies. The sensitivity of the pretransplant positive serum test for these antibodies ranges from 57% to 85.30% and the specificity is 85.10-100%. A total of 81.80% of patients who received rituximab as treatment for iMN recurrence achieved complete and partial remission, while 18.20% had no response to treatment. iMN recurrence was not associated with significantly different rates of graft loss (odds ratio = 1.03, 95% CI: 0.52-2.04, p = 0.524, I2 = 0.00%). Recurrence of iMN was not associated with increased risk of graft loss independently of whether patients were treated with rituximab (OR: 0.98, 95% CI: 0.39-2.50, I2: 0%) or not (OR: 1.22, 95% CI: 0.58-2.59, I2: 3.8%). Patients with iMN recurrence who achieved remission had significantly reduced risk of graft loss (OR: 0.14, 95% CI: 0.03 to 0.73). CONCLUSION The main outcome from this systematic review is that there is no statistically significant difference in graft survival in patients with iMN recurrence compared to those without recurrence in long-term follow-up. The achievement of remission is associated with significantly reduced risk of graft loss.
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Affiliation(s)
- Anastasios Panagakis
- Renal Transplantation Unit, Nephrology Department, Medical School, National and Kapodistrian University of Athens, Laiko Hospital Athens, 11527 Athens, Greece; (I.B.); (S.M.)
| | - Ioannis Bellos
- Renal Transplantation Unit, Nephrology Department, Medical School, National and Kapodistrian University of Athens, Laiko Hospital Athens, 11527 Athens, Greece; (I.B.); (S.M.)
| | | | - Stylianos Panagoutsos
- Department of Nephrology, Medical School, Democritus University of Thrace, Dragana Campus, 68100 Alexandroupolis, Greece; (S.P.); (P.P.)
| | - Ploumis Passadakis
- Department of Nephrology, Medical School, Democritus University of Thrace, Dragana Campus, 68100 Alexandroupolis, Greece; (S.P.); (P.P.)
| | - Smaragdi Marinaki
- Renal Transplantation Unit, Nephrology Department, Medical School, National and Kapodistrian University of Athens, Laiko Hospital Athens, 11527 Athens, Greece; (I.B.); (S.M.)
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5
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Bose B, Milanzi E, Pascoe EM, Johnson DW, Badve SV. The outcomes of patients with kidney failure due to focal segmental glomerulosclerosis (FSGS) in Australia and New Zealand: A cohort study using the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA). PLoS One 2023; 18:e0293721. [PMID: 37917639 PMCID: PMC10621846 DOI: 10.1371/journal.pone.0293721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 10/16/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND The outcomes of patients with focal segmental glomerulosclerosis (FSGS) on kidney replacement therapy (KRT) have not been well described. This study evaluated the outcomes of patients with kidney failure due to FSGS on KRT including dialysis and kidney transplantation. METHOD AND MATERIALS All adult patients with kidney failure who commenced KRT in Australia and New Zealand from 15th of May 1963 to 31st of December 2018 were retrospectively extracted from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. Outcomes of patients with FSGS were compared to those with other causes of kidney failure (non-FSGS). RESULTS 85,052 patients commenced KRT during the study period, of whom 2991 (3.5%) were patients with FSGS. Compared to patients with non-FSGS, patients with FSGS experienced similar mortality on dialysis (adjusted hazard ratio [aHR] 0.98, 95% CI 0.90-1.06, p = 0.55) and following kidney transplantation (aHR 0.92, 95% CI 0.73-1.15, p = 0.47). The risk of first kidney allograft loss was higher in patients with FSGS (aHR 1.20, 95% CI 1.04-1.37, p = 0.01). However, when death was analysed as a competing risk, the survival in both groups was similar (sub-hazard ratio [SHR] 1.09, 95% CI 0.94-1.28, p = 0.26). Patients with FSGS had a longer waiting time for kidney transplantation (aHR 0.92, 95% CI 0.86-0.98, p = 0.02) and experienced an increased risk of disease recurrence in the allograft (aHR 1.73, 95% CI 1.35-2.21, p<0.001). Compared to patients with other forms of glomerular disease, patients with FSGS experienced similar dialysis and transplant patient survival and death-censored rate of kidney transplantation and allograft loss but higher rates of primary kidney disease recurrence. CONCLUSION FSGS was associated with similar dialysis and transplant patient survival and death-censored first allograft loss compared to non-FSGS and other forms of glomerular disease.
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Affiliation(s)
- Bhadran Bose
- Australasian Kidney Trials Network, The University of Queensland, Queensland, Australia
- Department of Nephrology, Nepean Hospital, Kingswood, Australia
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, Adelaide, Australia
| | - Elasma Milanzi
- Australasian Kidney Trials Network, The University of Queensland, Queensland, Australia
| | - Elaine M. Pascoe
- Australasian Kidney Trials Network, The University of Queensland, Queensland, Australia
- Centre for Kidney Disease Research, The University of Queensland, Queensland, Australia
| | - David W. Johnson
- Australasian Kidney Trials Network, The University of Queensland, Queensland, Australia
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, Adelaide, Australia
- Centre for Kidney Disease Research, The University of Queensland, Queensland, Australia
- Division of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Sunil V. Badve
- Australasian Kidney Trials Network, The University of Queensland, Queensland, Australia
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, Adelaide, Australia
- Department of Nephrology, St George Hospital, Sydney, Australia
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6
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Carvajal Abreu K, Loos S, Fischer L, Pape L, Wiech T, Kemper MJ, Tönshoff B, Oh J, Schild R. Case report: Early onset de novo FSGS in a child after kidney transplantation-a successful treatment. Front Pediatr 2023; 11:1280521. [PMID: 37830056 PMCID: PMC10566293 DOI: 10.3389/fped.2023.1280521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 09/14/2023] [Indexed: 10/14/2023] Open
Abstract
Background Early onset de novo focal segmental glomerular sclerosis (FSGS) in the kidney allograft in patients without FSGS in the native kidney is a rare disorder in children. It usually occurs mostly beyond the first year after kidney transplantation and often leads to graft loss. Standardized treatment protocols have not yet been established. Case description We describe a boy with early onset de novo FSGS in the transplanted kidney and non-selective glomerular proteinuria (maximum albumin-to-creatinine ratio of 3.8 g/g; normal range, ≤0.03 g/g creatinine). Manifestation occurred at 30 days posttransplant and was accompanied by a significant graft dysfunction (eGFR 61 ml/min per 1.73 m2). Treatment with 25 sessions of plasmapheresis over 14 weeks and three consecutive days of methylprednisolone pulse therapy (10 mg/kg per day) followed by oral prednisolone as rejection prophylaxis (3.73 mg/m2 per day) led to sustained remission of proteinuria (albumin-to-creatinine ratio of 0.028 g/g) and normalization of graft function (eGFR 92 ml/min per 1.73 m2) after 14 weeks. The follow-up period was 36 months. Conclusions This case underlines the efficacy of immunosuppressive and antibody eliminating therapy in early onset de novo FSGS after kidney transplantation.
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Affiliation(s)
- Karla Carvajal Abreu
- Department of Pediatric Nephrology, Pediatric Hepatology and Pediatric Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sebastian Loos
- Department of Pediatric Nephrology, Pediatric Hepatology and Pediatric Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lutz Fischer
- Department of Hepatobiliary Surgery and Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lars Pape
- Department of Pediatrics II, University Hospital of Essen, University of Essen-Duisburg, Essen, Germany
| | - Thorsten Wiech
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Markus J. Kemper
- Department of Pediatrics, Asklepios Klinik Nord-Heidberg, Hamburg, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Jun Oh
- Department of Pediatric Nephrology, Pediatric Hepatology and Pediatric Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Raphael Schild
- Department of Pediatric Nephrology, Pediatric Hepatology and Pediatric Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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7
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Sageshima J, Chandar J, Chen LJ, Shah R, Al Nuss A, Vincenzi P, Morsi M, Figueiro J, Vianna R, Ciancio G, Burke GW. How to Deal With Kidney Retransplantation-Second, Third, Fourth, and Beyond. Transplantation 2022; 106:709-721. [PMID: 34310100 DOI: 10.1097/tp.0000000000003888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Kidney transplantation is the best health option for patients with end-stage kidney disease. Ideally, a kidney transplant would last for the lifetime of each recipient. However, depending on the age of the recipient and details of the kidney transplant, there may be a need for a second, third, fourth, or even more kidney transplants. In this overview, the outcome of multiple kidney transplants for an individual is presented. Key issues include surgical approach and immunologic concerns. Included in the surgical approach is an analysis of transplant nephrectomy, with indications, timing, and immunologic impact. Allograft thrombosis, whether related to donor or recipient factors merits investigation to prevent it from happening again. Other posttransplant events such as rejection, viral illness (polyomavirus hominis type I), recurrent disease (focal segmental glomerulosclerosis), and posttransplant lymphoproliferative disease may lead to the need for retransplantation. The pediatric recipient is especially likely to need a subsequent kidney transplant. Finally, noncompliance/nonadherence can affect both adults and children. Innovative approaches may reduce the need for retransplantation in the future.
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Affiliation(s)
- Junichiro Sageshima
- Division of Transplant Surgery, Department of Surgery, University of California Davis School of Medicine, Sacramento, CA
| | - Jayanthi Chandar
- Division of Pediatric Kidney Transplantation, Department of Pediatrics, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Linda J Chen
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Rushi Shah
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Ammar Al Nuss
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Paolo Vincenzi
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Mahmoud Morsi
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Jose Figueiro
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Rodrigo Vianna
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
- Division of Liver and GI Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Gaetano Ciancio
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - George W Burke
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
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8
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Kizilbash SJ, Jensen CJ, Kouri AM, Balani SS, Chavers B. Steroid avoidance/withdrawal and maintenance immunosuppression in pediatric kidney transplantation. Pediatr Transplant 2022; 26:e14189. [PMID: 34786800 DOI: 10.1111/petr.14189] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/30/2021] [Accepted: 10/06/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Corticosteroids have been an integral part of maintenance immunosuppression for pediatric kidney transplantation. However, prolonged steroid therapy is associated with significant toxicities resulting in several SW/avoidance strategies in recent years. METHOD/OBJECTIVE This comprehensive review aims to discuss steroid-related toxicities and the safety, efficacy, and benefit of steroid avoidance/withdrawal immunosuppression in pediatric kidney transplant recipients. RESULTS Initial studies of SW/avoidance conducted in the setting of CSA and AZA showed an increased incidence of AR but no increase in graft loss or mortality with SW/avoidance maintenance immunosuppression. Studies performed under modern immunosuppression (induction therapy, Tac, and MMF) show no significant increase in AR or graft loss with SW/avoidance immunosuppression. Furthermore, SW/avoidance immunosuppression is associated with significant improvement in growth, BMI, BP control, and lipid profile in pediatric kidney transplant recipients. Despite these data, SW/avoidance remains controversial, and only 40% of pediatric kidney transplant recipients in the United States are currently on SW/avoidance maintenance immunosuppression. CONCLUSION SW/avoidance maintenance immunosuppression is safe and associated with fewer side effects compared with steroid-inclusive maintenance immunosuppression in pediatric kidney transplant recipients.
