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Mella A, Calvetti R, Barreca A, Congiu G, Biancone L. Kidney transplants from elderly donors: what we have learned 20 years after the Crystal City consensus criteria meeting. J Nephrol 2024:10.1007/s40620-024-01888-w. [PMID: 38446386 DOI: 10.1007/s40620-024-01888-w] [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: 05/26/2022] [Accepted: 01/03/2024] [Indexed: 03/07/2024]
Abstract
Based on the current projection of the general population and the combined increase in end-stage kidney disease with age, the number of elderly donors and recipients is increasing, raising crucial questions about how to minimize the discard rate of organs from elderly donors and improve graft and patient outcomes. In 2002, extended criteria donors were the focus of a meeting in Crystal City (VA, USA), with a goal of maximizing the use of organs from deceased donors. Since then, extended criteria donors have progressively contributed to a large number of transplanted grafts worldwide, posing specific issues for allocation systems, recipient management, and therapeutic approaches. This review analyzes what we have learned in the last 20 years about extended criteria donor utilization, the promising innovations in immunosuppressive management, and the molecular pathways involved in the aging process, which constitute potential targets for novel therapies.
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Affiliation(s)
- Alberto Mella
- Renal Transplant Center" A. Vercellone," Nephrology, Dialysis, and Renal Transplant Division, "Città Della Salute e Della Scienza" Hospital, Department of Medical Sciences, University of Turin, Corso Bramante, 88, 10126, Turin, Italy
| | - Ruggero Calvetti
- Renal Transplant Center" A. Vercellone," Nephrology, Dialysis, and Renal Transplant Division, "Città Della Salute e Della Scienza" Hospital, Department of Medical Sciences, University of Turin, Corso Bramante, 88, 10126, Turin, Italy
| | - Antonella Barreca
- Division of Pathology, "Città Della Salute e Della Scienza" Hospital, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Giovanni Congiu
- Renal Transplant Center" A. Vercellone," Nephrology, Dialysis, and Renal Transplant Division, "Città Della Salute e Della Scienza" Hospital, Department of Medical Sciences, University of Turin, Corso Bramante, 88, 10126, Turin, Italy
| | - Luigi Biancone
- Renal Transplant Center" A. Vercellone," Nephrology, Dialysis, and Renal Transplant Division, "Città Della Salute e Della Scienza" Hospital, Department of Medical Sciences, University of Turin, Corso Bramante, 88, 10126, Turin, Italy.
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2
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Yamanaga S, Hidaka Y, Kawabata C, Toyoda M, Tanaka K, Yamamoto Y, Inadome A, Takeda A, Yokomizo H. Water intake, baseline biopsy, and graft function after living donor kidney transplantation. Sci Rep 2024; 14:3715. [PMID: 38355944 PMCID: PMC10866883 DOI: 10.1038/s41598-024-54163-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 02/09/2024] [Indexed: 02/16/2024] Open
Abstract
Increased water intake is recommended for kidney transplant recipients; however, its efficacy remains controversial. We hypothesized that pre-existing histological findings of the allograft might modulate the impact of water intake. We retrospectively analyzed 167 adults with living-donor kidney transplants (April 2011-May 2020; median observation period, 77 months) whose baseline biopsy data were available. We compared the chronic-change group (n = 38) with the control group (n = 129) to assess the impact of self-reported daily water intake on the estimated glomerular filtration rate (eGFR). The range distribution of water intake was as follows: - 1000 ml (n = 4), 1000-1500 ml (n = 23), 1500-2000 ml (n = 64), 2000-2500 ml (n = 57), 2500-3000 ml (n = 16), and 3000 - ml (n = 3). Donor age was significantly higher in the chronic-change group. In the control group, the ΔeGFR/year increase was correlated with water intake. However, the increase in the water intake of the chronic-change group significantly decreased ΔeGFR/year (1000-1500 ml: + 1.95 ml/min/1.73 m2 and > 2000 ml: - 1.92 ml/min/1.73 m2, p = 0.014). This study suggested a potential influence of increased water intake on recipients with marginal grafts in living donor kidney transplantation.
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Affiliation(s)
- Shigeyoshi Yamanaga
- Department of Surgery, Japanese Red Cross Kumamoto Hospital, 2-1-1 Nagamine Minami, Higashi-ku, Kumamoto, 861-8520, Japan.
| | - Yuji Hidaka
- Department of Surgery, Japanese Red Cross Kumamoto Hospital, 2-1-1 Nagamine Minami, Higashi-ku, Kumamoto, 861-8520, Japan
| | - Chiaki Kawabata
- Department of Nephrology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Mariko Toyoda
- Department of Nephrology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Kosuke Tanaka
- Department of Surgery, Kyoto University, Kyoto, Japan
| | - Yasuhiro Yamamoto
- Department of Urology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Akito Inadome
- Department of Urology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Asami Takeda
- Department of Nephrology, Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan
| | - Hiroshi Yokomizo
- Department of Surgery, Japanese Red Cross Kumamoto Hospital, 2-1-1 Nagamine Minami, Higashi-ku, Kumamoto, 861-8520, Japan
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Wang M, Lv J, Zhao J, Wang H, Chen J, Wu J. Postreperfusion Renal Allograft Biopsy Predicts Outcome of Single-Kidney Transplantation: A 10-Year Observational Study in China. Kidney Int Rep 2024; 9:96-107. [PMID: 38312778 PMCID: PMC10831381 DOI: 10.1016/j.ekir.2023.10.021] [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: 06/06/2023] [Revised: 09/15/2023] [Accepted: 10/23/2023] [Indexed: 02/06/2024] Open
Abstract
Introduction Biopsy findings often lead to the discard of many donor kidneys although their clinical value is not fully understood. We investigated the predictive value of postreperfusion biopsy on long-term allograft outcome after single-kidney transplantation. Methods We retrospectively evaluated the significance of histologic findings, read by experienced renal pathologists, in 461 postreperfusion biopsy specimens collected from 2010 to 2017 after deceased donor renal transplant; and performed time-to-event analyses to determine the association between histology and hazard of death-censored graft failure. Recipients were followed-up with over a median time of 6.8 (range, 0.2-11.9) years. We assessed specimens using the Remuzzi score (scale of 0-12) and categorized them into low-score (≤3) and high-score (>3) groups. Kappa coefficients were calculated to assess agreement in procurement versus reperfusion biopsies. Results High Remuzzi score kidneys came from older donors with a higher incidence of hypertension, higher final creatinine, death from cerebrovascular disease, expanded criteria donor, and a higher kidney donor risk index (KDRI) (all P < 0.001). In adjusted analyses, Remuzzi score was independently associated with death-censored graft failure (hazard ratio [HR] 1.389 for each 1 score rise in Remuzzi score, 95% confidence interval 1.181-1.633, P < 0.001). Overall histologic agreement (procurement biopsy versus reperfusion biopsy) was kappa = 0.137. Conclusion Our findings suggest that postreperfusion biopsy is associated with long-time graft outcomes after transplant from a deceased donor. Agreement between procurement and reperfusion biopsy was found to be low. Prospective trials are necessary to optimize procurement biopsy practices.
