1
|
Divard G, Aubert O, Debiais-Deschamp C, Raynaud M, Goutaudier V, Sablik M, Sayeg C, Legendre C, Obert J, Anglicheau D, Lefaucheur C, Loupy A. Long-Term Outcomes after Conversion to a Belatacept-Based Immunosuppression in Kidney Transplant Recipients. Clin J Am Soc Nephrol 2024; 19:628-637. [PMID: 38265815 PMCID: PMC11108246 DOI: 10.2215/cjn.0000000000000411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 01/19/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND Conversion to a belatacept-based immunosuppression is currently used as a calcineurin inhibitor (CNI) avoidance strategy when the CNI-based standard-of-care immunosuppression is not tolerated after kidney transplantation. However, there is a lack of evidence on the long-term benefit and safety after conversion to belatacept. METHODS We prospectively enrolled 311 kidney transplant recipients from 2007 to 2020 from two referral centers, converted from CNI to belatacept after transplant according to a prespecified protocol. Patients were matched at the time of conversion to patients maintained with CNIs, using optimal matching. The primary end point was death-censored allograft survival at 7 years. The secondary end points were patient survival, eGFR, and safety outcomes, including serious viral infections, immune-related complications, antibody-mediated rejection, T-cell-mediated rejection, de novo anti-HLA donor-specific antibody, de novo diabetes, cardiovascular events, and oncologic complications. RESULTS A total of 243 patients converted to belatacept (belatacept group) were matched to 243 patients maintained on CNIs (CNI control group). All recipient, transplant, functional, histologic, and immunologic parameters were well balanced between the two groups with a standardized mean difference below 0.05. At 7 years post-conversion to belatacept, allograft survival was 78% compared with 63% in the CNI control group ( P < 0.001 for log-rank test). The safety outcomes showed a similar rate of patient death (28% in the belatacept group versus 36% in the CNI control group), active antibody-mediated rejection (6% versus 7%), T-cell-mediated rejection (4% versus 4%), major adverse cardiovascular events, and cancer occurrence (9% versus 11%). A significantly higher rate of de novo proteinuria was observed in the belatacept group as compared with the CNI control group (37% versus 21%, P < 0.001). CONCLUSIONS This real-world evidence study shows that conversion to belatacept post-transplant was associated with lower risk of graft failure and acceptable safety outcomes compared with patients maintained on CNIs. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Long-term Outcomes after Conversion to Belatacept, NCT04733131 .
Collapse
Affiliation(s)
- Gillian Divard
- INSERM U970 PARCC, Pa`ris Institute for Transplantation and Organ Regeneration, Université Paris Cité, Paris, France
- Kidney Transplant Department, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Olivier Aubert
- INSERM U970 PARCC, Pa`ris Institute for Transplantation and Organ Regeneration, Université Paris Cité, Paris, France
- Kidney Transplant Department, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Charlotte Debiais-Deschamp
- INSERM U970 PARCC, Pa`ris Institute for Transplantation and Organ Regeneration, Université Paris Cité, Paris, France
- Kidney Transplant Department, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marc Raynaud
- INSERM U970 PARCC, Pa`ris Institute for Transplantation and Organ Regeneration, Université Paris Cité, Paris, France
| | - Valentin Goutaudier
- INSERM U970 PARCC, Pa`ris Institute for Transplantation and Organ Regeneration, Université Paris Cité, Paris, France
| | - Marta Sablik
- INSERM U970 PARCC, Pa`ris Institute for Transplantation and Organ Regeneration, Université Paris Cité, Paris, France
| | - Caroline Sayeg
- Kidney Transplant Department, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Christophe Legendre
- INSERM U970 PARCC, Pa`ris Institute for Transplantation and Organ Regeneration, Université Paris Cité, Paris, France
- Kidney Transplant Department, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Julie Obert
- INSERM U970 PARCC, Pa`ris Institute for Transplantation and Organ Regeneration, Université Paris Cité, Paris, France
| | - Dany Anglicheau
- Kidney Transplant Department, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Necker-Enfants Malades Institute, INSERM U1151, Université de Paris Cité, Paris, France
| | - Carmen Lefaucheur
- INSERM U970 PARCC, Pa`ris Institute for Transplantation and Organ Regeneration, Université Paris Cité, Paris, France
- Kidney Transplant Department, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Alexandre Loupy
- INSERM U970 PARCC, Pa`ris Institute for Transplantation and Organ Regeneration, Université Paris Cité, Paris, France
- Kidney Transplant Department, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| |
Collapse
|
2
|
Polychronopoulou E, Bourdon F, Teta D. SGLT2 inhibitors in diabetic and non-diabetic kidney transplant recipients: current knowledge and expectations. FRONTIERS IN NEPHROLOGY 2024; 4:1332397. [PMID: 38685973 PMCID: PMC11056593 DOI: 10.3389/fneph.2024.1332397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 04/03/2024] [Indexed: 05/02/2024]
Abstract
The beneficial effect of sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been shown recently in numerous randomized controlled trials (RCT) and systematic reviews. According to KDIGO guidelines, SGLT2i currently represent a first choice for diabetic patients with chronic kidney disease (CKD). In addition, a recent meta-analysis of 13 large led by the 'SGLT2 inhibitor Meta-Analysis Cardio-Renal Trialists' Consortium' (SMART-C) provided solid evidence of SGLT2i beneficial effects in CKD or in patients with heart failure, with and without diabetes. Collectively, the patients treated with SGLT2i had a decreased risk of CKD progression, acute kidney injury (AKI), end-stage kidney disease (ESKD) or death from heart failure. Whether these cardio-renal benefits should be extrapolated to kidney transplant recipients (KTR) needs to be assessed in further studies. In this article, we report recent data accumulated so far in the literature, looking at the efficacy and safety of SGLT2i in diabetic and non-diabetic KTR. We found encouraging data regarding the use of SGLT2i in KTR with diabetes. These agents appeared to be safe, and they reduced body weight and blood pressure in this group of patients. Potential effects on kidney graft function and survival are yet to be investigated.
Collapse
Affiliation(s)
- Erietta Polychronopoulou
- Service of Nephrology, Hôpital du Valais, Sion, Switzerland
- Transplantation Center, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fanny Bourdon
- Service of Nephrology, Hôpital du Valais, Sion, Switzerland
| | - Daniel Teta
- Service of Nephrology, Hôpital du Valais, Sion, Switzerland
| |
Collapse
|
3
|
Luft FC. Calcineurin inhibition, cardiovascular consequences, vascular resistance, and potential responses. Acta Physiol (Oxf) 2024; 240:e14084. [PMID: 38214031 DOI: 10.1111/apha.14084] [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: 08/18/2023] [Revised: 10/20/2023] [Accepted: 01/01/2024] [Indexed: 01/13/2024]
Abstract
AIM To place the consequences of calcineurin inhibition in a cardiovascular context. METHODS Literature review coupled with personal encounters. RESULTS Calcineurin is a calcium-binding and calmodulin-binding protein that is conserved across evolution from yeast to mammals. The enzyme functions as a calcium-dependent, calmodulin-stimulated protein phosphatase. Its role in regulating physiology has largely been elucidated by observing calcineurin inhibition. Calcineurin inhibition transformed organ transplantation from an experiment into a therapy and made much of general immunotherapy possible. The function of this phosphatase and how its inhibition leads to toxicity concern us to this date. Initial research from patients and animal models implicated a panoply of factors contributing to hypertension and vasculopathy. Subsequently, the role of calcineurin in regulating the effective fluid volume, sodium reabsorption, and potassium and hydrogen ion excretion was elucidated by investigating calcineurin inhibition. Understanding the regulatory effects of calcineurin on endothelial and vascular smooth muscle cell function has also made substantial progress. However, precisely how the increase in systemic vascular resistance arises requires further mechanistic research. CONCLUSION Calcineurin inhibition continues to save lives; however, options to counteract the negative effects of calcineurin inhibition should be vigorously pursued.
Collapse
Affiliation(s)
- Friedrich C Luft
- Experimental and Clinical Research Center, a cooperation between the Max-Delbrück Center for Molecular Medicine and the Charité Medical Faculty, Berlin, Germany
| |
Collapse
|
4
|
van den Born JC, Meziyerh S, Vart P, Bakker SJL, Berger SP, Florquin S, de Fijter JW, Gomes-Neto AW, Idu MM, Pol RA, Roelen DL, van Sandwijk MS, de Vries DK, de Vries APJ, Bemelman FJ, Sanders JSF. Comparison of 2 Immunosuppression Minimization Strategies in Kidney Transplantation: The ALLEGRO Trial. Transplantation 2024; 108:556-566. [PMID: 37650722 DOI: 10.1097/tp.0000000000004776] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND Evidence on the optimal maintenance of immunosuppressive regimen in kidney transplantation recipients is limited. METHODS The Amsterdam, LEiden, GROningen trial is a randomized, multicenter, investigator-driven, noninferiority, open-label trial in de novo kidney transplant recipients, in which 2 immunosuppression minimization strategies were compared with standard immunosuppression with basiliximab, corticosteroids, tacrolimus, and mycophenolic acid. In the minimization groups, either steroids were withdrawn from day 3, or tacrolimus exposure was reduced from 6 mo after transplantation. The primary endpoint was kidney transplant function at 24 mo. RESULTS A total of 295 participants were included in the intention-to-treat analysis. Noninferiority was shown for the primary endpoint; estimated glomerular filtration rate at 24 mo was 45.3 mL/min/1.73 m 2 in the early steroid withdrawal group, 49.0 mL/min/1.73 m 2 in the standard immunosuppression group, and 44.7 mL/min/1.73 m 2 in the tacrolimus minimization group. Participants in the early steroid withdrawal group were significantly more often treated for rejection ( P = 0.04). However, in this group, the number of participants with diabetes mellitus during follow-up and total cholesterol at 24 mo were significantly lower. CONCLUSIONS Tacrolimus minimization can be considered in kidney transplant recipients who do not have an increased immunological risk. Before withdrawing steroids the risk of rejection should be weighed against the potential metabolic advantages.
