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Udomkarnjananun S, Schagen MR, Hesselink DA. A review of landmark studies on maintenance immunosuppressive regimens in kidney transplantation. ASIAN BIOMED 2024; 18:92-108. [PMID: 39175954 PMCID: PMC11338012 DOI: 10.2478/abm-2024-0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
Immunosuppressive medications play a pivotal role in kidney transplantation, and the calcineurin inhibitors (CNIs), including cyclosporine A (CsA) and tacrolimus (TAC), are considered as the backbone of maintenance immunosuppressive regimens. Since the introduction of CNIs in kidney transplantation, the incidence of acute rejection has decreased, and allograft survival has improved significantly. However, CNI nephrotoxicity has been a major concern, believed to heavily impact long-term allograft survival and function. To address this concern, several CNI-sparing regimens were developed and studied in randomized, controlled, clinical trials, aiming to reduce CNI exposure and preserve long-term allograft function. However, more recent information has revealed that CNI nephrotoxicity is not the primary cause of late allograft failure, and its histopathology is neither specific nor pathognomonic. In this review, we discuss the historical development of maintenance immunosuppressive regimens in kidney transplantation, covering the early era of transplantation, the CNI-sparing era, and the current era where the alloimmune response, rather than CNI nephrotoxicity, appears to be the major contributor to late allograft failure. Our goal is to provide a chronological overview of the development of maintenance immunosuppressive regimens and summarize the most recent information for clinicians caring for kidney transplant recipients (KTRs).
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Affiliation(s)
- Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok10330, Thailand
- Excellence Center for Solid Organ Transplantation, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok10330, Thailand
- Renal Immunology and Transplantation Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok10330, Thailand
- Center of Excellence on Translational Research in Inflammation and Immunology (CETRII), Department of Microbiology, Chulalongkorn University, Bangkok10330, Thailand
| | - Maaike R. Schagen
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam3000, The Netherlands
| | - Dennis A. Hesselink
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam3000, The Netherlands
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2
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Jung S, Lee S, Jeon H, Kim MH, Lee JS, Chang SH, Kim HJ, Jang H. Successful management of proteinuria in recurrent immunoglobulin A nephropathy after deceased donor kidney transplantation: A case report. Medicine (Baltimore) 2024; 103:e36990. [PMID: 38241588 PMCID: PMC10798750 DOI: 10.1097/md.0000000000036990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/26/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Immunoglobulin A nephropathy (IgAN) is the most common type of primary glomerulonephritis, and recurrent IgAN is common after kidney transplantation (KT). Owing to the differences in various biopsy protocols and follow-ups in each study, the recurrence rate varies from 9.7% to 46%. Although the relapse rates are high, there is no definitive treatment for IgAN recurrence. METHODS We present a case of successful management of proteinuria in recurrent IgAN after deceased donor KT. A 60-year-old man diagnosed with IgAN 20 years prior, who progressed to end-stage renal disease, underwent deceased donor KT 5 years prior and was admitted to our hospital with progressively increasing proteinuria. RESULTS The pathological examination of the kidney biopsy specimen revealed recurrent IgAN. High-dose steroid treatment was initiated, and the patient was discharged while maintaining steroid treatment. However, outpatient follow-up showed that proteinuria did not decrease while steroids were maintained. Therefore, an angiotensin receptor blocker was administered after explaining its benefits to the patient. After the addition of angiotensin receptor blocker, proteinuria continued to decrease. CONCLUSION This case report highlights the importance of using renin-angiotensin system inhibitors with supportive care in cases of suspected of recurrent IgAN after KT. It also emphasizes the need to prescribe renin-angiotensin system inhibitors when steroid therapy is unsuccessful in cases of recurrent IgAN after KT.
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Affiliation(s)
- Sehyun Jung
- Division of Nephrology, Department of Internal Medicine, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Seunghye Lee
- Division of Nephrology, Department of Internal Medicine, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Hyejin Jeon
- Division of Nephrology, Department of Internal Medicine, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Min Hye Kim
- Department of Pathology, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Jong Sil Lee
- Department of Pathology, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, South Korea
| | - Se-Ho Chang
- Division of Nephrology, Department of Internal Medicine, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, South Korea
| | - Hyun-Jung Kim
- Division of Nephrology, Department of Internal Medicine, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, South Korea
| | - Hani Jang
- Division of Nephrology, Department of Internal Medicine, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
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Sani A, Movalled K, Kamanaj A, Hassannezhad S, Hosseinifard H, Rashidi Y, Ghojazadeh M, Niknafs B, Zununi Vahed S, Ardalan M. Interventions for decreasing the risk of recurrent IgA nephropathy: A systematic review and meta-analysis. Transpl Immunol 2023; 80:101878. [PMID: 37348769 DOI: 10.1016/j.trim.2023.101878] [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: 08/21/2022] [Revised: 03/28/2023] [Accepted: 06/19/2023] [Indexed: 06/24/2023]
Abstract
Recurrent IgA nephropathy (rIgAN) is an important cause of kidney allograft loss. Till now, no proven strategies have been confirmed to prevent/decrease the rIgAN. Here, a systematic review and meta-analysis were performed on the available interventions impacting rIgAN. PubMed, Embase, Web of sciences, ProQuest, and Cochrane library databases along with Google Scholar were searched for articles evaluating the rIgAN after kidney transplantation (up to 23 February 2023). The main inclusion criteria were kidney transplantation because of primary IgAN and articles studying the rate of the rIgAN based on different therapeutic interventions to find their effects on the disease recurrence. Based on our criteria, 11 papers were included in this systematic review, two of which pleased the criteria for the meta-analysis. Meta-analysis showed that the risk of the rIgAN in the steroid-free group was 3.33 times more than that of the steroid-receiving group (Pooled Hazard Ratio = 3.33, 95% CI 0.60 to18.33, Z-value = 1.38, p-value = 0.16). Steroid-free therapy increases the risk of rIgAN in kidney transplant recipients with primary IgAN. High-quality trials with large sample sizes studies are needed to confirm the impact of the steroids on decreasing the rate of the rIgAN.
