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Korkor MS, El-Desoky T, Mosaad YM, Salah DM, Hammad A. Multidrug resistant 1 (MDR1) C3435T and G2677T gene polymorphism: impact on the risk of acute rejection in pediatric kidney transplant recipients. Ital J Pediatr 2023; 49:57. [PMID: 37198710 DOI: 10.1186/s13052-023-01469-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 05/01/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Tacrolimus is the backbone drug in kidney transplantation. Single nucleotide polymorphism of Multidrug resistant 1 gene can affect tacrolimus metabolism consequently it can affect tacrolimus trough level and incidence of acute rejection. The aim of this study is to investigate the impact of Multidrug resistant 1 gene, C3435T and G2677T Single nucleotide polymorphisms on tacrolimus pharmacokinetics and on the risk of acute rejection in pediatric kidney transplant recipients. METHODS Typing of Multidrug resistant 1 gene, C3435T and G2677T gene polymorphism was done using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) for 83 pediatric kidney transplant recipients and 80 matched healthy controls. RESULTS In Multidrug resistant 1 gene (C3435T), CC, CT genotypes and C allele were significantly associated with risk of acute rejection when compared to none acute rejection group (P = 0.008, 0.001 and 0.01 respectively). The required tacrolimus doses to achieve trough level were significantly higher among CC than CT than TT genotypes through the 1st 6 months after kidney transplantation. While, in Multidrug resistant 1 gene (G2677T), GT, TT genotypes and T allele were associated with acute rejection when compared to none acute rejection (P = 0.023, 0.033 and 0.028 respectively). The required tacrolimus doses to achieve trough level were significantly higher among TT than GT than GG genotypes through the 1st 6 months after kidney transplantation. CONCLUSION The C allele, CC and CT genotypes of Multidrug resistant 1 gene (C3435T) and the T allele, GT and TT genotypes of Multidrug resistant 1 gene (G2677T) gene polymorphism may be risk factors for acute rejection and this can be attributed to their effect on tacrolimus pharmacokinetics. Tacrolimus therapy may be tailored according to the recipient genotype for better outcome.
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Affiliation(s)
- Mai S Korkor
- Pediatric Nephrology Unit, Mansoura University Children's Hospital, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
| | - Tarek El-Desoky
- Pediatric respiratory and allergy Unit, Faculty of Medicine, Mansoura University Children's Hospital, Mansoura University, Mansoura, Egypt
| | - Youssef M Mosaad
- Clinical Immunology Unit, clinical pathology department and Mansoura Research center for cord stem cells (MARC_CSC), Faculty of medicine, Mansura University, Mansoura, Egypt
| | - Doaa M Salah
- Pediatric Department, Pediatric Nephrology Unit & Kidney Transplantation Unit, Cairo University Children Hospital, Kasr Al-Ainy Faculty of Medicine, Cairo University , Cairo, Egypt
| | - Ayman Hammad
- Pediatric Nephrology Unit, Mansoura University Children's Hospital, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Bajaj S, Gershony S, Afshar K, Blydt-Hansen TD. Clinical indicators of slow graft function and outcome after pediatric kidney transplantation. Pediatr Transplant 2022; 26:e14353. [PMID: 35781749 DOI: 10.1111/petr.14353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 06/06/2022] [Accepted: 06/07/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Lesser degrees of perioperative ischemia-reperfusion injury that does not require dialysis may nonetheless influence allograft outcomes, necessitating evaluation of suitable surrogate indicators of perioperative allograft injury. METHODS This retrospective analysis of pediatric kidney transplants evaluated two indicators representing pace and completeness of recovery, for association with 12-month estimated glomerular filtration rate (eGFR) and first-year rate of eGFR decline: time to creatinine nadir (TTN) and ratio of recipient/donor unadjusted GFR (uGFRR/D ) at 1-month post-transplant. Donor, recipient, and perioperative risk factors were tested further for association with these 2 indicators. RESULTS 179 patients (190 transplants) aged 13 (IQR 7-17) years and 56% male were included. Twelve-month eGFR was strongly associated with unadjusted GFR at 1 month (uGFR1M , p < .001) and uGFRR/D (p = .003), but not with TTN. None of the indicators was associated with the rate of subsequent eGFR decline after 1-month post-transplant. As a potential surrogate indicator, uGFR1M is effectively modeled by TTN and uGFRR/D (adjusted R2 = 0.57) and is associated with 12-month eGFR (β = 0.81 ± 0.08; p < .001). Clinical factors associated with uGFRR/D included donor uGFR (p < .001), BSA (p = .026), age (p = .074), and recipient BSA (p < .001). Factors associated with pace of recovery (TTN) included donor uGFR (p = .018), type (p = .019), and recipient BSA (p = .022). CONCLUSIONS The uGFRR/D ratio, but not TTN, is a useful indicator of perioperative allograft damage that is associated with one-year functional outcome; and uGFR1M is a potential early surrogate outcome. Donor, recipient, and perioperative factors that are associated with slow allograft function are identified.
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Affiliation(s)
- Sargun Bajaj
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sharon Gershony
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kourosh Afshar
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tom David Blydt-Hansen
- Department of Pediatrics (Nephrology), University of British Columbia, Vancouver, British Columbia, Canada
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3
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Early prediction of renal graft function: Analysis of a multi-center, multi-level data set. Curr Res Transl Med 2022; 70:103334. [DOI: 10.1016/j.retram.2022.103334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/05/2022] [Accepted: 01/14/2022] [Indexed: 11/20/2022]
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4
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Ha J, Jung CW, Choi S, Kim MG, Gwon JG, Kim JK, Kim CD, Min JW, Yang J, Ahn C. Impact of acute kidney injury on graft outcomes of deceased donor kidney transplantation: A nationwide registry-based matched cohort study in Korea. PLoS One 2021; 16:e0260076. [PMID: 34788335 PMCID: PMC8598029 DOI: 10.1371/journal.pone.0260076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 11/02/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Favorable long-term and short-term graft survival and patient survival after kidney transplantation (KT) from deceased donors with acute kidney injury (AKI) have been reported. However, few studies have evaluated effects of donor AKI status on graft outcomes after KT in Asian population. Thus, the purpose of this study was to evaluate graft function after KTs from donors with AKI compared to matched KTs from donors without AKI using a multicenter cohort in Korea. METHODS We analyzed a total of 1,466 KTs collected in Korean Organ Transplant Registry between April 2014 and December 2017. KTs from AKI donors (defined as donors with serum creatinine level ≥ 2 mg/dL) and non-AKI donors (275 cases for each group) were enrolled using a 1:1 propensity score matching. Graft outcomes including graft and patient survival, delayed graft function (DGF), rejection rate, and serially measured estimated glomerular filtration rate (eGFR) were evaluated. RESULTS After propensity matching, KTs from AKI donors showed higher rate of DGF (44.7% vs. 24.0%, p < 0.001). However, the rejection rate was not significantly different between the two groups (KTs from AKI donors vs. KTs from non-AKI donors). eGFRs measured after 6 months, 1 year, 2 years and 3 years were not significantly different by donor AKI status. With median follow-up duration of 3.52 years, cox proportional hazards models revealed hazard ratio of 0.973 (95% confidence interval [CI], 0.584 to 1.621), 1.004 (95% CI, 0.491 to 2.054) and 0.808 (95% confidence interval [CI], 0.426 to 1.532) for overall graft failure, death-censored graft failure and patient mortality, respectively, in KTs from AKI donors compared to KTs from non-AKI donors as a reference. CONCLUSIONS KTs from AKI donors showed comparable outcomes to KTs from non-AKI donors, despite a higher incidence of DGF. Results of this study supports the validity of using kidneys from deceased AKI donors in Asian population.
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Affiliation(s)
- Jane Ha
- Department of Medicine, Korea University College of Medicine, Seoul, Korea
| | - Cheol Woong Jung
- Department of Surgery, Korea University Anam Hospital, Seoul, Korea
| | - Sunkyu Choi
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Myung-Gyu Kim
- Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Jun Gyo Gwon
- Department of Surgery, Korea University Anam Hospital, Seoul, Korea
| | - Joong Kyung Kim
- Department of Internal Medicine, Bongseng Memorial Hospital, Busan, Korea
| | - Chan-Duck Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Ji Won Min
- Division of Nephrology, Department of Internal Medicine, Bucheon St. Mary’s Hospital, Bucheon, Korea
| | - Jaeseok Yang
- Department of Nephrology, Seoul National University Hospital, Seoul, Korea
| | - Curie Ahn
- Department of Nephrology, Seoul National University Hospital, Seoul, Korea
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5
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Dong JJ, Cao J, Gill J, Miles C, Plumb T. Functional joint models for chronic kidney disease in kidney transplant recipients. Stat Methods Med Res 2021; 30:1932-1943. [PMID: 33970050 DOI: 10.1177/09622802211009265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This functional joint model paper is motivated by a chronic kidney disease study post kidney transplantation. The available kidney organ is a scarce resource because millions of end-stage renal patients are on the waiting list for kidney transplantation. The life of the transplanted kidney can be extended if the progression of the chronic kidney disease stage can be slowed, and so a major research question is how to extend the transplanted kidney life to maximize the usage of the scarce organ resource. The glomerular filtration rate is the best test to monitor the progression of the kidney function, and it is a continuous longitudinal outcome with repeated measures. The patient's survival status is characterized by time-to-event outcomes including kidney transplant failure, death with kidney function, and death without kidney function. Few studies have been carried out to simultaneously investigate these multiple clinical outcomes in chronic kidney disease stage patients based on a joint model. Therefore, this paper proposes a new functional joint model from this clinical chronic kidney disease study. The proposed joint models include a longitudinal sub-model with a flexible basis function for subject-level trajectories and a competing-risks sub-model for multiple time-to event outcomes. The different association structures can be accomplished through a time-dependent function of shared random effects from the longitudinal process or the whole longitudinal history in the competing-risks sub-model. The proposed joint model that utilizes basis function and competing-risks sub-model is an extension of the standard linear joint models. The application results from the proposed joint model can supply some useful clinical references for chronic kidney disease study post kidney transplantation.