Collapse
Affiliation(s)
- Joost C van den Born
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Soufian Meziyerh
- Department of Internal Medicine, Division of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
- Transplant Center, Leiden University Medical Center, Leiden, the Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Priya Vart
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Stephan J L Bakker
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Stefan P Berger
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Sandrine Florquin
- Department of Pathology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Johan W de Fijter
- Department of Internal Medicine, Division of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - António W Gomes-Neto
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Mirza M Idu
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Robert A Pol
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Dave L Roelen
- Department of Immunology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marit S van Sandwijk
- Renal Transplant Unit, Department of Internal Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Dorottya K de Vries
- Transplant Center, Leiden University Medical Center, Leiden, the Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Aiko P J de Vries
- Department of Internal Medicine, Division of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
- Transplant Center, Leiden University Medical Center, Leiden, the Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederike J Bemelman
- Renal Transplant Unit, Department of Internal Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan Stephan F Sanders
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| |
Collapse
|
5
|
Pham NYT, Cruz D, Madera-Marin L, Ravender R, Garcia P. Diabetic Kidney Disease in Post-Kidney Transplant Patients. J Clin Med 2024; 13:793. [PMID: 38337487 PMCID: PMC10856396 DOI: 10.3390/jcm13030793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/09/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
Post-transplant diabetes mellitus (PTDM) is a common occurrence in post-kidney transplantation and is associated with greater mortality, allograft failure, and increased risk of infections. The primary goal in the management of PTDM is to achieve glycemic control to minimize the risk of complications while balancing the need for immunosuppression to maintain the health of the transplanted kidney. This review summarizes the effects of maintenance immunosuppression and therapeutic options among kidney transplant recipients. Patients with PTDM are at increased risk of diabetic kidney disease development; therefore, in this review, we focus on evidence supporting the use of novel antidiabetic agents and discuss their benefits and potential side effects in detail.
Collapse
Affiliation(s)
- Ngoc-Yen T. Pham
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, NM 87106, USA
| | - Diego Cruz
- Hospital General San Juan de Dios, Guatemala City 01001, Guatemala;
| | - Luis Madera-Marin
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, NM 87106, USA
| | - Raja Ravender
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, NM 87106, USA
| | - Pablo Garcia
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, NM 87106, USA
| |
Collapse
|
6
|
Born A, Bocchi F, Kuhn C, Amstutz U, Baumgartner MR, Sidler D. Tacrolimus monitoring in hair samples of kidney transplant recipients. Front Med (Lausanne) 2023; 10:1307505. [PMID: 38111700 PMCID: PMC10726046 DOI: 10.3389/fmed.2023.1307505] [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] [Received: 10/06/2023] [Accepted: 11/15/2023] [Indexed: 12/20/2023] Open
Abstract
Background Calcineurin inhibitors, including tacrolimus, remain a cornerstone of immunosuppressive therapy after kidney transplantation. However, the therapeutic window is narrow, and nephrotoxic side effects occur with overdose, while the risk of alloimmunization and graft rejection increases with underdose. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) allows quantification of tacrolimus in biological samples from patients. This study investigates the feasibility of quantifying tacrolimus in scalp hair from kidney transplant (KT) recipients and correlates hair tacrolimus concentrations with tacrolimus dosage and blood trough levels. The aim was to provide proof-of-principle for hair tacrolimus drug monitoring in KT recipients. Method Single-center prospective study between September 9, 2021 and December 4, 2021, including KT recipients under tacrolimus. Minors, patients with active skin or hair diseases, and patients with scalp hair shorter than 4 cm were excluded from participation. Scalp hair was collected from the posterior vertex of patients, cut into segments, and analyzed for tacrolimus by LC-MS/MS. Patients filled out a questionnaire on hair treatments and washing habits. In parallel, tacrolimus trough levels were measured in whole blood and correlated with hair tacrolimus concentrations. Results In total, 39 consenting KT recipients were included, and hair samples were collected at 53 visits. Tacrolimus was detected in 98% of hair samples from patients exposed to the drug. Tacrolimus hair levels and whole blood trough levels were correlated with a beta coefficient of 0.42 (95% CI: -0.22-1.1, p = n.s.). Age and dark hair affected hair tacrolimus measurements, while different tacrolimus formulations (immediate release vs. extended release), hair washes, and permanent coloring did not. Longitudinal measurements in a subgroup of patients indicate that long-term measurement of hair tacrolimus levels is feasible. Conclusion Measuring tacrolimus in hair is a potentially reliable method to monitor drug exposure in KT patients. Rapid wash-in effects and consistent concentrations over time indicate that tacrolimus is incorporated into the hair matrix, allowing temporal resolution in the analysis of recent exposure and exposure history. This method provides a simple and low-risk alternative to regular blood sampling, sparing patients from frequent hospital visits through the self-collection of hair samples.
Collapse
Affiliation(s)
- Alexander Born
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Federica Bocchi
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Kuhn
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ursula Amstutz
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Daniel Sidler
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
7
|
Oliveras L, Montero N, Cruzado JM. Searching in the maze: sodium-glucose cotransporter-2 inhibitors in kidney transplant recipients to improve survival. Clin Kidney J 2023; 16:909-913. [PMID: 37260989 PMCID: PMC10229278 DOI: 10.1093/ckj/sfad045] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Indexed: 11/29/2023] Open
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2is) improve cardiovascular and renal outcomes in chronic kidney disease patients with and without diabetes. Kidney transplant recipients have been excluded from landmark trials using SGLT2is and literature on safety and efficacy are scarce. Recent studies suggest that the SGLT2i use in kidney transplant recipients with diabetes is safe, paving the way to investigate whether SGLT2is could also reduce cardiovascular events and kidney function deterioration in kidney allograft recipients.
Collapse
Affiliation(s)
- Laia Oliveras
- Nephrology Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Catalonia, Spain
| | - Núria Montero
- Nephrology Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Catalonia, Spain
| | - Josep M Cruzado
- Nephrology Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Catalonia, Spain
- Biomedical Research Institute (IDIBELL), Hospital Duran i Reynals, L'Hospitalet de Llobregat, Catalonia, Spain
- Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, L'Hospitalet de Llobregat, Catalonia, Spain
| |
Collapse
|
8
|
Xiong D, Yue B, Ye S, Wang H, Ban L, Chen Y, Lv J, Zhou M, Yin P, Chen J. The impact of long-term exposure to tacrolimus on chronic kidney disease after lung transplantation: A retrospective analysis from a single transplantation center. Transpl Immunol 2023; 78:101810. [PMID: 36918103 DOI: 10.1016/j.trim.2023.101810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/06/2023] [Accepted: 02/26/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a progressive and irreversible complication in lung transplant patients who have received long-term treatment with tacrolimus. This study aimed to verify long-term tacrolimus exposure values in CKD progression. METHODS We retrospectively analyzed the clinical data of adult lung transplant recipients performed at our center between 2012 and October 2015. Patients who completed the 5-year follow-up period were enrolled in this study. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. RESULTS Eighty patients were analyzed. Compared with baseline (109 ± 38.1 mL/min/1.73 m2), the average eGFR values of our patients gradually decreased during the fifth-year post transplantation (46.5%, 58.3 ± 28.3 mL/min/1.73 m2), and the decline in eGFR values was particularly pronounced in the first year (31.2%, 74.6 ± 28.91 mL/min/1.73 m2). Moreover, 10 (12.7%), 21 (26.9%), 24 (31.2%), 28 (41.2%), and 48 (60%) patients had eGFR <60 mL/min/1.73 m2 at 3, 6, 1, 3, and 5 years after lung transplantation (LT), respectively. A significant negative correlation was found between tacrolimus dose and eGFR 6 months after LT (P = 0.0414). We found no correlation between the serum tacrolimus concentration and CKD progression. CONCLUSION eGFR constantly decreased and the incidence of CKD increased during the 5-year follow-up period after LT. The tacrolimus dose had a significant negative correlation with eGFR at 6 months after LT. Meanwhile, whole-blood tacrolimus trough concentrations were not correlated with eGFR decline. When possible, lower dosing within 1 year after LT can reduce potential nephrotoxic side effects.
