1
|
Barrett-Chan E, Wang L, Bone J, Thachil A, Vytlingam K, Blydt-Hansen T. Optimizing the approach to monitoring allograft inflammation using serial urinary CXCL10/creatinine testing in pediatric kidney transplant recipients. Pediatr Transplant 2024; 28:e14718. [PMID: 38553815 DOI: 10.1111/petr.14718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/04/2024] [Accepted: 02/05/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Urinary CXCL10/creatinine (uCXCL10/Cr) is proposed as an effective biomarker of subclinical rejection in pediatric kidney transplant recipients. This study objective was to model implementation in the clinical setting. METHODS Banked urine samples at a single center were tested for uCXCL10/Cr to validate published thresholds for rejection diagnosis (>80% specificity). The positive predictive value (PPV) for rejection diagnosis for uCXCL10/Cr-indicated biopsy was modeled with first-positive versus two-test-positive approaches, with accounting for changes associated with urinary tract infection (UTI), BK and CMV viremia, and subsequent recovery. RESULTS Seventy patients aged 10.5 ± 5.6 years at transplant (60% male) had n = 726 urine samples with n = 236 associated biopsies (no rejection = 167, borderline = 51, and Banff 1A = 18). A threshold of 12 ng/mmol was validated for Banff 1A versus no-rejection diagnosis (AUC = 0.74, 95% CI = 0.57-0.92). The first-positive test approach (n = 69) did not resolve a clinical diagnosis in 38 cases (55%), whereas the two-test approach resolved a clinical diagnosis in the majority as BK (n = 17/60, 28%), CMV (n = 4/60, 7%), UTI (n = 8/60, 13%), clinical rejection (n = 5/60, 8%), and transient elevation (n = 18, 30%). In those without a resolved clinical diagnosis, PPV from biopsy for subclinical rejection is 24% and 71% (p = .017), for first-test versus two-test models, respectively. After rejection treatment, uCXCL10/Cr level changes were all concordant with change in it-score. Sustained uCXCL10/Cr after CMV and BK viremia resolution was associated with later acute rejection. CONCLUSIONS Urinary CXCL10/Cr reliably identifies kidney allograft inflammation. These data support a two-test approach to reliably exclude other clinically identifiable sources of inflammation, for kidney biopsy indication to rule out subclinical rejection.
Collapse
Affiliation(s)
| | - Li Wang
- University of British Columbia, Vancouver, British Columbia, Canada
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Jeffrey Bone
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Amy Thachil
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Kevin Vytlingam
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Tom Blydt-Hansen
- University of British Columbia, Vancouver, British Columbia, Canada
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| |
Collapse
|
2
|
Madhvapathy SR, Wang JJ, Wang H, Patel M, Chang A, Zheng X, Huang Y, Zhang ZJ, Gallon L, Rogers JA. Implantable bioelectronic systems for early detection of kidney transplant rejection. Science 2023; 381:1105-1112. [PMID: 37676965 DOI: 10.1126/science.adh7726] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 07/19/2023] [Indexed: 09/09/2023]
Abstract
Early-stage organ transplant rejection can be difficult to detect. Percutaneous biopsies occur infrequently and are risky, and measuring biomarker levels in blood can lead to false-negative and -positive outcomes. We developed an implantable bioelectronic system capable of continuous, real-time, long-term monitoring of the local temperature and thermal conductivity of a kidney for detecting inflammatory processes associated with graft rejection, as demonstrated in rat models. The system detects ultradian rhythms, disruption of the circadian cycle, and/or a rise in kidney temperature. These provide warning signs of acute kidney transplant rejection that precede changes in blood serum creatinine/urea nitrogen by 2 to 3 weeks and approximately 3 days for cases of discontinued and absent administration of immunosuppressive therapy, respectively.
Collapse
Affiliation(s)
- Surabhi R Madhvapathy
- Department of Materials Science and Engineering, Northwestern University, Evanston, IL, USA 60208
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, USA 60208
| | - Jiao-Jing Wang
- Comprehensive Transplant Center, Northwestern University, Chicago, IL, USA 60611
| | - Heling Wang
- Department of Mechanical Engineering, Northwestern University, Evanston, IL, USA 60208
- Department of Civil Engineering, Northwestern University, Evanston, IL, USA 60208
- Laboratory of Flexible Electronics Technology, Tsinghua University, Beijing, 100085 China
| | - Manish Patel
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, USA 60208
- Department of Intervention Radiology, University of Illinois at Chicago, Chicago, IL, USA 60612
| | - Anthony Chang
- Department of Pathology, University of Chicago, Chicago, IL USA 60637
| | - Xin Zheng
- Comprehensive Transplant Center, Northwestern University, Chicago, IL, USA 60611
| | - Yonggang Huang
- Department of Mechanical Engineering, Northwestern University, Evanston, IL, USA 60208
- Department of Civil Engineering, Northwestern University, Evanston, IL, USA 60208
| | - Zheng J Zhang
- Comprehensive Transplant Center, Northwestern University, Chicago, IL, USA 60611
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA 60611
- Simpson Querrey Institute for BioNanotechnology, Northwestern University, Chicago, IL, USA 60611
| | - Lorenzo Gallon
- Comprehensive Transplant Center, Northwestern University, Chicago, IL, USA 60611
- Department of Nephrology, Northwestern University, Chicago, IL, USA 60611
| | - John A Rogers
- Department of Materials Science and Engineering, Northwestern University, Evanston, IL, USA 60208
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, USA 60208
- Department of Biomedical Engineering, Northwestern University, Evanston, IL, USA 60208
- Department of Neurological Surgery, Northwestern University, Chicago, IL, USA 60611
| |
Collapse
|
3
|
Danger R, Le Berre L, Cadoux M, Kerleau C, Papuchon E, Mai HL, Nguyen TVH, Guérif P, Morelon E, Thaunat O, Legendre C, Anglicheau D, Lefaucheur C, Couzi L, Del Bello A, Kamar N, Le Quintrec M, Goutaudier V, Renaudin K, Giral M, Brouard S. Subclinical rejection-free diagnostic after kidney transplantation using blood gene expression. Kidney Int 2023; 103:1167-1179. [PMID: 36990211 DOI: 10.1016/j.kint.2023.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 02/16/2023] [Accepted: 03/08/2023] [Indexed: 03/29/2023]
Abstract
We previously established a six-gene-based blood score associated with operational tolerance in kidney transplantation which was decreased in patients developing anti-HLA donor-specific antibodies (DSA). Herein, we aimed to confirm that this score is associated with immunological events and risk of rejection. We measured this using quantitative PCR (qPCR) and NanoString methods from an independent multicenter cohort of 588 kidney transplant recipients with paired blood samples and biopsies at one year after transplantation validating its association with pre-existing and de novo DSA. From 441 patients with protocol biopsy, there was a significant decrease of the score of tolerance in 45 patients with biopsy-proven subclinical rejection (SCR), a major threat associated with pejorative allograft outcomes that prompted an SCR score refinement. This refinement used only two genes, AKR1C3 and TCL1A, and four clinical parameters (previous experience of rejection, previous transplantation, sex of recipient and tacrolimus uptake). This refined SCR score was able to identify patients unlikely to develop SCR with a C-statistic of 0.864 and a negative predictive value of 98.3%. The SCR score was validated in an external laboratory, with two methods (qPCR and NanoString), and on 447 patients from an independent and multicenter cohort. Moreover, this score allowed reclassifying patients with discrepancies between the DSA presence and the histological diagnosis of antibody mediated rejection unlike kidney function. Thus, our refined SCR score could improve detection of SCR for closer and noninvasive monitoring, allowing early treatment of SCR lesions notably for patients DSA-positive and during lowering of immunosuppressive treatment.
Collapse
Affiliation(s)
- Richard Danger
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France.
| | - Ludmilla Le Berre
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France
| | - Marion Cadoux
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France
| | - Clarisse Kerleau
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France
| | - Emmanuelle Papuchon
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France; Centre d'Investigation Clinique en Biothérapie, Centre de Ressources Biologiques (CRB), CHU Nantes, Nantes, France
| | - Hoa Le Mai
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France
| | - Thi-Van-Ha Nguyen
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France
| | - Pierrick Guérif
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France
| | - Emmanuel Morelon
- Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Hospices Civils de Lyon, INSERM Unit 1111, Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), Lyon, France
| | - Olivier Thaunat
- Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Hospices Civils de Lyon, INSERM Unit 1111, Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), Lyon, France
| | - Christophe Legendre
- Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Necker-Enfants Malades Institute, INSERM, Paris University, Paris, France
| | - Dany Anglicheau
- Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Necker-Enfants Malades Institute, INSERM, Paris University, Paris, France
| | - Carmen Lefaucheur
- Paris Translational Research Center for Organ Transplantation, INSERM UMR S970, Université Paris Cité, Kidney Transplant Department, Saint Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lionel Couzi
- Department of Nephrology, Transplantation, Dialysis, and Apheresis, CHU Bordeaux, Bordeaux, France
| | - Arnaud Del Bello
- Department of Nephrology and Organ Transplantation, Centre Hospitalier Universitaire de Toulouse, INSERM UMR1291 - Université Toulouse III, Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), Toulouse, Université Toulouse III Paul Sabatier, Toulouse, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Centre Hospitalier Universitaire de Toulouse, INSERM UMR1291 - Université Toulouse III, Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), Toulouse, Université Toulouse III Paul Sabatier, Toulouse, France
| | - Moglie Le Quintrec
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital of Lapeyronie, Montpellier, France
| | - Valentin Goutaudier
- Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Necker-Enfants Malades Institute, INSERM, Paris University, Paris, France; Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
| | - Karine Renaudin
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France; CHU Nantes, Service d'Anatomie et Cytologie Pathologiques, Nantes, France
| | - Magali Giral
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France; Centre d'Investigation Clinique en Biothérapie, Centre de Ressources Biologiques (CRB), CHU Nantes, Nantes, France; LabEx IGO "Immunotherapy, Graft, Oncology", Nantes Université, Nantes, France
| | - Sophie Brouard
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France; Centre d'Investigation Clinique en Biothérapie, Centre de Ressources Biologiques (CRB), CHU Nantes, Nantes, France; LabEx IGO "Immunotherapy, Graft, Oncology", Nantes Université, Nantes, France.
| |
Collapse
|
4
|
Kumar KV, Sathyan J, Prasannan M, Urs V, Prasannan B, Unni VN. Utility of protocol biopsy in the management of renal allograft recipients. INDIAN JOURNAL OF TRANSPLANTATION 2023. [DOI: 10.4103/ijot.ijot_50_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
|
5
|
The Histological Spectrum and Clinical Significance of T Cell-mediated Rejection of Kidney Allografts. Transplantation 2022; 107:1042-1055. [PMID: 36584369 DOI: 10.1097/tp.0000000000004438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
T cell-mediated rejection (TCMR) remains a significant cause of long-term kidney allograft loss, either indirectly through induction of donor-specific anti-HLA alloantibodies or directly through chronic active TCMR. Whether found by indication or protocol biopsy, Banff defined acute TCMR should be treated with antirejection therapy and maximized maintenance immunosuppression. Neither isolated interstitial inflammation in the absence of tubulitis nor isolated tubulitis in the absence of interstitial inflammation results in adverse outcomes, and neither requires antirejection treatment. RNA gene expression analysis of biopsy material may supplement conventional histology, especially in ambiguous cases. Lesser degrees of tubular and interstitial inflammation (Banff borderline) may portend adverse outcomes and should be treated when found on an indication biopsy. Borderline lesions on protocol biopsies may resolve spontaneously but require close follow-up if untreated. Following antirejection therapy of acute TCMR, surveillance protocol biopsies should be considered. Minimally invasive blood-borne assays (donor-derived cell-free DNA and gene expression profiling) are being increasingly studied as a means of following stable patients in lieu of biopsy. The clinical benefit and cost-effectiveness require confirmation in randomized controlled trials. Treatment of acute TCMR is not standardized but involves bolus corticosteroids with lymphocyte depleting antibodies for severe, refractory, or relapsing cases. Arteritis may be found with acute TCMR, active antibody-mediated rejection, or mixed rejections and should be treated accordingly. The optimal treatment ofchronic active TCMR is uncertain. Randomized controlled trials are necessary to optimally define therapy.