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Affiliation(s)
- Jianghu James Dong
- Department of Biostatistics, University of Nebraska Medical Center, NE, USA.,Division of Nephrology, University of Nebraska Medical Center, NE, USA
| | - Jiguo Cao
- Department of Statistics and Actuarial Science, Simon Fraser University, Burnaby, Canada
| | - Jagbir Gill
- Department of Medicine, University of British Columbia, BC, Canada
| | - Clifford Miles
- Division of Nephrology, University of Nebraska Medical Center, NE, USA
| | - Troy Plumb
- Division of Nephrology, University of Nebraska Medical Center, NE, USA
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6
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Atay FF, Taskapan H, Berktas B, Yildirim O, Dogan M, Piskin T. Factors Affecting eGFR Slope of Renal Transplant Patients During the First 2 Years. Transplant Proc 2019; 51:2318-2320. [PMID: 31400970 DOI: 10.1016/j.transproceed.2019.01.165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 01/21/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE In healthy individuals, glomerular filtration rate decreases by 1 mL/min/y after a peak level of 125.0 mL/min has been reached in adulthood. Any reduction greater than this is a progressive slope (slope more negative than -1 mL/min/y, stable [-1 to +1]), or an improvable slope if it shows more of an increase, that is, greater than +1.0 mL/min/y). The aim of the study was to determine the factors affecting estimated glomerular filtration rate (eGFR) slope during the first 2 years of renal transplant in patients with negative pretransplant panel-reactive antibody. MATERIALS AND METHODS The characteristics of 59 renal transplant patients, such as age, sex, etiology, and 2 years of laboratory data, were collected retrospectively. For each patient, the eGFR decline rate (slope) (mL/min-1/1.73 m2-1/y-1) was determined by linear regression analysis using all calculated eGFR values over the study period. FINDINGS Of 59 patients, 7 (11.8%) had a progressive slope, 22 (37.2%) had a stable slope, and 30 (50.8%) had an improvable slope. The first-year mean tacrolimus level was lower in patients with progressive slope than in the patients with stable slope and improvable slope (P < .022). The determinants of eGFR slope in multiple regression analysis were post-transplant hypertension (β = -0.393; P = .002) and the first-year mean tacrolimus level (β = 0.320; P = .01), whereas age, serum albumin, and 2-year mean tacrolimus level did not reach the level of significance. CONCLUSION Keeping tacrolimus levels high in the first year to prevent eGFR declining is important.
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Affiliation(s)
| | | | | | | | - Murat Dogan
- General Surgery, Inonu University, Malatya, Turkey
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7
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Lucero OM, Echaiz CF, Jafarian F, Fox MC, Vetto JT, Mueller RV, Teixeira PG, Zwald FO, Leitenberger JJ. Keratinocyte carcinomas arising near arteriovenous fistulas: Case series and safety considerations for dermatologic surgery: A report of the International Transplant Skin Cancer Collaborative. JAAD Case Rep 2018; 5:7-11. [PMID: 30547074 PMCID: PMC6282447 DOI: 10.1016/j.jdcr.2018.08.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Olivia M Lucero
- Department of Dermatology, Oregon Health and Sciences University, Portland, Oregon
| | | | - Fatemeh Jafarian
- Division of Dermatology, McGill University Health Center, Montreal, Canada
| | - Matthew C Fox
- Department of Dermatology, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - John T Vetto
- Department of Surgery, Oregon Health and Sciences University, Portland, Oregon
| | - Reid V Mueller
- Department of Surgery, Oregon Health and Sciences University, Portland, Oregon
| | - Pedro G Teixeira
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, Texas
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8
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Vest LS, Koraishy FM, Zhang Z, Lam NN, Schnitzler MA, Dharnidharka VR, Axelrod D, Naik AS, Alhamad TA, Kasiske BL, Hess GP, Lentine KL. Metformin use in the first year after kidney transplant, correlates, and associated outcomes in diabetic transplant recipients: A retrospective analysis of integrated registry and pharmacy claims data. Clin Transplant 2018; 32:e13302. [PMID: 29851159 PMCID: PMC6122956 DOI: 10.1111/ctr.13302] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2018] [Indexed: 12/18/2022]
Abstract
While guidelines support metformin as a therapeutic option for diabetic patients with mild-to-moderate renal insufficiency, the frequency and outcomes of metformin use in kidney transplant recipients are not well described. We integrated national U.S. transplant registry data with records from a large pharmaceutical claims clearinghouse (2008-2015). Associations (adjusted hazard ratio, 95% LCL aHR95% UCL ) of diabetes regimens (with and excluding metformin) in the first year post-transplant with patient and graft survival over the subsequent year were quantified by multivariate Cox regression, adjusted for recipient, donor, and transplant factors and propensity for metformin use. Among 14 144 recipients with pretransplant type 2 diabetes mellitus, 4.7% filled metformin in the first year post-transplant; most also received diabetes comedications. Compared to those who received insulin-based regimens without metformin, patients who received metformin were more likely to be female, have higher estimated glomerular filtration rates, and have undergone transplant more recently. Metformin-based regimens were associated with significantly lower adjusted all-cause (aHR 0.18 0.410.91 ), malignancy-related (aHR 0.45 0.450.99 ), and infection-related (aHR 0.12 0.320.85 ) mortality, and nonsignificant trends toward lower cardiovascular mortality, graft failure, and acute rejection. No evidence of increased adverse graft or patient outcomes was noted. Use of metformin-based diabetes treatment regimens may be safe in carefully selected kidney transplant recipients.
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Affiliation(s)
- L S Vest
- Saint Louis University, St. Louis, MO, USA
| | | | - Z Zhang
- Saint Louis University, St. Louis, MO, USA
| | - N N Lam
- University of Alberta, Edmonton, AB, Canada
| | | | | | | | - A S Naik
- Univ Michigan, Ann Arbor, MI, USA
| | | | | | - G P Hess
- Symphony Health, Conshohocken, PN, USA
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9
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Kang DH, Park YS, Lee DY. Senotherapy for attenuation of cellular senescence in aging and organ implantation. J IND ENG CHEM 2018. [DOI: 10.1016/j.jiec.2017.08.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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10
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Chun N, Fairchild RL, Li Y, Liu J, Zhang M, Baldwin WM, Heeger PS. Complement Dependence of Murine Costimulatory Blockade-Resistant Cellular Cardiac Allograft Rejection. Am J Transplant 2017; 17:2810-2819. [PMID: 28444847 PMCID: PMC5912159 DOI: 10.1111/ajt.14328] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 04/03/2017] [Accepted: 04/20/2017] [Indexed: 01/25/2023]
Abstract
Building on studies showing that ischemia-reperfusion-(I/R)-injury is complement dependent, we tested links among complement activation, transplantation-associated I/R injury, and murine cardiac allograft rejection. We transplanted BALB/c hearts subjected to 8-h cold ischemic storage (CIS) into cytotoxic T-lymphocyte associated protein 4 (CTLA4)Ig-treated wild-type (WT) or c3-/- B6 recipients. Whereas allografts subjected to 8-h CIS rejected in WT recipients with a median survival time (MST) of 37 days, identically treated hearts survived >60 days in c3-/- mice (p < 0.05, n = 4-6/group). Mechanistic studies showed recipient C3 deficiency prevented induction of intragraft and serum chemokines/cytokines and blunted the priming, expansion, and graft infiltration of interferon-γ-producing, donor-reactive T cells. MST of hearts subjected to 8-h CIS was >60 days in mannose binding lectin (mbl1-/- mbl2-/- ) recipients and 42 days in factor B (cfb-/- ) recipients (n = 4-6/group, p < 0.05, mbl1-/- mbl2-/- vs. cfb-/- ), implicating the MBL (not alternative) pathway. To pharmacologically target MBL-initiated complement activation, we transplanted BALB/c hearts subjected to 8-h CIS into CTLA4Ig-treated WT B6 recipients with or without C1 inhibitor (C1-INH). Remarkably, peritransplantation administration of C1-INH prolonged graft survival (MST >60 days, p < 0.05 vs. controls, n = 6) and prevented CI-induced increases in donor-reactive, IFNγ-producing spleen cells (p < 0.05). These new findings link donor I/R injury to T cell-mediated rejection through MBL-initiated, complement activation and support testing C1-INH administration to prevent CTLA4Ig-resistant rejection of deceased donor allografts in human transplant patients.