Collapse
Affiliation(s)
- Dian Xiong
- Lung Transplantation Center, Department of Thoracic Surgery, Nanjing Medical University Affiliated Wuxi People's Hospital, Wuxi 214023, China
| | - Bingqing Yue
- Lung Transplantation Center, Department of Thoracic Surgery, Nanjing Medical University Affiliated Wuxi People's Hospital, Wuxi 214023, China; Department of Lung Transplant, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310052, China
| | - Shugao Ye
- Lung Transplantation Center, Department of Thoracic Surgery, Nanjing Medical University Affiliated Wuxi People's Hospital, Wuxi 214023, China
| | - Hongmei Wang
- Lung Transplantation Center, Department of Thoracic Surgery, Nanjing Medical University Affiliated Wuxi People's Hospital, Wuxi 214023, China
| | - Le Ban
- Lung Transplantation Center, Department of Thoracic Surgery, Nanjing Medical University Affiliated Wuxi People's Hospital, Wuxi 214023, China
| | - Yuan Chen
- Lung Transplantation Center, Department of Thoracic Surgery, Nanjing Medical University Affiliated Wuxi People's Hospital, Wuxi 214023, China
| | - Jian Lv
- Lung Transplantation Center, Department of Thoracic Surgery, Nanjing Medical University Affiliated Wuxi People's Hospital, Wuxi 214023, China
| | - Min Zhou
- Lung Transplantation Center, Department of Thoracic Surgery, Nanjing Medical University Affiliated Wuxi People's Hospital, Wuxi 214023, China
| | - Pan Yin
- Department of Lung Transplant, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310052, China
| | - Jingyu Chen
- Lung Transplantation Center, Department of Thoracic Surgery, Nanjing Medical University Affiliated Wuxi People's Hospital, Wuxi 214023, China; Department of Lung Transplant, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310052, China.
| |
Collapse
|
9
|
Bertrand D, Matignon M, Morel A, Ludivine L, Lemoine M, Hanoy M, Roy FL, Nezam D, Hamzaoui M, de Nattes T, Moktefi A, François A, Laurent C, Etienne I, Guerrot D. Belatacept rescue conversion in kidney transplant recipients with vascular lesions (Banff cv score >2): a retrospective cohort study. Nephrol Dial Transplant 2023; 38:481-490. [PMID: 35544123 DOI: 10.1093/ndt/gfac178] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Immunosuppression in kidney transplant recipients with decreased graft function and histological vascular changes can be particularly challenging. The impact of a late rescue conversion to belatacept on kidney graft survival in this context has never been studied. METHODS We report a bicentric retrospective cohort study comparing a calcineurin inhibitor (CNI) to belatacept switch versus CNI continuation in 139 kidney transplant recipients with histological kidney vascular damage (cv ≥2, g + cpt ≤1, i + t ≤1) and low estimated glomerular filtration rate (≤40 mL/min/1.73 m²). Primary outcome was death-censored graft survival. RESULTS During the study follow-up, 10 graft losses (14.5%) occurred in the belatacept group (n = 69) versus 26 (37.1%) in the matched CNI group (n = 70) (P = .005). Death-censored graft survival was significantly higher in the belatacept group (P = .001). At 3 years, graft survival was 84.0% in the belatacept group compared with 65.1% in the control group. Continuing CNI was an independent risk factor for graft loss [hazard ratio (HR) 3.46; P < .005]. The incidence of cellular rejection after the conversion was low (4.3% in both groups) and not significantly different between groups (P = .84). Patients switched to belatacept developed significantly less donor-specific antibodies de novo. Belatacept was an independent risk factor for the occurrence of opportunistic infections (HR 4.84; P < .005). CONCLUSION The replacement of CNI with belatacept in patients with decreased allograft function and vascular lesions is associated with an improvement in graft survival and represents a valuable option in a context of organ shortage. Caution should be exercised regarding the increased risk of opportunistic infection.
Collapse
Affiliation(s)
- Dominique Bertrand
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Marie Matignon
- Nephrology and Transplantation Department, Cancerology-Immunity-Transplantation-Infectiology, Clinical Investigation Center-Biotherapies, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, INSERM U955, Paris-Est-Créteil University, Paris, France
| | - Antoine Morel
- Nephrology and Transplantation Department, Cancerology-Immunity-Transplantation-Infectiology, Clinical Investigation Center-Biotherapies, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, INSERM U955, Paris-Est-Créteil University, Paris, France
| | - Lebourg Ludivine
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Mathilde Lemoine
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Mélanie Hanoy
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Frank Le Roy
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Dorian Nezam
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Mouad Hamzaoui
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Tristan de Nattes
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Anissa Moktefi
- Department of Pathology, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Est-Créteil University, Paris, France
| | | | - Charlotte Laurent
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Isabelle Etienne
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Dominique Guerrot
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France.,INSERM U1096, Normandie Univ, UNIROUEN, Rouen, France
| |
Collapse
|
10
|
Vaulet T, Divard G, Thaunat O, Koshy P, Lerut E, Senev A, Aubert O, Van Loon E, Callemeyn J, Emonds MP, Van Craenenbroeck A, De Vusser K, Sprangers B, Rabeyrin M, Dubois V, Kuypers D, De Vos M, Loupy A, De Moor B, Naesens M. Data-Driven Chronic Allograft Phenotypes: A Novel and Validated Complement for Histologic Assessment of Kidney Transplant Biopsies. J Am Soc Nephrol 2022; 33:2026-2039. [PMID: 36316096 PMCID: PMC9678036 DOI: 10.1681/asn.2022030290] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/24/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND No validated system currently exists to realistically characterize the chronic pathology of kidney transplants that represents the dynamic disease process and spectrum of disease severity. We sought to develop and validate a tool to describe chronicity and severity of renal allograft disease and integrate it with the evaluation of disease activity. METHODS The training cohort included 3549 kidney transplant biopsies from an observational cohort of 937 recipients. We reweighted the chronic histologic lesions according to their time-dependent association with graft failure, and performed consensus k-means clustering analysis. Total chronicity was calculated as the sum of the weighted chronic lesion scores, scaled to the unit interval. RESULTS We identified four chronic clusters associated with graft outcome, based on the proportion of ambiguous clustering. The two clusters with the worst survival outcome were determined by interstitial fibrosis and tubular atrophy (IFTA) and by transplant glomerulopathy. The chronic clusters partially overlapped with the existing Banff IFTA classification (adjusted Rand index, 0.35) and were distributed independently of the acute lesions. Total chronicity strongly associated with graft failure (hazard ratio [HR], 8.33; 95% confidence interval [CI], 5.94 to 10.88; P<0.001), independent of the total activity scores (HR, 5.01; 95% CI, 2.83 to 7.00; P<0.001). These results were validated on an external cohort of 4031 biopsies from 2054 kidney transplant recipients. CONCLUSIONS The evaluation of total chronicity provides information on kidney transplant pathology that complements the estimation of disease activity from acute lesion scores. Use of the data-driven algorithm used in this study, called RejectClass, may provide a holistic and quantitative assessment of kidney transplant injury phenotypes and severity.