Collapse
|
6
|
Mehta RB, Melgarejo I, Viswanathan V, Zhang X, Pittappilly M, Randhawa P, Puttarajappa C, Sood P, Wu C, Sharma A, Molinari M, Hariharan S. Long-term immunological outcomes of early subclinical inflammation on surveillance kidney allograft biopsies. Kidney Int 2022; 102:1371-1381. [PMID: 36049641 DOI: 10.1016/j.kint.2022.07.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 07/07/2022] [Accepted: 07/26/2022] [Indexed: 01/12/2023]
Abstract
The long-term impact of early subclinical inflammation (SCI) through surveillance biopsy has not been well studied. To do this, we recruited a prospective observational cohort that included 1000 sequential patients who received a kidney transplant from 2013-2017 at our center. A total of 586 patients who underwent a surveillance biopsy in their first year post-transplant were included after excluding those with clinical rejections, and those who were unable to undergo a surveillance biopsy. Patients were classified based on their biopsy findings: 282 with NSI (No Significant Inflammation) and 304 with SCI-T (SCI and Tubulitis) which was further subdivided into 182 with SC-BLR (Subclinical Borderline Changes) and 122 with SC-TCMR (Subclinical T Cell Mediated Rejection, Banff 2019 classification of 1A or more). We followed the clinical and immunological events including Clinical Biopsy Proven Acute Rejection [C-BPAR], long-term kidney function and death-censored graft loss over a median follow-up of five years. Episodes of C-BPAR were noted at a median of two years post-transplant. Adjusted odds of having a subsequent C-BPAR was significantly higher in the SCI-T group [SC-BLR and SC-TCMR] compared to NSI 3.8 (2.1-7.5). The adjusted hazard for death-censored graft loss was significantly higher with SCI-T compared to NSI [1.99 (1.04-3.84)]. Overall, SCI detected through surveillance biopsy within the first year post-transplant is a harbinger for subsequent immunological events and is associated with a significantly greater hazard for subsequent C-BPAR and death-censored graft loss. Thus, our study highlights the need for identifying patients with SCI through surveillance biopsy and develop strategies to prevent further alloimmune injuries.
Collapse
Affiliation(s)
- Rajil B Mehta
- Division of Transplant Nephrology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Ivy Melgarejo
- Division of Transplant Nephrology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Vignesh Viswanathan
- Division of Transplant Nephrology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Xingyu Zhang
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Matthew Pittappilly
- Division of Transplant Nephrology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Parmjeet Randhawa
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Chethan Puttarajappa
- Division of Transplant Nephrology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Puneet Sood
- Division of Transplant Nephrology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Christine Wu
- Division of Transplant Nephrology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Akhil Sharma
- Division of Transplant Nephrology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michele Molinari
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sundaram Hariharan
- Division of Transplant Nephrology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
7
|
Hernández D, Vázquez-Sánchez T, Sola E, Lopez V, Ruiz-Esteban P, Caballero A, Salido E, Leon M, Rodriguez A, Serra N, Rodriguez C, Facundo C, Perello M, Silva I, Marrero-Miranda D, Cidraque I, Moreso F, Guirado L, Serón D, Torres A. Treatment of early borderline lesions in low immunological risk kidney transplant patients: a Spanish multicenter, randomized, controlled parallel-group study protocol: the TRAINING study. BMC Nephrol 2022; 23:357. [PMCID: PMC9639260 DOI: 10.1186/s12882-022-02989-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 10/24/2022] [Indexed: 11/09/2022] Open
Abstract
Abstract
Background
Subclinical inflammation, including borderline lesions (BL), is very common (30–40%) after kidney transplantation (KT), even in low immunological risk patients, and can lead to interstitial fibrosis/tubular atrophy (IFTA) and worsening of renal function with graft loss. Few controlled studies have analyzed the therapeutic benefit of treating these BL on renal function and graft histology. Furthermore, these studies have only used bolus steroids, which may be insufficient to slow the progression of these lesions. Klotho, a transmembrane protein produced mainly in the kidney with antifibrotic properties, plays a crucial role in the senescence-inflammation binomial of kidney tissue. Systemic and local inflammation decrease renal tissue expression and soluble levels of α-klotho. It is therefore important to determine whether treatment of BL prevents a decrease in α-klotho levels, progression of IFTA, and loss of kidney function.
Methods
The TRAINING study will randomize 80 patients with low immunological risk who will receive their first KT. The aim of the study is to determine whether the treatment of early BL (3rd month post-KT) with polyclonal rabbit antithymocyte globulin (Grafalon®) (6 mg/kg/day) prevents or decreases the progression of IFTA and the worsening of graft function compared to conventional therapy after two years post-KT, as well as to analyze whether treatment of BL with Grafalon® can modify the expression and levels of klotho, as well as the pro-inflammatory cytokines that regulate its expression.
Discussion
This phase IV investigator-driven, randomized, placebo-controlled clinical trial will examine the efficacy and safety of Grafalon® treatment in low-immunological-risk KT patients with early BL.
Trial registration
clinicaltrials.gov: NCT04936282. Registered June 23, 2021, https://clinicaltrials.gov/ct2/show/NCT04936282?term=NCT04936282&draw=2&rank=1. Protocol Version 2 of 21 January 2022. Sponsor: Canary Isles Institute for Health Research Foundation, Canary Isles (FIISC). mgomez@fciisc.org.
Collapse
|
8
|
Sakurabayashi K, Muramatsu M, Itabashi Y, Oguchi H, Kawamura T, Hamasaki Y, Mikami T, Tochigi N, Shishido S, Sakai K. Effects of antirejection therapies for early subclinical acute rejection in renal transplant protocol biopsies. RENAL REPLACEMENT THERAPY 2022. [DOI: 10.1186/s41100-022-00407-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Although recently strengthened immunosuppression protocols have decreased the incidence of clinical acute rejection of renal transplants, subclinical acute rejection and borderline changes remain problematic. This study was performed to evaluate the effects of antirejection therapies for early subclinical acute rejection and borderline changes.
Methods
In total, 269 renal transplant patients who received 3-month and 1-year protocol biopsies after renal transplantation were enrolled this study and divided into those with normal findings (Group A) and those with ≥ borderline changes (Group B) according to the 3-month pathological results. Pathological changes, graft function, and graft survival were evaluated at 1 year.
Results
The 3-month protocol biopsy revealed normal findings in 166 patients (Group A) and borderline changes and subclinical acute rejection in 103 patients (Group B). In Group A, 65.1% (n = 108) of the patients maintained normal findings at 1 year, while 30.1% (n = 50) deteriorated to ≥ borderline changes. In Group B, 52.4% (n = 54) of patients improved to normal. Among patients with subclinical acute rejection, 25.0% (n = 5) maintained subclinical acute rejection at 1 year despite antirejection therapy. The mean estimated glomerular filtration rate decreased from 60.4 ± 24.5 to 58.3 ± 19.0 mL/min/1.73 m2 in Group A and from 57.2 ± 28.2 to 53.7 ± 20.3 mL/min/1.73 m2 in Group B (p = 0.417). The 3-, 5-, and 7-year graft survival rates were 99.4%, 99.4%, and 97.6% in Group A and 100.0%, 98.6%, and 98.6% in Group B, respectively (p = 0.709).
Conclusions
Subclinical acute rejection is likely to recur. However, intervention for subclinical acute rejection in the early period after transplantation may help to prevent subsequent histological changes.
Collapse
|
9
|
Raza SS, Agarwal G, Anderson D, Deierhoi M, Fatima H, Hanaway M, Locke J, MacLennan P, Orandi B, Young C, Mannon RB, Seifert ME. Abnormal time-zero histology is predictive of kidney transplant outcomes. Clin Transplant 2022; 36:e14676. [PMID: 35437836 DOI: 10.1111/ctr.14676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/03/2022] [Accepted: 01/20/2022] [Indexed: 11/26/2022]
Abstract
Time-zero biopsies can detect donor-derived lesions at the time of kidney transplantation, but their utility in predicting long-term outcomes is unclear under the updated Kidney Allocation System. We conducted a single-center retrospective cohort study of 272 consecutive post-reperfusion time-zero biopsies. We tested the hypothesis that abnormal time-zero histology is a strong indicator of donor quality that increases the precision of the kidney donor profile index (KDPI) score to predict long-term outcomes. We detected abnormal biopsies in 42% of the cohort, which were independently associated with a 1.2-fold increased hazard for a composite of acute rejection, allograft failure, and death after adjusting for clinical characteristics including KDPI. By Kaplan-Meier analysis, the relationship between abnormal time-zero histology and the composite endpoint was only significant in the subgroup of deceased donor kidney transplants with KDPI scores > 35. Abnormal time-zero histology, particularly vascular intimal fibrosis and arteriolar hyalinosis scores, was independently associated with lower 12-month estimated GFR. In conclusion, abnormal time-zero histology is relatively common and identifies a group of kidney recipients at increased risk for worse long-term outcomes. Further studies are needed to determine the optimal patient population in which to deploy time-zero biopsies as an additional surveillance tool. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Syed Sikandar Raza
- Department of Medicine, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Gaurav Agarwal
- Department of Medicine, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Douglas Anderson
- Department of Surgery, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Mark Deierhoi
- Department of Surgery, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Huma Fatima
- Department of Pathology, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Michael Hanaway
- Department of Surgery, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Jayme Locke
- Department of Surgery, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Paul MacLennan
- Department of Surgery, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Babak Orandi
- Department of Surgery, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Carlton Young
- Department of Surgery, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Roslyn B Mannon
- Department of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Michael E Seifert
- Department of Medicine, University of Alabama School of Medicine, Birmingham, AL, USA.,Department of Pediatrics, University of Alabama School of Medicine, Birmingham, AL, USA
| |
Collapse
|
10
|
Sub-classification of borderline changes into diffuse or focal and its impact on long-term renal transplant outcomes. Transpl Immunol 2022; 72:101594. [DOI: 10.1016/j.trim.2022.101594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 11/22/2022]
|
11
|
Lezoeva E, Nilsson J, Wüthrich R, Mueller TF, Schachtner T. High PIRCHE Scores May Allow Risk Stratification of Borderline Rejection in Kidney Transplant Recipients. Front Immunol 2022; 13:788818. [PMID: 35250973 PMCID: PMC8894244 DOI: 10.3389/fimmu.2022.788818] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 01/31/2022] [Indexed: 12/11/2022] Open
Abstract
Background The diagnosis of borderline rejection (BLR) ranges from mild inflammation to clinically significant TCMR and is associated with an increased risk of allograft dysfunction. Currently, there is no consensus regarding its treatment due in part to a lack of biomarkers to identify cases with increased risk for immune-mediated injury. Methods We identified 60 of 924 kidney transplant recipients (KTRs) with isolated and untreated BLR. We analyzed the impact of predicted indirectly recognizable HLA epitopes (PIRCHE) score on future rejection, de novo DSA development, and recovery to baseline allograft function. Additionally, we compared the outcomes of different Banff rejection phenotypes. Results Total PIRCHE scores were significantly higher in KTRs with BLR compared to the entire study population (p=0.016). Among KTRs with BLR total PIRCHE scores were significantly higher in KTRs who developed TCMR/ABMR in follow-up biopsies (p=0.029). Notably, the most significant difference was found in PIRCHE scores for the HLA-A locus (p=0.010). PIRCHE scores were not associated with the development of de novo DSA or recovery to baseline allograft function among KTRs with BLR (p>0.05). However, KTRs under cyclosporine-based immunosuppression were more likely to develop de novo DSA (p=0.033) than those with tacrolimus, whereas KTRs undergoing retransplantation were less likely to recover to baseline allograft function (p=0.003). Conclusions High PIRCHE scores put KTRs with BLR at an increased risk for future TCMR/ABMR and contribute to improved immunological risk stratification. The benefit of anti-rejection treatment, however, needs to be evaluated in future studies.