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Affiliation(s)
- Sarah J Kizilbash
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Chelsey J Jensen
- Solid Organ Transplant, University of Minnesota, Minneapolis, Minnesota, USA
| | - Anne M Kouri
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shanthi S Balani
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Blanche Chavers
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
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9
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Farkas-Skiles CM, Ettenger RB, Zuckerman JE, Pearl M, Venick RS, Weng PL. De novo lupus-like glomerulonephritis after pediatric non-kidney organ transplantation. Pediatr Nephrol 2022; 37:153-161. [PMID: 34292379 PMCID: PMC8674157 DOI: 10.1007/s00467-021-05194-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/08/2021] [Accepted: 06/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND We propose a novel clinically significant finding, de novo lupus-like glomerulonephritis (DNLLGN), in patients with autoantibodies and kidney abnormalities in pediatric liver transplant (LT) and intestinal inclusive transplants (ITx). METHODS We describe the clinical, serologic, and histopathologic presentation and kidney outcomes in eight patients from our center found to have DNLLGN on kidney biopsy. RESULTS Pediatric recipients of non-kidney solid organ transplants developed an unusual de novo immune complex glomerulonephritis with morphologic similarity to lupus nephritis. Six had isolated LT (0.9% of all pediatric LT at our center) and two had ITx (2.1% of all ITx). Five (63%) presented with nephrotic syndrome. Five patients had autoantibodies. Patients underwent kidney biopsy at a mean of 11.5 years in LT and 2.8 years in ITx after the index transplant. Biopsies demonstrated changes similar to focal or diffuse active lupus. Follow-up eGFR at a mean of 6 years after biopsy showed a mean decrease of 30 ml/min/1.73 m2 in all patients (p = 0.11). CONCLUSIONS DNLLGN has not been previously recognized in this clinical setting, yet 8 kidney biopsies from pediatric recipients of LT and ITx at our center in 25 years demonstrated this finding. DNLLGN appears to be an under-reported phenomenon of clinical significance. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Cristina M. Farkas-Skiles
- Department of Pediatrics, Division of Nephrology, University of California Los Angeles Medical Center, Los Angeles, CA USA
| | - Robert B. Ettenger
- Department of Pediatrics, Division of Nephrology, University of California Los Angeles Medical Center, Los Angeles, CA USA
| | - Jonathan E. Zuckerman
- Department of Pathology, University of California Los Angeles Medical Center, Los Angeles, CA USA
| | - Meghan Pearl
- Department of Pediatrics, Division of Nephrology, University of California Los Angeles Medical Center, Los Angeles, CA USA
| | - Robert S. Venick
- Department of Pediatrics, Division of Gastroenterology, University of California Los Angeles Medical Center, Los Angeles, CA USA
| | - Patricia L. Weng
- Department of Pediatrics, Division of Nephrology, University of California Los Angeles Medical Center, Los Angeles, CA USA
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10
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De Souza L, Prunster J, Chan D, Chakera A, Lim WH. Recurrent glomerulonephritis after kidney transplantation: a practical approach. Curr Opin Organ Transplant 2021; 26:360-380. [PMID: 34039882 DOI: 10.1097/mot.0000000000000887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW This review will provide a practical approach in the assessment of kidney failure patients with primary glomerulonephritides (GN) being considered for kidney transplantation, focusing on high-risk subtypes of immunoglobulin A nephropathy, focal segmental glomerulosclerosis, idiopathic membranous glomerulonephritis and membranoproliferative glomerulonephritis. RECENT FINDINGS Recurrent glomerulonephritis remains one of the most common causes of allograft loss in kidney transplant recipients. Although the epidemiology and clinical outcomes of glomerulonephritis recurrence occurring after kidney transplantation are relatively well-described, the natural course and optimal treatment strategies of recurrent disease in kidney allografts remain poorly defined. With a greater understanding of the pathophysiology and treatment responses of patients with glomerulonephritis affecting the native kidneys, these discoveries have laid the framework for the potential to improve the management of patients with high-risk glomerulonephritis subtypes being considered for kidney transplantation. SUMMARY Advances in the understanding of the underlying immunopathogenesis of primary GN has the potential to offer novel therapeutic options for kidney patients who develop recurrent disease after kidney transplantation. To test the efficacy of novel treatment options in adequately powered clinical trials requires a more detailed understanding of the clinical and histological characteristics of kidney transplant recipients with recurrent glomerulonephritis.
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Affiliation(s)
- Laura De Souza
- Department of Renal Medicine, Cairns Hospital, Cairns North, Queensland
| | - Janelle Prunster
- Department of Renal Medicine, Cairns Hospital, Cairns North, Queensland
| | - Doris Chan
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth
| | - Aron Chakera
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth
| | - Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth
- Medical School, University of Western Australia, Crawley, Western Australia, Australia
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11
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Boonpheng B, Hansrivijit P, Thongprayoon C, Mao SA, Vaitla PK, Bathini T, Choudhury A, Kaewput W, Mao MA, Cheungpasitporn W. Rituximab or plasmapheresis for prevention of recurrent focal segmental glomerulosclerosis after kidney transplantation: A systematic review and meta-analysis. World J Transplant 2021; 11:303-319. [PMID: 34316454 PMCID: PMC8291000 DOI: 10.5500/wjt.v11.i7.303] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 05/10/2021] [Accepted: 06/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Focal segmental glomerulosclerosis (FSGS) is one of the most common glomerular diseases leading to renal failure. FSGS has a high risk of recurrence after kidney transplantation. Prevention of recurrent FSGS using rituximab and/or plasmapheresis has been evaluated in multiple small studies with conflicting results.
AIM To assess the risk of recurrence of FSGS after transplantation using prophylactic rituximab with or without plasmapheresis, and plasmapheresis alone compared to the standard treatment group without preventive therapy.
METHODS This meta-analysis and systematic review were performed by first conducting a literature search of the MEDLINE, EMBASE, and Cochrane databases, from inception through March 2021; search terms included ‘FSGS,’ ’steroid-resistant nephrotic syndrome’, ‘rituximab,’ and ‘plasmapheresis,’. We identified studies that assessed the risk of post-transplant FSGS after use of rituximab with or without plasmapheresis, or plasmapheresis alone. Inclusion criteria were: Original, published, randomized controlled trials or cohort studies (either prospective or retrospective), case–control, or cross-sectional studies; inclusion of odds ratio, relative risk, and standardized incidence ratio with 95% confidence intervals (CI), or sufficient raw data to calculate these ratios; and subjects without interventions (controls) being used as comparators in cohort and cross-sectional studies. Effect estimates from individual studies were extracted and combined using a random effects model.
RESULTS Eleven studies, with a total of 399 kidney transplant recipients with FSGS, evaluated the use of rituximab with or without plasmapheresis; thirteen studies, with a total of 571 kidney transplant recipients with FSGS, evaluated plasmapheresis alone. Post-transplant FSGS recurred relatively early. There was no significant difference in recurrence between the group that received rituximab (with or without plasmapheresis) and the standard treatment group, with a pooled risk ratio of 0.82 (95%CI: 0.47-1.45, I2 = 65%). Similarly, plasmapheresis alone was not associated with any significant difference in FSGS recurrence when compared with no plasmapheresis; the pooled risk ratio was 0.85 (95%CI: 0.60-1.21, I2 = 23%). Subgroup analyses in the pediatric and adult groups did not yield a significant difference in recurrence risk. We also reviewed and analyzed post-transplant outcomes including timing of recurrence and graft survival.
CONCLUSION Overall, the use of rituximab with or without plasmapheresis, or plasmapheresis alone, is not associated with a lower risk of FSGS recurrence after kidney transplantation. Future studies are required to assess the effectiveness of rituximab with or without plasmapheresis among specific patient subgroups with high-risk for FSGS recurrence.
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Affiliation(s)
- Boonphiphop Boonpheng
- Division of Nephrology, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, United States
| | - Panupong Hansrivijit
- Department of Internal Medicine, UPMC Pinnacle, Harrisburg, PA 17104, United States
| | | | - Shennen A Mao
- Division of Transplant Surgery, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Pradeep K Vaitla
- Division of Nephrology, Department of Internal Medicine, University of Mississippi Medical Center, Jackson, MS 39216, United States
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85721, United States
| | - Avishek Choudhury
- School of Systems and Enterprises, Stevens Institute of Technology, Hoboken, NJ 07030, United States
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand
| | - Michael A Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, United States
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12
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Al-Jehani MH, Al-Husayni F, Aljabri A, AlMaghraby HQ, Banamah TA. Cyclophosphamide as a Treatment for Focal Segmental Glomerular Sclerosis Recurrence in a Kidney Transplant Patient. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e929097. [PMID: 33539328 PMCID: PMC7871296 DOI: 10.12659/ajcr.929097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patient: Female, 24-year-old Final Diagnosis: Focal segmental glomerulosclerosis Symptoms: Facia • lower extremity edema Medication: — Clinical Procedure: — Specialty: Nephrology
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Affiliation(s)
- Mariann H Al-Jehani
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Faisal Al-Husayni
- Department of Internal Medicine, National Guard Hospital, King Abdulaziz Medical City, Jeddah, Saudi Arabia.,Department of Internal Medicine, King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdullah Aljabri
- Department of Internal Medicine, National Guard Hospital, King Abdulaziz Medical City, Jeddah, Saudi Arabia.,Department of Internal Medicine, King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Hatim Qasim AlMaghraby
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.,Department of Pathology, National Guard Hospital, King Abdulaziz Medical City, Jeddah, Saudi Arabia.,Department of Pathology, King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Turki A Banamah
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.,Department of Nephrology, National Guard Hospital, Jeddah, Saudi Arabia.,Department of Nephrology, King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
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13
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Vallianou K, Marinaki S, Skalioti C, Lionaki S, Darema M, Melexopoulou C, Boletis I. Therapeutic Options for Recurrence of Primary Focal Segmental Glomerulonephritis (FSGS) in the Renal Allograft: Single-Center Experience. J Clin Med 2021; 10:jcm10030373. [PMID: 33498160 PMCID: PMC7863737 DOI: 10.3390/jcm10030373] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/09/2021] [Accepted: 01/14/2021] [Indexed: 12/12/2022] Open
Abstract
Focal Segmental Glomerulosclerosis (FSGS) recurrence after kidney transplantation (KTx) is relatively frequent and is associated with poor graft survival. The aim of this study was to investigate which management strategies were associated with better outcomes in our cohort of KTx recipients with primary FSGS. We retrospectively collected data on patients with primary FSGS who received a KTx between 1993 and 2019. A history of biopsy proven FSGS in native kidneys and new onset of significant proteinuria early post-KTx led to the diagnosis of recurrence, which was confirmed by graft biopsy. From 1993 to 2019 we performed 46 KTxs in patients with primary FSGS. We identified 26 episodes of recurrence in 25 patients, 67% of them occurring in males. They were younger at the time of KTx (33.8 vs. 41.1 years old, p = 0.067) and had progressed to end stage renal disease (ESRD) faster after FSGS diagnosis (61.4 vs. 111.2 months, p = 0.038), while they were less likely to have received prophylactic plasmapheresis (61.5% vs. 90%, p = 0.029). 76.7% of recurrences were found early, after a median of 0.5 months (IQR 0.1-1) with a median proteinuria was 8.5 (IQR 4.9-11.9) g/day. All patients with recurrence were treated with plasmapheresis, while 8 (30.7%) additionally received rituximab, 1 (3.8%) abatacept, and 4 (15.4%) ACTH. 7 (27%) patients experienced complete and 11 (42.3%) partial remission after a mean time of 3 (±1.79) and 4.4 (±2.25) months, respectively. Prognosis was worse for patients who experienced a recurrence. Eleven (42.3%) patients lost their graft from FSGS in a median time of 33 (IQR 17.5-43.3) months. In this series of patients, primary FSGS recurred frequently after KTx. Prophylacic plasmapheresis was shown efficacious in avoiding FSGS recurrence, while timely diagnosis and plasmapheresis-based regimens induced remission in more than half of the patients.