Collapse
Affiliation(s)
- Thibaut Vaulet
- ESAT Stadius Center for Dynamical Systems, Signal Processing, and Data Analytics, KU Leuven, Leuven, Belgium
| | - Gillian Divard
- Paris Translational Research Center for Organ Transplantation, Université de Paris, INSERM, PARCC, Paris, France; Kidney Transplant Department, Necker Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Olivier Thaunat
- CIRI, INSERM U1111, Université Claude Bernard Lyon I, CNRS UMR5308, Ecole Normale Supérieure de Lyon, Univ. Lyon, Lyon, France
- Department of Transplantation, Nephrology, and Clinical Immunology, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Priyanka Koshy
- Department of Imaging and Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Evelyne Lerut
- Department of Imaging and Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Aleksandar Senev
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross–Flanders, Mechelen, Belgium
| | - Olivier Aubert
- Paris Translational Research Center for Organ Transplantation, Université de Paris, INSERM, PARCC, Paris, France; Kidney Transplant Department, Necker Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Elisabet Van Loon
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - Jasper Callemeyn
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - Marie-Paule Emonds
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross–Flanders, Mechelen, Belgium
| | - Amaryllis Van Craenenbroeck
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Department of Nephrology and Kidney Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Katrien De Vusser
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Department of Nephrology and Kidney Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Department of Nephrology and Kidney Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Maud Rabeyrin
- Department of Pathology, Hospices Civils de Lyon, Bron, France
| | - Valérie Dubois
- Human Leukocyte Antigen (HLA) Laboratory, French National Blood Service (EFS), Décines-Charpieu, France
| | - Dirk Kuypers
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Department of Nephrology and Kidney Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Maarten De Vos
- ESAT Stadius Center for Dynamical Systems, Signal Processing, and Data Analytics, KU Leuven, Leuven, Belgium
- Department of Development and Regeneration, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, Université de Paris, INSERM, PARCC, Paris, France; Kidney Transplant Department, Necker Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Bart De Moor
- ESAT Stadius Center for Dynamical Systems, Signal Processing, and Data Analytics, KU Leuven, Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Department of Nephrology and Kidney Transplantation, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
11
|
Time-Limited Therapy with Belatacept in Kidney Transplant Recipients. J Clin Med 2022; 11:jcm11113229. [PMID: 35683619 PMCID: PMC9181670 DOI: 10.3390/jcm11113229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 04/28/2022] [Accepted: 05/27/2022] [Indexed: 02/04/2023] Open
Abstract
Introduction: In kidney transplant recipients, belatacept is usually pursued indefinitely after it has been started. In the setting of the belatacept shortage and after having evaluated the benefit–risk ratio, we established a strategy consisting of time-limited belatacept therapy/transient calcineurin inhibitor withdrawal, whose results are analyzed in that study. Methods: We considered all the kidney transplant recipients that had been switched from conventional immunosuppressive therapy to belatacept and then for whom belatacept has been withdrawn intentionally. Furthermore, in the first 8 patients, we assessed changes in peripheral blood mononuclear cells (PBMC) transcriptome using RNAseq before and 3 months after belatacept withdrawal. Results: Over the study period, 28 out of 94 patients had belatacept intentionally withdrawn including 25 (89%) switched to low-dose CNI. One rejection due to poor compliance occurred. The eGFR after 12 months remained stable from 48 ± 19 mL.1.73 m−2 to 46 ± 17 mL.1.73 m−2 (p = 0.68). However, patients that resumed belatacept/withdrew CNIs (n = 10) had a trend towards a better eGFR comparing with the others (n = 15): 54 ± 20 mL.1.73 m−2 vs. eGFR 43 ± 16 mL.1.73 m−2, respectively (p = 0.15). The only factor associated with belatacept resumption was when the withdrawal took place during the COVID-19 outbreak. Transcriptome analysis of PBMCs, did not support rebound in alloimmune response. Conclusions: These findings underpin the use of belatacept as part of a time-limited therapy, in selected kidney transplant recipients, possibly as an approach to allow efficient vaccination against SARS-CoV-2.
Collapse
|
12
|
Menon R, Otto EA, Berthier CC, Nair V, Farkash EA, Hodgin JB, Yang Y, Luo J, Woodside KJ, Zamani H, Norman SP, Wiggins RC, Kretzler M, Naik AS. Glomerular endothelial cell-podocyte stresses and crosstalk in structurally normal kidney transplants. Kidney Int 2022; 101:779-792. [PMID: 34952098 PMCID: PMC9067613 DOI: 10.1016/j.kint.2021.11.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 10/14/2021] [Accepted: 11/15/2021] [Indexed: 12/18/2022]
Abstract
Increased podocyte detachment begins immediately after kidney transplantation and is associated with long-term allograft failure. We hypothesized that cell-specific transcriptional changes in podocytes and glomerular endothelial cells after transplantation would offer mechanistic insights into the podocyte detachment process. To test this, we evaluated cell-specific transcriptional profiles of glomerular endothelial cells and podocytes from 14 patients of their first-year surveillance biopsies with normal histology from low immune risk recipients with no post-transplant complications and compared these to biopsies of 20 healthy living donor controls. Glomerular endothelial cells from these surveillance biopsies were enriched for genes related to fluid shear stress, angiogenesis, and interferon signaling. In podocytes, pathways were enriched for genes in response to growth factor signaling and actin cytoskeletal reorganization but also showed evidence of podocyte stress as indicated by reduced nephrin (adhesion protein) gene expression. In parallel, transcripts coding for proteins required to maintain podocyte adherence to the underlying glomerular basement membrane were downregulated, including the major glomerular podocyte integrin α3 and the actin cytoskeleton-related gene synaptopodin. The reduction in integrin α3 protein expression in surveillance biopsies was confirmed by immunoperoxidase staining. The combined growth and stress response of patient allografts post-transplantation paralleled similar changes in a rodent model of nephrectomy-induced glomerular hypertrophic stress that progress to develop proteinuria and glomerulosclerosis with shortened kidney life span. Thus, even among patients with apparently healthy allografts with no detectable histologic abnormality including alloimmune injury, transcriptomic changes reflecting cell stresses are already set in motion that could drive hypertrophy-associated glomerular disease progression.
Collapse
Affiliation(s)
- Rajasree Menon
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA.
| | - Edgar A Otto
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Celine C Berthier
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Viji Nair
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Evan A Farkash
- Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jeffrey B Hodgin
- Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Yingbao Yang
- Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jinghui Luo
- Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Kenneth J Woodside
- Division of Transplant Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Haniyeh Zamani
- School of Arts and Sciences, University of Michigan, Ann Arbor, Michigan, USA
| | - Silas P Norman
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Roger C Wiggins
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Matthias Kretzler
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Abhijit S Naik
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
| |
Collapse
|
13
|
Salvadori M, Tsalouchos A. Innovative immunosuppression in kidney transplantation: A challenge for unmet needs. World J Transplant 2022; 12:27-41. [PMID: 35433332 PMCID: PMC8968476 DOI: 10.5500/wjt.v12.i3.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 01/27/2022] [Accepted: 03/06/2022] [Indexed: 02/06/2023] Open
Abstract
Due to the optimal results obtained in kidney transplantation and to the lack of interest of the industries, new innovative drugs in kidney transplantation are difficult to be encountered. The best strategy to find the new drugs recently developed or under development is to search in the sections of kidney transplantation still not completely covered by the drugs on the market. These unmet needs are the prevention of delayed graft function (DGF), the protection of the graft over the long time and the desensitization of preformed anti human leukocyte antigen antibodies and the treatment of the acute antibody-mediated rejection. These needs are particularly relevant due to the expansion of some kind of kidney transplantation as transplantation from non-heart beating donor and in the case of antibody-incompatible grafts. The first are particularly exposed to DGF, the latter need a safe desensitization and a safe treatments of the antibody mediated rejections that often occur. Particular caution is needed in treating these drugs. First, they are described in very recent studies and the follow-up of their effect is of course rather short. Second, some of these drugs are still in an early phase of study, even if in well-conducted randomized controlled trials. Particular caution and a careful check need to be used in trials launched 2 or 3 years ago. Indeed, is always necessary to verify whether the study is still going on or whether and why the study itself was abandoned.
Collapse
Affiliation(s)
- Maurizio Salvadori
- Department of Renal Transplantation, Careggi University Hospital, Florence 50139, Italy
| | - Aris Tsalouchos
- Division of Nephrology, Santa Maria Annunziata Hospital, Florence 50012, Italy
| |
Collapse
|
14
|
Karolin A, Escher G, Rudloff S, Sidler D. Nephrotoxicity of Calcineurin Inhibitors in Kidney Epithelial Cells is Independent of NFAT Signaling. Front Pharmacol 2022; 12:789080. [PMID: 35140605 PMCID: PMC8819135 DOI: 10.3389/fphar.2021.789080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/29/2021] [Indexed: 01/01/2023] Open
Abstract
Background: Calcineurin inhibitors (CNIs) such as cyclosporine A and tacrolimus are commonly used after renal transplantation to suppress the immune system. In lymphoid cells, cyclosporine A acts via the calcineurin/nuclear factor of activated T-cell (NFAT) axis. In non-lymphoid cells, such as kidney epithelial cells, cyclosporine A induces calcineurin inhibitor toxicity. It is unknown via which off-targets cyclosporine A induces calcineurin inhibitor toxicity in kidney epithelial cells. Methods: To measure a compound’s potential to induce nephrotoxicity, the expression of the surrogate marker Fn14 was measured by flow cytometry. Compounds were tested for their potential to induce Fn14 either chemically or plasmid-mediated. Mice were injected with various compounds, and changes in nephrotoxic gene expression levels of the kidney epithelial cells were then analyzed. Results: Fn14 is specifically upregulated due to calcineurin inhibitor toxicity inducing agents. Inhibition of the NFAT axis showed no increase of the Fn14 expression on the surface of kidney cells. However, inhibition of p38 MAPK, phosphoinositide-3-kinase (PI3K)/Akt, protein kinase C (PKC), and inhibitor of nuclear factor-κB (IκB) kinase (IKK) showed clear induction of Fn14 and increased expressions of nephrotoxic, inflammatory, and fibrotic genes in vitro and in vivo. Conclusions: These findings show that cyclosporine A acts independently of NFAT on kidney epithelial cells. Moreover, inhibition of serine/threonine protein kinases mimics cyclosporine A’s activity on kidney epithelial cells. This mimicking effect indicates that these protein kinases are off-targets of cyclosporine A and damage structural renal cells when inhibited and therefore contributes likely to the development and progression of calcineurin inhibitor toxicity.