Collapse
Affiliation(s)
- Ekaterina Lezoeva
- Department of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Jakob Nilsson
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
| | - Rudolf Wüthrich
- Department of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas F. Mueller
- Department of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Schachtner
- Department of Nephrology, University Hospital Zurich, Zurich, Switzerland
- *Correspondence: Thomas Schachtner, ; orcid.org/0000-0001-5549-4798
| |
Collapse
|
12
|
Decrease in CD14++CD16+ Monocytes in Low-Immunological-Risk Kidney Transplant Patients with Subclinical Borderline Inflammation. J Clin Med 2021; 10:jcm10215051. [PMID: 34768571 PMCID: PMC8585102 DOI: 10.3390/jcm10215051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 11/23/2022] Open
Abstract
We determined the association between CD14++CD16+ monocytes and subclinical infiltrates that do not reach the histological threshold for rejection (≥Banff IA). We studied low-immunological-risk kidney-transplant recipients in a clinical trial (NCT02284464; EudraCT 2012-003298-24) whose protocol biopsy in the third month showed no significant changes or borderline lesions (BL). Flow cytometry was used to analyze the percentage of CD14++CD16+ monocytes in peripheral blood (PB) and blood from a fine-needle-aspiration biopsy (FNAB). A protocol biopsy was performed in 81 low-immunological-risk patients, of whom 15 were excluded (BK polyomavirus and rejection). The 28 (42.4%) with borderline lesions had significantly low levels of CD14++CD16+ in PB compared to patients with normal biopsies (7.9 ± 5.4 vs. 13.0 ± 12.8; p = 0.047). Patients without significant changes had similar percentages of CD14++CD16+ monocytes in the graft blood (GB) and FNAB blood. The percentage of these monocytes in the patients with an interstitial infiltrate, however, increased significantly in the FNAB blood compared to the GB: 16.9 ± 16.6 vs. 7.9 ± 5.4; p = 0.006. A difference of 50% in CD14++CD16+ in the GB versus the PB was a significant risk factor (p = 0.002) for BL, increasing the risk seven times. A decrease in CD14++CD16+ in the PB could be associated with the recruitment of these cells to the graft tissue in cases of subclinical BL inflammatory infiltrates below the threshold for rejection.
Collapse
|
13
|
Donor-derived Cell-free DNA in Solid-organ Transplant Diagnostics: Indications, Limitations, and Future Directions. Transplantation 2021; 105:1203-1211. [PMID: 33534526 DOI: 10.1097/tp.0000000000003651] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The last few years have seen an explosion in clinical research focusing on the use of donor-derived cell-free DNA (dd-cfDNA) in solid-organ transplants (SOT). Although most of the literature published so far focuses on kidney transplants, there are several recent as well as ongoing research studies on heart, lung, pancreas, and liver transplants. Though initially studied as a noninvasive means of identifying subclinical or acute rejection in SOT, it is rapidly becoming clear that instead of being a specific marker for allograft rejection, dd-cfDNA is more appropriately described as a marker of severe injury, although the most common cause of this injury is allograft rejection. Multiple studies in kidney transplants have shown that although sensitivity for the diagnosis of antibody-mediated rejection is excellent, it is less so for T-cell-mediated rejection. It is possible that combining dd-cfDNA with other novel urine- or blood-based biomarkers may increase the sensitivity for the diagnosis of rejection. Irrespective of the cause, though, elevated dd-cfDNA seems to portend adverse allograft prognosis and formation of de novo donor-specific antibody. Although current data do not lend themselves to a clear conclusion, ongoing studies may reveal the utility of serial surveillance for the management of SOT as following levels of dd-cfDNA over time may provide windows of opportunity to intervene early and before irreversible allograft injury. Finally, cost-effectiveness studies will be needed to guide the ideal incorporation of dd-cfDNA into routine clinical practice.
Collapse
|
14
|
The Utility of Donor-specific Antibody Monitoring and the Role of Kidney Biopsy in Simultaneous Liver and Kidney Recipients With De Novo Donor-specific Antibodies. Transplantation 2021; 105:1548-1555. [PMID: 32732618 DOI: 10.1097/tp.0000000000003399] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND There is limited information about the utility of donor-specific antibody (DSA) against HLA monitoring and the role of protocol kidney biopsy for de novo DSA (dnDSA) in simultaneous liver and kidney (SLK) transplant recipients. METHODS We analyzed SLK transplant recipients transplanted between January 2005 and December 2017, who had DSA checked posttransplant. Patients were divided into 2 groups based on whether they developed dnDSA posttransplant (dnDSA+) or not (dnDSA-). Kidney graft rejection ±45 d of dnDSA and a kidney death-censored graft survival were the primary endpoints. RESULTS A total of 83 SLK transplant recipients fulfilled our selection criteria. Of those, 23 were dnDSA+ and 60 were dnDSA-. Twenty-two of 23 dnDSA+ patients had DSA against class II HLA, predominantly against DQ. Fifteen recipients underwent kidney biopsy ±45 d of dnDSA. Six of these were clinically indicated due to kidney graft dysfunction. The other 9 had a protocol kidney biopsy only due to dnDSA, and 6 of these 9 had a rejection. Also, 3 recipients had sequential biopsies of both the kidney and liver grafts. Among those with sequential biopsies of both grafts, there was a difference between the organs in the rate and types of rejections. At last follow up, dnDSA was not associated with graft failure of either the kidney or liver. CONCLUSIONS Although our study was limited by a small sample size, it suggests the potential utility of DSA monitoring and protocol kidney biopsy for dnDSA.
Collapse
|
15
|
Hoffmann AJ, Gibson IW, Ho J, Nickerson P, Rush D, Sharma A, Wishart D, Blydt-Hansen TD. Early surveillance biopsy utilization and management of pediatric renal allograft acute T cell-mediated rejection in Canadian centers: Observations from the PROBE multicenter cohort study. Pediatr Transplant 2021; 25:e13870. [PMID: 33026135 DOI: 10.1111/petr.13870] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Early TCMR surveillance with protocol kidney biopsy is used differentially among pediatric kidney transplant centers. Little has been reported about actual center-based differences, and this variability may influence TCMR ascertainment, treatment, and monitoring more broadly. METHODS Data from the PROBE multicenter study were used to identify patients from centers conducting ESB or LSIB. ESB was defined as >50% of patients having at least 1 surveillance biopsy in the first 9 months. Patients were compared for number of biopsies, rejection episodes, treatment, and follow-up monitoring. RESULTS A total of 261 biopsies were performed on 97 patients over 1-2 years of follow-up. A total of 228 (87%) of biopsies were performed in ESB centers. Compared to LSIB centers, ESB centers had 7-fold more episodes of TCMR diagnosed on any biopsy [0.8 ± 1.2 vs 0.1 ± 0.4; P < .001] and a 3-fold higher rate from indication biopsies [0.3 ± 0.9 vs 0.1 ± 0.3; P = .04]. The proportion of rejection treatment varied based on severity: Banff borderline i1t1 (40%);>i1t1 and < Banff 1A (86%); and ≥ Banff 1A (100%). Biopsies for follow-up were performed after treatment in 80% of cases (n = 28) of rejection almost exclusively at ESB centers, with 17 (61%) showing persistence of TCMR (≥i1t1). CONCLUSIONS Practice variation exists across Canadian pediatric renal transplant centers with ESB centers identifying more episodes of rejection. Additionally, treatment of Banff borderline is not universal and varies with severity regardless of center type. Lastly, follow-up biopsies are performed inconsistently and invariably show persistence of rejection.
Collapse
Affiliation(s)
| | - Ian W Gibson
- Department of Pathology, University of Manitoba, Winnipeg, MB, Canada
| | - Julie Ho
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Nickerson
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Shared Health Services Manitoba, Transplant/Immunology Lab, Winnipeg, MB, Canada
| | - David Rush
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Atul Sharma
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
| | - David Wishart
- The Metabolomics Innovation Centre, University of Alberta, Edmonton, AB, Canada
| | | |
Collapse
|
16
|
Impact of Subclinical Borderline Inflammation on Kidney Transplant Outcomes. Transplant Direct 2021; 7:e663. [PMID: 33511268 PMCID: PMC7837932 DOI: 10.1097/txd.0000000000001119] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 11/18/2020] [Indexed: 12/17/2022] Open
Abstract
Supplemental Digital Content is available in the text. Background. Surveillance biopsies permit early detection of subclinical inflammation before clinical dysfunction, but the impact of detecting early subclinical phenotypes remains unclear. Methods. We conducted a single-center retrospective cohort study of 441 consecutive kidney transplant recipients between 2015 and 2018 with surveillance biopsies at 6 months post-transplant. We tested the hypothesis that early subclinical inflammation (subclinical borderline changes, T cell-mediated rejection, or microvascular injury) is associated with increased incidence of a composite endpoint including acute rejection and allograft failure. Results. Using contemporaneous Banff criteria, we detected subclinical inflammation in 31%, with the majority (75%) having a subclinical borderline phenotype (at least minimal inflammation with mild tubulitis [>i0t1]). Overall, subclinical inflammation was independently associated with the composite endpoint (adjusted hazard ratio, 2.88; 1.11-7.51; P = 0.03). The subgroup with subclinical borderline inflammation, predominantly those meeting the Banff 2019 i1t1 threshold, was independently associated with 5-fold increased hazard for the composite endpoint (P = 0.02). Those with concurrent subclinical inflammation and subclinical chronic allograft injury had worse outcomes. The effect of treating subclinical inflammation was difficult to ascertain in small heterogeneous subgroups. Conclusions. Subclinical acute and chronic inflammation are common at 6 months post-transplant in kidney recipients with stable allograft function. The subclinical borderline phenotype with both tubulitis and interstitial inflammation was independently associated with poor long-term outcomes. Further studies are needed to elucidate the role of surveillance biopsies for management of allograft inflammation in kidney transplantation.
Collapse
|
17
|
Puttarajappa CM, Mehta R, Roberts MS, Smith KJ, Hariharan S. Economic analysis of screening for subclinical rejection in kidney transplantation using protocol biopsies and noninvasive biomarkers. Am J Transplant 2021; 21:186-197. [PMID: 32558153 PMCID: PMC7744316 DOI: 10.1111/ajt.16150] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 02/07/2023]
Abstract
Subclinical rejection (SCR) screening in kidney transplantation (KT) using protocol biopsies and noninvasive biomarkers has not been evaluated from an economic perspective. We assessed cost-effectiveness from the health sector perspective of SCR screening in the first year after KT using a Markov model that compared no screening with screening using protocol biopsy or biomarker at 3 months, 12 months, 3 and 12 months, or 3, 6, and 12 months. We used 12% subclinical cellular rejection and 3% subclinical antibody-mediated rejection (SC-ABMR) for the base-case cohort. Results favored 1-time screening at peak SCR incidence rather than repeated screening. Screening 2 or 3 times was favored only with age <35 years and with high SC-ABMR incidence. Compared to biomarkers, protocol biopsy yielded more quality-adjusted life years (QALYs) at lower cost. A 12-month biopsy cost $13 318/QALY for the base-case cohort. Screening for cellular rejection in the absence of SC-ABMR was less cost effective with 12-month biopsy costing $46 370/QALY. Screening was less cost effective in patients >60 years. Using biomarker twice or thrice was cost effective only if biomarker cost was <$700. In conclusion, in KT, screening for SCR more than once during the first year is not economically reasonable. Screening with protocol biopsy was favored over biomarkers.
Collapse
Affiliation(s)
- Chethan M. Puttarajappa
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania,Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rajil Mehta
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania,Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark S. Roberts
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kenneth J. Smith
- Department of Medicine, Section of Decision Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sundaram Hariharan
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania,Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
18
|
Protocol Biopsies in Patients With Subclinical De Novo Donor-specific Antibodies After Kidney Transplantation: A Multicentric Study. Transplantation 2020; 104:1726-1737. [PMID: 32732853 DOI: 10.1097/tp.0000000000003055] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND De novo donor-specific antibodies (DSAs) are associated with antibody-mediated rejection (AMR) and allograft loss. Whether monitoring of de novo DSA (dnDSA) paired with systematic kidney biopsy should become routine remains to be established. METHODS A retrospective multicentric study (9 French kidney transplant units of the Spiesser group) included patients without graft dysfunction biopsied because of the presence of dnDSA (One Lambda, mean fluorescence intensity [MFI], >1000). RESULTS One hundred twenty-three patients (85 male/38 female; mean age, 49.5 ± 13.1 y old) were biopsied after the detection of a dnDSA, 65.3 months (median) after kidney transplantation. Graft function was stable within 3 months before biopsy (estimated glomerular filtration rate, 55.3 ± 18.9 mL/min/1.73 m). Fifty-one subclinical AMRs (sAMRs) (41.4%) were diagnosed, of which 32 (26%) active and 19 (15.5%) chronic active sAMR. Seventy-two biopsies revealed no AMR (58.5%). Predictive factors associated with the diagnosis of active sAMR were MFI of immunodominant DSA >4000, MFI of the sum of DSA >6300, age of the recipient <45 years old, and the absence of steroids at biopsy. The presence of proteinuria >200 mg/g was predictive of chronic active sAMR. The decrease of estimated glomerular filtration rate at 5 years post-biopsy was significantly higher in patients with acute sAMR (-25.2 ± 28.3 mL/min/1.73 m) and graft survival significantly lower. CONCLUSIONS Performing a kidney graft biopsy for the occurrence of dnDSA without renal dysfunction leads to the diagnosis of a sAMR in over 40% of cases. Nevertheless, we did not observe any effect of standard treatment in acute sAMR.