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14
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Factors Influencing Disease Recurrence and Graft Survival in Patients who Developed End-Stage Renal Disease Due to Focal Segmental Glomerulosclerosis and Underwent Renal Transplantation. Int Surg 2021. [DOI: 10.9738/intsurg-d-15-00154.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Aim
The aim of our study was to determine the factors effecting disease recurrence and graft survival in patients who developed end-stage renal disease (ESRD) due to focal segmental glomerulosclerosis (FSGS) and underwent renal transplantation (Rtx).
Methods
A total of 37 patients with FSGS (female/male: 10/27) who underwent Rtx in our transplant center between 2001 and 2014 were included in the study. The patients were diagnosed with FSGS by biopsy. Comparative analyses were performed in order to determine the factors effecting disease recurrence and graft survival. Plasmapheresis was performed with 40 mL/kg plasma. The diagnosis of the recurrence of FSGS and the acute rejections were also confirmed by biopsy.
Results
Statistical analyses revealed that, recurrence rates were higher in Rtx recipients from deceased donor [deceased donor versus living donor, 2 (50.0%) versus 3 (9.1%), P = 0.024]. However, no correlation was found between recurrence and renal replacement treatment (RRT) methods, duration of RRT, preoperative or postoperative prophylactic plasmapheresis, the presence of preoperative nephrotic proteinuria, donor's or recipient's age or gender, kinship with donor, time interval between development of FSGS and ESRD, or performing native nephrectomy. Graft survival rates were higher in Rtx patients that were transplanted from living donor, first-degree relatives, and in patients without recurrence.
Conclusion
In countries where organ donation is insufficient, living donors can be used with a low risk of recurrence for Rtx candidates with FSGS. Also, grafts from living donors, particularly from first-degree relatives, have higher survival rates.
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15
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Singh T, Kharadjian TB, Astor BC, Panzer SE. Long-term outcomes in kidney transplant recipients with end-stage kidney disease due to anti-glomerular basement membrane disease. Clin Transplant 2020; 35:e14179. [PMID: 33259076 DOI: 10.1111/ctr.14179] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/03/2020] [Accepted: 11/21/2020] [Indexed: 12/26/2022]
Abstract
Anti-glomerular basement membrane (GBM) disease causes rapidly progressive glomerulonephritis and end-stage kidney disease (ESKD). Studies of post-transplant outcomes in patients with ESKD due to anti-GBM disease in the United States are lacking. To better characterize outcomes of transplant recipients with a history of anti-GBM disease, we examined patient survival and graft survival among recipients with anti-GBM disease compared with IgA nephropathy at a single center in the United States. We analyzed patient survival, graft survival, disease recurrence, and malignancy rates for kidney transplant recipients with ESKD due to biopsy-proven anti-GBM disease who underwent kidney transplantation at our center between 1994 and 2015. 26 patients with biopsy-proven anti-GBM disease and 314 patients with IgAN underwent kidney transplantation from 1994 to 2015. The incidence of graft loss was 6.2 per 100 person-years for anti-GBM disease, which was similar to IgAN (4.08 per 100 person-years, p = .09). Patient mortality for anti-GBM was 0.03 per 100 person-years, similar to IgAN (0.02 per 100 person-years, p = .12). Disease recurrence occurred in one of the 26 anti-GBM patients. Four out of 26 patients (15%) developed malignancy, most commonly skin cancer. Long-term graft and patient survival for patients with ESKD due to anti-GBM was similar to IgAN after kidney transplantation.
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Affiliation(s)
- Tripti Singh
- Department of Medicine, University of Wisconsin Hospital & Clinics Madison, Madison, WI, USA
| | - Talar B Kharadjian
- Department of Medicine, University of Wisconsin Hospital & Clinics Madison, Madison, WI, USA
| | - Brad C Astor
- Department of Medicine, University of Wisconsin Hospital & Clinics Madison, Madison, WI, USA.,Department of Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Sarah E Panzer
- Department of Medicine, University of Wisconsin Hospital & Clinics Madison, Madison, WI, USA
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16
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Korneffel K, Gehring B, Rospert D, Rees M, Ortiz J. BK Virus in Renal Transplant Patients Using Alemtuzumab for Induction Immunosuppression. EXP CLIN TRANSPLANT 2020; 18:557-563. [DOI: 10.6002/ect.2019.0041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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17
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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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18
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Morello W, Puvinathan S, Puccio G, Ghiggeri GM, Dello Strologo L, Peruzzi L, Murer L, Cioni M, Guzzo I, Cocchi E, Benetti E, Testa S, Ghio L, Caridi G, Cardillo M, Torelli R, Montini G. Post-transplant recurrence of steroid resistant nephrotic syndrome in children: the Italian experience. J Nephrol 2020; 33:849-857. [PMID: 31617157 PMCID: PMC7381476 DOI: 10.1007/s40620-019-00660-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/09/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Steroid resistant nephrotic syndrome (SRNS) is a frequent cause of end stage renal disease in children and post-transplant disease recurrence is a major cause of graft loss. METHODS We identified all children with SRNS who underwent renal transplantation in Italy, between 2005 and 2017. Data were retrospectively collected for the presence of a causative gene mutation, sex, histology, duration of pre-transplant dialysis, age at onset and transplant, HLA matching, recurrence, therapy for recurrence, and graft survival. RESULTS 101 patients underwent a first and 22 a second renal transplant. After a median follow-up of 58.5 months, the disease recurred on the first renal transplant in 53.3% of patients with a non-genetic and none with a genetic SRNS. Age at transplant > 9 years and the presence of at least one HLA-AB match were independent risk factors for recurrence. Duration of dialysis was longer in children with relapse, but did not reach statistical significance. Overall, 24% of patients lost the first graft, with recurrence representing the commonest cause. Among 22 patients who underwent a second transplant, 5 suffered of SRNS recurrence. SRNS relapsed in 5/9 (55%) patients with disease recurrence in their first transplant and 2 of them lost the second graft. CONCLUSIONS Absence of a causative mutation represents the major risk factor for post-transplant recurrence in children with SRNS, while transplant can be curative in genetic SRNS. A prolonged time spent on dialysis before transplantation has no protective effect on the risk of relapse and should not be encouraged. Retransplantation represents a second chance after graft loss for recurrence.
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Affiliation(s)
- William Morello
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, University of Milan, via della Commenda, 9, 20122, Milan, Italy
| | - Sairaj Puvinathan
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, University of Milan, via della Commenda, 9, 20122, Milan, Italy
| | - Giuseppe Puccio
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, University of Milan, via della Commenda, 9, 20122, Milan, Italy
| | - Gian Marco Ghiggeri
- Division of Nephrology, Dialysis, and Transplantation, Scientific Institute for Research and Health Care, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Luca Dello Strologo
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Rome, Italy
| | - Licia Peruzzi
- Pediatric Nephrology Unit, Regina Margherita Children's Hospital, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Luisa Murer
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Women's and Children's Health, Hospital-University of Padova, Padua, Italy
| | - Michela Cioni
- Division of Nephrology, Dialysis, and Transplantation, Scientific Institute for Research and Health Care, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Isabella Guzzo
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Rome, Italy
| | - Enrico Cocchi
- Pediatric Nephrology Unit, Regina Margherita Children's Hospital, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Elisa Benetti
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Women's and Children's Health, Hospital-University of Padova, Padua, Italy
| | - Sara Testa
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, University of Milan, via della Commenda, 9, 20122, Milan, Italy
| | - Luciana Ghio
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, University of Milan, via della Commenda, 9, 20122, Milan, Italy
| | - Gianluca Caridi
- Division of Nephrology, Dialysis, and Transplantation, Scientific Institute for Research and Health Care, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Massimo Cardillo
- North Italy Transplant program (NITp), UOC Coordinamento Trapianti, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Rosanna Torelli
- North Italy Transplant program (NITp), UOC Coordinamento Trapianti, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, University of Milan, via della Commenda, 9, 20122, Milan, Italy.
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19
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Noguchi H, Tsuchimoto A, Ueki K, Kaku K, Okabe Y, Nakamura M. Reduced Recurrence of Primary IgA Nephropathy in Kidney Transplant Recipients Receiving Everolimus With Corticosteroid: A Retrospective, Single-Center Study of 135 Transplant Patients. Transplant Proc 2020; 52:3118-3124. [PMID: 32600641 DOI: 10.1016/j.transproceed.2020.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/27/2020] [Accepted: 05/12/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Long-term kidney allograft survival remains a major clinical challenge. Recurrent glomerulonephritis disease, including recurrence of IgA nephropathy (IgAN), is a significant barrier to long-term kidney allograft survival. We performed a retrospective, observational study to evaluate the role of everolimus (EVR) in the risk of recurrent IgAN. METHODS The study included data from 135 patients aged ≥16 years with biopsy-proven IgAN on native kidneys who underwent a kidney transplant (KT) between December 2002 and December 2018. RESULTS Patients who underwent de novo KT received mycophenolate mofetil (MMF) (n = 107) or EVR (n = 28). The mean recipient age in the MMF and EVR groups was 44.9 ± 13.7 and 41.1 ± 10.1, respectively. The median (interquartile range) follow-up period was 90.9 (64.9-115.3) and 21.2 (11.4-30.6) months, respectively (< .0001). All patients received continuous corticosteroid and tacrolimus therapy. The death-censored graft survival rate after KT and the recurrence-free survival rate did not differ significantly between the groups. Univariate and multivariate Cox regression analyses identified EVR for de novo KT as an independent predictive factor for recurrence-free survival (P = .024). CONCLUSIONS Our findings suggest that EVR-based regimens with tacrolimus and corticosteroid therapy for de novo KT reduce the recurrence of IgAN compared with MMF-based regimens with tacrolimus and corticosteroid therapy.