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Affiliation(s)
- Meifang Wang
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Zhejiang Province, Hangzhou, China
- National Key Clinical Department of Kidney Diseases, Hangzhou, China
- Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Junhao Lv
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Zhejiang Province, Hangzhou, China
- National Key Clinical Department of Kidney Diseases, Hangzhou, China
- Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Jie Zhao
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Zhejiang Province, Hangzhou, China
- National Key Clinical Department of Kidney Diseases, Hangzhou, China
- Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Huiping Wang
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Zhejiang Province, Hangzhou, China
- National Key Clinical Department of Kidney Diseases, Hangzhou, China
- Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Jianghua Chen
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Zhejiang Province, Hangzhou, China
- National Key Clinical Department of Kidney Diseases, Hangzhou, China
- Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Jianyong Wu
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Zhejiang Province, Hangzhou, China
- National Key Clinical Department of Kidney Diseases, Hangzhou, China
- Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
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Duarte R, Castro P, Leal R, Marques MG, Rodrigues L, Santos L, Romãozinho C, Alves R, Figueiredo A. Dual Kidney Transplantation: Single-Center Experience. Transplant Proc 2023; 55:1390-1395. [PMID: 37429787 DOI: 10.1016/j.transproceed.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/06/2023] [Accepted: 05/30/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Dual and en bloc kidney transplantation are strategies used to mitigate the disparity between a reduced organ pool and an ever-increasing need for organ procurement. En bloc refers to the implantation of 2 kidneys from a pediatric donor, compensating for small renal mass, whereas dual expanded criteria donor (DECD) transplantation refers to older donors with grafts otherwise rejected for single transplant, including expanded. This study describes one center's experience with dual and en bloc transplantation. METHODS A retrospective cohort study of dual kidney transplants (en bloc and DECD) from 1990 through 2021. The analysis included demographic, clinical, and survival analysis. RESULTS Of 46 patients who underwent dual kidney transplantation, 17 (37 %) received en-bloc transplantation. The overall mean recipient age was 49.4 ± 13.9 years old, younger in the en-bloc subgroup (39.2 vs 59.8 years old, P < .01). The mean time on dialysis was 37 ± 25 months. Delayed graft function was present in 17.4 % and primary nonfunction in 6.4 %, all from the DECD group. The estimated glomerular filtration rates at 1 and 5 years were 76.7 ± 28.7 and 80.4 ± 24.8 mL/min/1.73 m2, lower in the DECD group (65.9 vs 88.7 mL/min/1.73 m2, P = 0.02). Eleven recipients lost their graft during the study period: 63.6% from death with a functioning graft, 27.3% due to chronic graft dysfunction (a mean of 76.3 months after transplantation), and 9.1% due to vascular complications. Subgroup comparison found no differences regarding cold ischemia time or length of hospitalization. Kaplan-Meier estimates, censored for death with a functioning graft, resulted in a mean graft survival of 21.3 ± 1.3 years, with survival rates of 93.5, 90.5, and 84.1% at 1, 5, and 10 years, respectively, without significant differences between subgroups. CONCLUSIONS Both DECD and en bloc strategies provide safe and effective options to further expand the use of otherwise rejected kidneys. Neither of the 2 techniques was superior to the other.
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Affiliation(s)
- Rui Duarte
- Departamento de Nefrologia, Centro Hospitalar do Médio Tejo, Torres Novas, Portugal.
| | - Pedro Castro
- Departamento de Nefrologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Rita Leal
- Departamento de Nefrologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
| | - Maria Guedes Marques
- Departamento de Nefrologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
| | - Luís Rodrigues
- Departamento de Nefrologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
| | - Lídia Santos
- Departamento de Nefrologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
| | - Catarina Romãozinho
- Departamento de Nefrologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
| | - Rui Alves
- Departamento de Nefrologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
| | - Arnaldo Figueiredo
- Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal; Serviço de Urologia e Transplantação Renal, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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Villanego F, Vigara LA, Cazorla JM, Naranjo J, Atienza L, Garcia AM, Montero ME, Minguez MC, Garcia T, Mazuecos A. Evaluation of Expanded Criteria Donors Using the Kidney Donor Profile Index and the Preimplantation Renal Biopsy. Transpl Int 2022; 35:10056. [PMID: 35734238 PMCID: PMC9207180 DOI: 10.3389/ti.2022.10056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 04/28/2022] [Indexed: 11/13/2022]
Abstract
The increasing comorbidity of kidney transplant (KT) donors make it necessary to develop scores to correctly assess the quality of kidney grafts. This study analyzes the usefulness of the preimplantation biopsy and the Kidney Donor Profile Index (KDPI) as indicators of KT survival from expanded criteria donors (ECD). Retrospective study of KT in our center between January 2010 to June 2019 who received a kidney from an ECD and underwent a preimplantation biopsy. 266 KT were included. Graft survival was categorized by KDPI quartiles: Q1 = 86%, Q2 = 95%, Q3 = 99% and Q4 = 100%. KT from KDPI Q1 presented better survival (p = 0.003) and Q4 donors had worse renal function (p = 0.018) and poorer glomerular filtration rate (3rd month; p = 0.017, 1st year; p = 0.010). KT survival was analyzed according to KDPI quartile and preimplantation biopsy score simultaneously: Q1 donors with biopsy score ≤3 had the best survival, especially comparing against Q3 with a biopsy score >3 and Q4 donors (p = 0.014). In multivariable analysis, hyaline arteriopathy, glomerulosclerosis, and KDPI Q4 were predictors for graft survival. High KDPI and a greater histological injury in the preimplantation biopsy, especially glomerular and vascular lesions, were related to a higher rate of KT loss from ECD.
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Affiliation(s)
- F. Villanego
- Department of Nephrology, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - L. A. Vigara
- Department of Nephrology, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - J. M. Cazorla
- Department of Nephrology, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - J. Naranjo
- Department of Nephrology, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - L. Atienza
- Department of Pathology, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - A. M. Garcia
- Department of Nephrology, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - M. E. Montero
- Department of Nephrology, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - M. C. Minguez
- Department of Nephrology, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - T. Garcia
- Department of Nephrology, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - A. Mazuecos
- Department of Nephrology, Hospital Universitario Puerta del Mar, Cadiz, Spain
- *Correspondence: A. Mazuecos,
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Stewart DE, Foutz J, Kamal L, Weiss S, McGehee HS, Cooper M, Gupta G. The Independent Effects of Procurement Biopsy Findings on Ten-Year Outcomes of Extended Criteria Donor Kidney Transplants. Kidney Int Rep 2022; 7:1850-1865. [PMID: 35967103 PMCID: PMC9366372 DOI: 10.1016/j.ekir.2022.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/23/2022] [Indexed: 11/01/2022] Open
Abstract
Introduction Methods Results Conclusion
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7
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Yi Z, Salem F, Menon MC, Keung K, Xi C, Hultin S, Haroon Al Rasheed MR, Li L, Su F, Sun Z, Wei C, Huang W, Fredericks S, Lin Q, Banu K, Wong G, Rogers NM, Farouk S, Cravedi P, Shingde M, Smith RN, Rosales IA, O'Connell PJ, Colvin RB, Murphy B, Zhang W. Deep learning identified pathological abnormalities predictive of graft loss in kidney transplant biopsies. Kidney Int 2021; 101:288-298. [PMID: 34757124 DOI: 10.1016/j.kint.2021.09.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/12/2021] [Accepted: 09/09/2021] [Indexed: 10/19/2022]
Abstract
Interstitial fibrosis, tubular atrophy, and inflammation are major contributors to kidney allograft failure. Here we sought an objective, quantitative pathological assessment of these lesions to improve predictive utility and constructed a deep-learning-based pipeline recognizing normal vs. abnormal kidney tissue compartments and mononuclear leukocyte infiltrates. Periodic acid- Schiff stained slides of transplant biopsies (60 training and 33 testing) were used to quantify pathological lesions specific for interstitium, tubules and mononuclear leukocyte infiltration. The pipeline was applied to the whole slide images from 789 transplant biopsies (478 baseline [pre-implantation] and 311 post-transplant 12-month protocol biopsies) in two independent cohorts (GoCAR: 404 patients, AUSCAD: 212 patients) of transplant recipients to correlate composite lesion features with graft loss. Our model accurately recognized kidney tissue compartments and mononuclear leukocytes. The digital features significantly correlated with revised Banff 2007 scores but were more sensitive to subtle pathological changes below the thresholds in the Banff scores. The Interstitial and Tubular Abnormality Score (ITAS) in baseline samples was highly predictive of one-year graft loss, while a Composite Damage Score in 12-month post-transplant protocol biopsies predicted later graft loss. ITASs and Composite Damage Scores outperformed Banff scores or clinical predictors with superior graft loss prediction accuracy. High/intermediate risk groups stratified by ITASs or Composite Damage Scores also demonstrated significantly higher incidence of estimated glomerular filtration rate decline and subsequent graft damage. Thus, our deep-learning approach accurately detected and quantified pathological lesions from baseline or post-transplant biopsies and demonstrated superior ability for prediction of post-transplant graft loss with potential application as a prevention, risk stratification or monitoring tool.