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Affiliation(s)
- Anis Sani
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kobra Movalled
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Arash Kamanaj
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sina Hassannezhad
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran; Research Center for Evidence-Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hossein Hosseinifard
- Research Center for Evidence-Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Yasin Rashidi
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran; Kidney Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Morteza Ghojazadeh
- Research Center for Evidence-Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Bahram Niknafs
- Kidney Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sepideh Zununi Vahed
- Kidney Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Mohammadreza Ardalan
- Kidney Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
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Frutos MÁ, Crespo M, Valentín MDLO, Alonso-Melgar Á, Alonso J, Fernández C, García-Erauzkin G, González E, González-Rinne AM, Guirado L, Gutiérrez-Dalmau A, Huguet J, Moral JLLD, Musquera M, Paredes D, Redondo D, Revuelta I, Hofstadt CJVD, Alcaraz A, Alonso-Hernández Á, Alonso M, Bernabeu P, Bernal G, Breda A, Cabello M, Caro-Oleas JL, Cid J, Diekmann F, Espinosa L, Facundo C, García M, Gil-Vernet S, Lozano M, Mahillo B, Martínez MJ, Miranda B, Oppenheimer F, Palou E, Pérez-Saez MJ, Peri L, Rodríguez O, Santiago C, Tabernero G, Hernández D, Domínguez-Gil B, Pascual J. Recommendations for living donor kidney transplantation. Nefrologia 2022; 42 Suppl 2:5-132. [PMID: 36503720 DOI: 10.1016/j.nefroe.2022.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/26/2021] [Indexed: 06/17/2023] Open
Abstract
This Guide for Living Donor Kidney Transplantation (LDKT) has been prepared with the sponsorship of the Spanish Society of Nephrology (SEN), the Spanish Transplant Society (SET), and the Spanish National Transplant Organization (ONT). It updates evidence to offer the best chronic renal failure treatment when a potential living donor is available. The core aim of this Guide is to supply clinicians who evaluate living donors and transplant recipients with the best decision-making tools, to optimise their outcomes. Moreover, the role of living donors in the current KT context should recover the level of importance it had until recently. To this end the new forms of incompatible HLA and/or ABO donation, as well as the paired donation which is possible in several hospitals with experience in LDKT, offer additional ways to treat renal patients with an incompatible donor. Good results in terms of patient and graft survival have expanded the range of circumstances under which living renal donors are accepted. Older donors are now accepted, as are others with factors that affect the decision, such as a borderline clinical history or alterations, which when evaluated may lead to an additional number of transplantations. This Guide does not forget that LDKT may lead to risk for the donor. Pre-donation evaluation has to centre on the problems which may arise over the short or long-term, and these have to be described to the potential donor so that they are able take them into account. Experience over recent years has led to progress in risk analysis, to protect donors' health. This aspect always has to be taken into account by LDKT programmes when evaluating potential donors. Finally, this Guide has been designed to aid decision-making, with recommendations and suggestions when uncertainties arise in pre-donation studies. Its overarching aim is to ensure that informed consent is based on high quality studies and information supplied to donors and recipients, offering the strongest possible guarantees.
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Affiliation(s)
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | | | | | - Juana Alonso
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | | | - Esther González
- Nephrology Department, Hospital Universitario 12 Octubre, Spain
| | | | - Lluis Guirado
- Nephrology Department, Fundacio Puigvert, Barcelona, Spain
| | | | - Jorge Huguet
- RT Surgical Team, Fundació Puigvert, Barcelona, Spain
| | | | - Mireia Musquera
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | - David Paredes
- Donation and Transplantation Coordination Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Ignacio Revuelta
- Nephrology and RT Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Antonio Alcaraz
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Manuel Alonso
- Regional Transplantation Coordination, Seville, Spain
| | | | - Gabriel Bernal
- Nephrology Department, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Alberto Breda
- RT Surgical Team, Fundació Puigvert, Barcelona, Spain
| | - Mercedes Cabello
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | - Joan Cid
- Apheresis and Cell Therapy Unit, Haemotherapy and Haemostasis Department, Hospital Clinic Universitari, Barcelona, Spain
| | - Fritz Diekmann
- Nephrology and RT Department, Hospital Clinic Universitari, Barcelona, Spain
| | - Laura Espinosa
- Paediatric Nephrology Department, Hospital La Paz, Madrid, Spain
| | - Carme Facundo
- Nephrology Department, Fundacio Puigvert, Barcelona, Spain
| | | | | | - Miquel Lozano
- Apheresis and Cell Therapy Unit, Haemotherapy and Haemostasis Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | | | | | | | - Eduard Palou
- Immunology Department, Hospital Clinic i Universitari, Barcelona, Spain
| | | | - Lluis Peri
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | | | | | - Domingo Hernández
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | - Julio Pascual
- Nephrology Department, Hospital del Mar, Barcelona, Spain.
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Recomendaciones para el trasplante renal de donante vivo. Nefrologia 2022. [DOI: 10.1016/j.nefro.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Kizilbash SJ, Jensen CJ, Kouri AM, Balani SS, Chavers B. Steroid avoidance/withdrawal and maintenance immunosuppression in pediatric kidney transplantation. Pediatr Transplant 2022; 26:e14189. [PMID: 34786800 DOI: 10.1111/petr.14189] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/30/2021] [Accepted: 10/06/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Corticosteroids have been an integral part of maintenance immunosuppression for pediatric kidney transplantation. However, prolonged steroid therapy is associated with significant toxicities resulting in several SW/avoidance strategies in recent years. METHOD/OBJECTIVE This comprehensive review aims to discuss steroid-related toxicities and the safety, efficacy, and benefit of steroid avoidance/withdrawal immunosuppression in pediatric kidney transplant recipients. RESULTS Initial studies of SW/avoidance conducted in the setting of CSA and AZA showed an increased incidence of AR but no increase in graft loss or mortality with SW/avoidance maintenance immunosuppression. Studies performed under modern immunosuppression (induction therapy, Tac, and MMF) show no significant increase in AR or graft loss with SW/avoidance immunosuppression. Furthermore, SW/avoidance immunosuppression is associated with significant improvement in growth, BMI, BP control, and lipid profile in pediatric kidney transplant recipients. Despite these data, SW/avoidance remains controversial, and only 40% of pediatric kidney transplant recipients in the United States are currently on SW/avoidance maintenance immunosuppression. CONCLUSION SW/avoidance maintenance immunosuppression is safe and associated with fewer side effects compared with steroid-inclusive maintenance immunosuppression in pediatric kidney transplant recipients.
