1
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Morello W, Proverbio E, Puccio G, Montini G. A Systematic Review and Meta-Analysis of the Rate and Risk Factors for Post-transplant Disease Recurrence in Children With Steroid Resistant Nephrotic Syndrome. Kidney Int Rep 2022; 8:254-264. [PMID: 36815113 PMCID: PMC9939313 DOI: 10.1016/j.ekir.2022.10.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022] Open
Abstract
Introduction Posttransplant disease recurrence is a feared and severe complication in children with steroid resistant nephrotic syndrome (SRNS), but little is known about its incidence. Recent data suggest relapse is exceptional in patients with genetic SRNS, and initial steroid sensitivity may represent a risk factor for recurrence. Methods Systematic review and meta-analysis were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to describe the post-transplant relapse rate among children with SRNS; as well as the association between recurrence and all potential risk factors, including the presence of causative genetic mutations, initial steroid sensitivity, underlying histology, and gender. The inclusion criteria were as follows: (i) children with SRNS who are undergoing kidney transplant, (ii) available data on post-transplant recurrence, (iii) no patient selection according to the underlying histology, (iv) available data on genetic testing, and (v) prospective or retrospective cohort design. Results Of the 5818 records identified, 8 studies including 581 children with SRNS met the inclusion criteria. Overall posttransplant recurrence rate was 39% (95% confidence interval [CI] 34%-44%). No genetic patient relapsed, whereas the recurrence rate in patients with no causative genetic mutation identified was 61% (95% CI 53%-69%). Children with initial steroid sensitivity were at a higher risk for recurrence with a 1.91 relative risk (RR) (95% CI 1.48-2.46) compared with those with primary SRNS (PSRNS). Gender and histology did not significantly affect relapse rate. Conclusion Post-transplant recurrence is a common event in children with idiopathic non-genetic SRNS, complicating the clinical course in over 60% of patients. The presence of a causative genetic mutation virtually excludes a recurrence. Initial steroid sensitivity is the only other significant risk factor, doubling the risk of relapse.
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Affiliation(s)
- William Morello
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Emanuele Proverbio
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Giuseppe Puccio
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy,Department of Clinical Sciences and Community Health, University of Milan, Italy,Correspondence: Giovanni Montini, Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milano, Italy.
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2
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Ramirez-Guerrero G, Sevillano Prieto AM, Jara-Vilugrón F, Polanco Fernandez N, Gonzalez Monte E, Henandez Vicente A, Rodriguez Gayo LC, Praga Terente M, Andrés Belmonte A. Long-term plasmapheresis therapy in the management of focal segmental glomerulosclerosis recurrence after kidney transplantation. Transfus Apher Sci 2021; 60:103046. [PMID: 33455879 DOI: 10.1016/j.transci.2020.103046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 11/30/2022]
Abstract
The recurrence of primary focal segmental glomerulosclerosis (FSGS) after kidney transplantation (KT) appears in 30 % of the recipients. Sometimes it can cause the loss of the allograft. Although many treatments for this condition have been reported, 20 %-40 % of the affected patients are refractory or presents frequents relapses. In this paper we describe the evolution of three recipients treated with long-term plasmapheresis therapy after a recurrence of FSGS with a bad or incomplete response to other treatments. Although our findings require confirmation, long-term plasmapheresis could be a therapeutic option for this condition.
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Affiliation(s)
- Gonzalo Ramirez-Guerrero
- Department of Nephrology, Hospital Carlos Van Buren, Valparaiso. Street San Ignacio 725, Valparaíso, Chile
| | - Angel M Sevillano Prieto
- Department of Nephrology, Hospital 12 de Octubre, Avda. de Córdoba, s/n Madrid, PC: 28041, Spain.
| | - Fernando Jara-Vilugrón
- Department of Nephrology, Hospital Las Higueras, Alto Horno Street, Number 777, Talcahuano, Chile
| | | | - Esther Gonzalez Monte
- Department of Nephrology, Hospital 12 de Octubre, Avda. de Córdoba, s/n Madrid, PC: 28041, Spain
| | - Ana Henandez Vicente
- Department of Nephrology, Hospital 12 de Octubre, Avda. de Córdoba, s/n Madrid, PC: 28041, Spain
| | - Lucia C Rodriguez Gayo
- Department of Medicine, Universidad Complutense, Plaza Ramón y Cajal, Madrid, PC:28040, Spain
| | - Manuel Praga Terente
- Department of Nephrology, Hospital 12 de Octubre, Avda. de Córdoba, s/n Madrid, PC: 28041, Spain; Department of Medicine, Universidad Complutense, Plaza Ramón y Cajal, Madrid, PC:28040, Spain
| | - Amado Andrés Belmonte
- Department of Nephrology, Hospital 12 de Octubre, Avda. de Córdoba, s/n Madrid, PC: 28041, Spain
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3
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Morello W, Puvinathan S, Puccio G, Ghiggeri GM, Dello Strologo L, Peruzzi L, Murer L, Cioni M, Guzzo I, Cocchi E, Benetti E, Testa S, Ghio L, Caridi G, Cardillo M, Torelli R, Montini G. Post-transplant recurrence of steroid resistant nephrotic syndrome in children: the Italian experience. J Nephrol 2020; 33:849-857. [PMID: 31617157 PMCID: PMC7381476 DOI: 10.1007/s40620-019-00660-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/09/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Steroid resistant nephrotic syndrome (SRNS) is a frequent cause of end stage renal disease in children and post-transplant disease recurrence is a major cause of graft loss. METHODS We identified all children with SRNS who underwent renal transplantation in Italy, between 2005 and 2017. Data were retrospectively collected for the presence of a causative gene mutation, sex, histology, duration of pre-transplant dialysis, age at onset and transplant, HLA matching, recurrence, therapy for recurrence, and graft survival. RESULTS 101 patients underwent a first and 22 a second renal transplant. After a median follow-up of 58.5 months, the disease recurred on the first renal transplant in 53.3% of patients with a non-genetic and none with a genetic SRNS. Age at transplant > 9 years and the presence of at least one HLA-AB match were independent risk factors for recurrence. Duration of dialysis was longer in children with relapse, but did not reach statistical significance. Overall, 24% of patients lost the first graft, with recurrence representing the commonest cause. Among 22 patients who underwent a second transplant, 5 suffered of SRNS recurrence. SRNS relapsed in 5/9 (55%) patients with disease recurrence in their first transplant and 2 of them lost the second graft. CONCLUSIONS Absence of a causative mutation represents the major risk factor for post-transplant recurrence in children with SRNS, while transplant can be curative in genetic SRNS. A prolonged time spent on dialysis before transplantation has no protective effect on the risk of relapse and should not be encouraged. Retransplantation represents a second chance after graft loss for recurrence.