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Affiliation(s)
- N Chun
- Department of Medicine, Translational Transplant Research Center, Recanati Miller Transplant Institute, Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - R L Fairchild
- Department of Immunology, Cleveland Clinic, Cleveland, OH
| | - Y Li
- Department of Medicine, Translational Transplant Research Center, Recanati Miller Transplant Institute, Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - J Liu
- Department of Medicine, Translational Transplant Research Center, Recanati Miller Transplant Institute, Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - M Zhang
- SUNY Downstate Medical Center, Brooklyn, NY
| | - W M Baldwin
- Department of Immunology, Cleveland Clinic, Cleveland, OH
| | - P S Heeger
- Department of Medicine, Translational Transplant Research Center, Recanati Miller Transplant Institute, Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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Huang Y, Tilea A, Gillespie B, Shahinian V, Banerjee T, Grubbs V, Powe N, Rios-Burrows N, Pavkov M, Saran R. Understanding Trends in Kidney Function 1 Year after Kidney Transplant in the United States. J Am Soc Nephrol 2017; 28:2498-2510. [PMID: 28270413 DOI: 10.1681/asn.2016050543] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 02/01/2017] [Indexed: 01/08/2023] Open
Abstract
Lower eGFR 1 year after kidney transplant is associated with shorter allograft and patient survival. We examined how practice changes in the past decade correlated with time trends in average eGFR at 1 year after kidney transplant in the United States in a cohort of 189,944 patients who received a kidney transplant between 2001 and 2013. We calculated the average eGFR at 1 year after transplant for the recipient cohort of each year using the appropriate Modification of Diet in Renal Disease equation depending on the prevailing methodology of creatinine measurement, and used linear regression to model the effects of practice changes on the national post-transplant eGFR trend. Between the 2001-2005 period and the 2011-2013 period, average 1-year post-transplant eGFR remained essentially unchanged, with differences of 1.34 (95% confidence interval, 1.03 to 1.65) ml/min per 1.73 m2 and 0.66 (95% confidence interval, 0.32 to 1.01) ml/min per 1.73 m2 among deceased and living donor kidney transplant recipients, respectively. Over time, the mean age of recipients increased and more marginal organs were used; adjusting for these trends unmasked a larger temporal improvement in post-transplant eGFR. However, changes in immunosuppression practice had a positive effect on average post-transplant eGFR and balanced out the negative effect of recipient/donor characteristics. In conclusion, average 1-year post-transplant eGFR remained stable, despite increasingly unfavorable attributes in recipients and donors. With an aging ESRD population and continued organ shortage, preservation of average post-transplant eGFR will require sustained improvement in immunosuppression and other aspects of post-transplant care.
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Affiliation(s)
- Yihung Huang
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Anca Tilea
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Brenda Gillespie
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Vahakn Shahinian
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Tanushree Banerjee
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California; and
| | - Vanessa Grubbs
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California; and
| | - Neil Powe
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California; and
| | | | - Meda Pavkov
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rajiv Saran
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan;
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12
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Xu Q, Qiu X, Jiao Z, Zhang M, Chen J, Zhong M. NFATC1 genotypes affect acute rejection and long-term graft function in cyclosporine-treated renal transplant recipients. Pharmacogenomics 2017; 18:381-392. [PMID: 28244807 DOI: 10.2217/pgs-2016-0171] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
AIM To investigate the effects of SNPs in the cyclophilin A/calcineurin/nuclear factor of activated T-cells (NFATs) pathway genes (PPIA, PPP3CB, PPP3R1, NFATC1 and NFATC2) on cyclosporine (CsA) efficacy in renal transplant recipients. MATERIALS & METHODS Seventy-six tag SNPs were detected in 155 CsA-treated renal recipients with at least a 5-year follow-up. The associations of SNPs with acute rejection, nephrotoxicity, pneumonia and estimated glomerular filtration rate post transplant were explored. RESULTS NFATC1 rs3894049 GC was a risk factor for acute rejection compared with CC carriers (p = 0.0005). NFATC1 rs2280055 TT carriers had a more stable estimated glomerular filtration rate level than CC (p = 0.0004). CONCLUSION Detecting NFATC1 polymorphisms could help predict CsA efficacy in renal transplant patients.
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Affiliation(s)
- Qinxia Xu
- Department of Pharmacy, Huashan hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, China
| | - Xiaoyan Qiu
- Department of Pharmacy, Huashan hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, China
| | - Zheng Jiao
- Department of Pharmacy, Huashan hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, China
| | - Ming Zhang
- Department of Nephrology, Huashan hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, China
| | - Jianping Chen
- Key Lab of Reproduction Regulation of NPFPC, SIPPR, IRD, Fudan University, 779 Lao Hu Min Road, Shanghai, China
| | - Mingkang Zhong
- Department of Pharmacy, Huashan hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, China
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13
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Coyne B, Hollen PJ, Yan G, Brayman K. Risk Factors for Graft Loss in Pediatric Renal Transplant Recipients After Transfer of Care. Prog Transplant 2016; 26:356-364. [PMID: 27683424 DOI: 10.1177/1526924816667952] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Improvements in transplantation have increased the survival of children after kidney transplantation. These patients have complex needs, and the current medical system is not prepared to effectively transfer the care of these individuals from pediatric to adult health-care systems. Too often, transfer occurs during moments of crisis and is associated with poor outcomes. OBJECTIVE The aim of this study was to use a national database, the Scientific Registry of Transplant Recipients, to test the hypothesis that the increased risk of graft loss after transfer of care (from pediatric to adult services) for young adult kidney transplant recipients over a 2- to 3-year posttransfer follow-up period was related to these posttransfer risk factors (medication noncompliance, acute rejection, insurance status). DESIGN A retrospective, longitudinal, correlational design using secondary data was used to evaluate the transfer of care of 250 kidney transplant recipients (ages 16-25). RESULTS Seventy-seven (30.8%) individuals lost their graft within 3 years after transfer of care. Medication noncompliance, acute rejection, and serum creatinine >2.0 mg/dL at transfer were significant predictors of graft loss after accounting for multiple other factors. CONCLUSION These individuals are at risk for graft loss after transfer of care and may benefit from increased personalized care during this risky period.
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Affiliation(s)
- Bethany Coyne
- 1 Department of Pediatrics, University of Virginia Health System, Charlottesville, VA, USA
- 2 School of Nursing, University of Virginia, Charlottesville, VA, USA
| | - Patricia J Hollen
- 1 Department of Pediatrics, University of Virginia Health System, Charlottesville, VA, USA
- 2 School of Nursing, University of Virginia, Charlottesville, VA, USA
| | - Guofen Yan
- 3 Department of Public Health Sciences, School of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Kenneth Brayman
- 4 Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
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Armero C, Forte A, Perpiñán H. Bayesian longitudinal models for paediatric kidney transplant recipients. J Appl Stat 2016. [DOI: 10.1080/02664763.2015.1063117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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15
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Trailin AV, Pleten MV, Ostapenko TI, Iefimenko NF, Nikonenko OS. High Serum Level of β2-Microglobulin in Late Posttransplant Period Predicts Subsequent Decline in Kidney Allograft Function: A Preliminary Study. DISEASE MARKERS 2015; 2015:562580. [PMID: 26633915 PMCID: PMC4655033 DOI: 10.1155/2015/562580] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 10/15/2015] [Accepted: 10/20/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND Identification of patients at risk for kidney allograft (KAG) failure beyond the first posttransplant year is an unmet need. We aimed to determine whether serum beta-2-microglobulin (β2MG) in the late posttransplant period could predict a decline in KAG function. METHODS We assessed a value of single measurement of serum β2MG at one to seventeen years after transplantation in predicting the estimated glomerular filtration rate (eGFR) and the decline in eGFR over a period of two years in 79 recipients of KAG. RESULTS At baseline serum β2MG concentration was higher (P = 0.011) in patients with allograft dysfunction: 8.67 ± 2.48 µg/mL versus those with satisfactory graft function: 6.67 ± 2.13 µg/mL. Higher β2MG independently predicted the lower eGFR, the drop in eGFR by ≥25% after one and two years, and the value of negative eGFR slope. When combined with proteinuria and acute rejection, serum β2MG had excellent power in predicting certain drop in eGFR after one year (AUC = 0.910). In conjunction with posttransplant time serum β2MG had good accuracy in predicting certain eGFR drop after two years (AUC = 0.821). CONCLUSIONS Elevated serum β2MG in the late posttransplant period is useful in identifying patients at risk for rapid loss of graft function.