Collapse
Affiliation(s)
- Andrea Karolin
- Department for Nephrology and Hypertension, University Hospital Insel Bern, Bern, Switzerland
- Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | - Geneviève Escher
- Department for Nephrology and Hypertension, University Hospital Insel Bern, Bern, Switzerland
| | - Stefan Rudloff
- Department for Nephrology and Hypertension, University Hospital Insel Bern, Bern, Switzerland
| | - Daniel Sidler
- Department for Nephrology and Hypertension, University Hospital Insel Bern, Bern, Switzerland
- *Correspondence: Daniel Sidler,
| |
Collapse
|
15
|
Kattah AG, Albadri S, Alexander MP, Smith B, Parashuram S, Mai ML, Khamash HA, Cosio FG, Garovic VD. Impact of Pregnancy on GFR Decline and Kidney Histology in Kidney Transplant Recipients. Kidney Int Rep 2022; 7:28-35. [PMID: 35005311 PMCID: PMC8720805 DOI: 10.1016/j.ekir.2021.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction Women with advanced kidney disease are advised to wait until after transplant to pursue pregnancy, but the impact of pregnancy on estimated glomerular filtration rate (eGFR) decline and kidney histology is unclear. Methods We identified a cohort of women aged 18 to 44 years at transplant from 1996 to 2014 at our 3-site program (N = 816) and determined whether they had a pregnancy >20 weeks gestation post-transplant by chart review. Outcomes included rate of change in eGFR after pregnancy, changes in kidney histology before and after pregnancy, graft failure, and 50% reduction in eGFR. Results There were 37 women with one or more pregnancies lasting longer than 20 weeks gestation post-transplant. Comparing women with and without pregnancy post-transplant, there was a significant increase in the rate of eGFR decline after pregnancy (−2.4 ml/min per 1.73 m2 per year vs. −1.9 ml/min per 1.73 m2 per year in women with no pregnancy, P < 0.001). Pregnancy did not affect the risk of graft failure, death-censored graft failure, or 50% reduction in eGFR. Conclusion Pregnancy affects the rate of eGFR decline in the allograft. Postpregnancy biopsy findings revealed an increase in vascular injury, which could be a potential mechanism. We did not find a significant increase in risk of graft failure or reduction in eGFR by 50% owing to pregnancy.
Collapse
Affiliation(s)
- Andrea G Kattah
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Sam Albadri
- Department of Laboratory Medicine and Pathology, Hennepin HealthCare, Minneapolis, Minnesota, USA
| | - Mariam P Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Byron Smith
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Santosh Parashuram
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Marin L Mai
- Division of Nephrology, Mayo Clinic, Jacksonville, Florida, USA
| | - Hasan A Khamash
- Division of Nephrology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Fernando G Cosio
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Vesna D Garovic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
16
|
Qin C, Jin H, Zhang H, Zhang Y, Guan Z, Gao Y. Noninvasive Assessment of Interstitial Fibrosis and Tubular Atrophy in Renal Transplant by Combining Point-Shear Wave Elastography and Estimated Glomerular Filtration Rate. Diagnostics (Basel) 2021; 12:diagnostics12010018. [PMID: 35054186 PMCID: PMC8774870 DOI: 10.3390/diagnostics12010018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/02/2021] [Accepted: 12/09/2021] [Indexed: 11/16/2022] Open
Abstract
The purpose of this study was to evaluate the feasibility of the combination of point-shear wave elastography (p-SWE) and estimated glomerular filtration rate (eGFR) for assessing different stages of interstitial fibrosis and tubular atrophy (IF/TA) in patients with chronic renal allograft dysfunction (CAD). From September 2020 to August 2021, 47 patients who underwent renal biopsy and p-SWE examinations were consecutively enrolled in this study. The areas under the receiver operating characteristic curves (AUCs) were calculated to evaluate overall accuracy and to identify the optimal cutoff values for different IF/TA stages. A total of 43 patients were enrolled in this study. The renal cortical stiffness and eGFR showed a significant difference between IF/TA Grade 0–1 and Grade 2–3 (p < 0.001). Additionally, renal stiffness and eGFR were independent predictors for moderate-to-severe IF/TA (Grade ≥ 2) according to multiple logistic regression analysis. The combination of p-SWE and eGFR, with an optimal cutoff value of −1.63, was superior to eGFR alone in assessing moderate-to-severe interstitial fibrosis (AUC, 0.86 vs. 0.72, p = 0.02) or tubular atrophy (AUC, 0.88 vs. 0.74, p = 0.02). There was no difference between p-SWE and eGFR in assessing moderate-to-severe IF/TA (AUC, 0.85 vs. 0.79, p = 0.61). Therefore, combining p-SWE and eGFR is worthy of clinical popularization and application.
Collapse
Affiliation(s)
- Chi Qin
- The Training Site for Postgraduate of Jinzhou Medical University, Department of Ultrasound, The Third Medical Center of Chinese PLA General Hospital, 69 Yongding Road, Hai Dian, Beijing 100039, China;
| | - Hailong Jin
- Department of Organ Transplantation, The Third Medical Center of Chinese PLA General Hospital, 69 Yongding Road, Hai Dian, Beijing 100039, China;
- Correspondence: (H.J.); (Y.G.)
| | - Haixiang Zhang
- Department of Ultrasound, The Third Medical Center of Chinese PLA General Hospital, 69 Yongding Road, Hai Dian, Beijing 100039, China; (H.Z.); (Y.Z.)
| | - Yun Zhang
- Department of Ultrasound, The Third Medical Center of Chinese PLA General Hospital, 69 Yongding Road, Hai Dian, Beijing 100039, China; (H.Z.); (Y.Z.)
| | - Zhaojie Guan
- Department of Organ Transplantation, The Third Medical Center of Chinese PLA General Hospital, 69 Yongding Road, Hai Dian, Beijing 100039, China;
| | - Yongyan Gao
- Department of Ultrasound, The Third Medical Center of Chinese PLA General Hospital, 69 Yongding Road, Hai Dian, Beijing 100039, China; (H.Z.); (Y.Z.)
- Correspondence: (H.J.); (Y.G.)
| |
Collapse
|
17
|
Association of serum bicarbonate with graft survival and mortality in kidney transplant recipients. J Nephrol 2021; 35:619-627. [PMID: 34843097 DOI: 10.1007/s40620-021-01197-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 11/02/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Metabolic acidosis is an independent risk factor for kidney disease progression with a high prevalence after kidney transplantation (KTx). Remarkably, it is still unclear if there is an impact of metabolic acidosis on graft function and death after KTx. Thus, we wanted to investigate if serum bicarbonate is associated with long-term graft outcome and mortality after KTx. METHODS We performed a single-center retrospective study including adult de novo KTx patients between 1999 and 2015. Cox proportional hazard model was used to analyze a possible association between time-dependent serum bicarbonate measurements and graft failure or death. RESULTS Four hundred thirty KTRs were included in the analysis with a mean age of 50.9 ± 13.4 years. Mean observation time was 4.7 ± 2.8 years. Two hundred eighty-four (66%) patients were male and 318 (74%) had received a deceased donor kidney transplant. Mean bicarbonate and eGFR levels 1 year post-transplant amounted to 22.9 ± 3.1 mEq/L and 61 ± 26 ml/min/1.73 m2, respectively. Prevalence of metabolic acidosis was 31% 1 year after transplantation. Fourteen (3%) patients died and 31 (7%) suffered from graft failure. Higher bicarbonate levels were associated with significantly lower hazards for graft failure (Hazard Ratio (HR) = 0.88; 95% Confidence Interval (CI): 0.79-0.98) and mortality (HR = 0.79; 95% CI 0.66-0.93) after adjusting for potential confounders such as age, donor type and time-varying eGFR. CONCLUSIONS Our analysis showed that higher serum bicarbonate levels are positively associated with long-term graft and patient survival in kidney transplant recipients. Thus, serum bicarbonate may serve as a predictor and independent risk factor for graft and patient outcome after KTx as has been previously shown for patients with CKD.
Collapse
|
18
|
Naik AS, Wang SQ, Chowdhury M, Aqeel J, O'Connor CL, Wiggins JE, Bitzer M, Wiggins RC. Critical timing of ACEi initiation prevents compensatory glomerular hypertrophy in the remaining single kidney. Sci Rep 2021; 11:19605. [PMID: 34599260 PMCID: PMC8486841 DOI: 10.1038/s41598-021-99124-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/20/2021] [Indexed: 01/05/2023] Open
Abstract
Increasing evidence suggests that single in kidney states (e.g., kidney transplantation and living donation) progressive glomerulosclerosis limits kidney lifespan. Modeling shows that post-nephrectomy compensatory glomerular volume (GV) increase drives podocyte depletion and hypertrophic stress resulting in proteinuria and glomerulosclerosis, implying that GV increase could serve as a therapeutic target to prevent progression. In this report we examine how Angiotensin Converting Enzyme inhibition (ACEi), started before uninephrectomy can reduce compensatory GV increase in wild-type Fischer344 rats. An unbiased computer-assisted method was used for morphometric analysis. Urine Insulin-like growth factor-1 (IGF-1), the major diver of body and kidney growth, was used as a readout. In long-term (40-week) studies of uni-nephrectomized versus sham-nephrectomized rats a 2.2-fold increase in GV was associated with reduced podocyte density, increased proteinuria and glomerulosclerosis. Compensatory GV increase was largely prevented by ACEi started a week before but not after uni-nephrectomy with no measurable impact on long-term eGFR. Similarly, in short-term (14-day) studies, ACEi started a week before uni-nephrectomy reduced both GV increase and urine IGF-1 excretion. Thus, timing of ACEi in relation to uni-nephrectomy had significant impact on post-nephrectomy "compensatory" glomerular growth and outcomes that could potentially be used to improve kidney transplantation and live kidney donation outcomes.