Collapse
|
19
|
Lee DM, Abecassis MM, Friedewald JJ, Rose S, First MR. Kidney Graft Surveillance Biopsy Utilization and Trends: Results From a Survey of High-Volume Transplant Centers. Transplant Proc 2020; 52:3085-3089. [PMID: 32576474 DOI: 10.1016/j.transproceed.2020.04.1816] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/13/2020] [Accepted: 04/25/2020] [Indexed: 12/22/2022]
Abstract
An e-mail-based market research survey focused on high-volume US adult transplant centers was developed and implemented to assess surveillance based on United Network for Organ Sharing/Scientific Registry of Transplant Recipients data: 51 to 100 transplants, 101 to 200 transplants, and more than 200 transplants. Eighty-three centers responded to the survey. Respondent centers represented 13,837/21,167 (65%) of the total kidney transplants in 2018. In total, 38/83 (46%) centers reported the use of surveillance biopsies-20 centers in all patients and 18 in select patients. Surveillance biopsies were performed in 37% (7/19) of centers performing 51 to 100 transplants annually, in 44% (15/34) doing 101 to 200 transplants, and in 53% (16/30) of centers doing more than 200 transplants. Of the 20 centers doing surveillance biopsies in all patients, 17/20 (85%) perform more than 100 annual transplants, and 3/20 (15%) perform less than 100 annual transplants. Of the 45 centers not currently doing surveillance biopsies, 13 (29%) used surveillance biopsies in the past; discontinuation was primarily due to patient inconvenience, adverse events, and cost. Using survey percentages, it is estimated that surveillance biopsies are performed in approximately 34% of kidney transplant recipients and that 74% of all surveillance biopsies occur in centers performing more than 100 kidney transplants per year.
Collapse
Affiliation(s)
| | | | - John J Friedewald
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - M Roy First
- Transplant Genomics, Inc., Mansfield, MA; Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL.
| |
Collapse
|
20
|
Grzywińska M, Jankowska M, Banach-Ambroziak E, Szurowska E, Dębska-Ślizień A. Computation of the Texture Features on T2-Weighted Images as a Novel Method to Assess the Function of the Transplanted Kidney: Primary Research. Transplant Proc 2020; 52:2062-2066. [PMID: 32253002 DOI: 10.1016/j.transproceed.2020.02.084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 02/14/2020] [Accepted: 02/22/2020] [Indexed: 10/24/2022]
Abstract
Texture in medical images describes the internal structure of human tissues or organs. We hypothesize that textural analysis (TA) could be applied to assess renal function after kidney transplantation (KTx). This preliminary study aims to find a statistical difference between texture features in transplanted kidneys with different placement of region of interest (ROI). Also, we aimed at comparing results of TA with transplanted kidney function. For analysis, we used 9 retrospective examinations in patients with a transplanted kidney. All patients underwent a diagnostic magnetic resonance imaging (MRI) scan, including T2-weighted images. All MRI acquisition was performed using a 1.5T MRI (MAGNETOM Aera, Siemens Healthineers AG, Erlangen, Germany). Examinations were performed from indications other than KTx and in various times after KTx. We found an association between the texture parameters and the estimated glomerular filtration rate (4p estimate formula: Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI]) and between texture parameters and creatinine in ROI location in the cortex. Our findings make TA a promising tool for the assessment of the function of the transplanted kidney. However, the effect of binning, ROI size, and placement of ROI in the organ are yet to be determined and need further study.
Collapse
Affiliation(s)
| | - Magdalena Jankowska
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | | | - Edyta Szurowska
- Second Department of Radiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Alicja Dębska-Ślizień
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| |
Collapse
|
21
|
Impact of Subclinical Rejection on Kidney Graft Function. Transplant Proc 2019; 51:3304-3308. [DOI: 10.1016/j.transproceed.2019.08.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/30/2019] [Indexed: 11/18/2022]
|
22
|
Tajima S, Fu R, Shigematsu T, Noguchi H, Kaku K, Tsuchimoto A, Okabe Y, Masuda S. Urinary Human Epididymis Secretory Protein 4 as a Useful Biomarker for Subclinical Acute Rejection Three Months after Kidney Transplantation. Int J Mol Sci 2019; 20:ijms20194699. [PMID: 31546745 PMCID: PMC6801851 DOI: 10.3390/ijms20194699] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 09/20/2019] [Accepted: 09/20/2019] [Indexed: 02/07/2023] Open
Abstract
Kidney transplantation is the treatment of choice for patients with advanced chronic kidney disease (CKD) and end stage renal disease (ESRD). However, acute rejection (AR) is a common complication in kidney transplantation and is associated with reduced graft survival. Current diagnosis of AR relies mainly on clinical monitoring including serum creatinine, proteinuria, and confirmation by histopathologic assessment in the biopsy specimen of graft kidney. Although an early protocol biopsy is indispensable for depicting the severity of pathologic lesions in subclinical acute rejection (subAR), it is not acceptable in some cases and cannot be performed because of its invasive nature. Therefore, we examined the detection of noninvasive biomarkers that are closely related to the pathology of subAR in protocol biopsies three months after kidney transplantation. In this study, the urinary level of microtubule-associated protein 1 light chain 3 (LC3), monocyte chemotactic protein-1 (MCP-1), liver-type fatty acid-binding protein (L-FABP), neutrophil gelatinase-associated lipocalin (NGAL), and human epididymis secretory protein 4 (HE4) were measured three months after kidney transplantation. Urine samples of 80 patients undergoing kidney transplantation between August 2014 to September 2016, were prospectively collected after three months. SubAR was observed in 11 patients (13.8%) in protocol biopsy. The urinary levels of LC3, MCP-1, NGAL, and HE4 were significantly higher in patients with subAR than in those without, while those of L-FABP did not differ between the two groups. Multivariate regression models, receiver-operating characteristics (ROC), and areas under ROC curves (AUC) were used to identify predicted values of subAR. Urinary HE4 levels were able to better identify subAR (AUC = 0.808) than the other four urinary biomarkers. In conclusion, urinary HE4 is increased in kidney transplant recipients of subAR three months after kidney transplantation, suggesting that HE4 has the potential to be used as a novel clinical biomarker for predicting subAR.
Collapse
Affiliation(s)
- Soichiro Tajima
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Rao Fu
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Tomohiro Shigematsu
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Hiroshi Noguchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Keizo Kaku
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Akihiro Tsuchimoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Satohiro Masuda
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
- Department of Pharmacy, International University of Health and Welfare Narita Hospital, Minami-Aoyama, Minato-ku, Tokyo 107-0062, Japan.
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, International University of Health and Welfare Narita Hospital, Minami-Aoyama, Minato-ku, Tokyo 107-0062, Japan.
| |
Collapse
|
23
|
Cortesi C, Sedki M, Ruiz P, Salsamendi J, Mattiazzi A. Computed Tomography-Guided Kidney Transplant Biopsy Outcomes: A Single-Center Experience. EXP CLIN TRANSPLANT 2019; 18:676-681. [PMID: 31526335 DOI: 10.6002/ect.2019.0111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Percutaneous kidney transplant biopsy is typically performed using ultrasonographic guidance; computed tomography is an alternative modality used to obtain kidney allografttissuewhen ultrasonographyguided percutaneous kidney transplant biopsy is technically challenging. Studies examining postbiopsy outcomes in kidney transplant patients using a computed tomography-guided approach are scarce. Our goal was to reportthe incidence of nonsevere and severe complications in computed tomographyguided percutaneous kidney transplant biopsies and the potential risk factors. MATERIALS AND METHODS We retrospectively reviewed computed tomography-guided percutaneous kidney transplant biopsies in patients undergoing work-up for kidney allograft rejection between 2013 and 2017. Demographics, comorbidities, laboratory data, history of antiplatelet and/or anticoagulant use, and complications were assessed. RESULTS : During the study period, 28 patients underwent computed tomography-guided percutaneous kidney transplant biopsies; mean age was 57.5 ± 15.5 years, and 12 (43%)werewomen.Twenty-three patients (82%) were obese, with a body mass index greater than 30 kg/m². Our cohort of kidney transplant recipients included 21 (75%) from deceased donors and 7 (25%) from living-related donors. At the time of biopsy, 6 patients (21%) had elevated blood pressure (defined as > 160/90 mm Hg). One patient had severe complications, which included a significant decrease in hemoglobin requiring transfusion and a perinephric hematoma with worsening renal function. This was a morbidly obese patient whose blood pressure was elevated at the time of biopsy with a platelet count of 93 × 10³/mm³ and international normalized ratio of 1.21. CONCLUSIONS A computed tomography-guided percutaneous kidney transplant biopsy is a safe and effective alternative to obtain kidney tissue in the obese population and is associated with low rates of complications. In this study, we highlighted the need to achieve adequate blood pressure control and assess bleeding risk factors, such as platelet count and international normalized ratio, prior to biopsy.
Collapse
Affiliation(s)
- Camilo Cortesi
- From the Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | | | | | | | | |
Collapse
|
24
|
Subclinical Antibody-mediated Rejection After Kidney Transplantation: Treatment Outcomes. Transplantation 2019; 103:1722-1729. [PMID: 30507740 DOI: 10.1097/tp.0000000000002566] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
25
|
Nankivell BJ, Agrawal N, Sharma A, Taverniti A, P'Ng CH, Shingde M, Wong G, Chapman JR. The clinical and pathological significance of borderline T cell-mediated rejection. Am J Transplant 2019; 19:1452-1463. [PMID: 30501008 DOI: 10.1111/ajt.15197] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 10/28/2018] [Accepted: 11/15/2018] [Indexed: 01/25/2023]
Abstract
The pathological diagnosis of borderline rejection (BL-R) denotes possible T cell-mediated rejection (TCMR), but its clinical significance is uncertain. This single-center, cross-sectional cohort study compared the functional and histological outcomes of consecutive BL-R diagnoses (n = 146) against normal controls (n = 826) and acute TCMR (n = 55) from 551 renal transplant recipients. BL-R was associated with the following: contemporaneous renal dysfunction, acute tubular necrosis, and chronic tubular atrophy (P < .001); progressive tubular injury with fibrosis by longitudinal sequential histology (45.3% at 1 year); increased subsequent acute rejection (39.4%), allograft failure (P < .001), and patient mortality (P = .007). BL-R detected by biopsy indicated for impaired function was followed by suboptimal functional recovery (46.3%), persistent inflammation (27.2%), and acute rejection episodes (50.0%) despite antirejection treatment in 83.3%. By 1 year after BL-R, the incidence of new-onset microvascular inflammation (9.3%), C4d staining (22.3%), transplant glomerulopathy (13.3%), and de novo donor-specific antibodies (31.5%) exceeded normal controls (P < .05-.001). BL-R inflammation in protocol biopsy persisted in 28.0% and progressed to acute rejection in 32.6%; however, it resolved in 61.6% of the untreated cases. In summary, BL-R is a heterogeneous diagnostic grouping, ranging from mild inconsequential inflammation to clinically significant TCMR, which is capable of immune-mediated tubular injury resulting in inferior functional, immunological, and histological consequences.