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Affiliation(s)
- Andriy V. Trailin
- Department of Laboratory Diagnostics and General Pathology, State Institution “Zaporizhzhia Medical Academy of Postgraduate Education Ministry of Health of Ukraine”, 20 Winter Boulevard, Zaporizhzhia 69096, Ukraine
| | - Marina V. Pleten
- Department of Laboratory Diagnostics and General Pathology, State Institution “Zaporizhzhia Medical Academy of Postgraduate Education Ministry of Health of Ukraine”, 20 Winter Boulevard, Zaporizhzhia 69096, Ukraine
| | - Tatiana I. Ostapenko
- Department of Transplantology, Endocrine Surgery and Cardiovascular Surgery, State Institution “Zaporizhzhia Medical Academy of Postgraduate Education Ministry of Health of Ukraine”, Zaporizhzhia Regional Hospital, 10 Orikhiv Highway, Zaporizhzhia 69050, Ukraine
| | - Nadiia F. Iefimenko
- Department of Laboratory Diagnostics and General Pathology, State Institution “Zaporizhzhia Medical Academy of Postgraduate Education Ministry of Health of Ukraine”, 20 Winter Boulevard, Zaporizhzhia 69096, Ukraine
| | - Olexander S. Nikonenko
- Department of Transplantology, Endocrine Surgery and Cardiovascular Surgery, State Institution “Zaporizhzhia Medical Academy of Postgraduate Education Ministry of Health of Ukraine”, Zaporizhzhia Regional Hospital, 10 Orikhiv Highway, Zaporizhzhia 69050, Ukraine
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Bayesian Analysis of Glomerular Filtration Rate Trajectories in Kidney Transplant Recipients. Transplantation 2015; 99:533-9. [DOI: 10.1097/tp.0000000000000377] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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17
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Bahous SA, Khairallah M, Al Danaf J, Halaby R, Korjian S, Daaboul Y, Salameh P, Stephan A, Blacher J, Safar ME. Renal function decline in recipients and donors of kidney grafts: role of aortic stiffness. Am J Nephrol 2015; 41:57-65. [PMID: 25662778 DOI: 10.1159/000371858] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Accepted: 12/28/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Renal function decreases over time as a result of reduction in the number of functioning nephrons with age. In recipients and donors of kidney grafts, renal function decline may be linked differently to various parameters, namely arterial stiffness. METHODS We conducted a prospective cohort study including 101 recipients of kidney grafts and their donors aiming at determining the factors correlated to the renal function decline over time. Aortic stiffness was evaluated by the non-invasive measurement of aortic pulse wave velocity. The glomerular filtration rate was estimated using the Modification of Diet in Renal Disease (MDRD) equation and the annualized change was determined. RESULTS Decline in renal function was estimated at 1-year post-transplantation and annually thereafter (median follow-up 8 years, range 3.6-18.3), as the mean of the annualized decrease in the glomerular filtration rate. In recipients, filtration rate decreased by 4.8 ± 19.7 ml/min/1.73 m(2) the first post-transplant year and at a yearly rate of 2.2 ± 3.8 ml/min/1.73 m(2) thereafter. The first-year decline was related to smoking and acute rejection. Later decline was significantly associated with donor age and aortic stiffness. In living donors, renal function decline after the first year corresponded to 0.7 ml/min/1.73 m(2), was significantly lower than that of recipients (p < 0.001), and was determined by donor age at nephrectomy. CONCLUSION Recipients of kidney grafts show a glomerular filtration rate decline over time that is significantly associated with donor age and aortic stiffness after the first post-transplant year, while donors demonstrate a lower decline that is mostly determined by age at nephrectomy.
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Affiliation(s)
- Sola Aoun Bahous
- Division of Nephrology and Renal Transplantation, University Medical Center-Rizk Hospital, Ashrafieh, Beirut, Lebanon
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Enhanced posttransplant management of patients with diabetes improves patient outcomes. Kidney Int 2014; 86:610-8. [DOI: 10.1038/ki.2014.70] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 01/11/2014] [Accepted: 01/16/2014] [Indexed: 01/30/2023]
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19
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Does the KDIGO CKD risk stratification based on GFR and proteinuria predict kidney graft failure? Int Urol Nephrol 2014; 46:1857-65. [DOI: 10.1007/s11255-014-0761-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 06/03/2014] [Indexed: 10/25/2022]
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20
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McCaughan JA, Courtney AE, Maxwell AP. Estimated glomerular filtration rate decline as a predictor of dialysis in kidney transplant recipients. Am J Nephrol 2014; 39:297-305. [PMID: 24732139 DOI: 10.1159/000360426] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 02/05/2014] [Indexed: 01/16/2023]
Abstract
BACKGROUND It is now common for individuals to require dialysis following the failure of a kidney transplant. Management of complications and preparation for dialysis are suboptimal in this group. To aid planning, it is desirable to estimate the time to dialysis requirement. The rate of decline in the estimated glomerular filtration rate (eGFR) may be used to this end. METHODS This study compared the rate of eGFR decline prior to dialysis commencement between individuals with failing transplants and transplant-naïve patients. The rate of eGFR decline was also compared between transplant recipients with and without graft failure. eGFR was calculated using the four-variable MDRD equation with rate of decline calculated by least squares linear regression. RESULTS The annual rate of eGFR decline in incident dialysis patients with graft failure exceeded that of the transplant-naïve incident dialysis patients. In the transplant cohort, the mean annual rate of eGFR decline prior to graft failure was 7.3 ml/min/1.73 m(2) compared to 4.8 ml/min/1.73 m(2) in the transplant-naïve group (p < 0.001) and 0.35 ml/min/1.73 m(2) in recipients without graft failure (p < 0.001). Factors associated with eGFR decline were recipient age, decade of transplantation, HLA mismatch and histological evidence of chronic immunological injury. CONCLUSIONS Individuals with graft failure have a rapid decline in eGFR prior to dialysis commencement. To improve outcomes, dialysis planning and management of chronic kidney disease complications should be initiated earlier than in the transplant-naïve population.
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Requião-Moura LR, Ferraz E, Matos ACC, Tonato EJ, Ozaki KS, Durão MS, Câmara NOS, Pacheco-Silva A. Comparison of long-term effect of thymoglobulin treatment in patients with a high risk of delayed graft function. Transplant Proc 2013; 44:2428-33. [PMID: 23026612 DOI: 10.1016/j.transproceed.2012.07.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND T-lymphocyte depletion is a strategy to reverse the impact of ischemia-reperfusion injury (IRI) in progression to chronic allograft dysfunction, especially among patients at high risk for delayed graft function (DGF). METHODS The present work assessed the effect of thymoglobulin among a population with a high incidence of DGF. We analyzed 209 transplanted patients: 97 in the thymoglobulin and 112 in the control group. RESULTS The main complication was DGF (59.3%), with a similar incidence in both groups (63.9% vs. 55.3%; P = .36). Acute rejection episodes (ARE) were decreased with thymoglobulin (8.2% vs. 28.5%; P < .001), but cytomegalovirus viremia was 3.4-fold more frequent (58.3% vs. 17.1%; P < .001). One-year graft function was significantly better in the thymoglobulin group (59.2 ± 17.2 vs. 51.8 ± 15.3 mL/min; P = .004), even when censored by ARE (59.7 ± 17.5 vs. 53.3 ± 14.4; P = .023). The same difference was observed at the 2-year follow-up (P = .024), even when censored for ARE (P = .045). A multivariate analysis showed thymoglobulin to be a factor strongly associated with protection of graft function (P = .039). CONCLUSION Despite not reducing the incidence of DGF, thymoglobulin induction significantly reduced the incidence of ARE and showed a long-term profile of protection of renal graft function, independent of the reduction in ARE.
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Affiliation(s)
- L R Requião-Moura
- Universidade Federal de São Paulo, Division of Nephrology, Sao Paulo, Brazil
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22
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Abstract
Arterial hypertension is prevalent among kidney transplant recipients. The multifactorial pathogenesis involves the interaction of the donor and the recipient's genetic backgrounds with several environmental parameters that may precede or follow the transplant procedure (eg, the nature of the renal disease, the duration of the chronic kidney disease phase and maintenance dialytic therapy, the commonly associated cardiovascular disease with atherosclerosis and arteriosclerosis, the renal mass at implantation, the immunosuppressive regimen used, life of the graft, and de novo medical and surgical complications that may occur after a transplant). Among calcineurin inhibitors, tacrolimus seems to have a better cardiovascular profile. Steroid-free protocols and calcineurin inhibitor-free regimens seem to be associated with better blood pressure control. Posttransplant hypertension is a major amplifier of the chronic kidney disease-cardiovascular disease continuum. Despite the adverse effects of hypertension on graft and patient survival, blood pressure control remains poor because of the high cardiovascular risk profile of the donor-recipient pair. Although the optimal blood pressure level remains unknown, it is recommended to maintain the blood pressure at < 130/80 mm Hg and < 125/75 mm Hg in the absence or presence of proteinuria.
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Affiliation(s)
- Antoine Barbari
- Renal Transplantation Unit, Rafik Hariri University Hospital, Bir Hassan, Beirut-Lebanon.
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23
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Moranne O, Maillard N, Fafin C, Thibaudin L, Alamartine E, Mariat C. Rate of renal graft function decline after one year is a strong predictor of all-cause mortality. Am J Transplant 2013; 13:695-706. [PMID: 23311466 DOI: 10.1111/ajt.12053] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 11/05/2012] [Accepted: 11/08/2012] [Indexed: 01/25/2023]
Abstract
The slope of GFR associates with an increased risk for death in patients with native CKD but whether a similar association exists in kidney transplantation is not known. We studied an inception cohort of 488 kidney transplant recipients (mean follow-up of 12 ± 4 years) for whom GFR was longitudinally measured by inulin clearance (mGFR) at 1 year and then every 5 years. Association of mGFR at 1 year posttransplant and GFR slope after the first year with all-cause mortality was studied with a Cox regression model and a Fine and Gray competing risk model. While in Crude analysis, the mGFR value at 1 year posttransplant and the rate of mGFR decline were both associated with a higher risk of all-cause mortality, only the slope of mGFR remained a significant and strong predictor of death in multivariate analysis. Factors independently associated with a more rapid mGFR decline were feminine gender, higher HLA mismatch, retransplantation, longer duration of transplantation, CMV infection during the first year and higher rate of proteinuria. Our data suggest that the rate of renal graft function decline after 1 year is a strong predictor of all-cause mortality in kidney transplantation.
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Affiliation(s)
- O Moranne
- Service de Néphrologie, Département de Santé Publique, Hôpital Pasteur et Larchet, CHU de NICE, France.