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Affiliation(s)
- William Morello
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, University of Milan, via della Commenda, 9, 20122, Milan, Italy
| | - Sairaj Puvinathan
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, University of Milan, via della Commenda, 9, 20122, Milan, Italy
| | - Giuseppe Puccio
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, University of Milan, via della Commenda, 9, 20122, Milan, Italy
| | - Gian Marco Ghiggeri
- Division of Nephrology, Dialysis, and Transplantation, Scientific Institute for Research and Health Care, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Luca Dello Strologo
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Rome, Italy
| | - Licia Peruzzi
- Pediatric Nephrology Unit, Regina Margherita Children's Hospital, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Luisa Murer
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Women's and Children's Health, Hospital-University of Padova, Padua, Italy
| | - Michela Cioni
- Division of Nephrology, Dialysis, and Transplantation, Scientific Institute for Research and Health Care, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Isabella Guzzo
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Rome, Italy
| | - Enrico Cocchi
- Pediatric Nephrology Unit, Regina Margherita Children's Hospital, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Elisa Benetti
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Women's and Children's Health, Hospital-University of Padova, Padua, Italy
| | - Sara Testa
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, University of Milan, via della Commenda, 9, 20122, Milan, Italy
| | - Luciana Ghio
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, University of Milan, via della Commenda, 9, 20122, Milan, Italy
| | - Gianluca Caridi
- Division of Nephrology, Dialysis, and Transplantation, Scientific Institute for Research and Health Care, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Massimo Cardillo
- North Italy Transplant program (NITp), UOC Coordinamento Trapianti, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Rosanna Torelli
- North Italy Transplant program (NITp), UOC Coordinamento Trapianti, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, University of Milan, via della Commenda, 9, 20122, Milan, Italy.
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4
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Abstract
Human kidney tissue can now be generated via the directed differentiation of human pluripotent stem cells. This advance is anticipated to facilitate the modeling of human kidney diseases, provide platforms for nephrotoxicity screening, enable cellular therapy, and potentially generate tissue for renal replacement. All such applications will rely upon the accuracy and reliability of the model and the capacity for stem cell-derived kidney tissue to recapitulate both normal and diseased states. In this review, we discuss the models available, how well they recapitulate the human kidney, and how far we are from application of these cells for use in cellular therapies.
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Affiliation(s)
- Melissa H Little
- Murdoch Children's Research Institute, Parkville, Victoria 3052, Australia; .,Department of Paediatrics, University of Melbourne, Victoria 3010, Australia.,Department of Anatomy and Neuroscience, University of Melbourne, Victoria 3010, Australia
| | - Lorna J Hale
- Murdoch Children's Research Institute, Parkville, Victoria 3052, Australia;
| | - Sara E Howden
- Murdoch Children's Research Institute, Parkville, Victoria 3052, Australia; .,Department of Paediatrics, University of Melbourne, Victoria 3010, Australia
| | - Santhosh V Kumar
- Murdoch Children's Research Institute, Parkville, Victoria 3052, Australia; .,Department of Paediatrics, University of Melbourne, Victoria 3010, Australia
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5
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Peruzzi L, Albiani R, Giancaspero K. Plasma exchange in kidney transplantation: Still a valuable option for nephrotic syndrome recurrence. Transfus Apher Sci 2017; 56:525-530. [PMID: 28830667 DOI: 10.1016/j.transci.2017.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
About 30% of the cases of steroid resistant nephrotic syndrome display a genetically determined disease and will not recur after kidney transplant; the other cases with fully or partially immunological pathogenesis display a high risk of post transplant recurrence. Although lots of studies were carried out in the last 50 years the pathogenetic mechanism is still obscure and the therapeutic approach mostly empirical. The cornerstones principles of the therapies are based on removal of a still undefined "permeability factor" through plasma-exchange or other apheresis techniques and inhibition of its synthesis by the immunological system through different drugs. The probability of successfully inducing persistant remission is nowadays around 30%through the different schemes experimented so far which mostly include plasmapheresis. Rituximab in the last years has significantly increased the efficacy of the treatments. Non responders are rapidly evolving to graft loss and will most probably recur also in subsequent transplant. Apart from genetics no other risk factors are predictive for recurrence.