Collapse
Affiliation(s)
| | - Nidhi Agrawal
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia
| | - Ankit Sharma
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia.,School of Public Health, University of Sydney, Sydney, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Sydney, Australia
| | - Anne Taverniti
- Centre for Kidney Research, Children's Hospital at Westmead, Sydney, Australia
| | - Chow H P'Ng
- Tissue Pathology and Diagnostic Oncology, ICPMR, Sydney, Australia
| | - Meena Shingde
- Tissue Pathology and Diagnostic Oncology, ICPMR, Sydney, Australia
| | - Germaine Wong
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia.,School of Public Health, University of Sydney, Sydney, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Sydney, Australia
| | - Jeremy R Chapman
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia
| |
Collapse
|
26
|
Friedewald JJ, Kurian SM, Heilman RL, Whisenant TC, Poggio ED, Marsh C, Baliga P, Odim J, Brown MM, Ikle DN, Armstrong BD, charette JI, Brietigam SS, Sustento-Reodica N, Zhao L, Kandpal M, Salomon DR, Abecassis MM. Development and clinical validity of a novel blood-based molecular biomarker for subclinical acute rejection following kidney transplant. Am J Transplant 2019; 19:98-109. [PMID: 29985559 PMCID: PMC6387870 DOI: 10.1111/ajt.15011] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 06/12/2018] [Accepted: 07/03/2018] [Indexed: 01/25/2023]
Abstract
Noninvasive biomarkers are needed to monitor stable patients after kidney transplant (KT), because subclinical acute rejection (subAR), currently detectable only with surveillance biopsies, can lead to chronic rejection and graft loss. We conducted a multicenter study to develop a blood-based molecular biomarker for subAR using peripheral blood paired with surveillance biopsies and strict clinical phenotyping algorithms for discovery and validation. At a predefined threshold, 72% to 75% of KT recipients achieved a negative biomarker test correlating with the absence of subAR (negative predictive value: 78%-88%), while a positive test was obtained in 25% to 28% correlating with the presence of subAR (positive predictive value: 47%-61%). The clinical phenotype and biomarker independently and statistically correlated with a composite clinical endpoint (renal function, biopsy-proved acute rejection, ≥grade 2 interstitial fibrosis, and tubular atrophy), as well as with de novo donor-specific antibodies. We also found that <50% showed histologic improvement of subAR on follow-up biopsies despite treatment and that the biomarker could predict this outcome. Our data suggest that a blood-based biomarker that reduces the need for the indiscriminate use of invasive surveillance biopsies and that correlates with transplant outcomes could be used to monitor KT recipients with stable renal function, including after treatment for subAR, potentially improving KT outcomes.
Collapse
Affiliation(s)
| | | | | | - Thomas C. Whisenant
- UC San Diego Center for Computational Biology & Bioinformatics, San Diego, CA, USA
| | | | | | | | - Jonah Odim
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Merideth M. Brown
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | | | | | - jane I. charette
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Lihui Zhao
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Manoj Kandpal
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | |
Collapse
|
27
|
Zotta F, Guzzo I, Morolli F, Diomedi-Camassei F, Dello Strologo L. Protocol biopsies in pediatric renal transplantation: a precious tool for clinical management. Pediatr Nephrol 2018; 33:2167-2175. [PMID: 29980849 DOI: 10.1007/s00467-018-4007-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 06/15/2018] [Accepted: 06/18/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Kidney transplantation is the best treatment for children with end-stage kidney disease. Early results have improved, but late graft loss is still a major problem. Non-invasive, fully reliable early biomarkers of acute rejection are currently missing. METHODS Our aim was to evaluate the efficacy of protocol biopsies (PBXs) in a pediatric population. During 11 years, 209 renal transplantations were performed in 204 pediatric patients. Biopsies were performed 3-6 months, 1 year, and 5 years after transplantation. Procedure-related complications were systematically looked for by means of ultrasound scans. RESULTS Unexpected findings (mainly subclinical rejections) requiring therapeutic intervention were found in 19.3% biopsies performed at 3-6 months, in 18.4% in 12-month biopsies and in none of those performed after 5 years. The 13.6% patients at 12-month biopsies and 23.6% at 5-year biopsies showed calcineurin inhibitor (CNI) toxicity. Interstitial fibrosis and tubular atrophy (IF/TA) was found in 17.6 and 83.6% of patients at 12-month and 5-year biopsies, respectively. Complications of the PBX were infrequent. Five-year estimated glomerular filtration rate (GFR) was not significantly different in patients who received treatment for any cause and patients with normal histology. CONCLUSIONS Although we do not have a control group, we may speculate that patients who received treatment returned to a "standard" condition possibly improving final outcome. Protocol biopsies are a powerful diagnostic tool for the management of pediatric renal transplant recipients. In view of the lack of evidence that biopsies taken 5 years after transplantation lead to any therapeutic change, their use should be reconsidered.
Collapse
Affiliation(s)
- Federica Zotta
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Isabella Guzzo
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Federica Morolli
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | | | - Luca Dello Strologo
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
| |
Collapse
|
28
|
Mincham CM, Gibson IW, Sharma A, Wiebe C, Mandal R, Rush D, Nickerson P, Ho J, Wishart DS, Blydt-Hansen TD. Evolution of renal function and urinary biomarker indicators of inflammation on serial kidney biopsies in pediatric kidney transplant recipients with and without rejection. Pediatr Transplant 2018; 22:e13202. [PMID: 29696778 DOI: 10.1111/petr.13202] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2018] [Indexed: 01/06/2023]
Abstract
Urinary CXCL10 and metabolites are biomarkers independently associated with TCMR. We sought to test whether these biomarkers fluctuate in association with histological severity of TCMR over short time frames. Forty-nine pairs of renal biopsies obtained 1-3 months apart from 40 pediatric renal transplant recipients were each scored for TCMR acuity score (i + t; Banff criteria). Urinary CXCL10:Cr and TCMR MDS were obtained at each biopsy and were tested for association with changes between biopsies in acuity, estimated GFR (ΔeGFR), and 12-month ΔeGFR. Sequential biopsies were obtained 1.8 ± 0.8 months apart. Biopsy 1 was usually obtained under protocol (75%), and 62% percent had evidence of TCMR. Using each biopsy pair for comparison, ΔeGFR did not predict change in acuity. By contrast, change in acuity was significantly correlated with change in urinary CXCL10:Cr (ρ 0.45, P = .003) and MDS (ρ 0.29, P = .04) between biopsies. The 12-month ΔeGFR was not predicted by TCMR acuity or CXCL10:Cr at Biopsy 2; however, an inverse correlation was seen with urinary MDS (ρ -0.35; P = .02). Changes in eGFR correlate poorly with evolving TCMR acuity on histology. Urinary biomarkers may be superior for non-invasive monitoring of rejection, including histological response to therapy, and may be prognostic for medium-term function.
Collapse
Affiliation(s)
- Christine M Mincham
- Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Ian W Gibson
- Department of Pathology, University of Manitoba, Health Sciences Center, Winnipeg, MB, Canada
| | - Atul Sharma
- Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital at Health Sciences Center, Winnipeg, MB, Canada
| | - Chris Wiebe
- Department of Internal Medicine, Section of Nephrology, University of Manitoba, Health Sciences Center, Winnipeg, MB, Canada
| | - Rupasri Mandal
- Department of Immunology, University of Manitoba, Winnipeg, MB, Canada
| | - David Rush
- Department of Internal Medicine, Section of Nephrology, University of Manitoba, Health Sciences Center, Winnipeg, MB, Canada
| | - Peter Nickerson
- Department of Internal Medicine, Section of Nephrology, University of Manitoba, Health Sciences Center, Winnipeg, MB, Canada
| | - Julie Ho
- Department of Internal Medicine, Section of Nephrology, University of Manitoba, Health Sciences Center, Winnipeg, MB, Canada.,Department of Immunology, University of Manitoba, Winnipeg, MB, Canada
| | - David S Wishart
- The Metabolomics Innovation Center, University of Alberta, Edmonton, AB, Canada
| | - Tom D Blydt-Hansen
- Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| |
Collapse
|
29
|
Couvrat-Desvergnes G, Foucher Y, Le Borgne F, Dion A, Mourad G, Garrigue V, Legendre C, Rostaing L, Kamar N, Kessler M, Ladrière M, Morelon E, Buron F, Giral M, Dantan E. Comparison of graft and patient survival according to the transplantation centre policy for 1-year screening biopsy among stable kidney recipients: a propensity score-based study. Nephrol Dial Transplant 2018; 34:703-711. [DOI: 10.1093/ndt/gfy221] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Grégoire Couvrat-Desvergnes
- Department of Nephrology, Dialysis and Transplantation, Departmental Hospital of Vendée, La Roche-sur-Yon, France
- Centre de Recherche en Transplantation et Immunologie INSERM UMR1064, Université de Nantes, Centre Hospitalier Universitaire de Nantes, RTRS “Centaure”, Nantes, France
| | - Yohann Foucher
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Florent Le Borgne
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
- IDBC/A2com, Pacé, France
| | - Angelina Dion
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
| | - Georges Mourad
- Department of Nephrology, Dialysis and Transplantation, Lapeyronie University Hospital, Montpellier, France
| | - Valérie Garrigue
- Department of Nephrology, Dialysis and Transplantation, Lapeyronie University Hospital, Montpellier, France
| | - Christophe Legendre
- Kidney Transplant Center, Necker University Hospital, APHP, RTRS “Centaure”, Paris Descartes and Sorbonne Paris Cité Universities, Paris, France
| | - Lionel Rostaing
- Department of Nephrology, Dialysis, and Organ Transplantation, Rangueil University Hospital and University Paul Sabatier, Toulouse, France
| | - Nassim Kamar
- Department of Nephrology, Dialysis, and Organ Transplantation, Rangueil University Hospital and University Paul Sabatier, Toulouse, France
| | - Michèle Kessler
- Department of Renal Transplantation, Brabois University Hospital, Nancy, France
| | - Marc Ladrière
- Department of Renal Transplantation, Brabois University Hospital, Nancy, France
| | - Emmanuel Morelon
- Department of Nephrology, Transplantation and Clinic Immunology, RTRS “Centaure”, Edouard Herriot University Hospital, Hospices Civils, Lyon, France
| | - Fanny Buron
- Department of Nephrology, Transplantation and Clinic Immunology, RTRS “Centaure”, Edouard Herriot University Hospital, Hospices Civils, Lyon, France
| | - Magali Giral
- Centre de Recherche en Transplantation et Immunologie INSERM UMR1064, Université de Nantes, Centre Hospitalier Universitaire de Nantes, RTRS “Centaure”, Nantes, France
- Centre d’Investigation Clinique en Biothérapie, Labex Transplantex, Nantes, France
| | - Etienne Dantan
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
| |
Collapse
|
30
|
Jamshaid F, Froghi S, Di Cocco P, Dor FJ. Novel non-invasive biomarkers diagnostic of acute rejection in renal transplant recipients: A systematic review. Int J Clin Pract 2018; 72:e13220. [PMID: 30011113 DOI: 10.1111/ijcp.13220] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 06/07/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Acute rejection is a significant complication detrimental to kidney transplant function. Current accepted means of diagnosis is percutaneous renal biopsy, a costly and invasive procedure. There is an urgent need to detect and validate non-invasive biomarkers capable of replacing the biopsy. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS Comprehensive literature searches of Medline, EMBASE and Cochrane Central Register of Controlled Trials databases were performed. Eligible studies were included as per inclusion criteria and assessed for quality using the GRADE quality of evidence tool. Outcomes evaluated included biomarker diagnostic performance, number of patients/samples, mean age and gender ratio, immunosuppression regime, in addition to clinical applications of the biomarker(s) tested. PRISMA guidelines were followed. Where possible, statistical analysis of comparative performance data was performed. RESULTS 23 studies were included in this review, including 19 adult, 3 paediatric and 1 mixed studies. A total of 2858 participants and 50 candidate non-invasive tests were identified. Sensitivity, specificity and area under the curve performance values ranged 36%-100%, 30%-100% and 0.55-0.98, respectively. CONCLUSIONS Although larger, more robust multi-centre validation studies are needed before non-invasive biomarkers can replace the biopsy, numerous candidate tests have demonstrated significant promise for various facets of postoperative management. Suggested uses include: ruling out patients with a low risk of acute rejection to avoid the need for biopsy, non-invasive testing where the biopsy is contraindicated and a prompt diagnosis is needed, and integration into a serial blood monitoring protocol in conjunction with serum creatinine.