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Identification and characterization of kidney transplants with good glomerular filtration rate at 1 year but subsequent progressive loss of renal function. Transplantation 2013; 94:931-9. [PMID: 23044665 DOI: 10.1097/tp.0b013e3182692b70] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND After the first year after kidney transplantation, 3% to 5% of grafts fail each year but detailed studies of how grafts progress to failure are lacking. This study aimed to analyze the functional stability of kidney transplants between 1 and 5 years after transplantation and to identify initially well-functioning grafts with progressive decline in allograft function. METHODS The study included 788 adult conventional kidney transplants performed at the Mayo Clinic Rochester between January 2000 and December 2005 with a minimum graft survival and follow-up of 2.6 years. The modification of diet in renal disease equation for estimating glomerular filtration rate (eGFR(MDRD)) was used to calculate the slope of renal function over time using all available serum creatinine values between 1 and 5 years after transplantation. RESULTS Most transplants demonstrated good function (eGFR(MDRD) ≥40 mL/min) at 1 year with positive eGFR(MDRD) slope between 1 and 5 years after transplantation. However, a subset of grafts with 1-year eGFR(MDRD) ≥40 mL/min exhibited strongly negative eGFR(MDRD) slope between 1 and 5 years suggestive of progressive loss of graft function. Forty-one percent of this subset reached graft failure during follow-up, accounting for 69% of allograft failures occurring after 2.5 years after transplantation. This pattern of progressive decline in estimated glomerular filtration rate despite good early function was associated with but not fully attributable to factors suggestive of enhanced antidonor immunity. CONCLUSIONS Longitudinal analysis of serial estimated glomerular filtration ratemeasurements identifies initially well-functioning kidney transplants at high risk for subsequent graft loss. For this subset, further studies are needed to identify modifiable causes of functional decline.
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Braun H, Schmidt BMW, Raiss M, Baisantry A, Mircea-Constantin D, Wang S, Gross ML, Serrano M, Schmitt R, Melk A. Cellular senescence limits regenerative capacity and allograft survival. J Am Soc Nephrol 2012; 23:1467-73. [PMID: 22797186 DOI: 10.1681/asn.2011100967] [Citation(s) in RCA: 132] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Long-term graft survival after kidney transplantation remains unsatisfactory and unpredictable. Interstitial fibrosis and tubular atrophy are major contributors to late graft loss; features of tubular cell senescence, such as increased p16(INK4a) expression, associate with these tubulointerstitial changes, but it is unknown whether the relationship is causal. Here, loss of the INK4a locus in mice, which allows escape from p16(INK4a)-dependent senescence, significantly reduced interstitial fibrosis and tubular atrophy and associated with improved renal function, conservation of nephron mass, and transplant survival. Compared with wild-type controls, kidneys from INK4a(-/-) mice developed significantly less interstitial fibrosis and tubular atrophy after ischemia-reperfusion injury. Consistently, mice that received kidney transplants from INK4a/ARF(-/-) donors had significantly better survival 21 days after life-supporting kidney transplantation and developed less tubulointerstitial changes. This correlated with higher proliferative rates of tubular cells and significantly fewer senescent cells. Taken together, these data suggest a pathogenic role of renal cellular senescence in the development of interstitial fibrosis and tubular atrophy and kidney graft deterioration by preventing the recovery from injury. Inhibiting premature senescence could have therapeutic benefit in kidney transplantation but has to be balanced against the risks of suspending antitumor defenses.
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Affiliation(s)
- Heidi Braun
- Department of Kidney, Liver and Metabolic Diseases, Children's Hospital, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625 Hannover, Germany
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26
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Khalkhali HR, Ghafari A. Prediction of long-term kidney failure in renal transplant with chronic allograft dysfunction using stage-specific hazard rates. EXP CLIN TRANSPLANT 2012; 10:8-13. [PMID: 22309413 DOI: 10.6002/ect.2011.0049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES The process of kidney failure in renal transplant recipients with chronic allograft dysfunction is characterized by a progressive decline in glomerular filtration rate over time that it is determined by the 5-stage model. This study used stage-based statistical survival analysis to predict graft survival in renal transplant recipients with chronic allograft dysfunction. MATERIALS AND METHODS In a single-center, retrospective study, 214 renal transplant recipients with chronic allograft dysfunction were investigated at a university hospital in Iran from 1997 to 2005. At each patient visit, kidney function was assessed using glomerular filtration rate and stage of disease. RESULTS The estimated stage-specific hazard rates of disease progression are stage one, 453.936; stage two, 485.040; stage three, 545.808; and stage four; 649.488 per 1000 person-years. The estimated mean times in each stage were as follows: kidney damage with normal or increased glomerular filtration rate, 26.43 months; kidney damage with mildly decreased glomerular filtration rate, 24.74 months; moderate kidney disease, 21.98 months; and severe kidney disease; 18.48 months. These estimates yield a mean time from stage 1 to kidney failure of 91.63 months. The probability of graft survival was predicted using estimated stage-specific hazard rates. The 18th, 58th, 118th, and 155th months death-censored graft survival probabilities were 0.99, 0.75, 0.25, and 0.10. CONCLUSIONS In this method of survival analysis, we can determine a statistical model according to a real clinical model in renal transplant recipients with chronic allograft dysfunction. It enables us to determine the stage-specific hazard rates of disease progression. These findings can help nephrologists to understand the kidney disease process and better predict graft survival.
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Affiliation(s)
- Hamid Reza Khalkhali
- Department of Epidemiology and Biostatistics, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran.
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27
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Association Between Preoperative Allograft Function (Effective Renal Plasma Flow) and the Change in Glomerular Filtration Rate Among Living-Donor Kidney Transplant Recipients. Transplant Proc 2012; 44:248-53. [DOI: 10.1016/j.transproceed.2011.11.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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28
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Henze A, Raila J, Kempf C, Reinke P, Sefrin A, Querfeld U, Schweigert FJ. Vitamin A metabolism is changed in donors after living-kidney transplantation: an observational study. Lipids Health Dis 2011; 10:231. [PMID: 22151790 PMCID: PMC3250968 DOI: 10.1186/1476-511x-10-231] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 12/07/2011] [Indexed: 11/10/2022] Open
Abstract
Background The kidneys are essential for the metabolism of vitamin A (retinol) and its transport proteins retinol-binding protein 4 (RBP4) and transthyretin. Little is known about changes in serum concentration after living donor kidney transplantation (LDKT) as a consequence of unilateral nephrectomy; although an association of these parameters with the risk of cardiovascular diseases and insulin resistance has been suggested. Therefore we analyzed the concentration of retinol, RBP4, apoRBP4 and transthyretin in serum of 20 living-kidney donors and respective recipients at baseline as well as 6 weeks and 6 months after LDKT. Results As a consequence of LDKT, the kidney function of recipients was improved while the kidney function of donors was moderately reduced within 6 weeks after LDKT. With regard to vitamin A metabolism, the recipients revealed higher levels of retinol, RBP4, transthyretin and apoRBP4 before LDKT in comparison to donors. After LDKT, the levels of all four parameters decreased in serum of the recipients, while retinol, RBP4 as well as apoRBP4 serum levels of donors increased and remained increased during the follow-up period of 6 months. Conclusion LDKT is generally regarded as beneficial for allograft recipients and not particularly detrimental for the donors. However, it could be demonstrated in this study that a moderate reduction of kidney function by unilateral nephrectomy, resulted in an imbalance of components of vitamin A metabolism with a significant increase of retinol and RBP4 and apoRBP4 concentration in serum of donors.
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Affiliation(s)
- Andrea Henze
- Institute of Nutritional Science, Department of Physiology and Pathophysiology, University of Potsdam, Nuthetal, Germany.
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29
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Snanoudj R, Royal V, Elie C, Rabant M, Girardin C, Morelon E, Kreis H, Fournet JC, Noël LH, Legendre C. Specificity of histological markers of long-term CNI nephrotoxicity in kidney-transplant recipients under low-dose cyclosporine therapy. Am J Transplant 2011; 11:2635-46. [PMID: 21883915 DOI: 10.1111/j.1600-6143.2011.03718.x] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The specificity of chronic histological lesions induced by calcineurin inhibitors (CNI) is often questioned, but few studies have directly compared long-term lesions in renal-transplant patients who received this treatment and those who did not. We therefore conducted a retrospective study of 141 kidney-transplant recipients treated with (n = 48) or without (n = 93) cyclosporine (CsA) to compare the histological lesions observed at 3-month, 24-month and 10-year protocol biopsies. All of the chronic elementary lesions (glomerulosclerosis, interstitial fibrosis, tubular atrophy, arteriolar hyalinosis, fibrointimal thickening) progressed in frequency and severity in both groups, although significantly more in the CsA group. Ten-year biopsy results showed that 92% of patients in the CsA-treated group and 65% in the control group had arteriolar hyalinosis lesions. When we focused on muscular arteriolar hyaline deposits more specific to CsA arteriolopathy, we observed these lesions in 68% of CsA patients and 28% of patients who had never received CsA. CsA was not the sole factor involved in the development of arteriolar hyalinosis and was independently associated with an increased risk of graft loss. In summary, we observed that histological lesions commonly attributed to CsA nephrotoxicity were not sufficiently specific to definitively diagnose CNI nephrotoxicity.
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Affiliation(s)
- R Snanoudj
- Service de Transplantation Rénale Adulte, Hopital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France.