Collapse
Affiliation(s)
- Abhijit S Naik
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
- , F6676 UHS, 1500 E Medical Center Dr, Ann Arbor, MI, 48109-5676, USA.
| | - Su Q Wang
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Mahboob Chowdhury
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jawad Aqeel
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Jocelyn E Wiggins
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Markus Bitzer
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Roger C Wiggins
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
- , 1570B MSRB2, 1150 W Medical Center Dr, Ann Arbor, MI, 48109-5676, USA.
| |
Collapse
|
19
|
Naik AS, Aqeel J, Wang SQ, Chowdhury M, He K, Wiggins RC. Urine marker analysis identifies evidence for persistent glomerular podocyte injury across allograft lifespan. Clin Transplant 2021; 35:e14457. [PMID: 34387906 DOI: 10.1111/ctr.14457] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 11/27/2022]
Abstract
Long-term kidney transplant (KT) survival has remained relatively stagnant. Protocol biopsy studies suggest that glomerulosclerosis is a significant contributor to long-term graft failure. We previously demonstrated that podocyte loss in the 1st year post-transplantation predicted long-term allograft survival. However, whether increased podocyte loss continues over the lifespan of a KT remains unclear. We performed a cross-sectional analysis of 1,182 urine samples from 260 KT recipients up to 19-years after transplantation. Urine pellet mRNAs were assayed for podocyte (NPHS2/podocin and nephrin/NPHS1), distal tubule (aquaporin2), and profibrotic cytokine (TGFbeta1). Multivariable generalized estimating equations were used to obtain "population-averaged" effects for these markers over time post-KT. Consistent with early stresses both podocyte and tubular markers increased immediately post-KT. However, only podocyte markers continued to increase long-term. A role for hypertrophic stresses in driving podocyte loss over time is implied by their association with donor BMI, recipient BMI and donor-recipient BMI mismatch at transplantation. Furthermore, urine pellet podocin mRNA was associated with urine TGFbeta1, proteinuria and reduced eGFR, thereby linking podocyte injury to allograft fibrosis and survival. In conclusion we observed that podocyte loss continues long-term post-KT suggesting an important role in driving late graft loss. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Abhijit S Naik
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jawad Aqeel
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Su Q Wang
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Mahboob Chowdhury
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Kevin He
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Roger C Wiggins
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
20
|
Wojciechowski D, Wiseman A. Long-Term Immunosuppression Management: Opportunities and Uncertainties. Clin J Am Soc Nephrol 2021; 16:1264-1271. [PMID: 33853841 PMCID: PMC8455033 DOI: 10.2215/cjn.15040920] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The long-term management of maintenance immunosuppression in kidney transplant recipients remains complex. The vast majority of patients are treated with the calcineurin inhibitor tacrolimus as the primary agent in combination with mycophenolate, with or without corticosteroids. A tacrolimus trough target 5-8 ng/ml seems to be optimal for rejection prophylaxis, but long-term tacrolimus-related side effects and nephrotoxicity support the ongoing evaluation of noncalcineurin inhibitor-based regimens. Current alternatives include belatacept or mammalian target of rapamycin inhibitors. For the former, superior kidney function at 7 years post-transplant compared with cyclosporin generated initial enthusiasm, but utilization has been hampered by high initial rejection rates. Mammalian target of rapamycin inhibitors have yielded mixed results as well, with improved kidney function tempered by higher risk of rejection, proteinuria, and adverse effects leading to higher discontinuation rates. Mammalian target of rapamycin inhibitors may play a role in the secondary prevention of squamous cell skin cancer as conversion from a calcineurin inhibitor to an mammalian target of rapamycin inhibitor resulted in a reduction of new lesion development. Early withdrawal of corticosteroids remains an attractive strategy but also is associated with a higher risk of rejection despite no difference in 5-year patient or graft survival. A major barrier to long-term graft survival is chronic alloimmunity, and regardless of agent used, managing the toxicities of immunosuppression against the risk of chronic antibody-mediated rejection remains a fragile balance.
Collapse
Affiliation(s)
- David Wojciechowski
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | | |
Collapse
|
21
|
|
22
|
Krejčí K, Tichý T, Bednaříková J, Bartková M, Žamboch K, Orság J, Zadražil J. Nephrotoxicity of calcineurin inhibitors as a risk factor for BK polyomavirus replication after kidney transplantation. J Med Virol 2021; 93:3871-3879. [PMID: 32940913 DOI: 10.1002/jmv.26520] [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: 06/04/2020] [Revised: 09/04/2020] [Accepted: 09/14/2020] [Indexed: 11/11/2022]
Abstract
BK polyomavirus-associated nephropathy (PyVAN) is responsible for a significant percentage of transplanted kidneys prematurely terminating their function. Its occurrence is closely related to the intensity of immunosuppressive therapy. In a group of 161 newly transplanted patients, we prospectively evaluated 457 protocol renal biopsies performed within the first year after transplantation. Using the calcineurin inhibitors (CI) nephrotoxicity score, the incidence of nephrotoxicity was monitored as a manifestation of excessive immunosuppression. Findings were correlated with clinical evidence of active BK polyomavirus (BKPyV) replication and PyVAN. Compared to the normal histology, nephrotoxicity was associated with more frequent BKPyV viremia and viruria (p = .01 and p < .01, respectively) and more common occurrence of PyVAN. The persistence of toxicity in the subsequent biopsy proved to be a negative risk factor of viremia and viruria (p = .03 and p < .01, respectively), independently of the initial BKPyV status. Toxicity could also be used as a predictor of viremia and viruria (p = .04 and p < .01, respectively) even in the absence of viral replication at the time of initial biopsy. The early histological manifestation of CI nephrotoxicity was associated with significant BKPyV reactivation in the risky first posttransplant year.
Collapse
Affiliation(s)
- Karel Krejčí
- Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Tomáš Tichý
- Department of Clinical and Molecular Pathology, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Jana Bednaříková
- Department of Clinical Biochemistry, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Margita Bartková
- Department of Microbiology, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Kamil Žamboch
- Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Jiří Orság
- Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Josef Zadražil
- Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| |
Collapse
|
23
|
Hruba P, Madill-Thomsen K, Mackova M, Maluskova J, Voska L, Slatinska J, Halloran PF, Viklicky O. Three-month course of intragraft transcriptional changes in kidney allografts with early histological minimal injury - a cohort study. Transpl Int 2021; 34:974-985. [PMID: 33650206 DOI: 10.1111/tri.13856] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/08/2021] [Accepted: 02/24/2021] [Indexed: 11/30/2022]
Abstract
The tubulitis with/without interstitial inflammation not meeting criteria for T-cell-mediated rejection (minimal allograft injury) is the most frequent histological findings in early transplant biopsies. The course of transcriptional changes in sequential kidney graft biopsies has not been studied yet. Molecular phenotypes were analyzed using the Molecular Microscope® Diagnostic System (MMDx) in 46 indication biopsies (median 13 postoperative days) diagnosed as minimal allograft injury and in corresponding follow-up biopsies at 3 months. All 46 patients with minimal injury in early biopsy received steroid pulses. MMDx interpreted indication biopsies as no-rejection in 34/46 (74%), T-cell-mediated rejection (TCMR) in 4/46 (9%), antibody-mediated rejection in 6/46 (13%), and mixed rejection in 2/46 (4%) cases. Follow-up biopsies were interpreted by MMDx in 37/46 (80%) cases as no-rejection, in 4/46 (9%) as TCMR, and in 5/46 (11%) as mixed rejection. Follow-up biopsies showed a decrease in MMDx-assessed acute kidney injury (P = 0.001) and an increase of atrophy-fibrosis (P = 0.002). The most significant predictor of MMDx rejection scores in follow-up biopsies was the tubulitis classifier score in initial biopsies (AUC = 0.84, P = 0.002), confirmed in multivariate binary regression (OR = 16, P = 0.016). Molecular tubulitis score at initial biopsy has the potential to discriminate patients at risk for molecular rejection score at follow-up biopsy.