Collapse
Affiliation(s)
- Faisal Jamshaid
- MRC Centre for Transplantation, Guy's Campus, Kings College London School of Medicine, London, UK
| | - Saied Froghi
- MRC Centre for Transplantation, Guy's Campus, Kings College London School of Medicine, London, UK
- Imperial College London, Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, UK
| | - Pierpaolo Di Cocco
- Imperial College London, Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, UK
| | - Frank Jmf Dor
- Imperial College London, Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, UK
| |
Collapse
|
31
|
Giral M, Renaudin K, Naesens M, Luning R, Anglicheau D, Morelon E, Huneau A, Paul C, Brouard S, Couvrat-Desvergnes G, Foucher Y, Dantan E. The 1-year Renal Biopsy Index: a scoring system to drive biopsy indication at 1-year post-kidney transplantation. Transpl Int 2018; 31:947-955. [PMID: 29893433 DOI: 10.1111/tri.13290] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/26/2018] [Accepted: 06/07/2018] [Indexed: 11/27/2022]
Abstract
Surveillance biopsies after renal transplantation remain debatable. To drive the decision of such intervention, we propose a predictive score of abnormal histology at 1-year post-transplantation, named 1-year Renal Biopsy Index (1-RBI). We studied 466 kidney recipients from the DIVAT cohort alive with a functioning graft and a surveillance biopsy at 1-year post-transplantation. Patients displaying abnormal histology (49%) (borderline, acute rejection, interstitial fibrosis and tubular atrophy [IFTA] grade 2 or 3, glomerulonephritis) were compared to the normal or subnormal (IFTA grade 1) histology group. Obtained from a lasso penalized logistic regression, the 1-RBI was composed of recipient gender, serum creatinine at 3, 6, and 12 month post-transplantation and anticlass II immunization at transplantation (internal validation: AUC = 0.71, 95% CI [0.53-0.83]; external validation: AUC = 0.62, 95% CI [0.58-0.66]). While we could not determinate a threshold able to identify patients at high chance of normal or subnormal histology, we estimated and validated a discriminating threshold capable of identifying a subgroup of 15% of the patients with a risk of abnormal histology higher than 80%. The 1-RBI is computable online at www.divat.fr. The 1-RBI could be a useful tool to standardize 1-year biopsy proposal and may for instance help to indicate one in case of high risk of abnormal histology.
Collapse
Affiliation(s)
- Magali Giral
- CRTI UMR 1064, Inserm, Université de Nantes, ITUN, CHU Nantes, RTRS Centaure, Nantes, France
- Centre d'Investigation Clinique en Biothérapie, Labex Transplantex, Nantes, France
| | - Karine Renaudin
- Pathological Anatomy and Cytology, CHU Hôtel-Dieu, Nantes, France
| | - Maarten Naesens
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Redmer Luning
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Dany Anglicheau
- Kidney Transplant Center, Necker University Hospital, APHP, RTRS "Centaure", Paris Descartes and Sorbonne Paris Cité Universities, Paris, France
| | - Emmanuel Morelon
- Nephrology, Transplantation and Clinic Immunology Department, RTRS "Centaure", Edouard Herriot University Hospital, Hospices Civils, Lyon, France
| | - Alexandre Huneau
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
| | - Chloé Paul
- CRTI UMR 1064, Inserm, Université de Nantes, ITUN, CHU Nantes, RTRS Centaure, Nantes, France
- Centre d'Investigation Clinique en Biothérapie, Labex Transplantex, Nantes, France
| | - Sophie Brouard
- CRTI UMR 1064, Inserm, Université de Nantes, ITUN, CHU Nantes, RTRS Centaure, Nantes, France
- Centre d'Investigation Clinique en Biothérapie, Labex Transplantex, Nantes, France
| | - Grégoire Couvrat-Desvergnes
- CRTI UMR 1064, Inserm, Université de Nantes, ITUN, CHU Nantes, RTRS Centaure, Nantes, France
- Department of Nephrology, Dialysis and Transplantation, Departmental Hospital of Vendée, La Roche-sur-Yon, France
| | - Yohann Foucher
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
- CHU NANTES, Nantes, France
| | - Etienne Dantan
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
| |
Collapse
|
32
|
Zhu N, Rowe NE, Martin PR, Luke SS, Mcgregor TB, Myslik F, Mcalister VC, Sener A, Luke PP. Long-term results of protocol kidney biopsy directing steroid withdrawal in simultaneous pancreas-kidney transplant patients. Can Urol Assoc J 2018; 12:188-192. [PMID: 29485032 DOI: 10.5489/cuaj.4702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION We sought to determine whether protocol biopsies could be used to guide treatment and improve outcomes in simultaneous pancreas-kidney (SPK) patients. METHODS Between 2004 and 2013, protocol biopsies were performed on SPK patients at 3-6 months and one year post-transplant. Maintenance immunosuppression consisted of a calcineurin inhibitor, anti-proliferative agent, and corticosteroid. Corticosteroid was withdrawn in negative early biopsies, maintained in subclinical/ borderline biopsies, and increased if Banff IB or greater rejection was identified. Endpoints included presence of interstitial fibrosis and tubular atrophy on biopsy at one year (IF/TA), rejection episodes, and renal and pancreas function at five years' followup. RESULTS Forty-one SPK transplant patients were reviewed and a total of 75 protocol biopsies were identified. On early biopsy, 51% had negative biopsies, 44% had borderline rejection, and 5% had subclinical rejection. Renal and pancreas function were not significantly different at one, two, and five years post-transplant between negative vs. borderline early biopsy patients. No difference in the degree of IF/TA was found between these two groups. CONCLUSIONS To our knowledge, this is the first study to evaluate protocol biopsies as an investigative tool prior to steroid withdrawal in SPK patients. Our study suggests that there are no detrimental functional or histological effects at five years post-transplant, despite weaning steroids in the negative biopsy group.
Collapse
Affiliation(s)
- Nemin Zhu
- Western University Schulich School of Medicine and Dentistry, London, ON; Canada
| | - Neal E Rowe
- Department of Surgery, University of Ottawa, Ottawa, ON; Canada
| | - Paul R Martin
- Western University Schulich School of Medicine and Dentistry, London, ON; Canada.,Department of Surgery, London Health Sciences Centre, Western University, London, ON; Canada
| | - Sean S Luke
- Western University Schulich School of Medicine and Dentistry, London, ON; Canada
| | | | - Frank Myslik
- Western University Schulich School of Medicine and Dentistry, London, ON; Canada
| | - Vivian C Mcalister
- Western University Schulich School of Medicine and Dentistry, London, ON; Canada.,Department of Surgery, London Health Sciences Centre, Western University, London, ON; Canada.,Multi-Organ Transplant Program, London Health Sciences Centre, London, ON; Canada
| | - Alp Sener
- Western University Schulich School of Medicine and Dentistry, London, ON; Canada.,Department of Surgery, London Health Sciences Centre, Western University, London, ON; Canada.,Multi-Organ Transplant Program, London Health Sciences Centre, London, ON; Canada
| | - Patrick P Luke
- Western University Schulich School of Medicine and Dentistry, London, ON; Canada.,Department of Surgery, London Health Sciences Centre, Western University, London, ON; Canada.,Multi-Organ Transplant Program, London Health Sciences Centre, London, ON; Canada
| |
Collapse
|
33
|
Scintigraphic texture analysis for assessment of renal allograft function. Pol J Radiol 2018; 83:e1-e10. [PMID: 30038672 PMCID: PMC6047088 DOI: 10.5114/pjr.2018.74956] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 07/18/2017] [Indexed: 12/27/2022] Open
Abstract
Purpose Early detection and monitoring of kidney function during the post-transplantation period is one of the most important issues for improving the accuracy of an initial diagnosis. The aim of this study was to evaluate texture analysis (TA) in scintigraphic imaging to detect changes in kidney status after transplantation. Material and methods Scintigraphic images were used for TA from a total of 94 kidney allografts (39 rejected and 55 non-rejected). Images corresponding to the frames at the 2nd, 5th, and 20th minute of the study were used to determine the optimum time point for analysis of differences in texture features between the rejected and non-rejected allografts. Results Linear discriminant analysis indicated the best performance at the fifth minute frame for classification of the rejected and non-rejected allografts with receiver operating characteristic curve (Az) of 0.982, corresponding to 91.89% sensitivity, 96.49% specificity, and 94.68% accuracy. Also, TA can differentiate acute tubular necrosis from acute rejection with Az of 0.953 corresponding to 88% sensitivity, 92.31% specificity, and 90.62% accuracy at the 5th minute frame. The best correlation between texture feature and kidney function was achieved at the 20th minute frame (r = -0.396) for glomerular filtration rate. Conclusions TA has good potential for the characterisation of kidney failure after transplantation and can improve clinical diagnosis.
Collapse
|
34
|
Zachariah MS, Dwivedi AK, Yip CS, Chang SS, Gundroo A, Venuto RC, Tomaszewski J, Patel SK, Sharma R. Utility of Serial Protocol Biopsies Performed After 1 Year in Predicting Long-Term Kidney Allograft Function According to Histologic Phenotype. EXP CLIN TRANSPLANT 2017; 16:391-400. [PMID: 29206090 DOI: 10.6002/ect.2016.0323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Prognostic implications of early protocol biopsies have been studied; however, the value of late protocol biopsy in predicting graft outcome has not been well defined. Here, we compared the effects of early and late protocol biopsy histologic findings in stable kidney allografts and aimed to understand the significance of "borderline" rejection on allograft function. MATERIALS AND METHODS We studied 261 biopsies from 159 renal transplant recipients who were on a steroid-free, calcineurin inhibitor and mycophenolate mofetil regimen and who received transplants between 2004 and 2012 with mean follow-up of 5 years. Early (between 3 and 9 mo) and subsequent late (between 12 and 24 mo) protocol biopsies were performed. Biopsies were classified as normal, interstitial fibrosis and/or tubular atrophy, subclinical acute rejection with interstitial fibrosis and/or tubular atrophy, and borderline rejection with interstitial fibrosis and/or tubular atrophy. A linear mixed-effects model was used to determine the effects of early and late protocol biopsies on estimated glomerular filtration rate changes, with baseline time for estimated glomerular filtration rate fixed at 12 months. RESULTS The adjusted model showed that estimated glomerular filtration rate at 3 months, donor age, delayed graft function, and early protocol biopsies were associated with baseline estimated glomerular filtration rate at 12 months. Estimated glomerular filtration rate changes over time were associated with findings of interstitial fibrosis and/or tubular atrophy at early biopsy and subclinical acute rejection and borderline rejection at late biopsy. At last follow-up, final estimated glomerular filtration rate was significantly associated with interstitial fibrosis and/or tubular atrophy at early biopsy and with subclinical acute rejection at late biopsy. CONCLUSIONS Although early protocol biopsy predicted baseline estimated glomerular filtration rate, late biopsy was important for predicting changes in function over time. In addition, a diagnosis of "borderline" rejection on protocol biopsies predicted long-term graft function.
Collapse
Affiliation(s)
- Mareena S Zachariah
- From Department of Internal Medicine, Division of Nephrology, SUNY at the University at Buffalo, Buffalo, NY, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Parajuli S, Reville PK, Ellis TM, Djamali A, Mandelbrot DA. Utility of protocol kidney biopsies for de novo donor-specific antibodies. Am J Transplant 2017; 17:3210-3218. [PMID: 28805293 DOI: 10.1111/ajt.14466] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 07/24/2017] [Accepted: 07/29/2017] [Indexed: 01/25/2023]
Abstract
There is limited information about the role of protocol kidney biopsies for de novo donor-specific antibodies (dnDSA) in kidney transplant recipients, especially in those with stable graft function. We initiated a routine posttransplant DSA monitoring and surveillance biopsy program for dnDSA since 2014. We identified 45 kidney transplant recipients with dnDSA detected between January 2014 and February 2017 who underwent kidney biopsy within 60 days of detection of dnDSA. Twenty-nine (64%) had stable graft function and 16 (36%) had impaired graft function at the time of dnDSA detection. Even in the group with stable graft function, we found a high rate of rejection (53%) on biopsy. Eighty-eight percent of patients with impaired graft function had rejection. Those patients with impaired graft function had significantly lower estimated glomerular filtration rate at 12 months postbiopsy and at last follow-up. Those with impaired graft function had more graft failures; however, this result was not statistically significant. The high rate of asymptomatic rejection, and the fact that outcomes in asymptomatic patients are poor, is in support of the utility of surveillance biopsies in patients with dnDSA.