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Affiliation(s)
- Sarah J Kizilbash
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Chelsey J Jensen
- Solid Organ Transplant, University of Minnesota, Minneapolis, Minnesota, USA
| | - Anne M Kouri
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shanthi S Balani
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Blanche Chavers
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
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Long-Term Outcomes of Kidney Transplant Recipients with Glomerulonephritides by Induction Type and Steroid Avoidance. TRANSPLANTOLOGY 2022. [DOI: 10.3390/transplantology3010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Kidney transplant programs have different approaches to induction immunosuppression, and conflicting data exist on the role of steroid maintenance in recipients with glomerulonephritis (GN). GN patients are unique because of a higher risk for immune system exhaustion due to prior exposure to immunosuppressants to treat their GN; this raises questions regarding the optimal immunosuppression needed for transplant success and reduction of complications. We sought to assess the effect of induction type and steroid maintenance on the recipient and kidney graft survival in those with IgA nephropathy (IgAN), systemic lupus erythematosus related GN (SLE), small-vessel vasculitis (SVV), and anti-glomerular basement membrane disease (anti-GBM). We analyzed the Scientific Registry of Transplant Recipients (SRTR) database for adult, primary kidney recipients with the above glomerulonephritides through September 2019. Kaplan–Meier curves were generated to examine kidney graft and recipient survival. We used multivariable Cox proportional hazard models to investigate the impact of induction type and steroid maintenance in each group separately. Our study included 9176 IgAN, 5355 SLE, 1189 SVV, and 660 anti-GBM recipients. Neither induction type nor steroid maintenance therapy influenced recipient or death-censored graft survival in this cohort of recipients. Our findings provide an opportunity for recipients with a history of one of the studied glomerulonephritides to receive a more tailored immunosuppression regimen, considering their previous exposure to immunosuppressants.
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Adebiyi O, Umukoro P, Sharfuddin A, Taber T, Chen J, Lane KA, Li X, Goggins W, Yaqub MS. Patient and Graft Survival Outcomes During 2 Eras of Immunosuppression Protocols in Kidney Transplantation: Indiana University Retrospective Cohort Experience. Transplant Proc 2021; 53:2841-2852. [PMID: 34774307 DOI: 10.1016/j.transproceed.2021.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 09/24/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Since 1964 when Indiana University performed its first kidney transplant, immunosuppression protocol was steroid-based until 2004 when steroid-free immunosuppression protocol was adopted. We describe clinical outcomes on our patients administered early steroid withdrawal (ESW) protocol (5 days) compared with our historical cohort (HC), who were on chronic steroid-based immunosuppression. METHODS We performed a retrospective study evaluating kidney transplant recipients between 1993 and 2003 (HC, n = 1689) and between 2005 and 2016 (ESW cohort, n = 2097) at the Indiana University program, with a median follow-up of 10.5 years and 6.1 years, respectively. Primary outcomes were patient and death-censored graft survival at 1, 3, and 5 years in both study cohorts. Secondary outcomes were 1-year rates of biopsy-proven acute rejection; graft function at 1, 3, and 5 years; and risk of post-transplant infection (BK virus and cytomegalovirus) in the ESW cohort. Cox proportional model and Kaplan-Meier estimates were used to estimate survival probabilities. Fisher exact tests were used to compare episodes of acute rejection in the ESW cohort. RESULTS No difference was observed in patient survival between the ESW and HC cohorts (P = .13). Compared with the ESW cohort, death-censored graft survival was significantly worse in the HC (5 year: 86.4% vs 90.6%, log-rank P < .001). One-year acute rejection reported in the ESW cohort alone was 15.7% and significantly worse in Black patients and younger patients (P < .05). CONCLUSIONS In this sizeable single-center cohort study with significant ethnic diversity, ESW is a viable alternative to steroid-based immunosuppression protocol in kidney transplant recipients.
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Affiliation(s)
| | - Peter Umukoro
- Indiana University Health Transplant, Indianapolis, Indiana
| | | | - Tim Taber
- Indiana University Health Transplant, Indianapolis, Indiana
| | - Jeanne Chen
- Indiana University Health Transplant, Indianapolis, Indiana
| | - Kathleen A Lane
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis Indiana
| | - Xiaochun Li
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis Indiana
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Kurian SM, Spierling Bagsic SR, Case J, Barrick BL, Schaffer R, Rice JC, Marsh CL. UNOS/OPTN Data-guided Assessment of Focal Segmental Glomerulosclerosis After Kidney Transplantation and Evaluation of Immunosuppressive Protocols in a Steroid-free Center. Transplant Direct 2021; 7:e738. [PMID: 34386576 PMCID: PMC8354624 DOI: 10.1097/txd.0000000000001196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 05/14/2021] [Accepted: 05/26/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Focal segmental glomerulosclerosis (FSGS) is a common recurrent glomerulopathy associated with graft loss and patient survival after kidney transplantation (KT). However, its natural history, clinical predictors, and treatment response are still poorly understood. Steroid withdrawal regimens in KT have been associated with improvements in cardiovascular risk and patient outcomes. The Scripps Center for Organ Transplantation (SCOT) uses a rapid low-dose steroid withdrawal immunosuppression (IS) protocol for KT maintenance. METHODS We assessed the impact of our protocol on FSGS disease recurrence over a 10-y period to reassess our steroid and IS protocols and to evaluate if our patient outcomes diverge from published data. We compared 4 groups: steroids always, steroid free, steroid switch on, and steroid weaned off. We used IS and induction-matched retrospective data from United Network for Organ Sharing (UNOS) to investigate patient and graft survival for FSGS at SCOT. RESULTS Our analysis results differ from earlier studies showing that FSGS was associated with a higher risk of graft loss, perhaps because of selection of a UNOS data set filtered to match the SCOT IS protocol for making direct comparisons. Overall outcomes of graft failure and recipient death did not differ between SCOT patients and steroid-free transplant patient data from the UNOS data for FSGS. SCOT recurrence rate for FSGS was 7.5%, which was lower than in most published single-center studies. CONCLUSIONS Based on our results, we believe that it is safe to continue the steroid avoidance protocols at SCOT and the steroid-free protocol may not be detrimental when the adverse effects and toxicities associated with steroid use are considered.