Collapse
Affiliation(s)
- Petra Hruba
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Katelynn Madill-Thomsen
- Alberta Transplant Applied Genomics Centre, Edmonton, AB, Canada.,University of Alberta, Edmonton, AB, Canada
| | - Martina Mackova
- Alberta Transplant Applied Genomics Centre, Edmonton, AB, Canada
| | - Jana Maluskova
- Department of Pathology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ludek Voska
- Department of Pathology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Janka Slatinska
- Department of Nephrology and Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Philip F Halloran
- Alberta Transplant Applied Genomics Centre, Edmonton, AB, Canada.,University of Alberta, Edmonton, AB, Canada
| | - Ondrej Viklicky
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Department of Nephrology and Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| |
Collapse
|
24
|
Kuhn C, Lang BM, Lörcher S, Karolin A, Binet I, Beldi G, Golshayan D, Hadaya K, Mueller TF, Schaub S, Immer F, Stampf S, Koller M, Sidler D. Outcome of kidney transplantation from very senior donors in Switzerland - a national cohort study. Transpl Int 2021; 34:689-699. [PMID: 33529392 DOI: 10.1111/tri.13836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/18/2020] [Accepted: 01/29/2021] [Indexed: 11/29/2022]
Abstract
Kidney transplantation from older and marginal donors is effective to confront organ shortage. However, limitations after transplantation of kidneys from very marginal kidney donors remain unclear. We compared patient and graft outcome, achieved allograft function and quality of life of renal transplantations from Very Senior Donors (VSD, defined as donors aged 70 years and older) with Senior Donors (SD, aged 60-70 years) and Regular Donors (RD, aged younger than 60 years) in Switzerland. We evaluated the outcome of 1554 adult recipients of deceased donor kidney transplantations from 05/2008 to 12/2019; median follow-up was 4.7 years. Failure-free survival (freedom from graft loss or death), glomerular filtration rate (eGFR), and quality of life at 12 months were analyzed for RD (reference group, n = 940), SD (n = 404), and VSD (n = 210). Failure-free survival decreased with increasing donor age, mainly attributable to premature graft loss. Still, overall 5-year failure-free survival reached 83.1%, 81.0%, and 64.0% in the RD, SD, and VSD subgroups, respectively. eGFR 12 months post-transplantation was significantly higher in RD compared with SD and VSD. The acceptance rate of donor candidates for kidney TPL was 78% for the entire cohort (87% for RD, 79% for SD, and 56% for VSD). Deceased donor kidney transplantation from donors aged 70 years or older is associated with an inferior, yet acceptable failure-free outcome, with sustained quality of life.
Collapse
Affiliation(s)
- Christian Kuhn
- Klinik für Nephrologie und Hypertonie, Inselspital, Bern, Switzerland
| | - Brian M Lang
- Klinik für Transplantationsimmunologie und Nephrologie, Universitätsspital Basel, Basel, Switzerland.,Swiss Transplant Cohort Study (STCS), Basel, Switzerland
| | - Sylvia Lörcher
- Klinik für Nephrologie und Hypertonie, Inselspital, Bern, Switzerland
| | - Andrea Karolin
- Klinik für Nephrologie und Hypertonie, Inselspital, Bern, Switzerland
| | - Isabelle Binet
- Klinik für Nephrologie und Transplantationsmedizin, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Guido Beldi
- Klinik für Viszerale Chirurgie und Medizin, Inselspital, Bern, Switzerland
| | - Délaviz Golshayan
- Centre de Transplantation d'organes et Service de Néphrologie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Karine Hadaya
- Service de Néphrologie et Hypertension, Hôpitaux Universitaires Genève, Genève, Switzerland
| | - Thomas F Mueller
- Klinik für Nephrologie, Universitätsspital Zürich, Zürich, Switzerland
| | - Stefan Schaub
- Klinik für Transplantationsimmunologie und Nephrologie, Universitätsspital Basel, Basel, Switzerland
| | | | - Susanne Stampf
- Klinik für Transplantationsimmunologie und Nephrologie, Universitätsspital Basel, Basel, Switzerland.,Swiss Transplant Cohort Study (STCS), Basel, Switzerland
| | - Michael Koller
- Klinik für Transplantationsimmunologie und Nephrologie, Universitätsspital Basel, Basel, Switzerland
| | - Daniel Sidler
- Klinik für Nephrologie und Hypertonie, Inselspital, Bern, Switzerland
| |
Collapse
|
25
|
Suo C, Gui Z, Wang Z, Zhou J, Zheng M, Chen H, Fei S, Gu M, Tan R. Bortezomib limits renal allograft interstitial fibrosis by inhibiting NF-κB/TNF-α/Akt/mTOR/P70S6K/Smurf2 pathway via IκBα protein stabilization. Clin Sci (Lond) 2021; 135:53-69. [PMID: 33289516 DOI: 10.1042/cs20201038] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 11/26/2020] [Accepted: 12/08/2020] [Indexed: 01/06/2023]
Abstract
Chronic allograft dysfunction is a major cause of late graft failure after kidney transplantation. One of the histological changes is interstitial fibrosis, which is associated with epithelial-mesenchymal transition. Bortezomib has been reported to prevent the progression of fibrosis in organs. We used rat renal transplantation model and human kidney 2 cell line treated with tumor necrosis factor-α (TNF-α) to examine their response to bortezomib. To explore the mechanism behind it, we assessed the previously studied TNF-α/protein kinase B (Akt)/Smad ubiquitin regulatory factor 2 (Smurf2) signaling and performed RNA sequencing. Our results suggested that bortezomib could attenuate the TNF-α-induced epithelial-mesenchymal transition and renal allograft interstitial fibrosis in vitro and in vivo. In addition to blocking Akt/mammalian target of rapamycin (mTOR)/p70S6 kinase/Smurf2 signaling, bortezomib's effect on the epithelial-mesenchymal transition was associated with inhibition of nuclear factor kappa B (NF-κB) pathway by stabilizing inhibitor of NF-κB. The study highlighted the therapeutic potential of bortezomib on renal allograft interstitial fibrosis. Such an effect may result from inhibition of NF-κB/TNF-α/Akt/mTOR/p70S6 kinase/Smurf2 signaling via stabilizing protein of inhibitor of NF-κB.
Collapse
Affiliation(s)
- Chuanjian Suo
- Department of Urology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - Zeping Gui
- Department of Urology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - Zijie Wang
- Department of Urology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - Jiajun Zhou
- Department of Urology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - Ming Zheng
- Department of Urology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - Hao Chen
- Department of Urology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - Shuang Fei
- Department of Urology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - Min Gu
- Department of Urology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - Ruoyun Tan
- Department of Urology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| |
Collapse
|
26
|
Chronic Histologic Changes Are Present Regardless of HLA Mismatches: Evidence from HLA Identical Living Donor Kidney Transplants. Transplantation 2020; 105:e244-e256. [PMID: 33315759 DOI: 10.1097/tp.0000000000003579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND At 5 and 10 years after kidney transplantation, chronic histologic changes such as arteriolar hyalinosis and mesangial expansion are common, however, determining etiology is difficult. We compared surveillance biopsies in living donor kidney transplants (LDKTx) from HLA matched siblings (termed HLA-identical (HLA-ID)) to HLA non-ID to investigate which histologic changes were likely due to alloimmune injury and which were due to non-alloimmune injury. METHODS We performed a retrospective, cohort study comparing HLA-ID sibling LDKTx (n=175) to HLA non-ID LDKTx (n=175; matched for age, sex and year of transplant +/- 2 years) performed at a single institution from 03/1999 to 11/2018. RESULTS Baseline characteristics and maintenance immunosuppression were similar. Mortality rates were similar, but in the HLA-ID group, 10-year death-censored graft survival was higher (93.8% vs 80.9% HLA non-ID LDKTx, p<0.001), rejection rates were lower (after 1 year 9.6% vs 27.1%; p<0.001) and Banff inflammation scores including glomerulitis and peritubular capillaritis were lower on surveillance biopsies at 1, 5 and 10 years. In contrast, chronic Banff scores (interstitial fibrosis, arteriolar hyalinosis, mesangial expansion, etc.) were similar in prevalence and severity on surveillance biopsies at 1, 5 and 10 years. CONCLUSIONS HLA-ID LDKTx have less inflammation and less transplant glomerulopathy, but most chronic histologic changes were similar to less-well matched LDKTx. We conclude that these types of chronic changes are not associated with HLA mismatches and may be due to non-immunologic causes (hypertension, obesity, etc.) suggesting that new management approaches to prevent these lesions may be needed.
Collapse
|
27
|
Chen CC, Lin WC, Lee CY, Yang CY, Tsai MK. Two-year protocol biopsy after kidney transplantation in clinically stable recipients - a retrospective study. Transpl Int 2020; 34:185-193. [PMID: 33152140 DOI: 10.1111/tri.13785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/14/2020] [Accepted: 11/02/2020] [Indexed: 12/25/2022]
Abstract
The idea of protocol biopsy is to detect subclinical pathologies, including rejection, recurrent disease, or infection for early intervention and adjustment of immunosuppressants. Nevertheless, it is not adopted by most clinicians because of its low yield rate and uncertain long-term benefits. This retrospective study evaluated the impact of protocol biopsy on renal function and allograft survival. A two-year protocol biopsy was proposed for 190 stable patients; 68 of them accepted [protocol biopsy (PB) group], while 122 did not [nonprotocol biopsy (NPB) group]. The rejection diagnosis was made in 13 patients by protocol biopsy, and 11 of them had borderline rejection. In the following 5 years, graft survival was better in the PB group than in the NPB group (P = 0.0143). A total of 4 and 17 patients in the PB and NPB groups, respectively, had rejection events proven by indication biopsy. Renal function was better preserved in the PB group than in the NPB group (P = 0.0107) for patients with rejection events. Nevertheless, the survival benefit disappeared by a longer follow-up period (12-year, P = 0.2886). In conclusion, 2-year protocol biopsy detects subclinical pathological changes in rejection and preserves renal function by early intervention so as to prolong graft survival within 5 years.