Collapse
Affiliation(s)
- Sandesh Parajuli
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Patrick K Reville
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Thomas M Ellis
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Arjang Djamali
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Didier A Mandelbrot
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| |
Collapse
|
36
|
Kurian S, Velazquez E, Thompson R, Whisenant T, Rose S, Riley N, Harrison F, Gelbart T, Friedewald J, charrette J, Brietigam S, Peysakhovich J, First M, Abecassis M, Salomon D. Orthogonal Comparison of Molecular Signatures of Kidney Transplants With Subclinical and Clinical Acute Rejection: Equivalent Performance Is Agnostic to Both Technology and Platform. Am J Transplant 2017; 17:2103-2116. [PMID: 28188669 PMCID: PMC5519433 DOI: 10.1111/ajt.14224] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 01/06/2017] [Accepted: 01/20/2017] [Indexed: 01/25/2023]
Abstract
We performed orthogonal technology comparisons of concurrent peripheral blood and biopsy tissue samples from 69 kidney transplant recipients who underwent comprehensive algorithm-driven clinical phenotyping. The sample cohort included patients with normal protocol biopsies and stable transplant (sTx) function (n = 25), subclinical acute rejection (subAR, n = 23), and clinical acute rejection (cAR, n = 21). Comparisons between microarray and RNA sequencing (RNA-seq) signatures were performed and demonstrated a strong correlation between the blood and tissue compartments for both technology platforms. A number of shared differentially expressed genes and pathways between subAR and cAR in both platforms strongly suggest that these two clinical phenotypes form a continuum of alloimmune activation. SubAR is associated with fewer or less expressed genes than cAR in blood, whereas in biopsy tissues, this clinical phenotype demonstrates a more robust molecular signature for both platforms. The discovery work done in this study confirms a clear ability to detect gene expression profiles for sTx, subAR, and cAR in both blood and biopsy tissue, yielding equivalent predictive performance that is agnostic to both technology and platform. Our data also provide strong biological insights into the molecular mechanisms underlying these signatures, underscoring their logistical potential as molecular diagnostics to improve clinical outcomes following kidney transplantation.
Collapse
Affiliation(s)
- S.M. Kurian
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| | - E. Velazquez
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| | - R. Thompson
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| | - T. Whisenant
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| | - S. Rose
- Transplant Genomics Inc., Mansfield, MA
| | - N. Riley
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| | - F. Harrison
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| | - T. Gelbart
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| | - J.J. Friedewald
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - j. charrette
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - S. Brietigam
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - J. Peysakhovich
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - M.R. First
- Transplant Genomics Inc., Mansfield, MA,Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - M.M. Abecassis
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - D.R. Salomon
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| |
Collapse
|
37
|
The Use of Genomics and Pathway Analysis in Our Understanding and Prediction of Clinical Renal Transplant Injury. Transplantation 2017; 100:1405-14. [PMID: 26447506 DOI: 10.1097/tp.0000000000000943] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The development and application of high-throughput molecular profiling have transformed the study of human diseases. The problem of handling large, complex data sets has been facilitated by advances in complex computational analysis. In this review, the recent literature regarding the application of transcriptional genomic information to renal transplantation, with specific reference to acute rejection, acute kidney injury in allografts, chronic allograft injury, and tolerance is discussed, as is the current published data regarding other "omics" strategies-proteomics, metabolomics, and the microRNA transcriptome. These data have shed new light on our understanding of the pathogenesis of specific disease conditions after renal transplantation, but their utility as a biomarker of disease has been hampered by study design and sample size. This review aims to highlight the opportunities and obstacles that exist with genomics and other related technologies to better understand and predict renal allograft outcome.
Collapse
|
38
|
Abstract
Short-term outcomes in renal transplantation have improved significantly in the past few years. However, the improvement in long-term outcomes has been modest. The reasons for graft failure beyond the first year of transplantation have been attributed to several different factors. We believe that subclinical rejection (SCR) may be 1 of the factors that contribute to graft loss in the long run. We also believe that there are data to suggest that SCR leads to progressive fibrosis and loss of graft function. This has been demonstrated even in patients who have mild degrees of subclinical inflammation. This review outlines the major studies that have been published on this important topic. It also outlines potential risk factors for the development of SCR. The current approach and diagnostic methods are discussed as well as their pros and cons. Newer noninvasive methods of diagnosis as well as molecular diagnostics and their merits and shortcomings are also discussed in some depth. Thus, the proposed state of the art review on SCR will create a renewed interest at all levels including transplant clinicians, transplant researchers, pharmaceutical industries as well as regulatory organizations.
Collapse
|
39
|
Abstract
All causes of renal allograft injury, when severe and/or sustained, can result in chronic histological damage of which interstitial fibrosis and tubular atrophy are dominant features. Unless a specific disease process can be identified, what drives interstitial fibrosis and tubular atrophy progression in individual patients is often unclear. In general, clinicopathological factors known to predict and drive allograft fibrosis include graft quality, inflammation (whether "nonspecific" or related to a specific diagnosis), infections, such as polyomavirus-associated nephropathy, calcineurin inhibitors (CNI), and genetic factors. The incidence and severity of chronic histological damage have decreased substantially over the last 3 decades, but it is difficult to disentangle what effects individual innovations (eg, better matching and preservation techniques, lower CNI dosing, BK viremia screening) may have had. There is little evidence that CNI-sparing/minimization strategies, steroid minimization or renin-angiotensin-aldosterone system blockade result in better preservation of intermediate-term histology. Treatment of subclinical rejections has only proven beneficial to histological and functional outcome in studies in which the rate of subclinical rejection in the first 3 months was greater than 10% to 15%. Potential novel antifibrotic strategies include antagonists of transforming growth factor-β, connective tissue growth factor, several tyrosine kinase ligands (epidermal growth factor, platelet-derived growth factor, vascular endothelial growth factor), endothelin and inhibitors of chemotaxis. Although many of these drugs are mainly being developed and marketed for oncological indications and diseases, such as idiopathic pulmonary fibrosis, a number may hold promise in the treatment of diabetic nephropathy, which could eventually lead to applications in renal transplantation.
Collapse
Affiliation(s)
- Thomas Vanhove
- 1 Department of Microbiology and Immunology, KU Leuven-University of Leuven, Leuven, Belgium. 2 Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium. 3 Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | | |
Collapse
|
40
|
Mehta R, Cherikh W, Sood P, Hariharan S. Kidney allograft surveillance biopsy practices across US transplant centers: A UNOS survey. Clin Transplant 2017; 31. [PMID: 28251702 DOI: 10.1111/ctr.12945] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The approach to the diagnosis and management of subclinical rejection (SCR) in kidney transplant recipients remains controversial. METHODS We conducted a survey through UNOS across US transplant centers regarding their approach to surveillance biopsies and reasons for the nonperformance of surveillance biopsies. RESULTS Responses were obtained from 106/238 centers (45%), and only 18 (17%) of the centers performed surveillance biopsies on all patients and 22 (21%) performed biopsy for select cases. The most common time points for surveillance biopsies were 3 and 12 months post-transplant. The common reasons for not performing biopsies were low yield (n = 44, 65%) and the belief that it will not change outcome (n = 24, 36%). The incidence of SC-TCMR was ≥ 10% among 39% of centers. The mean serum creatinine was slightly worse by 0.06 mg/dL at 1 year and 0.07 mg/dL at 3 years among centers performing biopsy, P < .0001. The. 1-and 3-year Observed-Expected (O-E) graft survival was similar among centers performing biopsies vs. those not performing biopsy (P = .07, .88). CONCLUSION Only 17% of US centers perform surveillance biopsies, with another 21% performing surveillance biopsies in select cases (among centers that responded to the survey). Greater uniformity in the approach and management of this condition is of paramount importance.
Collapse
Affiliation(s)
- Rajil Mehta
- Division of Renal and Electrolytes and Division of Transplant Surgery, Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Wida Cherikh
- United Network of Organ Sharing, Richmond, VA, USA
| | - Puneet Sood
- Division of Renal and Electrolytes and Division of Transplant Surgery, Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sundaram Hariharan
- Division of Renal and Electrolytes and Division of Transplant Surgery, Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| |
Collapse
|
41
|
Ix JH, Katz R, Bansal N, Foster M, Weiner DE, Tracy R, Jotwani V, Hughes-Austin J, McKay D, Gabbai F, Hsu CY, Bostom A, Levey AS, Shlipak MG. Urine Fibrosis Markers and Risk of Allograft Failure in Kidney Transplant Recipients: A Case-Cohort Ancillary Study of the FAVORIT Trial. Am J Kidney Dis 2017; 69:410-419. [PMID: 28024930 PMCID: PMC7321838 DOI: 10.1053/j.ajkd.2016.10.019] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 10/05/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Kidney tubulointerstitial fibrosis marks risk for allograft failure in kidney transplant recipients, but is poorly captured by estimated glomerular filtration rate (eGFR) or urine albumin-creatinine ratio (ACR). Whether urinary markers of tubulointerstitial fibrosis can noninvasively identify risk for allograft failure above and beyond eGFR and ACR is unknown. STUDY DESIGN Case-cohort study. SETTING & PARTICIPANTS The FAVORIT (Folic Acid for Vascular Outcome Reduction in Transplantation) Trial was a randomized double-blind trial testing vitamin therapy to lower homocysteine levels in stable kidney transplant recipients. We selected a subset of participants at random (n=491) and all individuals with allograft failure during follow-up (cases; n=257). PREDICTOR Using spot urine specimens from the baseline visit, we measured 4 urinary proteins known to correlate with tubulointerstitial fibrosis on biopsy (urine α1-microglobulin [A1M], monocyte chemoattractant protein 1 [MCP-1], and procollagen type III and type I amino-terminal amino pro-peptide). OUTCOME Death-censored allograft failure. RESULTS In models adjusted for demographics, chronic kidney disease risk factors, eGFR, and ACR, higher concentrations of urine A1M (HR per doubling, 1.73; 95% CI, 1.43-2.08) and MCP-1 (HR per doubling, 1.60; 95% CI, 1.32-1.93) were strongly associated with allograft failure. When additionally adjusted for concentrations of other urine fibrosis and several urine injury markers, urine A1M (HR per doubling, 1.76; 95% CI, 1.27-2.44]) and MCP-1 levels (HR per doubling, 1.49; 95% CI, 1.17-1.89) remained associated with allograft failure. Urine procollagen type III and type I levels were not associated with allograft failure. LIMITATIONS We lack kidney biopsy data, BK titers, and HLA antibody status. CONCLUSIONS Urine measurement of tubulointerstitial fibrosis may provide a noninvasive method to identify kidney transplant recipients at higher risk for future allograft failure, above and beyond eGFR and urine ACR.
Collapse
Affiliation(s)
- Joachim H Ix
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, San Diego, CA; Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA; Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA.
| | - Ronit Katz
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, WA
| | - Nisha Bansal
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, WA
| | - Meredith Foster
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Daniel E Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Russell Tracy
- Department of Pathology, University of Vermont, Burlington, VT
| | - Vasantha Jotwani
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Jan Hughes-Austin
- Department of Orthopedic Surgery, University of California San Diego, San Diego, CA
| | - Dianne McKay
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, San Diego, CA
| | - Francis Gabbai
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, San Diego, CA; Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA
| | - Chi-Yuan Hsu
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | | | - Andrew S Levey
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Michael G Shlipak
- General Internal Medicine Section, San Francisco Veterans Affairs Hospital, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA; Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA
| |
Collapse
|
42
|
Single center experience of subclinical rejections and BK nephropathies by kidney allografts' surveillance biopsies. Adv Med Sci 2017; 62:110-115. [PMID: 28242482 DOI: 10.1016/j.advms.2016.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 07/05/2016] [Accepted: 07/07/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE Acute rejection of the kidney allograft remains the most important factor affecting the long-term graft outcome and is a major predictor of development of chronic damage and graft loss. Several studies have shown that early detection and treatment of subclinical rejection episodes may be beneficial for the graft outcome. The role of protocol (surveillance) biopsies and the value of donor specific antibodies (DSA) monitoring are still debatable. METHODS This is a prospective observational study involving seventeen kidney recipients transplanted in north-eastern part of Poland who underwent "zero", 3-month and 12-month allograft biopsies as well as DSA assessment. RESULTS Histologic analysis of the biopsies showed subclinical acute cellular rejection in 17.6% of patients (two tubulointerstitial, one vascular) at 3-months post transplantation, and additional case of borderline rejection at the 12-month point. Moreover, two cases (11.8%) of polyomavirus BK nephropathy were diagnosed (one at 3 and one at 12 month point). None of the patients developed de novo DSA. CONCLUSIONS Our protocol biopsies allowed us to detect significant proportion of patients with subclinical, but histologically relevant acute cellular rejection and BK nephropathy. Early therapeutic intervention had beneficial effects in a 4-year follow up.