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Affiliation(s)
- Sunil M. Kurian
- Division of Organ Transplant, Scripps Center for Organ Transplantation, Scripps Clinic & Green Hospital, La Jolla, CA
- Scripps Clinic Bio-Repository and Bio-Informatics Core, Scripps Clinic & Green Hospital, La Jolla, CA
| | | | - Jamie Case
- Division of Organ Transplant, Scripps Center for Organ Transplantation, Scripps Clinic & Green Hospital, La Jolla, CA
- Scripps Clinic Bio-Repository and Bio-Informatics Core, Scripps Clinic & Green Hospital, La Jolla, CA
| | - Bethany L. Barrick
- Division of Organ Transplant, Scripps Center for Organ Transplantation, Scripps Clinic & Green Hospital, La Jolla, CA
- Scripps Clinic Bio-Repository and Bio-Informatics Core, Scripps Clinic & Green Hospital, La Jolla, CA
| | - Randolph Schaffer
- Division of Organ Transplant, Scripps Center for Organ Transplantation, Scripps Clinic & Green Hospital, La Jolla, CA
| | - James C. Rice
- Division of Organ Transplant, Scripps Center for Organ Transplantation, Scripps Clinic & Green Hospital, La Jolla, CA
| | - Christopher L. Marsh
- Division of Organ Transplant, Scripps Center for Organ Transplantation, Scripps Clinic & Green Hospital, La Jolla, CA
- Scripps Clinic Bio-Repository and Bio-Informatics Core, Scripps Clinic & Green Hospital, La Jolla, CA
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Okihara M, Takeuchi H, Kikuchi Y, Akashi I, Kihara Y, Konno O, Iwamoto H, Oda T, Tanaka S, Unezaki S, Hirano T. Individual Lymphocyte Sensitivity to Steroids as a Reliable Biomarker for Clinical Outcome after Steroid Withdrawal in Japanese Renal Transplantation. J Clin Med 2021; 10:jcm10081670. [PMID: 33924724 PMCID: PMC8070672 DOI: 10.3390/jcm10081670] [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: 03/09/2021] [Revised: 04/09/2021] [Accepted: 04/10/2021] [Indexed: 11/17/2022] Open
Abstract
Recently, steroid reduction/withdrawal regimens have been attempted to minimize the side effects of steroids in renal transplantation. However, some recipients have experienced an increase/resumption of steroid administrations and acute graft rejection (AR). Therefore, we investigated the relationship between the individual lymphocyte sensitivity to steroids and the clinical outcome after steroid reduction/withdrawal. We cultured peripheral blood mononuclear cells (PBMCs) isolated from 24 recipients with concanavalin A (Con A) in the presence of methylprednisolone (MPSL) or cortisol (COR) for four days, and the 50% of PBMC proliferation (IC50) values and the PBMC sensitivity to steroids were calculated. Regarding the experience of steroid increase/resumption and incidence of AR within one year of steroid reduction/withdrawal, the IC50 values of these drugs before transplantation in the clinical event group were significantly higher than those in the event-free group. The cumulative incidence of steroid increase/resumption and AR in the PBMC high-sensitivity groups to these drugs before transplantation were significantly lower than those in the low-sensitivity groups. These observations suggested that an individual’s lymphocyte sensitivity to steroids could be a reliable biomarker to predict the clinical outcome after steroid reduction/withdrawal and to select the patients whose dose of steroids can be decreased and/or withdrawn after transplantation.
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Affiliation(s)
- Masaaki Okihara
- Department of Kidney Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan; (M.O.); (I.A.); (Y.K.); (O.K.); (H.I.)
| | - Hironori Takeuchi
- Department of Pharmacy, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan;
| | - Yukiko Kikuchi
- Department of Practical Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan; (Y.K.); (S.U.)
| | - Isao Akashi
- Department of Kidney Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan; (M.O.); (I.A.); (Y.K.); (O.K.); (H.I.)
| | - Yu Kihara
- Department of Kidney Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan; (M.O.); (I.A.); (Y.K.); (O.K.); (H.I.)
| | - Osamu Konno
- Department of Kidney Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan; (M.O.); (I.A.); (Y.K.); (O.K.); (H.I.)
| | - Hitoshi Iwamoto
- Department of Kidney Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan; (M.O.); (I.A.); (Y.K.); (O.K.); (H.I.)
| | - Takashi Oda
- Department of Nephrology, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan;
| | - Sachiko Tanaka
- Clinical Pharmacology, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan;
| | - Sakae Unezaki
- Department of Practical Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan; (Y.K.); (S.U.)
| | - Toshihiko Hirano
- Clinical Pharmacology, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan;
- Correspondence: ; Tel.: +81-042-676-5794
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Kurian SM, Bagsic SRS, Case J, Barrick BL, Schaffer R, Rice JC, Marsh CL. UNOS/OPTN data guided assessment of IgA nephropathy recurrence after kidney transplantation and evaluation of immunosuppressive protocols in a steroid free center. TRANSPLANTATION REPORTS 2020. [DOI: 10.1016/j.tpr.2020.100063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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12
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Singh T, Astor BC, Zhong W, Mandelbrot DA, Maursetter L, Panzer SE. The association of acute rejection vs recurrent glomerular disease with graft outcomes after kidney transplantation. Clin Transplant 2019; 33:e13738. [PMID: 31630440 DOI: 10.1111/ctr.13738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 07/29/2019] [Accepted: 10/10/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND It has been shown that glomerulonephritis (GN) recurrence affects graft survival more than acute rejection. Thus, we assessed allograft survival after biopsy-confirmed diagnosis of acute rejection or recurrent GN in current era of immunosuppression. METHODS Allograft survival following a biopsy diagnosis of acute rejection or recurrent GN was determined in adult kidney transplant recipients from 1994 to 2013. A total of 306 patients (35%) with IgA, 298 (35%) with FSGS, 177 (21%) with lupus nephritis, and 81 (9%) with membranous nephropathy were followed for a median of 6.3 years. RESULTS Among the 862 transplant recipients with primary GN, allograft loss was similar following a biopsy diagnosis of acute rejection or recurrent glomerular disease (11.5 vs 14.2/100 person-years, P = .15). Differences in allograft survival emerged after 2.5 years following recurrent disease, with significantly higher graft failure in patients with FSGS, MN, or LN compared with IgA after recurrence of disease (16.7 vs 7.5/100 person-years, P = .05). The advantage in allograft survival for IgA patients did not achieve significance after acute rejection (P = .10 for IgA vs FSGS, MN, and LN). CONCLUSIONS Allograft survival was similar after disease recurrence or acute rejection after kidney transplant in patients with ESRD due to GN.