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Affiliation(s)
- Licia Peruzzi
- Pediatric Nephrology Unit, Regina Margherita Children's Hospital, Città della Salute e della Scienza di Torino, Turin, Italy.
| | - Roberto Albiani
- Apheresis Unit, Regina Margherita Children's Hospital, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Karol Giancaspero
- Apheresis Unit, Regina Margherita Children's Hospital, Città della Salute e della Scienza di Torino, Turin, Italy
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6
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Abstract
Since first performed in 1954, kidney transplantation has evolved as the preferred long-term treatment of children with end stage renal disease (ESRD). The etiology of chronic kidney disease (CKD) and ESRD in children is broad and can be quite complicated, necessitating a multidisciplinary team to adequately care for these patients and their myriad needs. Precise surgical techniques and modern protocols for immunosuppression provide excellent long-term patient and graft survival. This article reviews the many etiologies of renal failure in the pediatric population focusing on those most commonly leading to the need for kidney transplantation. The processes of evaluation, kidney transplantation, short-term and long-term complications, as well as long-term outcomes are also reviewed.
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Affiliation(s)
- Jonathan P Roach
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 3123 East 16th Ave, Aurora, Colorado 80045.
| | - Margret E Bock
- Section of Nephrology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Jens Goebel
- Section of Nephrology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
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7
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Kolonko A, Piecha G, Więcek A. Successful Preemptive Kidney Transplantation With Rituximab Induction in a Patient With Focal Segmental Glomerulosclerosis and Massive Nephrotic Syndrome: A Case Report. Transplant Proc 2017; 48:3092-3094. [PMID: 27932154 DOI: 10.1016/j.transproceed.2016.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 07/05/2016] [Indexed: 11/25/2022]
Abstract
Primary focal segmental glomerulosclerosis (FSGS) recurs in 30% of patients receiving their first kidney transplant and often leads to graft loss. In the past, patients with FSGS and overt nephrotic syndrome rarely underwent transplantation. Rituximab (RTX), an anti-CD20-specific monoclonal antibody, was previously reported to be a valuable option in treating relapsing FSGS after kidney transplantation. We report here the first successful kidney transplantation in a young patient with primary FSGS and massive nephrotic syndrome treated with RTX induction. The patient was a 24-year-old woman who had developed nephrotic syndrome at the age of 4 years. FSGS was confirmed by results of a kidney biopsy, with subsequent treatment with cyclosporine and steroids, without remission. She was referred for a preemptive, deceased donor kidney transplant despite proteinuria levels reaching ∼10 g/d. She received induction therapy with 2 doses of RTX (375 mg/m2) at days 0 and 7, followed by tacrolimus 5 mg twice daily, mycophenolate mofetil 500 mg twice daily, and steroids after transplantation. Immediate kidney graft function was observed, with no proteinuria since day 13 posttransplant. The pretransplant soluble urokinase-type plasminogen activator receptor serum concentration was 4550 pg/mL; it decreased to 2191 pg/mL at day 13 and was 2073 pg/mL at 6 months' posttransplant. Thirty months after transplantation, the patient's serum creatinine level is 0.8 mg/dL, and no proteinuria has been observed. Successful kidney transplantation in a patient with pretransplant overt nephrotic syndrome secondary to FSGS, using rituximab as an induction therapy, is possible. Further recommendations for transplantation in such patients, however, should be based on results from larger clinical trials.
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Affiliation(s)
- A Kolonko
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland.
| | - G Piecha
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - A Więcek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
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8
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Abstract
Idiopathic nephrotic syndrome (INS) is one of the most common glomerular diseases in children and adults, and the central event is podocyte injury. INS is a heterogeneous disease, and treatment is largely empirical and in many cases unsuccessful, and steroids are the initial mainstay of therapy. Close to 70% of children with INS have some response to steroids and are labelled as steroid-‘sensitive’, and the rest as steroid-‘resistant’ (also termed focal segmental glomerulosclerosis), and single-gene mutations underlie a large proportion of the latter group. The burden of morbidity is enormous, both to patients with lifelong chronic disease and to health services, particularly in managing dialysis and transplantation. The target cell of nephrotic syndrome is the glomerular podocyte, and podocyte biology research has exploded over the last 15 years. Major advances in genetic and biological understanding now put clinicians and researchers at the threshold of a major reclassification of the disease and testing of targeted therapies both identified and novel. That potential is based on complete genetic analysis, deep clinical phenotyping, and the introduction of mechanism-derived biomarkers into clinical practice. INS can now be split off into those with a single-gene defect, of which currently at least 53 genes are known to be causative, and the others. Of the others, the majority are likely to be immune-mediated and caused by the presence of a still-unknown circulating factor or factors, and whether there is a third (or more) mechanistic group or groups remains to be discovered. Treatment is therefore now being refined towards separating out the monogenic cases to minimise immunosuppression and further understanding how best to stratify and appropriately direct immunosuppressive treatments within the immune group. Therapies directed specifically towards the target cell, the podocyte, are in their infancy but hold considerable promise for the near future.