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Affiliation(s)
- Hiroshi Noguchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akihiro Tsuchimoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenji Ueki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keizo Kaku
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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20
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Infante B, Rossini M, Di Lorenzo A, Coviello N, Giuseppe C, Gesualdo L, Giuseppe G, Stallone G. Recurrence of immunoglobulin A nephropathy after kidney transplantation: a narrative review of the incidence, risk factors, pathophysiology and management of immunosuppressive therapy. Clin Kidney J 2020; 13:758-767. [PMID: 33123355 PMCID: PMC7577761 DOI: 10.1093/ckj/sfaa060] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/18/2020] [Indexed: 01/04/2023] Open
Abstract
Glomerulonephritis (GN) is the underlying cause of end-stage renal failure in 30–50% of kidney transplant recipients. It represents the primary cause of end-stage renal disease for 25% of the dialysis population and 45% of the transplant population. For patients with GN requiring renal replacement therapy, kidney transplantation is associated with superior outcomes compared with dialysis. Recurrent GN was previously considered to be a minor contributor to graft loss, but with the prolongation of graft survival, the effect of recurrent disease on graft outcome assumes increasing importance. Thus the extent of recurrence of original kidney disease after kidney transplantation has been underestimated for several reasons. This review aims to provide updated knowledge on one particular recurrent renal disease after kidney transplantation, immunoglobulin A nephropathy (IgAN). IgAN is one of the most common GNs worldwide. The pathogenesis of IgAN is complex and remains incompletely understood. Evidence to date is most supportive of a several hit hypothesis. Biopsy is mandatory not only to diagnose the disease in the native kidney, but also to identify and characterize graft recurrence of IgAN in the kidney graft. The optimal therapy for IgAN recurrence in the renal graft is unknown. Supportive therapy aiming to reduce proteinuria and control hypertension is the mainstream, with corticosteroids and immunosuppressive treatment tailored for certain subgroups of patients experiencing a rapidly progressive course of the disease with active lesions on renal biopsy and considering safety issues related to infectious complications.
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Affiliation(s)
- Barbara Infante
- Department of Medical and Surgical Sciences, Nephrology, Dialysis and Transplantation Unit, University of Foggia, Foggia, Italy
| | - Michele Rossini
- Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplantation Unit, University of Bari "Aldo Moro", Bari, Italy
| | - Adelaide Di Lorenzo
- Department of Medical and Surgical Sciences, Nephrology, Dialysis and Transplantation Unit, University of Foggia, Foggia, Italy
| | - Nicola Coviello
- Department of Medical and Surgical Sciences, Nephrology, Dialysis and Transplantation Unit, University of Foggia, Foggia, Italy
| | - Castellano Giuseppe
- Department of Medical and Surgical Sciences, Nephrology, Dialysis and Transplantation Unit, University of Foggia, Foggia, Italy
| | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplantation Unit, University of Bari "Aldo Moro", Bari, Italy
| | | | - Giovanni Stallone
- Department of Medical and Surgical Sciences, Nephrology, Dialysis and Transplantation Unit, University of Foggia, Foggia, Italy
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21
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Recurrent Proliferative Glomerulonephritis With Monoclonal Immunoglobulin Deposits in Kidney Allografts Treated With Anti-CD20 Antibodies. Transplantation 2020; 103:1477-1485. [PMID: 30747850 DOI: 10.1097/tp.0000000000002577] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) is a distinct form of glomerulonephritis that often recurs after kidney transplantation causing severe graft injury and often failure. METHODS We describe post transplant outcomes and response to therapy in 20 recipients with PGNMID. Evidence of PGNMID recurrence or lack thereof was determined by protocol and clinical biopsies. RESULTS Histologic recurrence (deposition of monoclonal immunoglobulin) occurred in 18 of 20 recipients (90%), a median of 7 (1 to 65) months post transplant. At diagnosis, recurrence was generally associated with mild or no clinical manifestations and often with mild glomerular morphologic changes by light microcopy. Four of the 18 patients with recurrence did not progress and were not treated. Another 4 patients with recurrences were treated with cyclophosphamide with or without plasmapheresis, and 2 of these grafts were lost from glomerulonephritis. Nine patients with recurrences were treated with anti-CD20 antibodies (rituximab) alone, resulting in improvements in estimated glomerular filtration rate (31.5 ± 16 versus 38.8 ± 13.3 mL/min/1.73 m, P = 0.011) and proteinuria (1280 [117 to 3752] versus 168 [83 to 1613] mg/24 h, P = 0.012) although complete clinical remission was rare. One graft in this later group was lost from recurrence 141 months post transplant. Posttreatment biopsies demonstrated stable or improved glomerular histology in most cases. However, PGNMID did not resolve in any case. Four patients received rituximab 4 months pretransplant to prevent recurrence. However, 3 had mild recurrences. CONCLUSIONS Rituximab treatment of early PGNMID recurrence is effective, resulting in reasonable, long-term graft survival. Whether pretransplant rituximab modifies the course of recurrence requires additional studies.
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22
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Demir ME, Uyar M, Merhametsiz O. Combination of High-Dose Intravenous Cyclosporine and Plasma Exchange Treatment Is Effective in Post-Transplant Recurrent Focal Segmental Glomerulosclerosis: Results of Case Series. Transplant Proc 2020; 52:843-849. [PMID: 32199645 DOI: 10.1016/j.transproceed.2020.01.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/25/2019] [Accepted: 01/10/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Idiopathic focal segmental glomerulosclerosis (FSGS) commonly recurs in the early post-transplant period. The treatment protocols and results are conflictive in recurrent FSGS. We aimed to present the results of our treatment protocol and basic approach to the disease recurrences. METHODS This prospective, single-center study was conducted between the years 2015 and 2018. Twelve patients who fit completely the diagnosis of idiopathic FSGS by clinical, laboratory, and biopsy findings were included. A specific treatment protocol which consists of plasma exchange and high dose intravenous cyclosporine was delivered to the patients independently of induction protocols. Twenty-four months of outcomes of graft functions were evaluated. RESULTS Nine patients completed the treatment protocol and were documented for evaluation. All patients achieved a complete or partial remission in an average 24 months of follow-up period. CONCLUSION Idiopathic FSGS is more commonly recurrent than thought to be. The early detection of proteinuria is crucial because the administration of a plasma exchange-based treatment protocol can reverse proteinuria. We think our treatment protocol is a well-established, efficient, and safe choice for post-transplant recurrent FSGS in adults.
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Affiliation(s)
- Mehmet Emin Demir
- Yeni Yuzyil University, Private Gaziosmanpasa Hospital, Department of Nephrology and Organ Transplantation, Istanbul, Turkey.
| | - Murathan Uyar
- Yeni Yuzyil University, Private Gaziosmanpasa Hospital, Department of Nephrology and Organ Transplantation, Istanbul, Turkey
| | - Ozgur Merhametsiz
- Yeni Yuzyil University, Private Gaziosmanpasa Hospital, Department of Nephrology and Organ Transplantation, Istanbul, Turkey
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23
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Jorgensen DR, Wu CM, Hariharan S. Epidemiology of end-stage renal failure among twins and diagnosis, management, and current outcomes of kidney transplantation between identical twins. Am J Transplant 2020; 20:761-768. [PMID: 31595679 DOI: 10.1111/ajt.15638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 09/03/2019] [Accepted: 09/22/2019] [Indexed: 01/25/2023]
Abstract
The aim of the study is to provide a comprehensive overview of identical twin kidney transplantation in the modern era. We provide epidemiologic trends in the US twin population from 1959 to 2000, current methods to identify zygosity, outcomes for identical twin transplants, and a comprehensive management strategy for identical twin kidney transplantation. By 2019, we project that 433 010 dizygotic and monozygotic twins will be alive and at risk for developing ESRF. Monozygosity between a donor-recipient pair can be confirmed by concordance in sex, blood type, and HLA antigen match with precision testing using 13/17 Short Tandem Repeat sequencing to a likelihood of nearly 100%. Among identical twin transplants from 2001 to 2017, excellent patient and kidney graft survival rates were noted. Approximately 50% of kidney transplant recipients of identical twins transplant did not receive maintenance immunosuppression, and no differences in graft survival were noted among patients with and without immunosuppression at 6 and 12 months (P = .8 and .7). Patients with glomerulonephritis as the cause of ESRF had lower graft survival (P = .06) suggesting that recurrent glomerulonephritis as a likely cause of graft loss among these recipients.