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Affiliation(s)
- Tripti Singh
- Department of Medicine, Division of Nephrology, University of Wisconsin-Madison Hospital and Clinics, Madison, WI, USA
| | - Brad C Astor
- Department of Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin-Madison Hospital and Clinics, Madison, WI, USA
| | - Didier A Mandelbrot
- Department of Medicine, Division of Nephrology, University of Wisconsin-Madison Hospital and Clinics, Madison, WI, USA
| | - Laura Maursetter
- Department of Medicine, Division of Nephrology, University of Wisconsin-Madison Hospital and Clinics, Madison, WI, USA
| | - Sarah E Panzer
- Department of Medicine, Division of Nephrology, University of Wisconsin-Madison Hospital and Clinics, Madison, WI, USA
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13
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Barbour S, Djurdjev O, Gill JS, Dong JJ, Gill J. A propensity score matched analysis shows no adverse effect of early steroid withdrawal in non-diabetic kidney transplant recipients with and without glomerulonephritis. Kidney Int 2019; 96:460-469. [DOI: 10.1016/j.kint.2019.02.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 01/25/2019] [Accepted: 02/21/2019] [Indexed: 10/27/2022]
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14
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Immunosuppression after renal transplantation. MEMO-MAGAZINE OF EUROPEAN MEDICAL ONCOLOGY 2019. [DOI: 10.1007/s12254-019-0507-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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15
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Zhang J, Qiu J, Chen GD, Wang CX, Wang C, Yu SJ, Chen LZ. Etiological analysis of graft dysfunction following living kidney transplantation: a report of 366 biopsies. Ren Fail 2018; 40:219-225. [PMID: 29619905 PMCID: PMC6014316 DOI: 10.1080/0886022x.2018.1455592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/03/2018] [Accepted: 03/15/2018] [Indexed: 11/18/2022] Open
Abstract
AIM The aim of this study is to investigate the clinical features of graft dysfunction following living kidney transplantation and to assess its causes. METHODS We retrospectively analyzed a series of 366 living kidney transplantation indication biopsies with a clear etiology and diagnosis from July 2003 to June 2016 at our center. The classifications and diagnoses were performed based on clinical and pathological characteristics. All biopsies were evaluated according to the Banff 2007 schema. RESULTS Acute rejection (AR) occurred in 85 cases (22.0%), chronic rejection (CR) in 62 cases (16.1%), borderline rejection (BR) in 12 cases (3.1%), calcineurin inhibitor (CNI) toxicity damage in 41 cases (10.6%), BK virus-associated nephropathy (BKVAN) in 43 cases (11.1%), de novo or recurrent renal diseases in 134 cases (34.7%), and other causes in nine cases (2.3%); additionally, 20 cases had two simultaneous causes. The 80 cases with IgA nephropathy (IgAN) had the highest incidence (59.7%) of de novo or recurrent renal diseases. After a mean ± SD follow up of 3.7 ± 2.3 years, the 5-year graft cumulative survival rates of AR, CR, CNI toxicity, BKVAN, and de novo or recurrent renal diseases were 60.1%, 31.2%, 66.6%, 66.9%, and 67.1%, respectively. CONCLUSIONS A biopsy is helpful for the diagnosis of graft dysfunction. De novo or recurrent renal disease, represented by IgAN, is a major cause of graft dysfunction following living kidney transplantation.
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Affiliation(s)
- Jin Zhang
- Department of Organ Transplant, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jiang Qiu
- Department of Organ Transplant, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Guo-Dong Chen
- Department of Organ Transplant, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Chang-Xi Wang
- Department of Organ Transplant, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Chang Wang
- Department of Organ Transplant, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shuang-Jin Yu
- Department of Organ Transplant, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Li-Zhong Chen
- Department of Organ Transplant, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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16
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Piotti G, Gandolfini I, Palmisano A, Maggiore U. Metabolic risk profile in kidney transplant candidates and recipients. Nephrol Dial Transplant 2018; 34:388-400. [DOI: 10.1093/ndt/gfy151] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 05/01/2018] [Indexed: 12/30/2022] Open
Affiliation(s)
- Giovanni Piotti
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Ilaria Gandolfini
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Alessandra Palmisano
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Umberto Maggiore
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
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17
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Abstract
PURPOSE OF REVIEW With improving short-term kidney transplant outcomes, recurrent glomerular disease is being increasingly recognized as an important cause of chronic allograft failure. Further understanding of the risks and pathogenesis of recurrent glomerular disease enable informed transplant decisions, along with the development of preventive and treatment strategies. RECENT FINDINGS Multiple observational studies have highlighted differences in rates and outcomes for various recurrent glomerular diseases, although these rates have not markedly improved over the last decade. Emerging evidence supports use of rituximab to treat recurrent primary membranous nephropathy and possibly focal segmental glomerulosclerosis (FSGS), whereas eculizumab is effective in glomerular diseases associated with complement dysregulation [C3 glomerulopathy (C3G) and atypical hemolytic uremic syndrome (aHUS)]. SUMMARY Despite the potential for recurrence in the allograft, transplant remains the optimal therapy for patients with advanced chronic kidney disease (CKD) secondary to primary glomerular disease. Biomarkers and therapeutic options necessitate accurate pretransplant diagnoses with opportunities for improved surveillance and treatment of recurrent glomerular disease posttransplant.
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18
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Di Vico MC, Messina M, Fop F, Barreca A, Segoloni GP, Biancone L. Recurrent IgA nephropathy after renal transplantation and steroid withdrawal. Clin Transplant 2018; 32:e13207. [PMID: 29345747 DOI: 10.1111/ctr.13207] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2018] [Indexed: 01/19/2023]
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary glomerulonephritis; the reported recurrence rate of IgAN after renal transplantation is as high as 13%-50%. The impact of immunosuppressive therapy and steroid withdrawal on the risk of recurrence of IgAN is still under debate. We performed a retrospective single-center study, selecting 123 kidney transplants (rtx) in 120 patients, between January 1995 and December 2012, with IgAN on the native kidney. In 51 of 123 transplants, at least one post-transplantation biopsy for clinical indication was performed; in 28 of 51 transplants, IgAN recurrence (IgANr) was demonstrated. This group (G1; N = 28) was compared with a group without IgANr (G2; N = 23). In our study, clinically evident IgANr rate was 54.9% (28/51) on biopsied patients. At discharge, the use of the immunosuppressant drugs (tacrolimus, cyclosporine A, mycophenolate mofetil, azathioprine, mTor inhibitors) was not associated with an increased risk of IgANr (P = NS). At discharge, all patients were steroid treated. Neither the use of tacrolimus, mycophenolate mofetil, nor mTor inhibitors (mTori) at biopsy time were associated with IgANr. However, IgANr was significantly higher in patients who experienced steroid withdrawal at any post-transplantation time (OR 7.7 P = .03). The median time to recurrence after steroid withdrawal was 59 months (min 4.18, max 113.2).