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30
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Prevalence and Progression of Chronic Kidney Disease after Renal Transplantation. Transplant Proc 2011; 43:2587-91. [DOI: 10.1016/j.transproceed.2011.05.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Accepted: 05/24/2011] [Indexed: 11/17/2022]
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31
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Copley JB, Wüthrich RP. Therapeutic management of post-kidney transplant hyperparathyroidism. Clin Transplant 2011; 25:24-39. [PMID: 20572835 DOI: 10.1111/j.1399-0012.2010.01287.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Left uncontrolled, persistent post-kidney transplant hyperparathyroidism (HPT) may lead to or exacerbate pre-existing bone and cardiovascular disease. Parathyroidectomy has long been the primary treatment option for long-term uncontrolled HPT in post-kidney transplant patients. However, patients with contraindications for surgery and parathyroidectomy-associated complications, including graft loss, highlight the need for other approaches. Conventional medical therapies have limited impact on serum calcium (Ca) and parathyroid hormone (PTH) levels. Bisphosphonates and calcitonin, used to spare bone loss, and phosphorus supplementation, to correct hypophosphatemia, do not directly regulate PTH or Ca. Although vitamin D supplementation can reduce PTH, it is often contraindicated because of hypercalcemia. Studies of the calcimimetic cinacalcet in patients with post-kidney transplant HPT suggest that it can rapidly reduce serum PTH and Ca concentrations while increasing serum phosphorus concentrations toward the normal range. Although the clearest application for cinacalcet is the non-surgical treatment of hypercalcemic patients with persistent HPT, current indications for other transplant patients are as yet uncertain. Further studies are needed to determine the utility of cinacalcet in patients with spontaneous resolution of HPT or low bone turnover. This review discusses the pathophysiology of post-kidney transplant HPT, associated complications, and current options for clinical management.
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32
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Noppakun K, Cosio FG, Dean PG, Taler SJ, Wauters R, Grande JP. Living donor age and kidney transplant outcomes. Am J Transplant 2011; 11:1279-86. [PMID: 21564530 DOI: 10.1111/j.1600-6143.2011.03552.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We assessed the relationship between living donor (LD) age and kidney survival in 1063 adults transplanted between 1980 and 2007. Increasing LD age was associated with lower kidney function (GFR) before and after transplantation and loss of GFR beyond 1 year. Increasing LD age was also associated with low-moderate proteinuria posttransplant (151-1500 mg/day, p < 0.0001). By univariate analysis, reduced graft survival related to lower GFR at 1 year [HR = 0.925 (0.906-0.944), p < 0.0001], proteinuria [HR = 1.481 (1.333-1.646), p < 0.0001] and increasing LD age [HR = 1.271 (1.219-1.326), p = 0.001]. The impact of LD age on graft survival was noted particularly >4 years posttransplant and was modified by recipient age. Thus, compared to a kidney graft that was within 5 years of the recipient age, younger kidneys had a survival advantage [HR = 0.600 (0.380-0.949), p = 0.029] while older kidneys had a survival disadvantage [HR = 2.217 (1.507-3.261), p < 0.0001]. However, this effect was seen only in recipients <50 years old. By multivariate analysis, the relationship between LD age and graft survival was independent of GFR but related to proteinuria. In conclusion, LD age is an important determinant of long-term graft survival, particularly in younger recipients. Older kidneys with reduced survival are identifiable by the development of proteinuria posttransplant.
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Affiliation(s)
- K Noppakun
- Division of Nephrology and Hypertension, Department of Internal Medicine and William von Liebig transplant Center, Mayo Clinic, Rochester, MN, USA
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33
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Kasiske BL, Israni AK, Snyder JJ, Skeans MA. The relationship between kidney function and long-term graft survival after kidney transplant. Am J Kidney Dis 2011; 57:466-75. [PMID: 21257243 DOI: 10.1053/j.ajkd.2010.10.054] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Accepted: 10/26/2010] [Indexed: 12/27/2022]
Abstract
BACKGROUND Whether chronic kidney disease (CKD) staging provides a useful framework for predicting outcomes after kidney transplant is unclear. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS We used data from the Patient Outcomes in Renal Transplantation (PORT) Study, including 13,671 transplants from 12 centers during 10 years of follow-up. PREDICTOR Estimated glomerular filtration rate (eGFR; in milliliters per minute per 1.73 m(2)) at 12 months posttransplant. OUTCOMES All-cause graft failure (a composite end point consisting of return to dialysis therapy, pre-emptive retransplant, or death with function), death-censored graft failure, and death with a functioning graft. MEASUREMENTS The relationship between 12-month eGFR and subsequent graft outcomes through 10 years posttransplant was assessed using Cox proportional hazards analyses. RESULTS Stage 3 included 63% of patients and was subdivided into stages 3a (eGFR, 45-59 mL/min/1.73 m(2); 34%) and 3b (eGFR, 30-44 mL/min/1.73 m(2); 29%). Compared with stage 2 (eGFR, 60-89 mL/min/1.73 m(2); 24%), adjusted Cox proportional HRs for graft failure were 1.12 (95% CI, 1.01-1.24; P = 0.04) for stage 3a, 1.50 (95% CI, 1.35-1.66; P < 0.001) for stage 3b, 2.86 (95% CI, 2.53-3.22; P < 0.001) for stage 4 (eGFR, 15-29 mL/min/1.73 m(2); 9%), and 13.2 (95% CI, 10.7-16.4; P < 0.001) for stage 5 (eGFR <15 mL/min/1.73 m(2); 1%). For stage 1 (eGFR ≥ 90 mL/min/1.73 m(2); 3%), risk of graft failure was increased (1.41 [95% CI, 1.13-1.75]; P < 0.001), likely due to serum creatinine associations independent of kidney function. Similar associations were seen between CKD stages and mortality. LIMITATIONS Retrospective study; lack of gold-standard measurements of true GFR; lack of measures of comorbidity, inflammation, muscle mass, proteinuria, and other noncreatinine markers of eGFR. CONCLUSIONS CKD stages validated in the general population provide a useful framework for predicting outcomes after kidney transplant.
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Affiliation(s)
- Bertram L Kasiske
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN, USA.
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Requião-Moura L, de Souza Durão M, Tonato E, Carvalho Matos A, Ozaki K, Câmara N, Pacheco-Silva A. Effects of Ischemia and Reperfusion Injury on Long-Term Graft Function. Transplant Proc 2011; 43:70-3. [DOI: 10.1016/j.transproceed.2010.12.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Weir MR, Mulgaonkar S, Chan L, Shidban H, Waid TH, Preston D, Kalil RN, Pearson TC. Mycophenolate mofetil-based immunosuppression with sirolimus in renal transplantation: a randomized, controlled Spare-the-Nephron trial. Kidney Int 2010; 79:897-907. [PMID: 21191361 DOI: 10.1038/ki.2010.492] [Citation(s) in RCA: 149] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
As part of the Spare-the-Nephron trial, we evaluated the combination mycophenolate mofetil (MMF) and sirolimus (SRL) as a calcineurin inhibitor (CNI)-free regimen for the preservation of renal function in renal allograft recipients. This 2-year, open-label, multicenter trial randomized 299 patients of which 151 were maintained on MMF and a CNI, 148 on MMF plus SRL (n=120, tacrolimus; n=31, cyclosporine). Baseline characteristics including measured (iothalamate) glomerular filtration rate (GFR) were similar between groups. After 1 year, the mean percentage change from baseline in the primary end point of measured GFR was significantly higher in the MMF/SRL group compared with the MMF/CNI group. After 2 years, the change was indistinguishable. Calculated creatinine clearance and GFR were significantly greater with MMF/SRL at 2 years within which biopsy-proven acute rejection (BPAR) occurred in 14 MMF/SRL-treated patients (3 graft losses) and in 17 receiving the MMF/CNI (6 graft losses). Significantly, no patients receiving MMF/SRL but five treated with MMF/CNI died. Thus, compared with MMF/CNI treatment, a 2-year regimen of MMF/SRL resulted in similar measures of renal function but with fewer deaths and a trend to less BPAR and graft loss.
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Affiliation(s)
- Matthew R Weir
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA.
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Glomerular Filtration Rate Slopes Have Significantly Improved Among Renal Transplants in the United States. Transplantation 2010; 90:1499-505. [DOI: 10.1097/tp.0b013e3182003dda] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Udayaraj UP, Casula A, Ansell D, Dudley CRK, Ravanan R. Chronic kidney disease in kidney transplant recipients-is it different from chronic native kidney disease? Transplantation 2010; 90:765-70. [PMID: 20686443 DOI: 10.1097/tp.0b013e3181f00a04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The rate of change in estimated glomerular filtration rate (ΔeGFR), factors influencing ΔeGFR, and its association with mortality has not been well studied in renal transplant recipients. METHODS.: Adult kidney-only recipients between January 2001 and December 2004, with surviving grafts 1 year after transplantation, from England and Wales were followed up till 31 December 2006, graft failure or death. The four variable modification of diet in renal disease equation was used to estimate GFR and ΔeGFR assessed using linear least square regression. ΔeGFR of -1 mL/min/1.73m per year and above was considered to be stable or improving function. Linear regression and Cox regression analyses were used to examine factors influencing ΔeGFR and its association with mortality, respectively. RESULTS Of the 2, 927 patients included, ΔeGFR was -1.3±6.0 mL/min/1.73 m per year and eGFR remained stable or improved in the majority (54.8%). Baseline graft function at 1 year or live donor status did not influence ΔeGFR. Male donor to female recipient transplantation, younger recipients, diabetes, white race, and human leukocyte antigen mismatch were associated with faster decline in eGFR. ΔeGFR was not associated with mortality when censored for graft failure. CONCLUSIONS Majority of renal transplant recipients experienced stable or improved graft function. Specific donor and recipient characteristics influenced the rate of decline in eGFR. The lack of association of ΔeGFR with mortality, the stability of eGFR in the majority, and influence of donor characteristics on ΔeGFR suggest caution when applying prognosis knowledge from the native kidney disease to the kidney transplant population.