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Affiliation(s)
| | - Moin Saleem
- University of Bristol, Bristol Royal Hospital for Children, Bristol, UK
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9
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Kang HG, Seo H, Lim JH, Kim JI, Han KH, Park HW, Koo JW, Kim KH, Kim JH, Cheong HI, Ha IS. Markers of disease and steroid responsiveness in paediatric idiopathic nephrotic syndrome: Whole-transcriptome sequencing of peripheral blood mononuclear cells. J Int Med Res 2017. [PMID: 28639503 PMCID: PMC5536413 DOI: 10.1177/0300060516652762] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective To identify markers of disease and steroid responsiveness in paediatric idiopathic nephrotic syndrome. Methods Whole-transcriptome sequencing was performed of peripheral blood mononuclear cells (PBMCs) from patients with NS. Differentially expressed genes (DEGs) were identified in patients with active NS vs those in remission, and those with steroid-sensitive NS (SSNS) vs steroid-resistant NS (SRNS). Results A total of 1065 DEGs were identified in patients with NS (n = 10) vs those in remission (n = 9). These DEGs correlated with cytokine and/or immune system signalling and the extracellular matrix. Comparisons between SSNS (n = 6) and SRNS (n = 4) identified 1890 DEGs. These markers of steroid responsiveness were enriched with genes related to the cell cycle, targets of microRNAs, and genes related to cytokines. Conclusions Meaningful DEGs were identified. Additional studies with larger numbers of patients will provide more comprehensive data.
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Affiliation(s)
- Hee Gyung Kang
- 1 Department of Paediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea.,2 Research Coordination Centre for Rare Diseases, Seoul National University Hospital, Seoul, Republic of Korea
| | - Heewon Seo
- 3 Seoul National University Biomedical Informatics, Seoul National University College of Medicine, Seoul, Republic of Korea.,4 Systems Biomedical Informatics Research Centre, Seoul National University, Seoul, Republic of Korea
| | - Jae Hyun Lim
- 3 Seoul National University Biomedical Informatics, Seoul National University College of Medicine, Seoul, Republic of Korea.,4 Systems Biomedical Informatics Research Centre, Seoul National University, Seoul, Republic of Korea
| | - Jong Il Kim
- 5 Genomic Medicine Institute, Seoul National University, Seoul, Republic of Korea
| | - Kyoung Hee Han
- 6 Department of Paediatrics, Jeju University Hospital, Jeju, Korea
| | - Hye Won Park
- 7 Department of Paediatrics, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Ja Wook Koo
- 8 Department of Paediatrics, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Kee Hyuck Kim
- 9 Department of Paediatrics, National Health Insurance Corporation Ilsan Hospital, Gyeonggi-do, Republic of Korea
| | - Ju Han Kim
- 3 Seoul National University Biomedical Informatics, Seoul National University College of Medicine, Seoul, Republic of Korea.,4 Systems Biomedical Informatics Research Centre, Seoul National University, Seoul, Republic of Korea
| | - Hae Il Cheong
- 1 Department of Paediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea.,2 Research Coordination Centre for Rare Diseases, Seoul National University Hospital, Seoul, Republic of Korea.,10 Kidney Research Institute, Medical Research Centre, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Il-Soo Ha
- 1 Department of Paediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea.,10 Kidney Research Institute, Medical Research Centre, Seoul National University College of Medicine, Seoul, Republic of Korea
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10
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Abstract
Focal segmental glomerulosclerosis, which is a common glomerular disorder, manifests clinically with a nephrotic syndrome and has a high propensity for recurrence after kidney transplantation. The pathophysiology is currently unknown, and podocytes appear to be the target of one or several circulating factor(s) that lead to the recurrence of proteinuria after kidney transplantation. Identifying these circulating factor(s) and cells involved in its synthesis remains elusive; however, recently, our research on podocyte cytoskeleton biology has opened a new era of treatment. This review will highlight recent progress in the physiopathology of focal segmental glomerulosclerosis recurrence after transplantation and its treatment.
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11
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Recurrence and Treatment after Renal Transplantation in Children with FSGS. BIOMED RESEARCH INTERNATIONAL 2016; 2016:6832971. [PMID: 27213154 PMCID: PMC4860214 DOI: 10.1155/2016/6832971] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Revised: 03/14/2016] [Accepted: 04/04/2016] [Indexed: 01/15/2023]
Abstract
Focal segmental glomerulosclerosis (FSGS) is a common cause of end-stage renal disease and a common pathologic diagnosis of idiopathic nephrotic syndrome (NS), especially in steroid-resistant cases. FSGS is known to recur after kidney transplantation, frequently followed by graft loss. However, not all patients with FSGS suffer from recurrence after kidney transplantation, and genetic and secondary FSGS have a negligible risk of recurrence. Furthermore, many cases of recurrence achieve remission with the current management of recurrence (intensive plasmapheresis/immunosuppression, including rituximab), and other promising agents are being evaluated. Therefore, a pathologic diagnosis of FSGS itself should not cause postponement of allograft kidney transplantation. For patients with a high risk of recurrence who presented with classical symptoms of NS, that is, severe edema, proteinuria, and hypoalbuminemia, close monitoring of proteinuria is necessary, followed by immediate, intensive treatment for recurrence.