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Affiliation(s)
- Maria Cristina Di Vico
- Department of Medical Sciences, Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Maria Messina
- Department of Medical Sciences, Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Fabrizio Fop
- Department of Medical Sciences, Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Antonella Barreca
- Division of Pathology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Giuseppe Paolo Segoloni
- Department of Medical Sciences, Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Luigi Biancone
- Department of Medical Sciences, Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
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19
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Recurrent and de novo glomerulonephritis following renal transplantation: higher rates of rejection and lower graft survival. Int Urol Nephrol 2017; 49:2265-2272. [DOI: 10.1007/s11255-017-1719-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 10/06/2017] [Indexed: 01/05/2023]
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20
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Leeaphorn N, Garg N, Khankin EV, Cardarelli F, Pavlakis M. Recurrence of IgA nephropathy after kidney transplantation in steroid continuation versus early steroid-withdrawal regimens: a retrospective analysis of the UNOS/OPTN database. Transpl Int 2017; 31:175-186. [PMID: 28926143 DOI: 10.1111/tri.13075] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 07/24/2017] [Accepted: 09/14/2017] [Indexed: 11/27/2022]
Abstract
In the past 20 years, there has been an increase in use of steroid-withdrawal regimens in kidney transplantation. However, steroid withdrawal may be associated with an increased risk of recurrent IgA nephropathy (IgAN). Using United Network of (Organ Sharing/Organ Procurement and Transplantation Network) UNOS/OPTN data, we analyzed adult patients with end-stage renal disease (ESRD) due to IgAN who received their first kidney transplant between 2000 and 2014. For the primary outcome, we used a competing risk analysis to compare the cumulative incidence of graft loss due to IgAN recurrence between early steroid-withdrawal (ESW) and steroid continuation groups. The secondary outcomes were patient survival and death-censored graft survival (DCGS). A total of 9690 recipients were included (2831 in ESW group and 6859 in steroid continuation group). In total, 1238 recipients experienced graft loss, of which 191 (15.43%) were due to IgAN recurrence. In multivariable analysis, steroid use was associated with a decreased risk of recurrence (subdistribution hazard ratio 0.666, 95% CI 0.482-0.921; P = 0.014). Patient survival and DCGS were not different between the two groups. In the USA, ESW in transplant for ESRD due to IgAN is associated with a higher risk of graft loss due to disease recurrence. Future prospective studies are warranted to further address which patients with IgAN would benefit from steroid continuation.
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Affiliation(s)
- Napat Leeaphorn
- Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Neetika Garg
- Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Eliyahu V Khankin
- Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Francesca Cardarelli
- Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Martha Pavlakis
- Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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21
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Vlachopanos G, Bridson JM, Sharma A, Halawa A. Corticosteroid minimization in renal transplantation: Careful patient selection enables feasibility. World J Transplant 2016; 6:759-766. [PMID: 28058228 PMCID: PMC5175236 DOI: 10.5500/wjt.v6.i4.759] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 09/23/2016] [Accepted: 11/17/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To explore the benefits and harms of corticosteroid (CS) minimization following renal transplantation.
METHODS CS minimization attempts to improve cardiovascular risk factors (hypertension, diabetes, dyslipidemia), to enhance growth in children, to ameliorate bone disease and to lead to better compliance with immunosuppressive agents. Nevertheless, any benefit must be carefully weighed against the reduction in net immunosuppression and the potential harm to renal allograft function and survival.
RESULTS Complete CS avoidance or very early withdrawal (i.e., no CS after post-transplant day 7) seems to be associated with better outcomes in comparison with later withdrawal. However, an increased incidence of CS-sensitive acute rejection has been observed with all CS minimization strategies. Among the prerequisites for the safe application of CS minimization protocols are the administration of induction immunosuppression and the inclusion of calcineurin inhibitors in maintenance immunosuppression regimens.
CONCLUSION Transplant recipients at low immunological risk (primary transplant, low panel reactive antibodies) are thought as optimal candidates for CS minimization. CS avoidance may also be undesirable in patients at risk for glomerulonephritis recurrence or with severe delayed graft function and prolonged cold ischemia time. Thus, CS minimization is not yet ready for implementation in the majority of transplant recipients.
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22
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Roberti I, Vyas S. Immune-mediated nephropathies in kidney transplants: recurrent or de novo diseases. Pediatr Transplant 2016; 20:946-951. [PMID: 27561690 DOI: 10.1111/petr.12789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2016] [Indexed: 11/30/2022]
Abstract
IMN contribute to ESRD in 13% children with renal transplant (txp). Recurrent or de novo IMN can cause graft dysfunction and/or failure, but the details regarding incidence, therapy, and outcome remain poorly understood. Retrospective single-center study of all pediatric kidney txp was carried out since 1998. Clinical presentation, pathology, therapy, and graft outcomes of children with recurrent or de novo IMN were reviewed. IMN was the primary etiology of ESRD in 28 of the 149 txp recipients. Eleven children had biopsy-proven post-txp IMN-six were recurrent and five had de novo. Presentation varied with changes in SCr and/or proteinuria. Initial therapy included higher doses of steroids, MMF, and tacrolimus. Outcome was excellent with only one late graft loss. Full remission was achieved in all other patients, but some had re-recurrence of the IMN. Median follow-up time was 11.8 years. IMN (recurrent or de novo) occurred in 7.4% (11 of 149) of all kidney txp performed at our center. IMN post-txp was often seen late post-txp, usually asymptomatic and noted to have relapsing pattern. Early diagnosis and prompt therapy resulted in excellent long-term outcome in children diagnosed with post-txp IMN.