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Affiliation(s)
- Udaya P Udayaraj
- Richard Bright Renal Unit, Southmead Hospital, Southmead Road, Bristol, United Kingdom.
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Moore J, Tomson CRV, Tessa Savage M, Borrows R, Ferro CJ. Serum phosphate and calcium concentrations are associated with reduced patient survival following kidney transplantation. Clin Transplant 2010; 25:406-16. [PMID: 20608946 DOI: 10.1111/j.1399-0012.2010.01292.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The impact of disordered mineral and bone metabolism following kidney transplantation is not well defined. We studied the association of serum phosphate and calcium concentrations, and surrogate measures of arterial stiffness (augmentation index: AIx and Timing of the reflected wave: Tr), with long-term kidney transplant recipient and allograft survival. Prevalent adult renal transplant patients (n = 270) were prospectively studied over a median 88-month follow-up. Detailed demographic, clinical and laboratory data, in addition to both peripheral and central non-invasive blood pressure measurements, were recorded. Higher serum phosphate and calcium levels were associated with increased all-cause mortality (HR: 1.21; 95% CI 1.09,1.35, p < 0.001 and HR: 1.22; 95% CI 1.01,1.48; p < 0.04, respectively; adjusted Cox model) and death-uncensored graft loss (p < 0.001 and p = 0.03, respectively). In addition, serum calcium and phosphate were associated with death-censored graft loss on univariable analysis (p < 0.001 and p = 0.02, respectively), but did not retain significance on multivariable analysis. AIx and Tr were not associated with mortality or graft loss on multivariable analysis. This is the first report to demonstrate that both higher serum phosphate and calcium levels are associated with increased mortality in kidney transplant recipients. It highlights the need for randomized trials assessing current interventions available for improving disordered mineral-bone metabolism post transplantation.
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Affiliation(s)
- Jason Moore
- Department of Renal Medicine, University Hospital, Birmingham, UK
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Marcén R, Morales JM, Fernández-Rodriguez A, Capdevila L, Pallardó L, Plaza JJ, Cubero JJ, Puig JM, Sanchez-Fructuoso A, Arias M, Alperovich G, Serón D. Long-term graft function changes in kidney transplant recipients. NDT Plus 2010; 3:ii2-ii8. [PMID: 20508857 PMCID: PMC2875040 DOI: 10.1093/ndtplus/sfq063] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 03/29/2010] [Indexed: 11/12/2022] Open
Abstract
Background. Monitoring changes in glomerular filtration rate (GFR) is the recommended method for assessing the progression of kidney disease. The aim of this study was to assess the decline of graft function defined by the annualized change in GFR and the factors which affect it.Methods. Four thousand four hundred and eighty-eight patients, transplanted during the years 1990, 1994, 1998 and 2002 in 34 centres in Spain with allograft survival of at least 1 year, were included in the study. GFR was estimated using the four-variable equation of the Modification of Diet in Renal Diseases (MDRD) study. Linear mixed effects model was applied to determine the relation between the covariates and the annualized change in GFR after transplantation.Results. The average GFR at 12 months was 51.4 +/- 18.9 mL/min/1.73 m(2); most patients were in stage 3 of chronic kidney disease classification. The average patient slope, calculated in a linear model with varying-intercept and varying-slope without covariates, was -1.12 +/- 0.05 mL/min/year (slope +/- standard error). Some variables were related to both the 12-month GFR (intercept) and the slope: recipient gender, hepatitis C virus (HCV) status, estimated GFR (eGFR) at 3 months and proteinuria at 12 months. Some variables were only related to the slope of eGFR: time on dialysis, primary renal disease and immunosuppression. Others affected only the 12-month GFR: donor age, delayed graft function, acute rejection and systolic blood pressure at 12 months. Higher graft function at 3 months had a negative impact on the GFR slope. Cyclosporine-based immunosuppression had a less favourable effect on the rates of change in allograft function.Conclusions. There was a slow decline in GFR. Poor graft function was not associated with an increased rate of decline of allograft function. Immunosuppression with cyclosporine displayed the worst declining GFR rate.
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Affiliation(s)
- Roberto Marcén
- Department of Nephrology, Hospital Ramon y Cajal, MadridSpain
| | | | | | - Luis Capdevila
- Department of Nephrology, Hospital Vall D´Hebron, BarcelonaSpain
| | - Luis Pallardó
- Department of Nephrology, Hospital Dr Peset, ValenciaSpain
| | - Juan José Plaza
- Department of Nephrology, Fundación Jiménez Díaz, MadridSpain
| | - Juan José Cubero
- Department of Nephrology, Hospital Infanta Cristina, BadajozSpain
| | | | | | - Manual Arias
- Department of Nephrology, Hospital Marqués de Valdecilla, SantanderSpain
| | | | - Daniel Serón
- Department of Nephrology, Hospital Vall D´Hebron, BarcelonaSpain
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Gourishankar S, Leduc R, Connett J, Cecka JM, Cosio F, Fieberg A, Gaston R, Halloran P, Hunsicker L, Kasiske B, Rush D, Grande J, Mannon R, Matas A. Pathological and clinical characterization of the 'troubled transplant': data from the DeKAF study. Am J Transplant 2010; 10:324-30. [PMID: 20055809 PMCID: PMC3538367 DOI: 10.1111/j.1600-6143.2009.02954.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We are studying two cohorts of kidney transplant recipients, with the goal of defining specific clinicopathologic entities that cause late graft dysfunction: (1) prevalent patients with new onset late graft dysfunction (cross-sectional cohort); and (2) newly transplanted patients (prospective cohort). For the cross-sectional cohort (n = 440), mean time from transplant to biopsy was 7.5 +/- 6.1 years. Local pathology diagnoses included CAN (48%), CNI toxicity (30%), and perhaps surprisingly, acute rejection (cellular- or Ab-mediated) (23%). Actuarial rate of death-censored graft loss at 1 year postbiopsy was 17.7%; at 2 years, 29.8%. There was no difference in postbiopsy graft survival for recipients with versus without CAN (p = 0.9). Prospective cohort patients (n = 2427) developing graft dysfunction >3 months posttransplant undergo 'index' biopsy. The rate of index biopsy was 8.8% between 3 and 12 months, and 18.2% by 2 years. Mean time from transplant to index biopsy was 1.0 +/- 0.6 years. Local pathology diagnoses included CAN (27%), and acute rejection (39%). Intervention to halt late graft deterioration cannot be developed in the absence of meaningful diagnostic entities. We found CAN in late posttransplant biopsies to be of no prognostic value. The DeKAF study will provide broadly applicable diagnostic information to serve as the basis for future trials.
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Affiliation(s)
| | - Robert Leduc
- Biostatistics, University of Minnesota, Minneapolis, Minnesota
| | - John Connett
- Biostatistics, University of Minnesota, Minneapolis, Minnesota
| | | | | | - Ann Fieberg
- Biostatistics, University of Minnesota, Minneapolis, Minnesota
| | | | | | | | - Bertram Kasiske
- Medicine, University of Minnesota and Hennepin County Medical Center, Minneapolis, Minnesota
| | - David Rush
- Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | | | - Arthur Matas
- Surgery, University of Minnesota, Minneapolis, Minnesota
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Optimizing immunosuppression with sirolimus in the first year posttransplantation: experience in the United States. Transplant Proc 2010; 41:S13-7. [PMID: 19651289 DOI: 10.1016/j.transproceed.2009.06.096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Early and late kidney graft survival has improved considerably due to advances in clinical care, particularly immunosuppression. Many of the kidney transplants functioning today should serve their new owners for their life expectancy. What challenges this viewpoint and the main cause of late kidney function deterioration remains allograft nephropathy. Often this reflects an influence of the immunosuppression. Subclinical rejection, chronic nephrotoxicity, recurrent disease, infections, or diabetes may also contribute to this process. Optimal early and late immunosuppression is required, which provides efficacy without attendent risk for graft dysfunction due to nephrotoxicity. Since 1-year serum creatinine level often provides an indication of long-term graft function, early evaluation of subtle degrees of graft dysfunction should prompt a graft biopsy to identify treatable causes.
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Gaston RS. Chronic calcineurin inhibitor nephrotoxicity: reflections on an evolving paradigm. Clin J Am Soc Nephrol 2009; 4:2029-34. [PMID: 19850771 DOI: 10.2215/cjn.03820609] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Use of the calcineurin inhibitors (CNI) cyclosporine and tacrolimus has revolutionized solid organ transplantation. For more than 30 yr, the transplant community has dealt with nephrotoxicity attributed to these agents. Acute renal vasoconstriction (as described by many investigators, including John Curtis and colleagues) is the unequivocal consequence of their use; chronic CNI nephropathy, although indistinct in terms of histology and pathophysiology, has become accepted as a major cause of late kidney allograft failure. This article examines clinical, laboratory, and histologic findings that evolved into a paradigm that was never fully consistent with observed outcomes and new evidence that may offer an alternative interpretation for adverse events that are attributed to CNI nephrotoxicity in kidney transplant recipients.