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12
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Životić M, Bogdanović R, Peco-Antić A, Paripović D, Stajić N, Vještica J, Ćirović S, Trajković G, Marković-Lipkovski J. Glomerular nestin expression: possible predictor of outcome of focal segmental glomerulosclerosis in children. Pediatr Nephrol 2015; 30:79-90. [PMID: 25129203 DOI: 10.1007/s00467-014-2893-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 06/16/2014] [Accepted: 06/18/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND A high prevalence of chronic kidney disease among children with focal segmental glomerulosclerosis (FSGS) leads to a permanent quest for good predictors of kidney dysfunction. Thus, we carried out a retrospective cohort study in order to examine known clinical and morphological predictors of adverse outcome, as well as to investigate glomerular nestin expression as a potential new early predictor of kidney dysfunction in children with FSGS. Relationships between nestin expression and clinical and morphological findings were also investigated. METHODS Among 649 renal biopsy samples, obtained from two children's hospitals, FSGS was diagnosed in 60 children. Thirty-eight patients, who met the criteria for this study, were followed up for 9.0 ± 5.2 years. Using Kaplan-Meier and Cox's regression analysis, potential clinical and morphological predictors were applied in two models of prediction: after disease onset and after the biopsy. RESULTS The present study revealed the following significant predictors of kidney dysfunction: patients' ages at disease onset, as well as age at biopsy, resistance to corticosteroid treatment, serum creatinine level, urine protein/creatinine ratio, vascular involvement, tubular atrophy, interstitial fibrosis, and decreased glomerular nestin expression. CONCLUSIONS The most important finding of our study is that nestin can be used as a potential new early morphological predictor of kidney dysfunction in childhood onset of FSGS, since nestin has been obviously decreased in both sclerotic and normal glomeruli seen by light microscopy.
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Affiliation(s)
- Maja Životić
- Medical Faculty, University of Belgrade, Belgrade, Serbia
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13
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Lee SE, Min SI, Kim YS, Ha J, Ha IS, Cheong HI, Kim SJ, Choi Y, Kang HG. Recurrence of idiopathic focal segmental glomerulosclerosis after kidney transplantation: experience of a Korean tertiary center. Pediatr Transplant 2014; 18:369-76. [PMID: 24802343 DOI: 10.1111/petr.12257] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2014] [Indexed: 11/29/2022]
Abstract
FSGS is the second most common cause of idiopathic NS in children. It often progresses to ESRD and commonly recurs after KT. To investigate the risk factors and the prognosis of recurrence in pediatric idiopathic FSGS in Korea, retrospective review of 43 KT in 38 children with idiopathic FSGS of last two decades was conducted. The patients presented at the median age of 5.1 yr (range 1.1-13.8 yr) and received KT 5.7 yr later (range 1.3-17.6 yr). FSGS recurred in 20 allografts immediately after transplantation, only in those who presented with NS but not in those who presented with AUA. The risk factors for recurrence were age of onset >5 yr and progression to ESRD within six yr but not sooner than 18 months. CR was achieved in 13 patients with FSGS recurrence and sustained in nine without subsequent relapse over a median of six and a half yr (0.6-20.7 yr). Pediatric idiopathic FSGS presenting with NS recurred in more than half of patients after transplantation. Interestingly, more rapid progression within less than 18 months did not predict recurrence. To identify high-risk patients of recurrence, an international cooperative study would be necessary.
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Affiliation(s)
- Se Eun Lee
- Department of Pediatrics, Seoul National University College of Medicine and Research Center for Rare Diseases, Seoul, Korea
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14
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Ding WY, Koziell A, McCarthy HJ, Bierzynska A, Bhagavatula MK, Dudley JA, Inward CD, Coward RJ, Tizard J, Reid C, Antignac C, Boyer O, Saleem MA. Initial steroid sensitivity in children with steroid-resistant nephrotic syndrome predicts post-transplant recurrence. J Am Soc Nephrol 2014; 25:1342-8. [PMID: 24511128 DOI: 10.1681/asn.2013080852] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Of children with idiopathic nephrotic syndrome, 10%-20% fail to respond to steroids or develop secondary steroid resistance (termed initial steroid sensitivity) and the majority progress to transplantation. Although 30%-50% of these patients suffer disease recurrence after transplantation, with poor long-term outcome, no reliable indicator of recurrence has yet been identified. Notably, the incidence of recurrence after transplantation appears reduced in patients with steroid-resistant nephrotic syndrome (SRNS) due to monogenic disorders. We reviewed 150 transplanted patients with SRNS to identify biomarkers that consistently predict outcome of SRNS after transplantation. In all, 25 children had genetic or familial SRNS and did not experience post-transplant recurrence. We reviewed phenotypic factors, including initial steroid sensitivity, donor type, age, ethnicity, time to ESRD, and time on dialysis, in the remaining 125 children. Of these patients, 57 (45.6%) developed post-transplant recurrence; 26 of 28 (92.9%) patients with initial steroid sensitivity recurred after transplantation, whereas only 26 of 86 (30.2%) patients resistant from the outset recurred (odds ratio, 30; 95% confidence interval, 6.62 to 135.86; P<0.001). We were unable to determine recurrence in two patients (one with initial steroid sensitivity), and nine patients did not receive initial steroids. Our data show that initial steroid sensitivity is highly predictive of post-transplant disease recurrence in this pediatric patient population. Because a pathogenic circulating permeability factor in nephrotic syndrome remains to be confirmed, we propose initial steroid sensitivity as a surrogate marker for post-transplant recurrence.