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Affiliation(s)
- Isabel Roberti
- Barnabas Health Children's Kidney Center, West Orange, NJ, USA.
| | - Shefali Vyas
- Barnabas Health Children's Kidney Center, West Orange, NJ, USA
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23
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Naesens M, Berger S, Biancone L, Crespo M, Djamali A, Hertig A, Öllinger R, Portolés J, Zuckermann A, Pascual J. Lymphocyte-depleting induction and steroid minimization after kidney transplantation: A review. Nefrologia 2016; 36:469-480. [DOI: 10.1016/j.nefro.2016.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 03/12/2016] [Accepted: 03/28/2016] [Indexed: 12/28/2022] Open
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24
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O'Shaughnessy MM, Liu S, Montez-Rath ME, Lenihan CR, Lafayette RA, Winkelmayer WC. Kidney Transplantation Outcomes across GN Subtypes in the United States. J Am Soc Nephrol 2016; 28:632-644. [PMID: 27432742 DOI: 10.1681/asn.2016020126] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 05/28/2016] [Indexed: 12/28/2022] Open
Abstract
Differences in kidney transplantation outcomes across GN subtypes have rarely been studied. From the US Renal Data System, we identified all adult (≥18 years) first kidney transplant recipients (1996-2011) with ESRD attributed to one of six GN subtypes or two comparator kidney diseases. We computed hazard ratios (HRs) for death, all-cause allograft failure, and allograft failure excluding death as a cause (competing risks framework) using Cox proportional hazards regression. Among the 32,131 patients with GN studied, patients with IgA nephropathy (IgAN) had the lowest mortality rates and patients with IgAN or vasculitis had the lowest allograft failure rates. After adjusting for patient- and transplant-related factors, compared with IgAN (referent), FSGS, membranous nephropathy, membranoproliferative GN, lupus nephritis, and vasculitis associated with HRs (95% confidence intervals) for death of 1.57 (1.43 to 1.72), 1.52 (1.34 to 1.72), 1.76 (1.55 to 2.01), 1.82 (1.63 to 2.02), and 1.56 (1.34 to 1.81), respectively, and with HRs for allograft failure excluding death as a cause of 1.20 (1.12 to 1.28), 1.27 (1.14 to 1.41), 1.50 (1.36 to 1.66), 1.11 (1.02 to 1.20), and 0.94 (0.81 to 1.09), respectively. Considering external comparator groups, and comparing with IgAN, autosomal dominant polycystic kidney disease (ADPKD) and diabetic nephropathy associated with higher HRs for mortality [1.22 (1.12 to 1.34) and 2.57 (2.35 to 2.82), respectively], but ADPKD associated with a lower HR for allograft failure excluding death as a cause [0.85 (0.79 to 0.91)]. Reasons for differential outcomes by GN subtype and cause of ESRD should be examined in future research.
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Affiliation(s)
| | - Sai Liu
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Maria E Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Colin R Lenihan
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Richard A Lafayette
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Wolfgang C Winkelmayer
- Section of Nephrology, Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas
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25
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Messina M, di Vico MC, Ariaudo C, Mazzucco G, Fop F, Segoloni GP, Biancone L. Treatment protocol with pulse and oral steroids for IgA Nephropathy after kidney transplantation. J Nephrol 2016; 29:575-83. [PMID: 27217158 DOI: 10.1007/s40620-016-0314-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 04/29/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND No specific treatment for IgA nephropathy (IgAN) after kidney transplantation is currently available. METHODS We conducted a retrospective single-center study on 29 patients with biopsy-proven de novo and recurrent IgAN after kidney transplantation, divided into two groups. Group 1 (n = 16) received intravenous methylprednisolone 500 mg per day for three consecutive days at the beginning of months 1, 3 and 5, plus oral prednisone 0.5 mg/kg every other day for 6 months. The control group (n = 13, Group 2) received supportive therapies. RESULTS The two groups were comparable for serum creatinine (sCr) and proteinuria at the time of renal biopsy, but differed significantly at the end of follow-up. sCr was 1.8 ± 0.4 mg/dl in Group 1 vs. 2.7 ± 0.9 in Group 2 (p = 0.002), and proteinuria was 0.9 g/day in Group 1 vs. 1.9 in Group 2 (p = 0.04). The composite outcome of death-censored graft loss or doubling of sCr displayed 2 events in Group 1 (12.5 % of the entire group) and 5 events in Group 2 (38.5 % of the entire group), p = 0.19, odds ratio (OR) 4.4 [95 % confidence interval (CI) 0.7-27.8]. CONCLUSIONS In the absence of therapeutic guidelines for de novo or recurrent IgAN after kidney transplantation, our study reports that therapy with pulse and oral steroids for 6 months is associated with an improved renal function. Nevertheless, further randomized controlled studies in larger patient cohorts are necessary to establish the gold standard treatment.
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Affiliation(s)
- Maria Messina
- Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città della Salute e della Scienza Hospital and University of Turin, Cso Bramante 88, 10126, Turin, Italy
| | - Maria Cristina di Vico
- Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città della Salute e della Scienza Hospital and University of Turin, Cso Bramante 88, 10126, Turin, Italy
| | - Claudia Ariaudo
- Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città della Salute e della Scienza Hospital and University of Turin, Cso Bramante 88, 10126, Turin, Italy
| | - Gianna Mazzucco
- Division of Pathology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Fabrizio Fop
- Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città della Salute e della Scienza Hospital and University of Turin, Cso Bramante 88, 10126, Turin, Italy
| | - Giuseppe Paolo Segoloni
- Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città della Salute e della Scienza Hospital and University of Turin, Cso Bramante 88, 10126, Turin, Italy
| | - Luigi Biancone
- Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città della Salute e della Scienza Hospital and University of Turin, Cso Bramante 88, 10126, Turin, Italy.