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Affiliation(s)
- Robert S Gaston
- Division of Nephrology, 625 THT, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
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Ljuca F, Imamović S, Mesić D, Hasukić SH, Omerović S, Bazardzanović M, Iljazagić-Halilović F. Micophenolat Mofetil versus Azathioprine: effects on renal graft function in early posttransplant period. Bosn J Basic Med Sci 2009; 9:156-60. [PMID: 19485949 DOI: 10.17305/bjbms.2009.2836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
All conventional immunosuppressive tree drugs-protocols are based on Cyclosporine; consisting of low doses of Cyclosporine (CsA), Azathioprine (AZA) or Mycophenolate Mofetil (MMF) and Prednisolone. AZA has been used in clinical transplantation for more than 30 years and was the first immunosuppressive agent to achieve widespread use in organ transplantation. MMF was introduced in clinical practice in 1995 after several clinical trials proved that it was more efficient than AZA for prevention of acute rejection episodes. Our aim was to evaluate influence of AZA and MMF on renal graft function in early post-transplant stage. Study recruited 74 patients who underwent kidney transplantation in University Clinical Centre Tuzla. All patients received CsA and corticosteroid-based immunosuppression, as a part of triple immunosuppressive regiment, 40 patients received AZA and 34 MMF. In order to assess renal graft function, following parameters were evaluated: glomerular filtration rate GFR (ml/min) creatinine clearance (CrCl) (ml/min), 24 h urine output (ml/day), and from the serum potassium, sodium, urea and creatinine (mmol/dm3). Significantly higher average values of 24 hour urine output were recorded during first seven postoperative days in patients receiving MMF compared to those treated with AZA. Serum creatinine values showed statistically significant decrease, starting with the second postoperative day, in MMF vs. AZA group (168,7+/-70,5 vs. 119,9+/-42,6; p<0,0007). GFR was significantly higher in MMF compared to the AZA group of patients. On the first post-transplant day CrCl was higher in AZA group (24,3+/-10 vs. 17,5+/-7,3; p=0,01), next six days situation is reversed CrCl is significantly higher in the MMF group (43,7+/-15 vs. 53, 4+/-22, 8 p=0,006). MMF vs. AZA therapy was associated with protective effect against worsening of renal function in first seven post-transplant days.
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Affiliation(s)
- Farid Ljuca
- Department of Physiology, Faculty of Medicine, University of Tuzla, Tuzla, Bosnia and Herzegovina
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Calcineurin inhibitor sparing with mycophenolate in kidney transplantation: a systematic review and meta-analysis. Transplantation 2009; 87:591-605. [PMID: 19307799 DOI: 10.1097/tp.0b013e318195a421] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Limiting the exposure of kidney transplant recipients to calcineurin inhibitors (CNIs) has potential merit, but there is no clear consensus on the utility of current strategies. In an attempt to aid clarification, we conducted a systematic review and meta-analysis of randomized trials that assessed CNI sparing (minimization or elimination) with mycophenolate as sole adjunctive immunosuppression. METHODS The search strategy identified trials where CNI sparing was accompanied by the continuation of, or conversion to, mycophenolate and compared with standard or higher dose CNI therapy. Two investigators independently examined each trial for eligibility, quality, and outcome measures. Additional subgroup analyses were assessed: (1) de novo CNI sparing; (2) elective CNI sparing beyond 2 months posttransplantation; and (3) CNI sparing for transplant dysfunction. RESULTS Nineteen randomized controlled trials met the inclusion criteria permitting analysis of 3312 renal transplant recipients with median follow-up of 12 months. CNI sparing significantly improved glomerular filtration rate (weighted mean difference 4.4 mL/min, 95% confidence interval [CI] 2.9-5.9, P<0.001); with some evidence, albeit weak, of improved graft survival (odds ratio 0.72, 95% CI 0.52-1.01, P=0.06). Acute rejection rates were only increased after elective CNI elimination (odds ratio 2.23, 95% CI 1.57-3.17, P<0.001). There were no significant differences in mortality, malignancy or incidence of infections. CONCLUSIONS CNI sparing strategies with adjunctive mycophenolate may play an important role in kidney transplant recipients. Improvements in short-term graft function, and possibly graft survival, are achievable. Longer term studies are needed to substantiate the short-term benefits, and refining elective CNI elimination protocols may help to reduce the risk of rejection.
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Melk A, Schmidt BMW, Braun H, Vongwiwatana A, Urmson J, Zhu LF, Rayner D, Halloran PF. Effects of donor age and cell senescence on kidney allograft survival. Am J Transplant 2009; 9:114-23. [PMID: 19133932 DOI: 10.1111/j.1600-6143.2008.02500.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The biological processes responsible for somatic cell senescence contribute to organ aging and progression of chronic diseases, and this may contribute to kidney transplant outcomes. We examined the effect of pre-existing donor aging on the performance of kidney transplants, comparing mouse kidney isografts and allografts from old versus young donors. Before transplantation, old kidneys were histologically normal, but displayed an increased expression of senescence marker p16(INK4a). Old allografts at day 7 showed a more rapid emergence of epithelial changes and a further increase in the expression of p16(INK4a). Similar but much milder changes occurred in old isografts. These changes were absent in young allografts at day 7, but emerged by day 21. The expression of p16(INK4a) remained low in young kidney allografts at day 7, but increased with severe rejection at day 21. Isografts from young donors showed no epithelial changes and no increase in p16(INK4a). The measurements of the alloimmune response-infiltrate, cytology, expression of perforin, granzyme B, IFN-gamma and MHC-were not increased in old allografts. Thus, old donor kidneys display abnormal parenchymal susceptibility to transplant stresses and enhanced induction of senescence marker p16(INK4a), but were not more immunogenic. These data are compatible with a key role of somatic cell senescence mechanisms in kidney transplant outcomes by contributing to donor aging, being accelerated by transplant stresses, and imposing limits on the capacity of the tissue to proliferate.
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Affiliation(s)
- A Melk
- Division of Pediatric Nephrology, Gastroenterology and Metabolic Diseases, Children's Hospital, Hannover Medical School, Hannover, Germany.
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Pauly RP, Asad RA, Hanley JA, Pierratos A, Zaltzman J, Chery A, Chan CT. Long-term clinical outcomes of nocturnal hemodialysis patients compared with conventional hemodialysis patients post-renal transplantation. Clin Transplant 2009; 23:47-55. [DOI: 10.1111/j.1399-0012.2008.00899.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Djamali A. [Can the renal transplant patient be really considered as a patient with chronic renal insufficiency?]. Nephrol Ther 2008; 4 Suppl 1:S36-S39. [PMID: 18703397 DOI: 10.1016/s1769-7255(08)73650-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
To assess if the renal transplant patient can really be considered as a patient with chronic renal insufficiency, disease progression and outcomes were compared in both groups. At the same stage of chronic kidney disease (CKD), the deterioration of renal function was slower and graft survival was longer in renal transplant patients. Despite slower rates of kidney function decline, overall patient survival was similar between the two groups. Interestingly, stage 3 adjusted mortality rates were greater in kidney transplant recipients, most likely because of the disease burden (history of end-stage renal disease in renal transplant recipients) and immunosuppression. The three major causes of mortality in transplant patients (cardiovascular, infectious and malignant) may present with specific characteristics in transplant patients. Renal transplantation is thus a specific form of CKD, controlled by 3 factors, a single kidney, immunosuppression and the burden of the disease. The general application of the KDOQI and KDIGO guidelines to kidney transplant recipients requires therefore further evaluation.
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Affiliation(s)
- A Djamali
- Nephrology Research, University of Wisconsin-Madison, 3034 Fish Hatchery Rd, #B, Madison, WI 53713, USA.
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Tang IY, Meier-Kriesche HU, Kaplan B. Immunosuppressive strategies to improve outcomes of kidney transplantation. Semin Nephrol 2007; 27:377-92. [PMID: 17616271 DOI: 10.1016/j.semnephrol.2007.03.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The introduction of several immunosuppressive agents over the past decade has reduced the rate of acute rejection significantly and has improved short-term renal allograft survival. However, their impact on long-term outcomes remains unclear. Current immunosuppressive strategies are focused on improving long-term graft and patient survival along with maintaining allograft function. The approval of the new immunosuppressive agents: rabbit antithymocyte globulin, basiliximab, daclizumab, tacrolimus, mycophenolate, and sirolimus, also has facilitated the development of steroid- and calcineurin inhibitor-sparing regimens in kidney transplantation. We discuss the impact of various immunosuppressive regimens on the outcome measures of kidney transplantation: acute rejection episodes, allograft survival, and renal function.
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Affiliation(s)
- Ignatius Y Tang
- Transplantation Medicine, Section of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
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Abbud-Filho M, Adams PL, Alberú J, Cardella C, Chapman J, Cochat P, Cosio F, Danovitch G, Davis C, Gaston RS, Humar A, Hunsicker LG, Josephson MA, Kasiske B, Kirste G, Leichtman A, Munn S, Obrador GT, Tibell A, Wadström J, Zeier M, Delmonico FL. A Report of the Lisbon Conference on the Care of the Kidney Transplant Recipient. Transplantation 2007; 83:S1-22. [PMID: 17452912 DOI: 10.1097/01.tp.0000260765.41275.e2] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Mario Abbud-Filho
- Instituto de Urologia e Nefrologia & Medical School - FAMERP, São José do Rio Preto-SP, Brazil
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50
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Abstract
Although patients with end-stage renal disease can be maintained with dialysis therapy, the superiority of patient survival with renal transplantation makes transplantation the preferred method of renal replacement. Potent immunosuppressive therapies, particularly calcineurin inhibitors, have greatly reduced the incidence of acute rejection. However, long-term allograft survival remains limited. We discuss the impact of acute rejection on long-term allograft survival and discuss other factors leading to late allograft loss, including calcineurin inhibitor toxicity, chronic allograft nephropathy, and BK virus nephropathy, as well as donor and recipient factors associated with long-term allograft loss.
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Affiliation(s)
- JogiRaju Tantravahi
- Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida College of Medicine, Gainesville, Florida 32601-0224, USA
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