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Affiliation(s)
- Zhengzi Yi
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Fadi Salem
- Pathology Division, Department of Molecular and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Madhav C Menon
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Nephrology Division, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Karen Keung
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia; Department of Nephrology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Caixia Xi
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sebastian Hultin
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - M Rizwan Haroon Al Rasheed
- Pathology Division, Department of Molecular and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Li Li
- Pathology Division, Department of Molecular and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Fei Su
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zeguo Sun
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Chengguo Wei
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Weiqing Huang
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samuel Fredericks
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Qisheng Lin
- Nephrology Division, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Khadija Banu
- Nephrology Division, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Germaine Wong
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Natasha M Rogers
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Samira Farouk
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Paolo Cravedi
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Meena Shingde
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - R Neal Smith
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ivy A Rosales
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Philip J O'Connell
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Department of Nephrology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Robert B Colvin
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Barbara Murphy
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Weijia Zhang
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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Ninan J, Smith ML, Mathur AK, Harbell JW, Jadlowiec CC, Nair SS, Moss A, Reddy KS, Heilman RL. Correlation of Chronic Histologic Changes on Preimplantation Frozen Section Biopsy With Transplant Outcomes After Deceased Donor Kidney Transplantation. Arch Pathol Lab Med 2021; 146:205-212. [PMID: 34086859 DOI: 10.5858/arpa.2020-0675-oa] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— It is unclear if preimplantation frozen section biopsy correlates with outcomes after deceased donor kidney transplantation. OBJECTIVE.— To assess if chronic histologic changes on the preimplant frozen section correlates with graft loss and estimated glomerular filtration rate independently of kidney donor profile index (KDPI). DESIGN.— Seven hundred three preimplantation biopsies were reviewed and a Banff sum score was calculated using glomerular sclerosis, interstitial fibrosis, vascular intimal thickening, and arteriolar hyalinosis. The posttransplant outcomes were compared for preimplantation biopsy Banff sum 0-1, 2-3, and 4-9. The cohort was also stratified by KDPI 85 or less versus more than 85. RESULTS.— For the entire biopsy cohort, graft survival, estimated glomerular filtration rate at 1 year and chronic changes on a 1-year posttransplant biopsy were superior in the group with preimplantation Banff sum 0-1. After stratifying by KDPI, the Banff sum no longer correlated with graft survival. In a univariate mode, using the Banff sum score as a continuous variable, a higher Banff sum score was significantly associated with graft failure (P = .03); however, after adjusting the KDPI, the Banff sum score no longer correlated with graft failure (P = .45). The 1-year estimated glomerular filtration rate and 1 year biopsy changes were superior in the group with Banff sum 0-1 only in the cohort with KDPI 85 or less. CONCLUSIONS.— In donor kidneys used for transplant, preimplantation biopsy chronic changes correlate with estimated glomerular filtration rate and biopsy findings at 1 year, but biopsies with mostly mild chronicity and sum scores less than or equal to 5 did not impact graft survival beyond KDPI.
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Affiliation(s)
- Jacob Ninan
- From the Department of Medicine (Ninan, Nair, Heilman), Mayo Clinic Arizona Phoenix, Arizona
| | - Maxwell L Smith
- Department of Laboratory Medicine and Pathology (Smith), Mayo Clinic Arizona Phoenix, Arizona
| | - Amit K Mathur
- the Department of Surgery (Mathur, Harbell, Jadlowiec, Moss, Reddy), Mayo Clinic Arizona Phoenix, Arizona
| | - Jack W Harbell
- the Department of Surgery (Mathur, Harbell, Jadlowiec, Moss, Reddy), Mayo Clinic Arizona Phoenix, Arizona
| | - Caroline C Jadlowiec
- the Department of Surgery (Mathur, Harbell, Jadlowiec, Moss, Reddy), Mayo Clinic Arizona Phoenix, Arizona
| | - Sumi Sukumaran Nair
- From the Department of Medicine (Ninan, Nair, Heilman), Mayo Clinic Arizona Phoenix, Arizona
| | - Adyr Moss
- the Department of Surgery (Mathur, Harbell, Jadlowiec, Moss, Reddy), Mayo Clinic Arizona Phoenix, Arizona
| | - Kunam S Reddy
- the Department of Surgery (Mathur, Harbell, Jadlowiec, Moss, Reddy), Mayo Clinic Arizona Phoenix, Arizona
| | - Raymond L Heilman
- From the Department of Medicine (Ninan, Nair, Heilman), Mayo Clinic Arizona Phoenix, Arizona
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9
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Pajenda S, Rasul S, Hacker M, Wagner L, Geist BK. Dynamic 2-deoxy-2[18F] fluoro-D-glucose PET/MRI in human renal allotransplant patients undergoing acute kidney injury. Sci Rep 2020; 10:8270. [PMID: 32427878 PMCID: PMC7237443 DOI: 10.1038/s41598-020-65267-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/29/2020] [Indexed: 12/11/2022] Open
Abstract
Patients after solid organ kidney transplantation (KTX) often suffer from acute kidney injury (AKI). Parameters as serum creatinine indicate a loss of kidney function, although no distinction of the cause and prognosis can be made. Imaging tools measuring kidney function have not been widely in clinical use. In this observational study we evaluated 2-deoxy-2[18F] fluoro-D-glucose (FDG) PET/MRI in thirteen patients after KTX with AKI as a functional assessment of the graft. Twenty-four healthy volunteers served as control. General kidney performance (GKP), initial flow (IF) and renal response function (RF) were calculated by standardized uptake values (SUV) and time activity curves (TAC). The GKP measured for the total kidney and medulla was significantly higher in healthy patients compared to patients after KTX (p = 0.0002 and p = 0.0004, respectively), but no difference was found for the GKP of the cortex (p = 0.59). The IF in KTX patients correlated with renal recovery, defined as change in serum creatinine 10 days after PET/MRI (r = 0.80, p = 0.001). With regard to the RF, a negative correlation for tubular damage was found (r = -0.74, p = 0.004). In conclusion, parameters obtained from FDG PET/MRI showed a possible predictive feature for renal recovery in KTX patients undergoing AKI.