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26
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Cantarovich D, Rostaing L, Kamar N, Ducloux D, Saint-Hillier Y, Mourad G, Garrigue V, Wolf P, Ellero B, Cassuto E, Albano L, Völp A, Soulillou JP. Early corticosteroid avoidance in kidney transplant recipients receiving ATG-F induction: 5-year actual results of a prospective and randomized study. Am J Transplant 2014; 14:2556-64. [PMID: 25243534 DOI: 10.1111/ajt.12866] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 06/05/2014] [Accepted: 06/15/2014] [Indexed: 01/25/2023]
Abstract
One hundred ninety-seven patients received anti-T-lymphocyte globulins Fresenius, mycophenolate mofetil and delayed cyclosporine, and were randomized to ≥6-month corticosteroids (+CS; n=99) or no CS (-CS; n=98). One- and five-year actual graft survival (censored for death) was 93.2% and 86.4% in the +CS group versus 94.9% and 89.8% in the -CS group (5-year follow-up, p=0.487). Freedom from clinical rejection was 86.9% and 81.8% versus 74.5% and 74.5% (p=0.144), respectively, at 1 and 5 years; 5-year freedom from biopsy-proven rejection was 88.9% versus 83.7% (p=0.227). More late first rejections occurred in the +CS group. Significantly lower 5-year graft survival in patients experiencing rejection was observed for +CS (55.6% vs. 92.0%; p=0.005) with 8/18 versus 2/25 graft losses. Renal function at 5 years was stable and comparable (median serum creatinine, 159 vs. 145 µmol/L; creatinine clearance, 53.5 vs. 56.6 mL/min). More +CS patients developed diabetes, dyslipidemia and malignancies. Rejections in -CS patients occurred early after transplantation and did not impair long-term renal function. In patients receiving CS, rejections occurred later and with a higher risk for subsequent graft failure. A similar and not inferior 5-year efficacy profile and a reduced morbidity were observed in CS-free patients compared to patients who received CS for at least 6 months.
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Affiliation(s)
- D Cantarovich
- Institut de Transplantation-Urologie-Néphrologie (ITUN), Centre Hospitalier et Universitaire de Nantes, Nantes, France
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27
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Von Visger JR, Gunay Y, Andreoni KA, Bhatt UY, Nori US, Pesavento TE, Elkhammas EA, Winters HA, Nadasdy T, Singh N. The risk of recurrent IgA nephropathy in a steroid-free protocol and other modifying immunosuppression. Clin Transplant 2014; 28:845-54. [PMID: 24869763 DOI: 10.1111/ctr.12389] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2014] [Indexed: 12/17/2022]
Abstract
Recurrent glomerulonephritis is an important cause of kidney allograft failure. The effect of immunosuppression on recurrent IgA nephropathy (IgAN) is unclear. We analyzed the impact of steroids and other immunosuppression on the risk of recurrent IgAN post-kidney transplantation. Between June 1989 and November 2008, 3311 kidney transplants were performed at our center. IgAN was the primary disease in 124 patients; of these, 75 (60.5%) patients received steroid-based immunosuppression (15 undergoing late steroid withdrawal), and 49 (39.5%) were maintained on steroid-free immunosuppression. Recurrent IgAN was diagnosed in 27 of 124 (22%) patients in clinically indicated kidney allograft biopsies over a median follow-up of 6.86 ± 5.4 yr. On cox proportional hazards model multivariate analysis, the hazard risk (HR) of IgAN recurrence was significantly higher in patients managed with steroid-free (HR 8.59: 3.03, 24.38, p < 0.001) and sirolimus-based (HR = 3.00:1.16, 7.75, p = 0.024) immunosuppression without antilymphocyte globulin induction (HR = 4.5: 1.77, 11.73, p = 0.002). Mycophenolate use was associated with a lower risk (HR = 0.42: 0.19, 0.95, p = 0.036), whereas cyclosporine did not have a significant impact on the risk of IgAN recurrence (p = 0.61). These results warrant future prospective studies regarding the role of steroids and other immunosuppression drugs in reducing recurrence of IgAN and other glomerulonephritis post-transplant.
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Affiliation(s)
- J R Von Visger
- Division of Nephrology, Department of Internal Medicine, The Ohio State University College of Medicine and Public Health, Columbus, OH, USA
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28
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Sever MS. Transplantation-steroid-impaired glucose metabolism: a hope for improvement? Nephrol Dial Transplant 2013; 29:479-82. [PMID: 24285429 DOI: 10.1093/ndt/gft478] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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29
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Floege J, Regele H, Gesualdo L. The ERA-EDTA database on recurrent glomerulonephritis following renal transplantation. Nephrol Dial Transplant 2013; 29:15-21. [DOI: 10.1093/ndt/gft299] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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30
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Chavers BM, Rheault MN, Gillingham KJ, Matas AJ. Graft loss due to recurrent disease in pediatric kidney transplant recipients on a rapid prednisone discontinuation protocol. Pediatr Transplant 2012; 16:704-10. [PMID: 22574837 PMCID: PMC3419316 DOI: 10.1111/j.1399-3046.2012.01714.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Recurrent disease is the fourth most common cause of graft loss (GL) in pediatric KTx recipients. We studied the incidence of recurrent disease and GL due to recurrent disease in pediatric KTx recipients on a RDP protocol. Between 2002 and 2010, we performed 74 KTxs in patients aged 5-18 yr using an RDP protocol, 25 (34%) were at risk of recurrence of primary disease. Outcomes were compared to 69 historical controls (18 [26%] at risk of recurrence), KTx between 1996 and 2000. Follow-up period was 39 ± 25 months in RDP and 124 ± 38 months in controls. The incidence of recurrent disease at three yr post-KTx was 16% in RDP and 28% in controls (p = NS). Mean time to recurrent disease was 22 ± 26 months in RDP and 46 ± 48 months in controls (p = 0.54). Nine (12%) grafts were lost in the RDP group (1-recurrence) and 32 (46%) in the control group (4-recurrence). Time to GL was 85 months in the RDP recipient and 46 ± 21 months in controls. An RDP protocol in pediatric KTx recipients may not be associated with increased risk of graft loss due to recurrent disease.
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Affiliation(s)
- Blanche M. Chavers
- Department of Pediatrics, University of Minnesota Medical School, 2450 Riverside Avenue, East Building, 6 Floor, Minneapolis, MN 55454,Department of Surgery, University of Minnesota Medical School, MMC 195, 420 Delaware Street S.E., Minneapolis, MN 55455
| | - Michelle N. Rheault
- Department of Pediatrics, University of Minnesota Medical School, 2450 Riverside Avenue, East Building, 6 Floor, Minneapolis, MN 55454
| | - Kristen J. Gillingham
- Department of Surgery, University of Minnesota Medical School, MMC 195, 420 Delaware Street S.E., Minneapolis, MN 55455
| | - Arthur J. Matas
- Department of Surgery, University of Minnesota Medical School, MMC 195, 420 Delaware Street S.E., Minneapolis, MN 55455
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31
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Lau RL, Hanudel MR, Ettenger RB. Corticosteroids in recurrence of glomerular disease in renal transplantation: do we know the right questions to ask? Pediatr Transplant 2012; 16:684-7. [PMID: 22943665 DOI: 10.1111/j.1399-3046.2012.01776.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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