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Affiliation(s)
- Dana R Jorgensen
- Department of Medicine, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Christine M Wu
- Department of Medicine, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Sundaram Hariharan
- Department of Medicine, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
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24
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Raaijmakers A, Craig E, Kim S, Kennedy SE, McCarthy HJ. Adrenocorticotrophic Hormone-Induced Remission of Pediatric Post-transplantation Recurrent Focal Segmental Glomerulosclerosis. Kidney Int Rep 2020; 5:239-243. [PMID: 32043040 PMCID: PMC7000846 DOI: 10.1016/j.ekir.2019.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 11/16/2019] [Accepted: 11/18/2019] [Indexed: 11/22/2022] Open
Affiliation(s)
- Anke Raaijmakers
- Department of Nephrology, Sydney Children's Hospital, Sydney, Australia.,Department of Development and Regeneration, University of Leuven, Leuven, Belgium
| | - Elizabeth Craig
- Department of Nephrology, Sydney Children's Hospital, Sydney, Australia
| | - Siah Kim
- Department of Nephrology, Sydney Children's Hospital, Sydney, Australia.,School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, Australia.,Department of Nephrology, Children's Hospital at Westmead, Sydney, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, University of Sydney, Australia
| | - Sean E Kennedy
- Department of Nephrology, Sydney Children's Hospital, Sydney, Australia.,School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, Australia
| | - Hugh J McCarthy
- Department of Nephrology, Sydney Children's Hospital, Sydney, Australia.,School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, Australia.,Department of Nephrology, Children's Hospital at Westmead, Sydney, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, University of Sydney, Australia
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25
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Martin WP, White J, López-Hernández FJ, Docherty NG, le Roux CW. Metabolic Surgery to Treat Obesity in Diabetic Kidney Disease, Chronic Kidney Disease, and End-Stage Kidney Disease; What Are the Unanswered Questions? Front Endocrinol (Lausanne) 2020; 11:289. [PMID: 33013677 PMCID: PMC7462008 DOI: 10.3389/fendo.2020.00289] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 04/17/2020] [Indexed: 12/11/2022] Open
Abstract
Obesity is a major factor in contemporary clinical practice in nephrology. Obesity accelerates the progression of both diabetic and non-diabetic chronic kidney disease and, in renal transplantation, both recipient and donor obesity increase the risk of allograft complications. Obesity is thus a major driver of renal disease progression and a barrier to deceased and living donor kidney transplantation. Large observational studies have highlighted that metabolic surgery reduces the incidence of albuminuria, slows chronic kidney disease progression, and reduces the incidence of end-stage kidney disease over extended follow-up in people with and without type 2 diabetes. The surgical treatment of obesity and its metabolic sequelae has therefore the potential to improve management of diabetic and non-diabetic chronic kidney disease and aid in the slowing of renal decline toward end-stage kidney disease. In the context of patients with end-stage kidney disease, although complications of metabolic surgery are higher, absolute event rates are low and it remains a safe intervention in this population. Pre-transplant metabolic surgery increases access to kidney transplantation in people with obesity and end-stage kidney disease. Metabolic surgery also improves management of metabolic complications post-kidney transplantation, including new-onset diabetes. Procedure selection may be critical to mitigate the risks of oxalate nephropathy and disruption to immunosuppressant pharmacokinetics. Metabolic surgery may also have a role in the treatment of donor obesity, which could increase the living kidney donor pool with potential downstream impact on kidney paired exchange programmes. The present paper provides a comprehensive coverage of the literature concerning renal outcomes in clinical studies of metabolic surgery and integrates findings from relevant mechanistic pre-clinical studies. In so doing the key unanswered questions for the field are brought to the fore for discussion.
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Affiliation(s)
- William P. Martin
- Diabetes Complications Research Centre, School of Medicine, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland
- *Correspondence: William P. Martin
| | - James White
- Diabetes Complications Research Centre, School of Medicine, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland
| | - Francisco J. López-Hernández
- Instituto de Estudios de Ciencias de la Salud de Castilla y León-Instituto de Investigación Biomédica de Salamanca (IECSCYL-IBSAL), Hospital Virgen Vega, Salamanca, Spain
| | - Neil G. Docherty
- Diabetes Complications Research Centre, School of Medicine, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland
| | - Carel W. le Roux
- Diabetes Complications Research Centre, School of Medicine, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland
- Division of Investigative Science, Imperial College London, London, United Kingdom
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26
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Singh T, Astor BC, Zhong W, Mandelbrot DA, Maursetter L, Panzer SE. The association of acute rejection vs recurrent glomerular disease with graft outcomes after kidney transplantation. Clin Transplant 2019; 33:e13738. [PMID: 31630440 DOI: 10.1111/ctr.13738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 07/29/2019] [Accepted: 10/10/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND It has been shown that glomerulonephritis (GN) recurrence affects graft survival more than acute rejection. Thus, we assessed allograft survival after biopsy-confirmed diagnosis of acute rejection or recurrent GN in current era of immunosuppression. METHODS Allograft survival following a biopsy diagnosis of acute rejection or recurrent GN was determined in adult kidney transplant recipients from 1994 to 2013. A total of 306 patients (35%) with IgA, 298 (35%) with FSGS, 177 (21%) with lupus nephritis, and 81 (9%) with membranous nephropathy were followed for a median of 6.3 years. RESULTS Among the 862 transplant recipients with primary GN, allograft loss was similar following a biopsy diagnosis of acute rejection or recurrent glomerular disease (11.5 vs 14.2/100 person-years, P = .15). Differences in allograft survival emerged after 2.5 years following recurrent disease, with significantly higher graft failure in patients with FSGS, MN, or LN compared with IgA after recurrence of disease (16.7 vs 7.5/100 person-years, P = .05). The advantage in allograft survival for IgA patients did not achieve significance after acute rejection (P = .10 for IgA vs FSGS, MN, and LN). CONCLUSIONS Allograft survival was similar after disease recurrence or acute rejection after kidney transplant in patients with ESRD due to GN.
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Affiliation(s)
- Tripti Singh
- Department of Medicine, Division of Nephrology, University of Wisconsin-Madison Hospital and Clinics, Madison, WI, USA
| | - Brad C Astor
- Department of Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin-Madison Hospital and Clinics, Madison, WI, USA
| | - Didier A Mandelbrot
- Department of Medicine, Division of Nephrology, University of Wisconsin-Madison Hospital and Clinics, Madison, WI, USA
| | - Laura Maursetter
- Department of Medicine, Division of Nephrology, University of Wisconsin-Madison Hospital and Clinics, Madison, WI, USA
| | - Sarah E Panzer
- Department of Medicine, Division of Nephrology, University of Wisconsin-Madison Hospital and Clinics, Madison, WI, USA
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27
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Lim WH, Shingde M, Wong G. Recurrent and de novo Glomerulonephritis After Kidney Transplantation. Front Immunol 2019; 10:1944. [PMID: 31475005 PMCID: PMC6702954 DOI: 10.3389/fimmu.2019.01944] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/01/2019] [Indexed: 12/13/2022] Open
Abstract
The prevalence, pathogenesis, predictors, and natural course of patients with recurrent glomerulonephritis (GN) occurring after kidney transplantation remains incompletely understood, including whether there are differences in the outcomes and advances in the treatment options of specific GN subtypes, including those with de novo GN. Consequently, the treatment options and approaches to recurrent disease are largely extrapolated from the general population, with responses to these treatments in those with recurrent or de novo GN post-transplantation poorly described. Given a greater understanding of the pathogenesis of GN and the development of novel treatment options, it is conceivable that these advances will result in an improved structure in the future management of patients with recurrent or de novo GN. This review focuses on the incidence, genetics, characteristics, clinical course, and risk of allograft failure of patients with recurrent or de novo GN after kidney transplantation, ascertaining potential disparities between “high risk” disease subtypes of IgA nephropathy, idiopathic membranous glomerulonephritis, focal segmental glomerulosclerosis, and membranoproliferative glomerulonephritis. We will examine in detail the management of patients with high risk GN, including the pre-transplant assessment, post-transplant monitoring, and the available treatment options for disease recurrence. Given the relative paucity of data of patients with recurrent and de novo GN after kidney transplantation, a global effort in collecting comprehensive in-depth data of patients with recurrent and de novo GN as well as novel trial design to test the efficacy of specific treatment strategy in large scale multicenter randomized controlled trials are essential to address the knowledge deficiency in this disease.
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Affiliation(s)
- Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.,School of Medicine, University of Western Australia, Perth, WA, Australia
| | - Meena Shingde
- NSW Health Pathology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
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28
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ACTH Gel in Resistant Focal Segmental Glomerulosclerosis After Kidney Transplantation. Transplantation 2019; 103:202-209. [PMID: 29894413 DOI: 10.1097/tp.0000000000002320] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Treatment of focal segmental glomerular sclerosis (FSGS) after kidney transplantation is challenging with unpredictable outcomes. The objective was to investigate the use of adrenocorticotropic hormone (ACTH) analogue gel in kidney transplant recipients with de novo or recurrent FSGS resistant to therapeutic plasma exchange (TPE) and/or rituximab. METHODS We performed a retrospective review of cases of de novo or recurrent resistant FSGS at 2 large US transplant centers between April 2012 and December 2016. Proteinuria was measured by urine protein to creatinine ratio. RESULTS We identified 20 cases of posttransplant recurrent and de novo FSGS resistant to conventional therapy with TPE and rituximab. Mean ± SD age was 49 ± 15.5 years, 14 (70%) were male, 13 (65%) were whites, and 8 (38%) had previous kidney transplants. Median (interquartile range) of recurrent and de novo FSGS was 3 (0.75-7.5) months posttransplant. The majority of patients, 15 (75%), received TPE as a treatment at the time of diagnosis and 10 (50%) received rituximab, which was started before the use of ACTH gel. There was a significant improvement of urine protein to creatinine ratio from a mean ± SD of 8.6 ± 7.6 g/g before ACTH gel to 3.3 ± 2.3 g/g after the use of ACTH gel (P = 0.004). Ten (50%) patients achieved complete or partial remission. CONCLUSIONS Although, the response varied among the recipients, ACTH gel might be an effective therapy for posttransplant resistant FSGS cases that fail to respond to TPE and rituximab.
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29
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Günay E, Çelebi T, Şen S, Aşcı G, Sarsik Kumbaraci B, Gökalp C, Yılmaz M, Töz H. Investigation of the Factors Affecting Allograft Kidney Functions: Results of 10 Years. Transplant Proc 2019; 51:1082-1085. [PMID: 31101175 DOI: 10.1016/j.transproceed.2019.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 02/16/2019] [Accepted: 02/16/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Significant improvements in patient and graft survival and reductions in the frequency of acute rejection were obtained in the early period after renal transplantation, but this success was not sufficiently reflected in the long term. Allograft kidney losses in the long term remain a significant problem. In this study, we investigated the specific causes of graft losses in patients who had a good clinical course in the first year but developed graft loss in the long term. METHODS A total of 118 patients who underwent kidney transplantation in 2005 and 2006 in the Organ Transplantation Center of Ege University Medical Faculty Hospital were evaluated. The inclusion criteria were to be older than 18 years and have a serum creatinine value of <2 mg/dL at the 12th month after transplantation. RESULTS Sixty-one percent of the recipients were male, and the mean age at the time of transplantation was 34 ± 11 years (18 to 61). We observed 29 graft losses during the mean follow-up period of 129 ± 35 months (27 to 162). Three of the graft losses were death by functional graft. Of the 26 patients with graft loss, 16 had chronic rejection, and 8 had recurrent glomerulonephritis. The relationship between nonimmune causes and graft loss was not detected. CONCLUSIONS In conclusion, nonimmune factors may not be as important as we think in relatively young and healthier recipients. Chronic rejection and recurrent glomerulonephritis are the main causes of long-term graft loss of patients with good graft function at the end of the first year. Improvement of long-term survival will be possible with the prevention and effective treatment of these 2 problems.