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Affiliation(s)
- Sahra Pajenda
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna. Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Sazan Rasul
- Department of Biomedical Imaging and Image- Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna. Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Marcus Hacker
- Department of Biomedical Imaging and Image- Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna. Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Ludwig Wagner
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna. Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Barbara Katharina Geist
- Department of Biomedical Imaging and Image- Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna. Waehringer Guertel 18-20, 1090, Vienna, Austria
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10
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Pre-implantation kidney biopsy: value of the expertise in determining histological score and comparison with the whole organ on a series of discarded kidneys. J Nephrol 2019; 33:167-176. [PMID: 31471818 DOI: 10.1007/s40620-019-00638-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/10/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Evidence about the reliability of pre-implantation biopsy is still conflicting, depending on both biopsy type and pathologist's expertise. Aim of the study is to evaluate the agreement of general v specialist pathologists and to compare scores on biopsy and whole organs in a set of discarded kidneys. METHODS 46 discarded kidneys were identified with their corresponding biopsies. The biopsies were reviewed by three general and two specialist pathologists, blinded to the original report, according to Remuzzi score. The intraclass correlation coefficient (ICC) was calculated for both groups. Discarded kidneys were scored according to Remuzzi score by a single specialist pathologist. Biopsies and organs were compared by Wilcoxon signed rank test. Weighted κ coefficients between biopsy and organ scores were also calculated. RESULTS Specialist pathologists achieved higher values of ICC, reaching excellent or good agreement in most of the parameters, while general pathologists values were mainly fair or good. On whole organs, scores were consistently lower than biopsies, with a significant difference in most of the parameters. Weighted κ coefficient was slight or fair for most of the parameters. CONCLUSIONS Our data suggests that the creation of a pool of specialist pathologists would improve organ utilization. Moreover, biopsies are not representative of the whole organ. As the Remuzzi score on biopsy is a major reasons for discard, a quota of transplantable kidneys may be erroneously discarded. Refinement in Remuzzi cut-offs based on expert reporting and recognition of sampling error of biopsies in correlation with clinical outcome data should be undertaken.
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11
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Moeckli B, Sun P, Lazeyras F, Morel P, Moll S, Pascual M, Bühler LH. Evaluation of donor kidneys prior to transplantation: an update of current and emerging methods. Transpl Int 2019; 32:459-469. [PMID: 30903673 DOI: 10.1111/tri.13430] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 03/18/2019] [Indexed: 02/06/2023]
Abstract
The lack of suitable kidney donor organs has led to rising numbers of patients with end stage renal disease waiting for kidney transplantation. Despite decades of clinical experience and research, no evaluation process that can reliably predict the outcome of an organ has yet been established. This review is an overview of current methods and emerging techniques in the field of donor kidney evaluation prior to transplantation. Established techniques like histological evaluation, clinical scores, and machine perfusion systems offer relatively reliable predictions of delayed graft function but are unable to consistently predict graft survival. Emerging techniques including molecular biomarkers, new imaging technologies, and normothermic machine perfusion offer innovative approaches toward a more global evaluation of an organ with better outcome prediction and possibly even identification of targets for therapeutic interventions prior to transplantation. These techniques should be studied in randomized controlled trials to determine whether they can be safely used in routine clinical practice to ultimately reduce the discard rate and improve graft outcomes.
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Affiliation(s)
- Beat Moeckli
- Department of Surgery and Transplantation, Zurich University Hospital, Zurich, Switzerland
| | - Pamela Sun
- Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - François Lazeyras
- Department of Radiology and Medical Informatics, CIBM, Geneva University Hospital, Geneva, Switzerland
| | - Philippe Morel
- Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Solange Moll
- Department of Pathology, Geneva University Hospital, Geneva, Switzerland
| | - Manuel Pascual
- Transplantation Center Lausanne, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Léo H Bühler
- Department of Surgery, Geneva University Hospital, Geneva, Switzerland
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12
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Truong LD, Gaber LW, Khan F. Donor-related diabetic nephropathy: a comprehensive clinicopathological study. Hum Pathol 2018; 85:136-144. [PMID: 30448223 DOI: 10.1016/j.humpath.2018.10.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/23/2018] [Accepted: 10/31/2018] [Indexed: 12/16/2022]
Abstract
Knowledge on renal involvement in kidney donors with diabetes, that is, diabetic nephropathy (DN), is limited. During the 7 years (2010-2017), 921 postperfusion biopsies were performed for living donors (14%) or deceased donors (86%). The Renal Pathology Society classification schema for DN (class 0-IV) was used. Biopsies with light microscopic changes of DN (at least class IIa) were selected for study. Eleven biopsies (1.2%) showed DN, all from deceased donors (class IIa in 8, class IIb in 2, and class III in 1 biopsy). The glomerular basement membrane thickness ranged from 439 ± 52 to 725 ± 82 nm. These biopsies also displayed arterionephrosclerosis. They were from 9 deceased donors (fulfilling clinical criteria for acceptance in all, diabetes ;[>6 years] in 8, hypertension in 6, and proteinuria [1+] in all). Follow-up biopsies (5-342 weeks after transplant) showed DN of the same class (7 biopsies), probably progression (1), or progression (3). At follow-up (15-416 weeks), all recipients were alive. One graft was lost at 76 weeks because of progressive DN. The other 10 grafts were functioning, but the serum creatinine reached 2.0 to 2.7 mg/dL in 5 of them. Although diabetes is frequent in kidney donors, donor-related DN is unusual. It is observed only in deceased donors, but the risk factors for its development are not known. Donor-related DN may be stable or progress. Whether it resolves, especially for DN in early phase, remains unknown. It may adversely impact the graft outcome with a magnitude proportional to the severity of the tissue injury in the postperfusion biopsies.
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Affiliation(s)
- Luan D Truong
- Department of Pathology and Genomic Medicine, The Houston Methodist Hospital, Weil Cornell Medical College, Houston, TX 77030, USA; Department of Surgery, J.C. Walter Transplant Center, The Houston Methodist Hospital, Houston, TX 77030, USA.
| | - Lillian W Gaber
- Department of Pathology and Genomic Medicine, The Houston Methodist Hospital, Weil Cornell Medical College, Houston, TX 77030, USA; Department of Surgery, J.C. Walter Transplant Center, The Houston Methodist Hospital, Houston, TX 77030, USA
| | - Faiza Khan
- Department of Medicine, Renal Section, The Houston Methodist Hospital, Houston, TX 77030, USA
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13
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Colussi G, Casati C, Colombo VG, Camozzi MLP, Salerno FR. Renal transplants from older deceased donors: Is pre-implantation biopsy useful? A monocentric observational clinical study. World J Transplant 2018; 8:110-121. [PMID: 30148077 PMCID: PMC6107519 DOI: 10.5500/wjt.v8.i4.110] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/09/2018] [Accepted: 05/13/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To compare survival of kidney transplants from deceased extended criteria donors (ECD) according to: (1) donor graft histological score; and (2) allocation of high score grafts either to single (SKT) or dual (DKT) transplant.
METHODS Renal biopsy was performed as part of either a newly adopted DKT protocol, or of surveillance protocol in the past. A total 185 ECD graft recipients were categorized according to pre-implantation graft biopsy into 3 groups: SKT with graft score 1 to 4 [SKT(1-4), n = 102]; SKT with donor graft score 5 to 8 [SKT(> 4), n = 30]; DKT with donor graft score 5 to 7 (DKT, n = 53). Graft and patient survival were analyzed by Kaplan-Meier curves and compared by log-rank test. Mean number of functioning graft years by transplant reference, and mean number of dialysis-free life years by donor reference in recipients were also calculated at 1, 3 and 6 years from transplantation.