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Affiliation(s)
- Wen Y Ding
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, United Kingdom; Academic Renal Unit, University of Bristol, Southmead Hospital, Bristol, United Kingdom
| | - Ania Koziell
- Department of Paediatric Nephrology, Evelina Children's Hospital, London, United Kingdom; Department of Experimental Immunobiology, King's College London, Guy's Hospital, London, United Kingdom
| | - Hugh J McCarthy
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, United Kingdom; Academic Renal Unit, University of Bristol, Southmead Hospital, Bristol, United Kingdom
| | - Agnieszka Bierzynska
- Academic Renal Unit, University of Bristol, Southmead Hospital, Bristol, United Kingdom
| | | | - Jan A Dudley
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Carol D Inward
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Richard J Coward
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, United Kingdom; Academic Renal Unit, University of Bristol, Southmead Hospital, Bristol, United Kingdom
| | - Jane Tizard
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Christopher Reid
- Department of Paediatric Nephrology, Evelina Children's Hospital, London, United Kingdom
| | - Corinne Antignac
- Pediatric Nephrology, French Institute of Health and Medical Research Unit 983, Necker Hospital for Sick Children, Paris, France
| | - Olivia Boyer
- Pediatric Nephrology, French Institute of Health and Medical Research Unit 983, Necker Hospital for Sick Children, Paris, France
| | - Moin A Saleem
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, United Kingdom; Academic Renal Unit, University of Bristol, Southmead Hospital, Bristol, United Kingdom;
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15
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Nongnuch A, Assanatham M, Sumethkul V, Chalermsanyakorn P, Kitiyakara C. Early posttransplant nephrotic range proteinuria as a presenting feature of minimal change disease and acute T cell-mediated rejection. Transplant Proc 2014; 46:290-4. [PMID: 23267783 DOI: 10.1016/j.transproceed.2012.07.140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 07/19/2012] [Indexed: 02/08/2023]
Abstract
Early-onset nephrotic range proteinuria is an extremely rare presentation of an acute rejection episode. Herein, we have reported a patient who developed nephrotic range proteinuria 7 days after receiving a renal allograft from his sister despite minor changes in serum creatinine levels. A kidney biopsy spcimen revealed a T cell-mediated acute rejection process concomitant with minimal change disease (MCD). Proteinuria and renal dysfunction improved dramatically in response to corticosteroids. The possibility of acute cellular rejection and coexisting MCD should be considered in patients with early posttransplantation nephrosis and normal serum creatinine levels. The coexistence of these entities provides support for the role of T cells in the pathogenesis of MCD.
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Affiliation(s)
- A Nongnuch
- Renal Unit, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok Thailand
| | - M Assanatham
- Renal Unit, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok Thailand
| | - V Sumethkul
- Renal Unit, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok Thailand
| | - P Chalermsanyakorn
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok Thailand
| | - C Kitiyakara
- Renal Unit, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok Thailand.
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16
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Marinaki S, Lionaki S, Boletis JN. Glomerular disease recurrence in the renal allograft: a hurdle but not a barrier for successful kidney transplantation. Transplant Proc 2013; 45:3-9. [PMID: 23375268 DOI: 10.1016/j.transproceed.2012.12.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Almost all forms of primary as well as secondary glomerulonephritides may recur after renal transplantation. Recurrence of the original disease is now the third most common cause of late allograft loss. Nevertheless, in most cases it is difficult to assess the true impact of primary disease recurrence in the allograft; histological recurrence with mild features does not necessarily implicate clinically severe disease. Moreover it is often difficult to distinguish recurrent from de novo disease as in membranous glomerulopathy. Because recurrence occurs late, histological lesions of recurrent glomerulonephritis may be unmasked by chronic damage from other causes such as chronic rejection. Beside the difficulties to interpret renal histology due to the variety of allograft lesions, there are no well-established options to prevent clinically severe disease recurrence nor the therapeutic approaches to the problem. The purpose of this review was mainly to underline that almost all primary and secondary glomerulonephritides represent a contraindication to transplantation. For the majority of patients with end-stage renal disease due to glomerulonephritis, transplantation still represents the treatment of choice.
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Affiliation(s)
- S Marinaki
- Nephrology Department and Renal Transplant Unit, Laiko Hospital, Athens, Greece.