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Affiliation(s)
- Emrah Günay
- Department of Nephrology, University of Health Sciences, Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey.
| | - Tugba Çelebi
- Department of Internal Medicine, Ege University Medical Faculty, İzmir, Turkey
| | - Sait Şen
- Department of Pathology, Ege University Medical Faculty, İzmir, Turkey
| | - Gulay Aşcı
- Department of Nephrology, Ege University Medical Faculty, İzmir, Turkey
| | | | - Cenk Gökalp
- Department of Nephrology, Trakya University Medical Faculty, Edirne, Turkey
| | - Mumtaz Yılmaz
- Department of Nephrology, Ege University Medical Faculty, İzmir, Turkey
| | - Huseyin Töz
- Department of Nephrology, Ege University Medical Faculty, İzmir, Turkey
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30
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Mansur JB, Sandes-Freitas TV, Kirsztajn GM, Cristelli MP, Mata GF, de Paula MI, Grenzi PC, Martins SBS, Felipe CR, Tedesco-Silva H, Pestana JOM. Clinical features and outcomes of kidney transplant recipients with focal segmental glomerulosclerosis recurrence. Nephrology (Carlton) 2019; 24:1179-1188. [PMID: 30891898 DOI: 10.1111/nep.13589] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2019] [Indexed: 11/29/2022]
Abstract
AIM Focal segmental glomerulosclerosis recurs in up to 30% and up to 80% of adult and pediatric kidney transplant recipients, respectively. There is no standard of care treatment. The purpose of this study was to evaluate clinical characteristics, treatments and outcomes of patients with focal segmental glomerulosclerosis recurrence (FSGSr). METHODS This was a retrospective single-center cohort study including FSGSr patients treated with plasmapheresis (PP) and combinations of high dose steroids, cyclosporine and rituximab. RESULTS Among 61 patients included in this analysis the median time to diagnosis was 19 days. The incidence of first biopsy-confirmed FSGSr was 18% reaching 52.4% with follow-up biopsies. During PP treatment 54% of the patients developed infectious complications. PP was discontinued in 37% of patients due to treatment failure (no remission or graft loss) and in 26% due to an adverse event. All patients who discontinued PP due to adverse event did not show clinical response or lost the allograft. The incidence of acute rejection was 34.4%. The incidences of partial and complete remissions were 16.4% and 27.8%, respectively. Overall 6-years patient and graft survivals were 90.7% and 64.5%, respectively. CONCLUSION This analysis confirms the low, variable and unpredictable rate of FSGSr remission, inconsistencies among available therapeutic options and its high rate of adverse events, and the negative impact on graft survival.
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Affiliation(s)
- Juliana B Mansur
- Nephrology Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | | | - Gianna M Kirsztajn
- Nephrology Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Marina P Cristelli
- Nephrology Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Gustavo F Mata
- Nephrology Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Mayara I de Paula
- Nephrology Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Patricia C Grenzi
- Microbiology and Immunology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Suelen B S Martins
- Nephrology Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Claudia R Felipe
- Nephrology Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Hélio Tedesco-Silva
- Nephrology Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - José O M Pestana
- Nephrology Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
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31
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Recurrent glomerulonephritis following renal transplantation and impact on graft survival. BMC Nephrol 2018; 19:344. [PMID: 30509213 PMCID: PMC6278033 DOI: 10.1186/s12882-018-1135-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/12/2018] [Indexed: 11/22/2022] Open
Abstract
Background Recurrence of primary glomerulonephritis in the post-transplant period has been described in the literature but the risk remains poorly quantified and its impact on allograft outcomes and implications for subsequent transplants remain under-examined. Here we describe the rates and timing of post-transplant glomerulonephritis recurrence for IgA nephropathy, focal segmental glomerulosclerosis, mesangiocapillary GN and membranous GN based on 28 years of ANZDATA registry transplant data. Methods We investigated the rates of GN 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 GN recurrence occurred in 10.5% of transplants and was most common in mesangiocapillary GN. Median time to recurrence was shorter for FSGS compared to IGAN. GN recurrence was less common in patients over 50 years of age and after unrelated kidney donation. We identified a significantly higher risk of recurrence in secondary grafts following recurrence in a primary allograft for FSGS (RR 5.70, 95 CI: 2.41–13.5, p < 0.001) but not IGAN, MCGN or MN. At 10 years, recurrence occurs in 8.7, 10.8, 13.1, and 13.4% of allografts for FSGS, IGAN, MCGN and MN respectively. In all GN, recurrence significantly reduced death censored graft survival at 5 and 10 years. Conclusions GN recurrence occurs in a minority of patients at a significantly different rate for each GN. After a recurrence, there is no evidence for an increased risk of further recurrence in a subsequent graft except in FSGS.
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32
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Rituximab and Therapeutic Plasma Exchange in Recurrent Focal Segmental Glomerulosclerosis Postkidney Transplantation. Transplantation 2018; 102:e115-e120. [PMID: 29189487 DOI: 10.1097/tp.0000000000002008] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Focal segmental glomerulosclerosis (FSGS) is a common cause of end-stage renal disease with a high rate of recurrence after kidney transplantation. Several factors, such as white race, rapid progression, and previous allograft failure due to recurrence, were found to be risks of recurrence. Data are limited on the benefits of rituximab and/or therapeutic plasma exchange (TPE) in preventing recurrence. In this study, we sought to assess the efficacy of rituximab and TPE for the prevention and treatment of recurrent FSGS after kidney transplantation. METHODS We enrolled 66 patients with FSGS in this prospective observational study and followed their outcomes. Patients with high risk for recurrence received preventative therapy with TPE and/or rituximab. RESULTS Twenty-three (62%) of the 37 patients who received preventative therapy developed recurrence compared with 14 (51%) recurrences of the 27 patients who did not receive any therapy (P = 0.21). There was a trend for less relapse when rituximab was used as a therapy for recurrent FSGS (6/22 vs 9/18, P = 0.066). We used a clinical score of 5 values to assess the prediction of FSGS recurrence. A score of 3 or more had a predictive receiver operating characteristic curve of 0.72. Treatment with TPE and/or rituximab resulted in better allograft survival than historical studies. Allograft failure because of recurrent FSGS occurred in only 6 (9%) patients. CONCLUSIONS Preventative therapies do not decrease the recurrence rate of recurrent FSGS. However, prompt treatment of recurrence with these therapies may result in improved outcomes.
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Sofue T, Suzuki H, Ueda N, Kushida Y, Minamino T. Post-transplant immunoglobulin A deposition and nephropathy in allografts. Nephrology (Carlton) 2018; 23 Suppl 2:4-9. [PMID: 29968406 DOI: 10.1111/nep.13281] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2018] [Indexed: 12/16/2022]
Abstract
Post-transplant immunoglobulin A (IgA) nephropathy (IgAN) in the allograft is the major cause of allograft loss. Using a protocol biopsy, latent mesangial IgA deposition (IgAD) can be detected in the allograft. Latent IgAD is distinguished from IgAN by the absence of urinary abnormalities, although IgA is observed in the mesangium. However, the pathophysiology and most appropriate treatment strategy for latent mesangial IgAD in the allograft remain to be fully determined. Importantly, it is unknown whether all cases of post-transplant asymptomatic IgAD progress to symptomatic IgAN; indeed, IgA deposits disappear in some cases. The differences in allograft prognosis between asymptomatic IgAD and IgAN have also not been determined. Non-invasive methods of diagnosis of IgAD in the allograft using serological and pathological biomarkers are being developed. Possible serum biomarkers include serum galactose-deficient IgA1 (Gd-IgA1), Gd-IgA1-specific IgG and Gd-IgA1-specific IgA, and its immune complexes. Immunofluorescence analysis using Gd-IgA1 monoclonal antibody may provide a pathological biomarker. These serological and pathological biomarkers may be suitable for the characterization of the stage of IgAD. However, there is insufficient information regarding whether serological and pathological biomarkers can predict the progression of asymptomatic IgAD to symptomatic IgAN. We propose that the pathogenesis of IgAN can be defined through the clinical study of IgAD in the allograft using protocol biopsies conducted by nephrologists involved in clinical kidney transplantation.
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Affiliation(s)
- Tadashi Sofue
- Division of Nephrology and Dialysis, Department of Cardiorenal and Cerebrovascular Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Hitoshi Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Nobufumi Ueda
- Department of Urology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Yoshio Kushida
- Department of Diagnostic Pathology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tetsuo Minamino
- Division of Nephrology and Dialysis, Department of Cardiorenal and Cerebrovascular Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
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Cimeno A, Munley J, Drachenberg C, Weir M, Haririan A, Bromberg J, Barth RN, Scalea JR. Diabetic nephropathy after kidney transplantation in patients with pretransplantation type II diabetes: A retrospective case series study from a high-volume center in the United States. Clin Transplant 2018; 32:e13425. [PMID: 30326148 DOI: 10.1111/ctr.13425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/31/2018] [Accepted: 09/18/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with type II diabetes mellitus (DM) undergoing renal transplantation are at risk of diabetic nephropathy (DN) in the transplanted kidney. The true risk of developing post-transplantation DN is unknown, and post-transplantation DN is poorly characterized in the literature. METHODS The biopsy database at the University of Maryland Medical Center was queried for kidney transplant biopsies which demonstrated evidence of DN. The time from transplantation to biopsy-proven DN (time to diagnosis, TTD) was calculated and analyzed in the context of demographics, serum creatinine, and onset of diabetes. By extrapolating the total number of patients who developed DN in the last 2 years, we estimated the recurrence rate of DN. RESULTS Sixty patients whose renal biopsies met criteria were identified. The mean age was 56.6 (±1.58) years, and the mean creatinine level at time of biopsy was 1.65 (±0.12) mg/dL. Simultaneous pathological diagnoses were frequent on kidney biopsy; rejection was present at variable rates: classes I, IIA, IIB, and III were 5.0%, 66.7%, 18.4%, and 10%, respectively. The mean TTD was 1456 (±206) days. TTD was significantly shorter for patients receiving a cadaveric vs living donor renal transplant (1118 ± 184 vs 2470 ± 547 days, P = 0.004). Older patients (r = 0.378, P = 0.003) and patients with higher serum creatinine (r = 0.282, P = 0.029) had shorter TTDs. Extrapolations showed that 74.7% of patients would be free of DN 10 years after renal transplantation. CONCLUSIONS Diabetic nephropathy occurs after transplantation, and this appears to be due to both donor and recipient-derived factors. Encouragingly, our estimates suggest that as many as 75% of patients may be free of DN at 10 years following kidney transplantation.