RESULTS There were no statistically significant differences in graft and patient survival between SKT(1-4) and SKT(> 4), and between SKT(> 4) and DKT. Recipient renal function (plasma creatinine and creatinine clearance) at 1 years did not differ in SKT(1-4) and SKT(> 4) (plasma creatinine 1.71 ± 0.69 and 1.69 ± 0.63 mg/dL; creatinine clearance 49.6 + 18.5 and 52.6 + 18.8 mL/min, respectively); DKT showed statistically lower plasma creatinine (1.46 ± 0.57, P < 0.04) but not different creatinine clearance (55.4 + 20.4). Due to older donor age in the DKT group, comparisons were repeated in transplants from donors older than 70 years, and equal graft and patient survival in SKT and DKT were confirmed. Total mean number of functioning graft years by transplant reference at 1, 3 and 6 post-transplant years were equal between the groups, but mean number of dialysis-free life years by donor reference were significantly higher in SKT (mean difference compared to DKT at 6 years: 292 [IQR 260-318] years/100 donors in SKT(1-4) and 292.5 [(IQR 247.8-331.6) in SKT(> 4)].
CONCLUSION In transplants from clinically suitable ECD donors, graft survival was similar irrespective of pre-implantation biopsy score and of allocation to SKT or DKT. These results suggest use of caution in the use of histology as the only decision criteria for ECD organ allocation.
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Affiliation(s)
- Giacomo Colussi
- Fabio Rosario Salereno, Division of Nephrology, Dialysis and Renal Transplantatation, ASST Grande Ospedale Territoriale Niguarda, Milan 20162, Italy
| | - Costanza Casati
- Fabio Rosario Salereno, Division of Nephrology, Dialysis and Renal Transplantatation, ASST Grande Ospedale Territoriale Niguarda, Milan 20162, Italy
| | - Valeriana Giuseppina Colombo
- Fabio Rosario Salereno, Division of Nephrology, Dialysis and Renal Transplantatation, ASST Grande Ospedale Territoriale Niguarda, Milan 20162, Italy
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14
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Casati C, Colombo VG, Perrino M, Rossetti OM, Querques M, Giacomoni A, Binaggia A, Colussi G. Renal Transplants from Older Deceased Donors: Use of Preimplantation Biopsy and Differential Allocation to Dual or Single Kidney Transplant according to Histological Score Has No Advantages over Allocation to Single Kidney Transplant by Simple Clinical Indication. J Transplant 2018; 2018:4141756. [PMID: 29862061 PMCID: PMC5976897 DOI: 10.1155/2018/4141756] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 03/21/2018] [Accepted: 04/10/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Grafts from elderly donors (ECD) are increasingly allocated to single (SKT) or dual (DKT) kidney transplantation according to biopsy score. Indications and benefits of either procedure lack universal agreement. METHODS A total of 302 ECD-transplants in period from Jan 1, 2000, to Dec 31, 2015, were allocated to SKT (SKTpre) on clinical grounds alone (before Dec 2010, pre-DKT era, n = 170) or according to a clinical-histological protocol (after Dec 2010, DKT era, n = 132) to DKT (n = 48), SKT biopsy-based protocol ("high-risk", SKThr, n = 51), or SKT clinically based protocol ("low-risk", SKTlr, n = 33). Graft and patient survival were compared between the two periods and between different transplant categories. RESULTS Graft and overall survival in recipients from ECD in pre-DKT and DKT era did not differ (5-year graft survival 87.7% and 84.2%, resp.); equal survival in the 2 ECD periods was shown in both donor age ranges of 60-69 and >70-years, and in low-risk or high-risk ECD categories. Within the DKT protocol SKThr showed worst graft and overall survival in the 60-69 donor age range; DKT did not result in significantly better outcome than SKT from ECD in either era. One-year posttransplant creatinine clearance in recipients did not differ between any ECD transplant category. At 3 and 5 years after transplantation there were significantly higher total dialysis-free recipient life years from an equal donor number in the pre-DKT era than in the DKT protocol. CONCLUSIONS Use of a biopsy-based protocol to allocate grafts from aged donors to SKT or DKT did not result in better short term graft survival than a clinically based protocol with allocation only to SKT and reduced overall recipient dialysis-free life years in time.
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Affiliation(s)
- Costanza Casati
- Division of Nephrology, Dialysis and Kidney Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Valeriana Giuseppina Colombo
- Division of Nephrology, Dialysis and Kidney Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marialuisa Perrino
- Division of Nephrology, Dialysis and Kidney Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Marialuisa Querques
- Division of Nephrology, Dialysis and Kidney Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alessandro Giacomoni
- Division of Transplant Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Agnese Binaggia
- Division of Nephrology, Dialysis and Kidney Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giacomo Colussi
- Division of Nephrology, Dialysis and Kidney Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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15
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Kozakowski N, Eskandary F, Herkner H, Bond G, Oberbauer R, Regele H, Böhmig GA, Kikić Ž. Diffuse Extent of Peritubular Capillaritis in Late Antibody-Mediated Rejection: Associations With Levels of Donor-Specific Antibodies and Chronic Allograft Injury. Transplantation 2017; 101:e178-e187. [PMID: 28252564 DOI: 10.1097/tp.0000000000001707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Recently, diffuse peritubular capillaritis (ptc) has been suggested to independently predict chronic transplant injury and loss, and although the ptc score is a diagnostic criterion for antibody-mediated rejection, the utility of diffuse ptc is under debate. METHODS We evaluated the diagnostic value of ptc characteristics in this cross-sectional study including 85 biopsies of patients with donor-specific antibodies (DSA). Biopsies were reevaluated for the extent (diffuse vs focal), score and leukocytic composition in relation to DSA binding strength (mean fluorescence intensity [MFI]_max). Chronic allograft injury (transplant chronic glomerulopathy [cg] or chronic lesion score CLS]) were associated with ptc features. RESULTS Peritubular capillaritis was detected in 50% (76% mononuclear ptc). Peritubular capillaritis scores 1, 2, and 3 were present in 36%, 55%, and 9%, and focal or diffuse ptc in 36% or 64%. Diffuse ptc was associated with DSA MFI_max (median: 4407 vs 2419 [focal ptc; P = 0.04] or 1946 [no ptc; P = 0.004]), cg (58% vs no ptc 24% [P = 0.02]), and higher CLS (mean: 6.81 vs 4.67 [focal ptc, P = 0.01] or 5.18 [no ptc, P = 0.001]), respectively. The association of ptc score of 2 or greater with cg was slightly better than with diffuse ptc. Diffuse ptc and ptc score of 2 or greater remained independently related to cg after adjusting for DSA_MFI_max, C4d, or previous rejection episodes, however lost their independent relation after adjusting for total microcirculation scores. Diffuse ptc was the only ptc characteristic independently related to CLS. CONCLUSIONS Our results emphasize the clinical relevance of reporting diffuse ptc, which may relate to DSA binding strength and potentially to chronic graft injury.
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Affiliation(s)
- Nicolas Kozakowski
- 1 Institute of Clinical Pathology, Medical University Vienna, Vienna, Austria. 2 Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria. 3 Department of Emergency Medicine, Medical University Vienna, Vienna, Austria
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16
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Abstract
The old-for-old allocation policy used for kidney transplantation (KT) has confirmed the survival benefit compared to remaining listed on dialysis. Shortage of standard donors has stimulated the development of strategies aimed to expand acceptance criteria, particularly of kidneys from elderly donors. We have systematically reviewed the literature on those different strategies. In addition to the review of outcomes of expanded criteria donor or advanced age kidneys, we assessed the value of the Kidney Donor Profile Index policy, preimplantation biopsy, dual KT, machine perfusion and special immunosuppressive protocols. Survival and functional outcomes achieved with expanded criteria donor, high Kidney Donor Profile Index or advanced age kidneys are poorer than those with standard ones. Outcomes using advanced age brain-dead or cardiac-dead donor kidneys are similar. Preimplantation biopsies and related scores have been useful to predict function, but their applicability to transplant or refuse a kidney graft has probably been overestimated. Machine perfusion techniques have decreased delayed graft function and could improve graft survival. Investing 2 kidneys in 1 recipient does not make sense when a single KT would be enough, particularly in elderly recipients. Tailored immunosuppression when transplanting an old kidney may be useful, but no formal trials are available.Old donors constitute an enormous source of useful kidneys, but their retrieval in many countries is infrequent. The assumption of limited but precious functional expectancy for an old kidney and substantial reduction of discard rates should be generalized to mitigate these limitations.