Collapse
|
43
|
Efficacy of Acute Cellular Rejection Treatment According to Banff Score in Kidney Transplant Recipients: A Systematic Review. Transplant Direct 2016; 2:e115. [PMID: 27990480 PMCID: PMC5142362 DOI: 10.1097/txd.0000000000000626] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 09/14/2016] [Indexed: 11/25/2022] Open
Abstract
Supplemental digital content is available in the text. Background The poor prognosis classically associated with Banff grade 2 acute cell-mediated rejection (CMR) may be due to unrecognized antibody-mediated damage. We thus performed a systematic review of the literature to determine the rate of response to treatment in kidney transplant recipients with pure CMR, stratified by Banff class. Methods In addition to a manual search, databases interrogated included Excerpta Medica Database (EMBASE), Medical Literature Analysis and Retrieval System Online (MEDLINE), Evidence-Based Medicine (EBM) databases, Central, PubMed and CINAHL. Studies providing functional and/or histological response rates to the treatment of CMR rejection by Banff class (1997 or more recent) were included. Results Among the 746 articles identified, 5 articles were included in the final review. Two studies excluded some, and 2 excluded all features of antibody-mediated rejection, while providing data on functional recovery. The absence of functional recovery was reported in 4% of borderline, 15% for Banff grade 1A and IB pooled, 0% to 25% of Banff grade 1B alone, 11% to 20% of Banff grade 2A, and 38% of Banff grade 2B rejections. Conclusions The rate of functional recovery of pure Banff IIA CMR overlapped with that of Banff grade 1 CMR, whereas Banff grade 2B showed worse prognosis. There was important heterogeneity in the definition of response to treatment and paucity of data describing the histological response to treatment stratified by Banff class. There is a pressing need to standardize outcome metrics for the reversibility of rejection in kidney transplant recipients in order to design high-quality trials for novel therapeutic alternatives.
Collapse
|
44
|
Abstract
As both T cell and antibody-mediated rejection can have a subclinical phase, protocol biopsies provide an early opportunity to intervene before the onset of clinical allograft dysfunction. Protocol biopsies are usually done after reperfusion to establish baseline, between 3 and 6 months to identify subclinical rejection, and at 6-12 months to assess chronicity and persistent inflammation that have prognostic implication. Treatment of both subclinical T cell and antibody-mediated rejection prevents progression of rejection and development of interstitial fibrosis/tubular atrophy or transplant glomerulopathy. Although subclinical rejection has become less frequent in low-risk patients on triple immunosuppression containing tacrolimus, protocol biopsies may still be useful in selected population. Protocol biopsies are more likely to benefit patients at higher risk for rejection, including those who are highly sensitized, transplanted across donor-specific antibody barriers, or on calcineurin inhibitor/corticosteroids sparing regimens. Interstitial fibrosis on protocol biopsies, especially in conjunction with persistent inflammation, predicts lower allograft survival.
Collapse
|
45
|
Decreased Kidney Graft Survival in Low Immunological Risk Patients Showing Inflammation in Normal Protocol Biopsies. PLoS One 2016; 11:e0159717. [PMID: 27532630 PMCID: PMC4988662 DOI: 10.1371/journal.pone.0159717] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 07/07/2016] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The pros and cons for implementing protocol biopsies (PB) after kidney transplantation are still a matter of debate. We aimed to address the frequency of pathological findings in PB, to analyze their impact on long-term graft survival (GS) and to analyze the risk factors predicting an abnormal histology. METHODS We analyzed 946 kidney PB obtained at a median time of 6.5 (±2.9) months after transplantation. Statistics included comparison between groups, Kaplan-Meier and multinomial logistic regression analysis. RESULTS AND DISCUSSION PB diagnosis were: 53.4% normal; 46% IFTA; 12.3% borderline and 4.9% had subclinical acute rejection (SCAR). Inflammation had the strongest negative impact on GS. Therefore we split the cases into: "normal without inflammation", "normal with inflammation", "IFTA without inflammation", "IFTA with inflammation" and "rejection" (including SCAR and borderline). 15-year GS in PB diagnosed normal with inflammation was significantly decreased in a similar fashion as in rejection cases. Among normal biopsies, inflammation increased significantly the risk of 15-y graft loss (P = 0.01). Variables that predicted an abnormal biopsy were proteinuria, previous AR and DR-mismatch. CONCLUSION We conclude that inflammation in normal PB is associated with a significantly lower 15-y GS, comparable to rejection or IFTA with inflammation.
Collapse
|
46
|
Bamoulid J, Staeck O, Halleck F, Dürr M, Paliege A, Lachmann N, Brakemeier S, Liefeldt L, Budde K. Advances in pharmacotherapy to treat kidney transplant rejection. Expert Opin Pharmacother 2015; 16:1627-48. [PMID: 26159444 DOI: 10.1517/14656566.2015.1056734] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Current immunosuppressive combination therapy provides excellent prevention of T-cell-mediated rejection following renal transplantation; however, antibody-mediated rejection remains of high concern and accounts for a large number of long-term allograft losses. The recent development of protocol biopsies resulted in the definition of subclinical rejection (SCR), showing histologic evidence for rejection but unremarkable clinical course. AREAS COVERED This review describes the current knowledge and evidence of pharmacotherapy to treat kidney allograft rejections and covers SCR treatment options. Each substance is analyzed with regard to its classical indication and further discussed for the treatment of other forms of rejection. EXPERT OPINION Despite a lack of randomized trials, early acute T-cell-mediated rejection can be treated effectively in most cases without graft loss. The necessity to treat SCR is currently unclear. Due to a lack of effective therapies, new treatment approaches for antibody-mediated rejection are an urgent medical need to improve long-term outcomes. Future research should aim to better define pathophysiology and histology, stratify risk, and develop rational treatment strategies from randomized controlled trials, in order to establish the value of novel therapies in the arsenal of rejection pharmacotherapy. However, the effective prevention of rejection with minimal side effects still remains the goal in immunosuppression.
Collapse
Affiliation(s)
- Jamal Bamoulid
- Charité Universitätsmedizin Berlin, Department of Nephrology , Berlin , Germany +49 30 450 514002 ; +49 30 450 514902 ;
| | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Nilles KM, Krupp J, Lapin B, Sustento-Reodica N, Gallon L, Levitsky J. Incidence and impact of rejection following simultaneous liver-kidney transplantation. J Hepatol 2015; 62:340-5. [PMID: 25195555 DOI: 10.1016/j.jhep.2014.08.037] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 07/21/2014] [Accepted: 08/26/2014] [Indexed: 12/04/2022]
Abstract
BACKGROUND & AIMS Due to hepatic immunoregulation, simultaneous liver-kidney recipients are presumed to be reasonably protected from kidney rejection and typically receive less immunosuppression compared to kidney transplants alone. However, data to support these conclusions and practices are sparse. METHODS We characterized the incidence and types of rejection, graft function, and graft and patient survival in a large population of simultaneous liver-kidney recipients (n=140) with long-term follow-up at our centre (1998-2010). RESULTS Acute cellular, antibody-mediated, and chronic kidney rejection was diagnosed in 9 (6.4%), 2 (1.4%), and 1 (0.7%) patient, respectively. Borderline acute kidney rejection was diagnosed in another 16 patients (11.4%). Acute cellular liver rejection occurred in 16 (11.4%) and chronic liver rejection in 4 (2.9%). One-, three-, and five-year patient survival was 86.4%, 78.0%, and 74.0%, respectively, and did not significantly differ by presence or absence of kidney or liver rejection. However, kidney rejection was associated with decreased renal function by lower serum GFR over time (p=0.003). CONCLUSIONS Various forms of kidney rejection occurred in ∼20% of our simultaneous liver-kidney recipients and were associated with deterioration in graft function, indicating that the liver may not confer complete protective allo-immunity. More stringent graft monitoring and management strategies, perhaps more akin to kidney transplant alone, should be prospectively studied in simultaneous liver-kidney recipients.
Collapse
Affiliation(s)
- Kathy M Nilles
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - James Krupp
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brittany Lapin
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Lorenzo Gallon
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Josh Levitsky
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| |
Collapse
|
48
|
Vitalone MJ, Ganguly B, Hsieh S, Latek R, Kulbokas EJ, Townsend R, Sarwal MM. Transcriptional profiling of belatacept and calcineurin inhibitor therapy in renal allograft recipients. Am J Transplant 2014; 14:1912-21. [PMID: 24954576 DOI: 10.1111/ajt.12746] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 02/28/2014] [Accepted: 03/12/2014] [Indexed: 01/25/2023]
Abstract
Calcineurin inhibitor (CNI) use may lead to allograft injury and compromised renal function. Gene expression profiles of 12-month kidney biopsies from a Phase 3 study of belatacept and a CNI comparator, cyclosporine (CsA), were compared with expression profiles of a set of historical, demographically matched, preimplantation control biopsies. Gene set enrichment analysis was used to test each set of differentially expressed genes (DEGs) for the enrichment of an in vitro-derived CNI toxicity (CNIT) gene set and published gene sets associated with chronic allograft injury (CAI), immune modulation and tissue remodeling. The unique set of genes differentially expressed in CNI biopsies compared with preimplantation controls was enriched for genes associated with fibrosis, early tubulointerstitial damage and in vitro CNIT. The DEGs from belatacept biopsies were not enriched for the CNIT genes but, instead, exhibited enrichment for gene sets associated with immune response and tissue remodeling. A combined analysis of DEGs across both treatment groups identified select solute transporter and cellular differentiation genes whose expression at 12 months correlated with renal function at 36 months. These results provide mechanistic insights into the reduced CAI and higher renal function observed in belatacept- versus CsA-treated patients.
Collapse
Affiliation(s)
- M J Vitalone
- Transplant Division, California Pacific Medical Center Research Institute, California Pacific Medical Center, Sutter Health Care, San Francisco, CA; Department of Surgery, Stanford University, Palo Alto, CA
| | | | | | | | | | | | | |
Collapse
|
49
|
Vlachopanos G, Georgalis A. On the value and pitfalls of follow-up biopsies after acute rejection. Am J Transplant 2014; 14:237. [PMID: 24299069 DOI: 10.1111/ajt.12549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 09/23/2013] [Accepted: 09/25/2013] [Indexed: 01/25/2023]
Affiliation(s)
- G Vlachopanos
- Department of Nephrology, "Asclepieion" General Hospital, Athens, Greece
| | | |
Collapse
|
50
|
Lee JH, Lee HR, Choi SH, Jung P, Oh JS, Kim SM, Sin YH, Jung YS, Jung GS, Kim JK. Acute Renal Failure in a Renal Allograft Recipient Caused by a Post-Biopsy Renal Arteriovenous Fistula with Transplant Renal Artery Stenosis. KOREAN JOURNAL OF TRANSPLANTATION 2012. [DOI: 10.4285/jkstn.2012.26.4.287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Jin-Ho Lee
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Hee-Ryong Lee
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Seung-Ho Choi
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Peel Jung
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Joon-Seok Oh
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Seung-Min Kim
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Yong-Hun Sin
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Yeon-Soon Jung
- Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
| | - Gyoo-Sik Jung
- Department of Radiology, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
| | - Joong-Kyung Kim
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| |
Collapse
|