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Affiliation(s)
- Arielle Cimeno
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jennifer Munley
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Cinthia Drachenberg
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Matthew Weir
- Department of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Abdolreza Haririan
- Department of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jonathan Bromberg
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Rolf N Barth
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joseph R Scalea
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
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Lim WH, Wong G, McDonald SP, Chakera A, Luxton G, Isbel NM, Pilmore HL, Barbour T, Hughes P, Chadban SJ. Long-term outcomes of kidney transplant recipients with end-stage kidney disease attributed to presumed/advanced glomerulonephritis or unknown cause. Sci Rep 2018; 8:9021. [PMID: 29899355 PMCID: PMC5998026 DOI: 10.1038/s41598-018-27151-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 04/12/2018] [Indexed: 01/18/2023] Open
Abstract
People with biopsy-proven glomerulonephritis (GN) as their cause of end-stage kidney disease (ESKD) who undergo kidney transplantation incur significant risk of recurrent GN-related graft failure, but the risk in recipients with ESKD where GN was suspected but not biopsy proven (presumed/advanced GN) and when the cause of ESKD is unknown remains uncertain. Using the Australia and New Zealand Dialysis and Transplant registry, we examined the associations between primary kidney transplant recipients whose ESKD was attributed to: 1) commonly-recurring GN (i.e. IgA nephropathy, membranoproliferative GN, focal segmental glomerulosclerosis and membranous GN), 2) presumed/advanced GN, and 3) cause of ESKD unknown (uESKD) and GN-related graft failure using adjusted competing risk models. Of 5258 recipients followed for a median of 8 years, 3539 (67.3%) had commonly-recurring GN, 1195 (22.7%) presumed/advanced GN, and 524 (10.0%) uESKD. Compared to recipients with commonly-recurring GN, recipients with presumed/advanced GN or uESKD experienced a low incidence of GN-related graft failure (<1%) and a lower hazard of GN-related graft failure (adjusted sub-distribution hazard ratio [HR] 0.28 [95%CI 0.15-0.54,p < 0.001] and 0.20 [95%CI 0.06-0.64,p = 0.007], respectively). People with ESKD attributed to either presumed/advanced GN or unknown cause face a very low risk of graft failure secondary to GN recurrence after transplantation.
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Affiliation(s)
- Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia. .,School of Medicine and Pharmacology, University of Western Australia, Perth, Australia. .,Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia.
| | - Germaine Wong
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia.,Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Stephen P McDonald
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia.,South Australia Health and Medical Research Institute, Adelaide, Australia and University of Adelaide, Adelaide, Australia
| | - Aron Chakera
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
| | - Grant Luxton
- Department of Renal Medicine, Prince of Wales Hospital, Sydney, Australia
| | - Nicole M Isbel
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Helen L Pilmore
- Renal Unit, Auckland Hospital & Department of Medicine, Auckland University, Auckland, New Zealand
| | - Tom Barbour
- Department of Nephrology, Royal Melbourne Hospital and Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Peter Hughes
- Department of Nephrology, Royal Melbourne Hospital and Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Steven J Chadban
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia.,Renal Medicine, Royal Prince Alfred Hospital, Sydney, Australia.,Kidney Node, Charles Perkins Centre, University of Sydney, Sydney, Australia
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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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Vazquez Martul E. [The pathology of renal transplants]. REVISTA ESPAÑOLA DE PATOLOGÍA : PUBLICACIÓN OFICIAL DE LA SOCIEDAD ESPAÑOLA DE ANATOMÍA PATOLÓGICA Y DE LA SOCIEDAD ESPAÑOLA DE CITOLOGÍA 2018; 51:110-123. [PMID: 29602372 DOI: 10.1016/j.patol.2017.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 10/01/2017] [Indexed: 11/15/2022]
Abstract
In order to make an objective assessment of the histopathology of a renal biopsy during a kidney transplant, all the various elements involved in the process must be understood. It is important to know the characteristics of the donor organ, especially if the donor is older than 65. The histopathological features of the donor biopsy, especially its vascular status, are often related to an initial poor function of the transplanted kidney. The T lymphocyte inflammatory response is characteristic in acute cellular rejection; the degree of tubulitis, together with the amount of affected parenchyme, are important factors. The proportion of cellular sub-populations, such as plasma cells and macrophages, is also important, as they can be related to antibody-mediated humoral rejection. Immunofluorescent or immunohistochemical studies are necessary to rule out C4d deposits or immunogloblulins. The presence of abundant deposits of C4d in tubular basement membranes supports a diagnosis of humoral rejection, as does the presence of capillaritis, glomerulitis which, together with vasculitis, are typical diagnostic findings in C4d negative cases. Interstitial fibrosis, tubular atrophy and glomerular sclerosis, although non-specific, imply a chronic phase. Transplant glomerulopathy and multilamination in more than 6 layers of the tubular and glomerular basement membranes are quasi-specific characteristics of chronic humoral rejection. Electron microscopy is essential to identify of these pathologies as well as to demonstrate the presence of other glomerular renal diseases.
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Affiliation(s)
- Eduardo Vazquez Martul
- Ex Jefe de Servicio de Anatomía Patológica, Hospital Universitario A Coruña (retirado), A Coruña, España; Ex profesor asociado de la Facultad de Medicina, Universidad de Santiago de Compostela, Santiago de Compostela, A Coruña, España; Miembro del Club de Nefropatología (Sociedad Española de Nefrología), España.
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Singh T, Astor B, Zhong W, Mandelbrot D, Djamali A, Panzer S. Kidney Transplant Recipients With Primary Membranous Glomerulonephritis Have a Higher Risk of Acute Rejection Compared With Other Primary Glomerulonephritides. Transplant Direct 2017; 3:e223. [PMID: 29184911 PMCID: PMC5682767 DOI: 10.1097/txd.0000000000000736] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 08/01/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Despite being the leading cause of graft failure, there is a lack of published data about the rates of rejection in kidney transplant patients with glomerulonephritis as the cause of end-stage renal disease. METHODS We examined all consecutive adult (>18 years) renal transplant recipients with biopsy-proven native renal glomerular disease who underwent kidney transplant between 1994 and 2013. Glomerulonephritis groups included were IgA nephropathy (IgAN) (N = 306), focal segmental glomerulosclerosis (FSGS) (N = 298), membranous nephropathy (MN) (N = 81), and lupus nephritis (LN) (N = 177). RESULTS In the total cohort of 862 patients, 363 patients had an episode of acute rejection during the follow-up period of 19 years (incidence rate of 7.2% per year). Forty-five of 81 patients with MN had an episode of acute rejection during the follow-up period. Patients with MN had significantly higher incidence of acute rejection (12.1 per 100 person years, P < 0.05) in comparison to IgAN (7.2 per 100 person years), FSGS (7.4 per 100 person years), and LN (7.9 per 100 person years). Patients with MN had 1.9 times higher risk of developing acute rejection after transplant in comparison to IgAN (P < 0.005). In patients with MN, 33 of 45 (73.3%) rejection events were acute cellular rejection, 8 (17.8%) of 45 were acute antibody-mediated rejection and 6 of 45 (13.3%) were combined cellular and antibody-mediated acute rejection. Despite higher rates of acute rejection, 10-year allograft survival was similar in all subgroups. CONCLUSIONS Patients with MN have higher incidence of acute rejection after kidney transplant but have similar 10-year allograft survival in comparison to the other glomerular diseases like IgAN, FSGS, and LN.
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Affiliation(s)
- Tripti Singh
- Division of Nephrology, Departments of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Brad Astor
- Division of Nephrology, Departments of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Didier Mandelbrot
- Division of Nephrology, Departments of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Arjang Djamali
- Division of Nephrology, Departments of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sarah Panzer
- Division of Nephrology, Departments of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Kidney Transplant With Low Levels of DSA or Low Positive B-Flow Crossmatch: An Underappreciated Option for Highly Sensitized Transplant Candidates. Transplantation 2017; 101:2429-2439. [PMID: 28009780 DOI: 10.1097/tp.0000000000001619] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Avoiding donor-specific antibody (DSA) is difficult for sensitized patients. Improved understanding of the risk of low level DSA is needed. METHODS We retrospectively compared the outcomes of 954 patients transplanted with varied levels of baseline DSA detected by single antigen beads and B flow cytometric crossmatch (XM). Patients were grouped as follows: -DSA/-XM, +DSA/-XM, +DSA/low +XM, +DSA/high +XM, and -DSA/+XM and followed up for a mean of 4.1 ± 1.9 years (similar among groups, P = 0.49). RESULTS Death-censored allograft survival was similar in all groups except the +DSA/high +XM group, which was lower at 79.1% versus 96.2% in the -DSA/-XM group (P < 0.01). The incidence of chronic antibody-mediated rejection (CAMR) based on surveillance biopsy was higher with increasing DSA (8.2% -DSA/-XM, 17.0% +DSA/-XM, 30.6% +DSA/low +XM, and 51.2% +DSA/high +XM, P < 0.01), but similar in groups without baseline DSA (8.1% -DSA/-XM vs 15.4% -DSA/+XM, P = 0.19). Having a calculated panel-reactive antibody (cPRA) of 80% or greater was independently associated with CAMR (hazard ratio, 5.2; P = 0.03) even when DSA was undetected at baseline. By 2 years posttransplant, the incidence of CAMR was 19.4% in patients with cPRA of 80% or greater and undetected DSA and negative XM at baseline. CONCLUSIONS Kidney transplantation with low-level DSA with or without a low positive XM is a reasonable option for highly sensitized patients and may be advantageous compared with waiting for a negative XM deceased donor. The risk for CAMR is low in patients with no DSA even if the XM is positive. Patients with cPRA of 80% or greater are at risk for CAMR even if no DSA is detected.
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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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41
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Cosio FG, Cattran DC. Recent advances in our understanding of recurrent primary glomerulonephritis after kidney transplantation. Kidney Int 2016; 91:304-314. [PMID: 27837947 DOI: 10.1016/j.kint.2016.08.030] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 08/09/2016] [Accepted: 08/11/2016] [Indexed: 02/06/2023]
Abstract
Recurrent glomerulonephritis (GN) is an important cause of kidney allograft failure, particularly in younger recipients. Approximately 15% of death-censored graft failures are due to recurrent GN, but this incidence is likely an underestimation of the magnitude of the problem. Overall, 18% to 22% of kidney allografts are lost due to GN, either recurrent or presumed de novo. The impact of recurrent GN on allograft survival was recognized from the earliest times in kidney transplantation. However, progress in this area has been slow, and our understanding of GN recurrence remains limited, in large part due to incomplete understanding of the pathogenesis of these diseases. This review focuses on recent advances in our general understanding of the pathophysiology of primary GN, the risk of recurrence in the allograft, and the consequences for kidney graft survival. We focus specifically on the most common forms of primary GN, including focal segmental glomerulosclerosis, membranous nephropathy, membranoproliferative glomerulonephritis, and IgA nephropathy. New understanding of the pathogenesis of these diseases has had direct clinical implications for transplantation, allowing better identification of candidates at high risk of recurrence and earlier diagnoses, and it is expected to lead to significance improvements in the therapy and perhaps even prevention of GN recurrence. More than ever, it is essential to fully characterize GN before transplantation as this information will direct our management posttransplantation. Further, the relative rarity of recurrent GN dictates the need for multicenter studies in order to evaluate, test, and validate recent advances and therapies.