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17
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Thuret R, Kleinclauss F, Terrier N, Timsit MO. [Deceased donation in renal transplantation]. Prog Urol 2016; 26:909-939. [PMID: 27727092 DOI: 10.1016/j.purol.2016.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 08/23/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To review epidemiologic data's and medical results of deceased donation in renal transplantation. MATERIAL AND METHODS Relevant publications were identified through Medline (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) database using the following keywords, alone or in association, "brain death; cardiac arrest; deceased donation; organ procurement; transplantation". Articles were selected according to methods, language of publication and relevance. The reference lists were used to identify additional historical studies of interest. Both prospective and retrospective series, in French and English, as well as review articles and recommendations were selected. In addition, French national transplant and health agencies (http://www.agence-biomedecine.fr and http://www.has-sante.fr) databases were screened using identical keywords. A total of 2498 articles, 8 official reports and 17 newspaper articles were identified; after careful selection 157 publications were eligible for our review. RESULTS Deceased donation may involve either brain death or non-heartbeating donors (NHBD). Organ shortage led to the procurement of organs from expanded-criteria donors, with an increased age at donation and extended vascular disease, leading to inferior results after transplantation and underlining the need for careful donor management during brain death or cardiac arrest. Evolution of French legislation covering bioethics allowed procurement from Maastricht categories II and recently III non-heartbeating donors. CONCLUSION The increase of organ shortage emphasizes the need for a rigorous surgical technique during procurement to avoid loss of transplants. A history or current neoplasm in deceased-donors, requires attention to increase the pool of organs without putting the recipients at risk for cancer transmission. French NHBD program, especially from Maastricht category III, may stand for a potential source of valuable organs.
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Affiliation(s)
- R Thuret
- Service d'urologie et transplantation rénale, CHU de Montpellier, 34090 Montpellier, France; Université de Montpellier, 34090 Montpellier, France.
| | - F Kleinclauss
- Service d'urologie et transplantation rénale, CHRU de Besançon, 25030 Besançon, France; Université de Franche-Comté, 25030 Besançon, France; Inserm UMR 1098, 25030 Besançon, France
| | - N Terrier
- Service d'urologie et transplantation rénale, CHU de Grenoble, 38000 Grenoble, France
| | - M O Timsit
- Service d'urologie, hôpital européen Georges-Pompidou, AP-HP, 75015 Paris, France; Université Paris Descartes, 75006 Paris, France
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18
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Oppong YD, Farber JL, Chervoneva I, Martinez Cantarin MP. Correlation of acute tubular injury in reperfusion biopsy with renal transplant outcomes. Clin Transplant 2016; 30:836-44. [PMID: 27146243 DOI: 10.1111/ctr.12757] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2016] [Indexed: 11/28/2022]
Abstract
Acute tubular injury (ATI) is common at reperfusion, but its relationship to graft outcomes is unclear. Prior studies lack standardization of morphological assessments and included elements of acute and chronic tubular injury. This study aimed to evaluate the impact of ATI on graft outcomes. Reperfusion biopsies from 2004 to 2009 were retrospectively reviewed. ATI was assessed by a new standardized scoring system. We also assessed chronic injury (CI) by the Banff criteria. Outcomes evaluated included glomerular filtration rate (GFR) at 1 and 5 years and delayed graft function (DGF), acute rejection (AR), graft and patient survival. ATI did not correlate with DGF, AR, graft or overall survival. Mild-moderate ATI was not predictive of GFR post-transplant. Moderate-severe CI was associated with lower GFR at 5 years with a mean difference of -7.14 mL/min/1.73 m(2) (P=.04) and overall survival (HR 2.44, P=.01). Other predictors of graft function included donor age, DGF, and AR. Histologic criteria of ATI at implantation in the absence of donor demographics or clinical information do not provide sufficient predictability in outcomes after transplantation. On the other hand, histologic assessment of CI correlates with GFR and overall survival.
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Affiliation(s)
- Yaa D Oppong
- Division of Hospital Medicine, Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - John L Farber
- Department of Pathology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Inna Chervoneva
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA, USA
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19
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Young A, Dixon SN, Knoll GA, Garg AX, Lok CE, Lam NN, Kim SJ. The Canadian experience using the expanded criteria donor classification for allocating deceased donor kidneys for transplantation. Can J Kidney Health Dis 2016; 3:15. [PMID: 27014467 PMCID: PMC4806479 DOI: 10.1186/s40697-016-0106-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 01/07/2016] [Indexed: 11/13/2022] Open
Abstract
Background Although the outcomes of transplantation with expanded criteria donor (ECD) kidneys are inferior to non-ECD transplants in the USA, the impact of the ECD classification on Canadian kidney transplant recipients is not known. Objectives The objective of the study was to assess the performance of the US-derived ECD classification among deceased donor kidney transplant recipients in a Canadian setting. Design This study was a population-based cohort study. Setting The study was conducted in all adult kidney transplant centers in the province of Ontario. Patients The patients were incident-deceased donor kidney transplant recipients from January 1, 2005 to March 31, 2011. Measurements Study subjects were identified through the Trillium Gift of Life Network and linked to healthcare databases in Ontario. ECD status was based on age, hypertension, kidney function, and stroke-related death. Outcomes of interest included graft loss, death, and delayed graft function. Methods The Kaplan-Meier product limit method was used to graphically assess time to graft loss or death. Multivariable Cox proportional hazards models were used to assess graft loss or death as a function of ECD status. Multivariable logistic regression models were fitted for the outcome of delayed graft function. Results Of 1422 deceased donor kidney transplants, 325 (23 %) were from ECDs. The median donor age was 63 vs. 42 years for ECD vs. non-ECD, respectively. The 5-year cumulative incidence of total graft loss was 29.2 % in ECD and 20.7 % in non-ECD kidney transplants. The relative hazards for total graft loss (HR 1.48 [95 % CI, 1.10; 2.00]) and death-censored graft loss (HR 1.80 [95 % CI, 1.19, 2.71]) were increased in ECD vs. non-ECD transplants. Increased relative risks were also observed for death and delayed graft function, albeit not statistically significant. Limitations Although comprehensive in coverage and outcome ascertainment, the available details on covariate data may be limited in large healthcare databases. Conclusions The ECD classification identifies kidneys at increased risk for graft loss in Canadian patients. The performance of more granular measures of donor risk (e.g., Kidney Donor Risk Index) and its impact on organ allocation/utilization in Canadian patients requires further study. Electronic supplementary material The online version of this article (doi:10.1186/s40697-016-0106-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ann Young
- Department of Medicine, University of Toronto, Toronto, Ontario Canada
| | | | - Greg A Knoll
- Institute for Clinical Evaluative Sciences, Ontario, Canada ; Division of Nephrology, University of Ottawa, Ottawa, Ontario Canada
| | - Amit X Garg
- Institute for Clinical Evaluative Sciences, Ontario, Canada ; Division of Nephrology, Western University, London, Ontario Canada
| | - Charmaine E Lok
- Department of Medicine, University of Toronto, Toronto, Ontario Canada ; Institute for Clinical Evaluative Sciences, Ontario, Canada ; Division of Nephrology, Toronto General Hospital, University Health Network, University of 585 University Avenue, 11-PMB-129 Toronto, Ontario Canada
| | - Ngan N Lam
- Division of Nephrology, University of Alberta, Edmonton, Alberta Canada
| | - S Joseph Kim
- Department of Medicine, University of Toronto, Toronto, Ontario Canada ; Institute for Clinical Evaluative Sciences, Ontario, Canada ; Division of Nephrology, Toronto General Hospital, University Health Network, University of 585 University Avenue, 11-PMB-129 Toronto, Ontario Canada
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20
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Pisarski P, Schleicher C, Hauser I, Becker JU. German recommendations for pretransplantation donor kidney biopsies. Langenbecks Arch Surg 2016; 401:133-40. [PMID: 26994917 DOI: 10.1007/s00423-016-1384-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 02/12/2016] [Indexed: 12/20/2022]
Abstract
PURPOSE This manuscript reviews the data about the histopathologic and develops recommendations to standardise and improve the biopsy procedure, the biopsy handling, the histopathological evaluation, the communication of results and the collection of data from pretransplantation kidney biopsies of deceased donors in Germany. METHODS The recommendations are based on this literature review, on discussions at two workshops held by the German Society of Pathology and the German Organ Transplantation Foundation and on personal experiences of the authors. RESULTS These German recommendations advocate the use of punch biopsies, paraffin embedding and detailed descriptive reporting of histopathological findings. CONCLUSIONS These recommendations constitute only a starting point. Periodical revisions will help to simplify and optimise the recommendations with the ultimate goal to prospectively gather data for the elaboration of a computer-based algorithm that allows the exact prediction of transplantation outcome for a given match of donor and recipient.