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17
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Kandus A, Ponikvar R, Buturović-Ponikvar J, Bren AF, Oblak M, Mlinšek G, Kmetec A, Arnol M. Plasmapheresis and Immunoadsorption for Treatment and Prophylaxis of Recurrent Focal Segmental Glomerulosclerosis in Adult Recipients of Deceased Donor Renal Grafts. Ther Apher Dial 2013; 17:438-43. [DOI: 10.1111/1744-9987.12093] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - Rafael Ponikvar
- Department of Nephrology; University Medical Centre Ljubljana; Ljubljana; Slovenia
| | | | | | - Manca Oblak
- Department of Nephrology; University Medical Centre Ljubljana; Ljubljana; Slovenia
| | - Gregor Mlinšek
- Department of Nephrology; University Medical Centre Ljubljana; Ljubljana; Slovenia
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18
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Stewart ZA, Shetty R, Nair R, Reed AI, Brophy PD. Case report: successful treatment of recurrent focal segmental glomerulosclerosis with a novel rituximab regimen. Transplant Proc 2012; 43:3994-6. [PMID: 22172885 DOI: 10.1016/j.transproceed.2011.10.051] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Accepted: 10/24/2011] [Indexed: 12/12/2022]
Abstract
Focal segmental glomerulosclerosis (FSGS) is the cause of renal failure in more than 10% of pediatric patients undergoing renal transplantation. Recurrent FSGS is a major cause of pediatric allograft failure, with the risk increasing for patients undergoing retransplantation. Standard therapy for recurrent posttransplantation FSGS includes the use of intensive plasmapheresis (PP) in conjunction with cyclophosphamide or high-dose cyclosporine. However, many patients exhibit refractory disease, with rapid progression to allograft loss despite these interventions. Prior studies have reported conflicting data on the efficacy of adding rituximab therapy to the standard treatment regimen for recurrent posttransplantation FSGS. Here we present a successful therapeutic protocol with rapid elimination of PP after initiation of rituximab therapy for an adolescent patient with recurrent FSGS in the immediate postoperative period. The patient has maintained excellent allograft function through 12 months posttransplantation.
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Affiliation(s)
- Z A Stewart
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, USA.
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19
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Recurrent focal segmental glomerulosclerosis: a discrete clinical entity. Int J Nephrol 2012; 2012:246128. [PMID: 22288013 PMCID: PMC3263622 DOI: 10.1155/2012/246128] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Revised: 10/04/2011] [Accepted: 10/04/2011] [Indexed: 12/01/2022] Open
Abstract
Focal segmental glomerulosclerosis refers to a set of particular histopathologic lesions in which steroid-resistant podocyte injury leads to patchy adhesions between the glomerular tuft and Bowman's capsule, followed by progressive glomerulosclerosis and proteinuric renal failure. Because of the nonspecific nature of this lesion, it has been difficult to classify the various forms of primary nephrotic syndrome in children. However, with the recognition of hereditary FSGS caused by mutations podocyte slit diaphragm genes, it is increasingly clear that the steroid-resistant form of FSGS that recurs in the renal allografts (R-FSGS) constitutes a distinct clinical entity. Capitalizing on recent studies in which patients have been screened for slit diaphragm gene mutations, this review focuses on the natural history and pathogenesis of R-FSGS.
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Toledo K, Pérez-Sáez MJ, Navarro MD, Ortega R, Redondo MD, Agüera ML, Rodríguez-Benot A, Aljama P. Impact of recurrent glomerulonephritis on renal graft survival. Transplant Proc 2012; 43:2182-6. [PMID: 21839228 DOI: 10.1016/j.transproceed.2011.05.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Glomerular disease causes graft loss in the intermediate and long term, especially recurrent primary renal disease, negatively impacting graft survival. Thus, it must be considered a differential diagnosis in the evaluation of chronic graft dysfunction. METHODS The objectives of our study were to compare the impacts of primary glomerular disease on graft survival and association with interstitial fibrosis/tubular atrophy (IFTA) or transplant glomerulopathy. We examined the influence of the relapse of glomerulonephritis (GN) on renal graft survival in a retrospective study of 1057 patients undergoing renal transplantations between March 1981 and October 2009. Among this group, 128 patients were diagnosed with pretransplant GN by renal biopsy. We examined graft survival on recurrence compared with IFTA and transplant glomerulopathy using Kaplan-Meier analysis. RESULTS We analyzed a cohort of 128 patients who were diagnosed with pretransplant GN by renal biopsy, including 28.9% (37) of whom were males. The mean age was 42.04 ± 13.82 years. The most frequent type was immunoglobulin A GN (IgAGN; 31.3%), followed by membranoproliferative GN (MPGN; 28.9%), rapidly progressive GN (RPGN; 16.4%), focal-segmental GN (FSGN; 13.3%), membranous GN (9.4%), and minimal change GN; (0.8%). Among the 16 cases (12.5%) of GN recurrence; MPGN was associated most frequently (n = 10, 28.9%), followed by FSGN (n = 4, 23.5%), RPGN (n = 1, 4.8%), and IgAGN (n = 1, 2.5%). We noted that 11.8% of subjects to be positive for hepatitis C virus; while 3.9% were hepatitis B virus(HBV)-positive. We observed no differences in hepatic serology between patients who experienced recurrence (HBV 6.3% vs hepatitis C virus [HCV] 18.8%) compared with IFTA (HBV 3.1% vs HCV 9.4%). Fifty-one patients (39.8%) were biopsied after transplantation due to impaired renal function: there were recurrences of GN in 12.5% (n = 16), IFTA in 25% (n = 32), and transplant glomerulopathy in 2.3% (n = 3) cases. The average graft survival in our cohort was 8.36 ± 0.59 years. The median patient survival among those who experienced a recurrence was 8.36 ± 1.79 years; 7.19 ± 1.01 years in IFTA patients; and 3.31 ± 0.91 years in patients with transplant glomerulopathy (log-rank P = .06). Upon multivariate analysis, recurrence of GN was not an independent predictor of renal loss. CONCLUSIONS MPGN was the type of GN that recurred most frequently followed by FSGN. No differences in graft survival were noted between long-term recurrence of GN and other causes of chronic graft dysfunction. The recurrence of primary disease did not worsen the renal graft prognosis versus other causes of chronic graft dysfunction.