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Affiliation(s)
- Fernando G Cosio
- Division of Nephrology and Hypertension, Department of Internal Medicine, William von Liebig Center for Transplantation and Clinical Regeneration Mayo Clinic, Rochester, Minnesota, USA.
| | - Daniel C Cattran
- Department of Nephrology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Affiliation(s)
- Sandra Amaral
- Division of Nephrology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Alicia Neu
- Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Roberti I, Vyas S. Immune-mediated nephropathies in kidney transplants: recurrent or de novo diseases. Pediatr Transplant 2016; 20:946-951. [PMID: 27561690 DOI: 10.1111/petr.12789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2016] [Indexed: 11/30/2022]
Abstract
IMN contribute to ESRD in 13% children with renal transplant (txp). Recurrent or de novo IMN can cause graft dysfunction and/or failure, but the details regarding incidence, therapy, and outcome remain poorly understood. Retrospective single-center study of all pediatric kidney txp was carried out since 1998. Clinical presentation, pathology, therapy, and graft outcomes of children with recurrent or de novo IMN were reviewed. IMN was the primary etiology of ESRD in 28 of the 149 txp recipients. Eleven children had biopsy-proven post-txp IMN-six were recurrent and five had de novo. Presentation varied with changes in SCr and/or proteinuria. Initial therapy included higher doses of steroids, MMF, and tacrolimus. Outcome was excellent with only one late graft loss. Full remission was achieved in all other patients, but some had re-recurrence of the IMN. Median follow-up time was 11.8 years. IMN (recurrent or de novo) occurred in 7.4% (11 of 149) of all kidney txp performed at our center. IMN post-txp was often seen late post-txp, usually asymptomatic and noted to have relapsing pattern. Early diagnosis and prompt therapy resulted in excellent long-term outcome in children diagnosed with post-txp IMN.
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Affiliation(s)
- Isabel Roberti
- Barnabas Health Children's Kidney Center, West Orange, NJ, USA.
| | - Shefali Vyas
- Barnabas Health Children's Kidney Center, West Orange, NJ, USA
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Filippone EJ, Farber JL. Membranous nephropathy in the kidney allograft. Clin Transplant 2016; 30:1394-1402. [DOI: 10.1111/ctr.12847] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2016] [Indexed: 01/29/2023]
Affiliation(s)
- Edward J. Filippone
- Division of Nephrology; Department of Medicine; Sydney Kimmel Medical College at Thomas Jefferson University; Philadelphia PA USA
| | - John L. Farber
- Department of Pathology; Sydney Kimmel Medical College at Thomas Jefferson University; Philadelphia PA USA
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Nissaisorakarn V, Worawichawong S, Kantachuvesiri P, Limlek T, Sumethkul V, Kantachuvesiri S. Co-existing post-transplant membranous nephropathy and diabetic nephropathy: A case report. TRANSPLANTATION REPORTS 2016. [DOI: 10.1016/j.tpr.2016.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
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O'Shaughnessy MM, Liu S, Montez-Rath ME, Lenihan CR, Lafayette RA, Winkelmayer WC. Kidney Transplantation Outcomes across GN Subtypes in the United States. J Am Soc Nephrol 2016; 28:632-644. [PMID: 27432742 DOI: 10.1681/asn.2016020126] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 05/28/2016] [Indexed: 12/28/2022] Open
Abstract
Differences in kidney transplantation outcomes across GN subtypes have rarely been studied. From the US Renal Data System, we identified all adult (≥18 years) first kidney transplant recipients (1996-2011) with ESRD attributed to one of six GN subtypes or two comparator kidney diseases. We computed hazard ratios (HRs) for death, all-cause allograft failure, and allograft failure excluding death as a cause (competing risks framework) using Cox proportional hazards regression. Among the 32,131 patients with GN studied, patients with IgA nephropathy (IgAN) had the lowest mortality rates and patients with IgAN or vasculitis had the lowest allograft failure rates. After adjusting for patient- and transplant-related factors, compared with IgAN (referent), FSGS, membranous nephropathy, membranoproliferative GN, lupus nephritis, and vasculitis associated with HRs (95% confidence intervals) for death of 1.57 (1.43 to 1.72), 1.52 (1.34 to 1.72), 1.76 (1.55 to 2.01), 1.82 (1.63 to 2.02), and 1.56 (1.34 to 1.81), respectively, and with HRs for allograft failure excluding death as a cause of 1.20 (1.12 to 1.28), 1.27 (1.14 to 1.41), 1.50 (1.36 to 1.66), 1.11 (1.02 to 1.20), and 0.94 (0.81 to 1.09), respectively. Considering external comparator groups, and comparing with IgAN, autosomal dominant polycystic kidney disease (ADPKD) and diabetic nephropathy associated with higher HRs for mortality [1.22 (1.12 to 1.34) and 2.57 (2.35 to 2.82), respectively], but ADPKD associated with a lower HR for allograft failure excluding death as a cause [0.85 (0.79 to 0.91)]. Reasons for differential outcomes by GN subtype and cause of ESRD should be examined in future research.
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Affiliation(s)
| | - Sai Liu
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Maria E Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Colin R Lenihan
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Richard A Lafayette
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Wolfgang C Winkelmayer
- Section of Nephrology, Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas
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47
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FSGS Recurrence in Adults after Renal Transplantation. BIOMED RESEARCH INTERNATIONAL 2016; 2016:3295618. [PMID: 27144163 PMCID: PMC4842050 DOI: 10.1155/2016/3295618] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 03/27/2016] [Indexed: 12/18/2022]
Abstract
Recurrence of focal segmental glomerulosclerosis (FSGS) in the allograft occurs in 30–50% of patients, and it is associated with poor renal allograft survival. Major risk factors for recurrence are younger age at diagnosis, rapid progression to end-stage renal disease, white race, and the loss of previous allografts due to recurrence. Recent data support the hypothesis that circulating permeability factors play a crucial role in podocyte injury and progression of FSGS. Due to lack of controlled trials, the management of recurrent FSGS is inconsistent and highly empirical. Prophylactic and perioperative treatment with plasmapheresis and high-dose (intravenous) cyclosporine represent the main cornerstones of immunosuppressive therapy. In recent years, therapy with rituximab has shown promising results. Despite evidence of activation of the renin-angiotensin system (RAS) in recurrent FSGS and its association with progression, only limited data exist on the renoprotective role of RAS blockade in this setting. Further well designed studies are needed on pathogenesis risk factors and therapeutical options in FSGS and its recurrence after transplantation.
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48
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Saito H, Hamasaki Y, Tojo A, Shintani Y, Shimizu A, Nangaku M. Phospholipase A2 receptor positive membranous nephropathy long after living donor kidney transplantation between identical twins. Nephrology (Carlton) 2016; 20 Suppl 2:101-4. [PMID: 26031599 DOI: 10.1111/nep.12458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2015] [Indexed: 02/05/2023]
Abstract
Although membranous nephropathy (MN) is a commonly observed cause of post-transplant glomerulonephritis, distinguishing de novo from recurrent MN in kidney allograft is often difficult. Phospholipase A2 receptor (PLA2R) staining is useful for diagnosing recurrent MN in allografts similarly to idiopathic MN in native kidney. No specific treatment strategy has been established for MN, especially when accompanied with HCV infection in kidney transplant recipients. This report describes a 66-year-old man who was diagnosed as having PLA2R positive membranous nephropathy accompanied with already-known IgA nephropathy and HCV infection 26 years after kidney transplantation conducted between identical twins. PLA2R was detected along capillary loops, implying that this patient is affected by the same pathogenic mechanism as idiopathic MN, not secondary MN associated with other disorders such as HCV infection. The patient successfully achieved clinical remission after steroid therapy.
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Affiliation(s)
- Hisako Saito
- Division of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Yoshifumi Hamasaki
- Division of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Akihiro Tojo
- Division of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Yukako Shintani
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
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49
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Farooqui M, Alsaad K, Aloudah N, Alhamdan H. Treatment-resistant recurrent membranoproliferative glomerulonephritis in renal allograft responding to rituximab: case report. Transplant Proc 2016; 47:823-6. [PMID: 25891740 DOI: 10.1016/j.transproceed.2015.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 02/09/2015] [Indexed: 10/23/2022]
Abstract
We report a case of idiopathic membranoproliferative glomerulonephritis (MPGN) recurring 2 years after a living-unrelated kidney transplantation. The disease was refractory to intravenous immunoglobulin and plasmapheresis. Treatment with 2 doses of rituximab resulted in remission of the disease. The disease relapsed 18 months later after an episode of cytomegalovirus pneumonitis. After treatment of the pneumonitis, a lung biopsy was performed owing to persistent chest symptoms, which revealed bronchiolitis obliterans with organizing pneumonia. Bone marrow examination and culture revealed presence of acid-fast bacilli, and culture grew Mycobacterium tuberculosis. A repeated course of rituximab was withheld because of infection with tuberculosis, the patient's chest symptoms, and rare reports of noninfectious lung disease after the use of rituximab. The patient continues to have proteinuria with impaired kidney function.
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Affiliation(s)
- M Farooqui
- Division of Nephrology, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - K Alsaad
- Department of Pathology and Laboratory Medicine, King Abdullah International Medical Research Center and College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - N Aloudah
- Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - H Alhamdan
- Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Akl AI, Adel H, Rahim MA, Wafa EW, Shokeir AA. Outcome of glomerulonephritis in live-donor renal transplant recipients: A single-centre experience. Arab J Urol 2015; 13:295-305. [PMID: 26609451 PMCID: PMC4656810 DOI: 10.1016/j.aju.2015.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 08/31/2015] [Accepted: 09/03/2015] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES To investigate the frequency and risk factors affecting the incidence of post-transplantation glomerulonephritis (GN) and the impact of GN on the survival of the graft and the patient. PATIENTS AND METHODS Patients were classified based on histological findings into three groups. Graft survival was ascertained using the Kaplan-Meier method and significance calculated using log-rank tests. For multivariate analysis the Cox model was used. RESULTS Transplant glomerulopathy was the most prevalent glomerular disease in our series followed by recurrent GN and lastly de novo GN. In all, 50% of the de novo GN group had diabetes. The worst graft outcomes were in the recurrent GN group (P = 0.044). Multivariate analysis revealed ageing of the graft and mammalian target of rapamycin (mTOR) immunosuppression as risk factors for development of GN. While, the age of the recipient and donor, anti-lymphocyte globulin induction therapy, and acute rejection were risk factors for poor graft outcomes. CONCLUSIONS GN is an important issue after transplantation. Tracking the incidence and progression of histological findings in the graft may help to guide proper management and improve graft outcome.
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Affiliation(s)
- Ahmed Ibrahim Akl
- Department of Nephrology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Hany Adel
- Department of Nephrology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Mona Abdel Rahim
- Department of Pathology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Ehab Wahba Wafa
- Department of Nephrology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Ahmed A Shokeir
- Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
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