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Affiliation(s)
- Przemyslav Pisarski
- Department of General and Visceral Surgery, University Hospital Freiburg, Freiburg, Germany
| | | | - Ingeborg Hauser
- Medical Clinic III, Nephrology, University Hospital Frankfurt, Frankfurt, Germany
| | - Jan U Becker
- Institute of Pathology, University Hospital of Cologne, Kerpener Straße 62, 50937, Cologne, Germany.
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21
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Querard AH, Foucher Y, Combescure C, Dantan E, Larmet D, Lorent M, Pouteau LM, Giral M, Gillaizeau F. Comparison of survival outcomes between Expanded Criteria Donor and Standard Criteria Donor kidney transplant recipients: a systematic review and meta-analysis. Transpl Int 2016; 29:403-15. [PMID: 26756928 DOI: 10.1111/tri.12736] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/03/2015] [Accepted: 12/16/2015] [Indexed: 12/31/2022]
Abstract
In 2002, the United Network for Organ Sharing proposed increasing the pool of donor kidneys to include Expanded Criteria Donor (ECD). Outside the USA, the ECD definition remains the one used without questioning whether such a graft allocation criterion is valid worldwide. We performed a meta-analysis to quantify the differences between ECD and Standard Criteria Donor (SCD) transplants. We paid particular attention to select studies in which the methodology was appropriate and we took into consideration the geographical area. Thirty-two publications were included. Only five studies, all from the USA, reported confounder-adjusted hazard ratios comparing the survival outcomes between ECD and SCD kidney transplant recipients. These five studies confirmed that ECD recipients seemed to have poorer prognosis. From 29 studies reporting appropriate survival curves, we estimated the 5-year pooled nonadjusted survivals for ECD and SCD recipients. The relative differences between the two groups were lower in Europe than in North America, particularly for death-censored graft failure. It is of primary importance to propose appropriate studies for external validation of the ECD criteria in non-US kidney transplant recipients.
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Affiliation(s)
- Anne-Hélène Querard
- Nephrology, Dialysis, Transplantation, Centre Hospitalier Départemental de Vendée, La Roche sur Yon, France.,EA 4275 SPHERE - bioStatistics, Pharmacoepidemiology and Human sciEnces REsearch, Nantes University, Nantes, France.,Institute for Transplantation, Urology and Nephrology ITUN, CHU Nantes, RTRS 'Centaure', Inserm U1064, Nantes University, Nantes, France
| | - Yohann Foucher
- EA 4275 SPHERE - bioStatistics, Pharmacoepidemiology and Human sciEnces REsearch, Nantes University, Nantes, France.,Institute for Transplantation, Urology and Nephrology ITUN, CHU Nantes, RTRS 'Centaure', Inserm U1064, Nantes University, Nantes, France
| | - Christophe Combescure
- CRC & Division of Clinical Epidemiology, Department of Health and Community Medicine, University of Geneva & University Hospitals of Geneva, Geneva, Switzerland
| | - Etienne Dantan
- EA 4275 SPHERE - bioStatistics, Pharmacoepidemiology and Human sciEnces REsearch, Nantes University, Nantes, France
| | - David Larmet
- Institute for Transplantation, Urology and Nephrology ITUN, CHU Nantes, RTRS 'Centaure', Inserm U1064, Nantes University, Nantes, France
| | - Marine Lorent
- EA 4275 SPHERE - bioStatistics, Pharmacoepidemiology and Human sciEnces REsearch, Nantes University, Nantes, France
| | - Lise-Marie Pouteau
- Institute for Transplantation, Urology and Nephrology ITUN, CHU Nantes, RTRS 'Centaure', Inserm U1064, Nantes University, Nantes, France
| | - Magali Giral
- EA 4275 SPHERE - bioStatistics, Pharmacoepidemiology and Human sciEnces REsearch, Nantes University, Nantes, France.,Institute for Transplantation, Urology and Nephrology ITUN, CHU Nantes, RTRS 'Centaure', Inserm U1064, Nantes University, Nantes, France.,LabEx Transplantex Nantes, Centre d'Investigation Clinique Biothérapie, Nantes, France
| | - Florence Gillaizeau
- EA 4275 SPHERE - bioStatistics, Pharmacoepidemiology and Human sciEnces REsearch, Nantes University, Nantes, France.,Institute for Transplantation, Urology and Nephrology ITUN, CHU Nantes, RTRS 'Centaure', Inserm U1064, Nantes University, Nantes, France
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22
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Valor pronóstico de la biopsia renal preimplante en donantes fallecidos de edad avanzada en la función renal al año del trasplante. Nefrologia 2016; 36:33-41. [DOI: 10.1016/j.nefro.2015.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 03/10/2015] [Indexed: 11/21/2022] Open
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23
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White AD, Roberts H, Ecuyer C, Brady K, Pathak S, Clark B, Hostert LH, Attia MS, Wellberry-Smith M, Hudson A, Ahmad N. Impact of the new fast track kidney allocation scheme for declined kidneys in the United Kingdom. Clin Transplant 2015; 29:872-81. [DOI: 10.1111/ctr.12576] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Alan D. White
- Division of Surgery; Department of Transplantation; St James' University Hospital; Leeds UK
| | - Heather Roberts
- Division of Surgery; Department of Transplantation; St James' University Hospital; Leeds UK
| | - Clare Ecuyer
- Division of Surgery; Department of Transplantation; St James' University Hospital; Leeds UK
| | - Kathryn Brady
- Division of Surgery; Department of Transplantation; St James' University Hospital; Leeds UK
| | - Samir Pathak
- Division of Surgery; Department of Transplantation; St James' University Hospital; Leeds UK
| | - Brendan Clark
- Department of Histocompatibility and Immunogenetics; St James' University Hospital; Leeds UK
| | - Lutz H. Hostert
- Division of Surgery; Department of Transplantation; St James' University Hospital; Leeds UK
| | - Magdy S. Attia
- Division of Surgery; Department of Transplantation; St James' University Hospital; Leeds UK
| | | | - Alex Hudson
- National Health Service Blood and Transplant; Bristol UK
| | - Niaz Ahmad
- Division of Surgery; Department of Transplantation; St James' University Hospital; Leeds UK
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24
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Wang CJ, Wetmore JB, Crary GS, Kasiske BL. The Donor Kidney Biopsy and Its Implications in Predicting Graft Outcomes: A Systematic Review. Am J Transplant 2015; 15:1903-14. [PMID: 25772854 DOI: 10.1111/ajt.13213] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 01/06/2015] [Accepted: 01/07/2015] [Indexed: 01/25/2023]
Abstract
Despite a growing organ shortage in the United States, many deceased donor kidneys removed for transplantation are discarded. Kidney biopsy findings often play a role in these discards, although it is not clear whether biopsies reliably inform acceptance decisions. Therefore, we carried out a systematic review of the medical literature on the utility of both procurement and implantation biopsies for predicting posttransplant outcomes. Between January 1, 1994 and July 1, 2014, 47 studies were published in the English language literature that examined the association between pretransplant donor biopsy findings from 50 or more donors (with more than half being from deceased donors) and either posttransplant graft failure, delayed graft function, or graft function. In general, study quality was poor. All were retrospective or did not indicate if they were prospective. Results were heterogeneous, with authors as often as not concluding that biopsy results did not predict posttransplant outcomes. The percent glomerular sclerosis was most often examined, and failed to predict graft failure in 7 of 14 studies. Of 15 semiquantitative scoring systems proposed, none consistently predicted posttransplant outcomes across studies. Routine use of biopsies to help determine whether or not to transplant a kidney should be reexamined.