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Affiliation(s)
- K Toledo
- Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain.
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21
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Garaix F. [Characteristics of the pediatric patient before transplantation]. Nephrol Ther 2011; 7:587-91. [PMID: 22118787 DOI: 10.1016/j.nephro.2011.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Renal transplantation is the treatment of choice for end-stage renal disease during childhood. In France, access to transplantation is good and even better for children than for adults. Few contraindications, mostly temporary, might delay the transplantation. The different pathologies leading to end-stage renal disease in children require a specific pre-transplantation examination and a careful choice of the type of donor. Prevalence of disease recurrence is greater in children than in adults. It is one of the most frequent post-transplantation complications and contributes to the increase in patient morbidity and graft failure in our pediatrics cohorts. Kidney donations in North America are for the most part live-donation, which is not the case in France. However, thanks to parent's commitment, the ratio of living donor is currently increasing in France.
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Affiliation(s)
- Florentine Garaix
- Unité de néphrologie pédiatrique, Service de pédiatrie multidisciplinaire, CHU Timone-Enfants, 13005 Marseille, France.
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22
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Current world literature. Curr Opin Organ Transplant 2011; 16:650-60. [PMID: 22068023 DOI: 10.1097/mot.0b013e32834dd969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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23
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Okamoto M, Koshino K, Sakai K, Nobori S, Matsuyama M, Ushigome H, Okajima H, Masuzawa N, Yoshimura N. A case of recurrent focal segmental glomerulosclerosis (FSGS) involving massive proteinuria (>50 g/day) immediately after renal transplantation. Clin Transplant 2011; 25 Suppl 23:53-8. [PMID: 21623916 DOI: 10.1111/j.1399-0012.2011.01455.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A 15-yr-old girl with end-stage kidney disease caused by primary focal segmental glomerulosclerosis (FSGS) underwent a living-related donor kidney transplantation. The allograft functioned well immediately after reperfusion, but massive proteinuria exceeding 50 g/d appeared on day 3. Treatment with rituximab and plasma exchange (PE) successfully decreased the proteinuria to 10 g/d. A biopsy specimen on day 30 showed no segmental glomerulosclerosis but partial interstitial infiltration of inflammatory cells. An increased number of podocytes showed intracytoplasmic vacuolization, and an electron micrograph showed diffuse mild subendothelial edema and foot process effacement. The podocytes were hypertrophied but were not detached from the basement membrane. As the therapies used to reduce the patient's proteinuria were having a limited effect, intravenous steroid pulse therapy followed by low-density lipoprotein apheresis was performed. A biopsy specimen taken on day 120 showed no segmental glomerulosclerosis. Thrombus formation in one glomerulus and packed lymphocytes in the capillary loop of another glomerulus were detected. The patient's clinical course was compatible with FSGS recurrence. Although the early pathological changes were not typical of FSGS, they might be indicative of the primary lesion that subsequently progresses to typical FSGS.
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Affiliation(s)
- Masahiko Okamoto
- Department of Organ Interaction Research Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-Ku, Kyoto, Japan.
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Phenotypic evaluation of B-cell subsets after rituximab for treatment of acute renal allograft rejection in pediatric recipients. Transplantation 2011; 91:1010-8. [PMID: 21403590 DOI: 10.1097/tp.0b013e318213df29] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recently published pediatric trial of Rituximab for the treatment of CD20+ acute renal allograft rejection (AR) demonstrated transient depletion of circulating/intragraft B cells (Zarkhin et al., Am J Transplant 2008; 8: 2607). In this study, we have evaluated phenotypic definition of circulating B-cell subsets before and after standard of care and B-cell depletional AR therapies. METHODS We assessed peripheral B cells by flow cytometry at the time of AR and after AR treatment in 35 pediatric renal transplant recipients: 17 patients with AR who received Rituximab (R-AR; n=11) or steroid pulsing (S-AR; n=6), 18 stable patients with stable graft function with (iSTA; n=10) or without interval infection (hSTA; n=8), and 3 healthy volunteers. RESULTS Infections increased memory (P=0.02) and CD19+/CD27⁻/IgD⁻ double negative (DN) B cells (P=0.02) and decreased naive B cells (P=0.01) in iSTA group compared to hSTA patients. Decrease in naive/memory B cells ratio at AR was observed compared with hSTA patients (P=0.01). One year after AR treatment, S-AR patients had persistently lower naive/memory B-cell ratio (P=0.01) and higher DN B cells (P=0.0001) than hSTA patients, whereas after R-AR treatment naive/memory B-cell ratio (P=0.6) and DN B cells (P=0.13) recovered to levels of hSTA patients. R-AR patients with sustained AR resolution (n=8) had trend toward better graft survival (P=0.06) and higher naive B cells (P=0.004) than R-AR relapsers (n=3). CONCLUSIONS Increase in circulating memory B cells was seen in pediatric patients at AR. B cells persist as memory after S-AR treatment, whereas Rituximab resulted in repopulation of mostly naive B cells. The heterogeneity in B-cells reconstitution after rejection therapies deserves further investigation as a possible means to follow the clinical and immunologic outcomes of graft rejection.
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