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Affiliation(s)
- C J Wang
- Division of Nephrology, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - J B Wetmore
- Division of Nephrology, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - G S Crary
- Department of Pathology, Hennepin County Medical Center, Minneapolis, MN
| | - B L Kasiske
- Division of Nephrology, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
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25
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Tanrısev M, Hoşcoşkun C, Aşçı G, Sözbilen M, Fırat Ö, Ertilav M, Özkahya M, Töz H. Long-term outcome of kidney transplantation from elderly living and expanded criteria deceased donors. Ren Fail 2014; 37:249-53. [DOI: 10.3109/0886022x.2014.982488] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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26
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Abstract
PURPOSE OF REVIEW The current era of organ shortage has necessitated a widening of criteria for donation, considering donors who would have been considered unsuitable before. This review summarizes the recent advances in strategies to maximize the use of marginal kidneys without compromising the outcomes. RECENT FINDINGS Various strategies have been studied and implemented to optimize procurement and allocation of marginal kidneys, and to preserve their function. In particular, a growing number of transplant centers are using donors after circulatory death. Whereas normothermic ex-vivo and postmortem perfusion are promising procedures to improve the outcomes of marginal grafts in the future, dual-kidney transplantation is a viable approach which is at present potentially underutilized. Despite active research on new strategies to evaluate organ quality, pretransplant biopsy assessment currently remains the most reliable method. The practice of using living donors with advanced age is supported by available evidence, whereas the use of young living donors with minor medical abnormalities needs further investigation. SUMMARY Progress has been made in the recent years, clarifying the best criteria for evaluating, recovering, and allocating marginal kidney donors. However, further research is needed, with special regards to the criteria for using marginal living-kidney donors.
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Affiliation(s)
- Umberto Maggiore
- aTrapianti Rene-Pancreas (U.O.C. Nefrologia), Azienda Ospedaliero-Universitaria di Parma, Parma, Italy bRenal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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27
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Assis-Borba L, Cristelli MP, Paula MI, Franco MF, Tedesco-Silva H, Medina-Pestana JO. Expanding the use of expanded criteria donors in kidney transplantation. Int Urol Nephrol 2014; 46:1663-71. [PMID: 24677001 DOI: 10.1007/s11255-014-0695-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 03/17/2014] [Indexed: 01/16/2023]
Abstract
PURPOSE Although the use of kidney allografts from expanded criteria donors (ECD) has increased in recent years, the reported discard rates are also growing. The influence of ECD characteristics on transplant outcomes is still underevaluated. METHODS This retrospective study investigated the influence of preimplantation biopsy findings and delayed graft function (DGF) on patient and graft survivals and renal function at 36 months in a cohort of 372 ECD kidney transplant recipients. RESULTS Patient and graft survivals were 91.6 and 68.9 %. The incidence of biopsy-proven acute rejection was 31 %. There were no differences in patient (88.6 vs. 91.1 vs. 94.7 vs. 78.6 %, p = 0.10) or graft (78.1 vs. 72.2 vs. 60.5 vs. 62.6 %, p = 0.14) survivals and renal function (41.7 ± 25.6 vs. 39.9 ± 29.9 vs. 38.1 ± 30.6 vs. 37.4 ± 29.2 mL/min, p = 0.79) comparing ECD kidneys with mild, moderate, and severe histological changes or with no preimplantation biopsy, respectively. However, severe scored transplants had the worst death-censored graft survival (OR 3.1, 95 % CI 1.4-6.9, p = 0.007). No significant differences in patient (86.2 vs. 83.4 %, p = 0.17) or graft (73.7 vs. 65.9 %, p = 0.06) survivals and renal function (38.9 ± 28.6 vs. 39.9 ± 28.4 mL/min, p = 0.72) were observed comparing patients with or without DGF. Multivariable analysis found diabetes history as the only independent risk factor for graft loss (OR 2.1, 95 % CI 1.3-3.3, p = 0.003) or patient death (OR 3.1, 95 % CI 1.5-5.8, p < 0.001). CONCLUSIONS Within the limitations of sample size and short follow-up time, in this cohort of ECD kidney transplant recipients the severity of histological changes observed in preimplantation biopsies was independently associated with graft loss.
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Affiliation(s)
- Luciana Assis-Borba
- Transplant Division, Hospital do Rim e Hipertensão, UNIFESP, São Paulo, SP, Brazil
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28
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Spasovski G, Masin-Spasovska J. How to improve the survival of the kidney transplant - is it only the pharmaceutical management? Expert Opin Pharmacother 2014; 15:905-8. [PMID: 24617949 DOI: 10.1517/14656566.2014.896900] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Kidney transplantation is the best treatment option in chronic kidney disease patients. Despite the new potent immunosuppressants, the long-term graft survival has not significantly improved. This is a rather complex issue with interrelationship between pretransplant donor-recipient variables, recipient post-transplant perioperative non/immunological factors, the combination/dose of maintenance immunosuppression and the general noncompliance of the patient. The recipients with an increased immunological risk should be maintained on triple therapy with steroids, preferably tacrolimus (Tac) or cyclosporine (CsA) plus mycophenolate mofetil (MMF). Eventual calcineurin inhibitor (CNI) minimization should be coupled with either protocol biopsies or frequent biochemistry monitoring including periodical assessment of anti-human leukocyte antigen and donor-specific antibodies. Recipients with standard immunological risks may be considered for as low as possible triple immunosuppression (steroids, Tac/CsA, MMF) after a period of 6 - 12 months. In cases of CNI minimization, a modification with a higher dose of the other two drugs in the triple therapy combination might be considered. The nonadherence to the prescribed maintenance therapy should be regularly checked-up. In conclusion, antibody induction, MMF, steroids and low-dose Tac/CsA should be the mainstream therapy in majority of patients. The short- and mid-term encouraging results for CNI minimization/withdrawal seem to correspond to recent findings of chronic antibody-mediated rejection, and long-term results need further evaluation.
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Affiliation(s)
- Goce Spasovski
- University of Skopje, Medical Faculty, University Department of Nephrology , Vodnjanska 17, 1000 Skopje , Macedonia +389 70 268 232 ; +389 2 3178 102 ;
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