Collapse
Affiliation(s)
- Chien-Chia Chen
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Chou Lin
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Yuan Lee
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Yao Yang
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Meng-Kun Tsai
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.,Division of General Surgery, Department of Surgery, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan
| |
Collapse
|
28
|
Kukla A, Alexander MP, Turkevi-Nagy S, Merzkani M, Park W, Smith B, Zhang P, Benavides X, D'Costa M, Morales Alvarez C, Denic A, Bentall A, Kudva YC, Stegall M. Mesangial expansion at 5 years predicts death and death-censored graft loss after renal transplantation. Clin Transplant 2020; 35:e14147. [PMID: 33170556 DOI: 10.1111/ctr.14147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 11/04/2020] [Indexed: 11/28/2022]
Abstract
Death with a functioning graft and death-censored renal allograft failure remain major problems for which effective preventative protocols are lacking. The retrospective cohort study aimed to determine whether histologic changes on a 5-year surveillance kidney biopsy predict adverse outcomes after transplantation in recipients who had: both Type 2 diabetes (T2DM) and obesity (BMI ≥ 30 kg/m2 ) at the time of transplantation (T2DM/Obesity, n = 75); neither (No T2DM/No obesity, n = 78); No T2DM/Obesity (n = 41), and T2DM/No obesity (n = 47). On 5-year biopsies, moderate-to-severe mesangial expansion was more common in the T2DM/Obesity group (Banff mm score ≥2 = 49.3%; Tervaert classification MS ≥ 2b = 26.7%) compared to the other groups (p < .001 for both scores). Risk factors included older age, higher BMI, HbA1C, and triglycerides at 1-year post-transplant. Moderate-to-severe mesangial expansion correlated with death with function (HR 1.74 (1.01, 2.98), p = .045 Banff and 1.89 (1.01, 3.51) p = .045 Tervaert) and with death-censored graft loss (HR 3.2 (1.2, 8.8), p = .02 Banff and HR 3.8 (1.3, 11.5), p = .01 Tervaert) over a mean of 11.6 years of recipient follow-up post-transplant. These data suggest that mesangial expansion in recipients with T2DM and obesity may reflect systemic vascular injury and might be a novel biomarker to predict adverse outcomes post renal transplant.
Collapse
Affiliation(s)
- Aleksandra Kukla
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.,William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | | | - Sandor Turkevi-Nagy
- Department of Pathology, Albert Szent-Györgyi Health Centre, University of Szeged, Szeged, Hungary
| | - Massini Merzkani
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Walter Park
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA.,Division of Transplant Surgery, Departments of Surgery and Immunology, Mayo Clinic, Rochester, MN, USA
| | - Byron Smith
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA.,Division of Transplant Surgery, Departments of Surgery and Immunology, Mayo Clinic, Rochester, MN, USA
| | - Pingchuan Zhang
- Department of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
| | - Xiomara Benavides
- Division of Transplant Surgery, Departments of Surgery and Immunology, Mayo Clinic, Rochester, MN, USA
| | - Matthew D'Costa
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Catalina Morales Alvarez
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA.,Division of Transplant Surgery, Departments of Surgery and Immunology, Mayo Clinic, Rochester, MN, USA
| | - Aleksandar Denic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Andrew Bentall
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Yogish C Kudva
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA.,Division of Endocrinology, Diabetes, Metabolism, & Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Mark Stegall
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA.,Division of Transplant Surgery, Departments of Surgery and Immunology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
29
|
Gierczak V, Jouve T, Malvezzi P, Terrec F, Naciri-Bennani H, Janbon B, Rostaing L, Noble J. Impact of Immunosuppressive Strategies on Post-Kidney Transplantation Thrombocytopenia. Transplant Proc 2020; 53:941-949. [PMID: 33121819 DOI: 10.1016/j.transproceed.2020.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/11/2020] [Accepted: 09/18/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Thrombocytopenia after kidney transplantation is a common complication, partly induced by immunosuppressive therapies. Peritransplant thrombocytopenia may cause serious hemorrhages. We assessed the incidence of early posttransplantation thrombocytopenia (defined as a platelet count of <150,000 mm3 or <150 G/L) in de novo kidney transplant recipients (KTRs) across 4 immunosuppressive regimens. METHODS This was a single-center observational study that included all consecutive KTRs who received either Thymoglobulin (THY) or Grafalon (GRA) and maintenance therapy of either mycophenolate-mofetil (MMF) or everolimus (EVR), associated with tacrolimus/corticosteroids. RESULTS Between July 27, 2016, and September 7, 2018, 237 KTRs were included; 64.6% experienced thrombocytopenia within the first week. Thrombocytopenia was significantly more frequent (P = .004) among GRA-treated patients (73.4%) compared to THY-treated patients (61.3%). These patients also had lower nadir platelet count (120 ± 52 vs 142 ± 48 G/L; P = .002) and lower platelet count at discharge (227 ± 94 vs 243 ± 92 G/L; P = .25). More of the GRA-EVR group had thrombocytopenia (81.0% vs 61.4% in THY-MMF, 60.9% in THY-EVR, and 69.8% in GRA-MMF; P = .081) and a worse nadir platelet count (109 ± 41 in GRA-EVR vs 141 ± 47G/L in THY-MMF, 145 ± 52 G/L in THY-EVR, and 125 ± 56 G/L in GRA-MMF; P = .011) but GRA was the only risk factor for thrombocytopenia in multivariate analyses (P = .002). Rates of hemorrhage, red blood cell transfusions, reoperations needed within the first week, delayed graft function, acute rejection, graft loss, and death did not differ between the groups after a mean follow-up of 25 ± 8 months. CONCLUSIONS GRA associated with EVR led to more frequent and severe thrombocytopenia, although we found no significant clinical consequences.
Collapse
Affiliation(s)
- Valentine Gierczak
- Nephrology Department, Hémodialyse, Apheresis and Renal Transplantation, CHU Grenoble-Alpes, Grenoble, France; Grenoble Alpes University, Grenoble, France
| | - Thomas Jouve
- Nephrology Department, Hémodialyse, Apheresis and Renal Transplantation, CHU Grenoble-Alpes, Grenoble, France; Grenoble Alpes University, Grenoble, France
| | - Paolo Malvezzi
- Nephrology Department, Hémodialyse, Apheresis and Renal Transplantation, CHU Grenoble-Alpes, Grenoble, France
| | - Florian Terrec
- Nephrology Department, Hémodialyse, Apheresis and Renal Transplantation, CHU Grenoble-Alpes, Grenoble, France
| | - Hamza Naciri-Bennani
- Nephrology Department, Hémodialyse, Apheresis and Renal Transplantation, CHU Grenoble-Alpes, Grenoble, France
| | - Benedicte Janbon
- Nephrology Department, Hémodialyse, Apheresis and Renal Transplantation, CHU Grenoble-Alpes, Grenoble, France
| | - Lionel Rostaing
- Nephrology Department, Hémodialyse, Apheresis and Renal Transplantation, CHU Grenoble-Alpes, Grenoble, France; Grenoble Alpes University, Grenoble, France.
| | - Johan Noble
- Nephrology Department, Hémodialyse, Apheresis and Renal Transplantation, CHU Grenoble-Alpes, Grenoble, France
| |
Collapse
|
30
|
Everolimus Initiation With Early Calcineurin Inhibitor Withdrawal in De Novo Heart Transplant Recipients: Long-term Follow-up From the Randomized SCHEDULE Study. Transplantation 2020; 104:154-164. [PMID: 30893292 DOI: 10.1097/tp.0000000000002702] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND A calcineurin inhibitor (CNI)-free immunosuppressive regimen has been demonstrated to improve renal function early after heart transplantation, but long-term outcome of such a strategy has not been well described. METHODS In the randomized SCHEDULE trial, de novo heart transplant recipients received (1) everolimus with reduced-exposure CNI (cyclosporine) followed by CNI withdrawal at week 7-11 posttransplant or (2) standard-exposure cyclosporine, both with mycophenolate mofetil and corticosteroids; 95/115 randomized patients were followed up at 5-7 years posttransplant. RESULTS Mean measured glomerular filtration rate was 74.7 mL/min and 62.4 mL/min with everolimus and CNI, respectively. The mean difference was in favor of everolimus by 11.8 mL/min in the intent-to-treat population (P = 0.004) and 17.2 mL/min in the per protocol population (n = 75; P < 0.001). From transplantation to last follow-up, the incidence of biopsy-proven acute rejection (BPAR) was 77% (37/48) and 66% (31/47) (P = 0.23) with treated BPAR in 50% and 23% (P < 0.01) in the everolimus and CNI groups, respectively; no episode led to hemodynamic compromise. Coronary allograft vasculopathy (CAV) assessed by coronary intravascular ultrasound was present in 53% (19/36) and 74% (26/35) of everolimus- and CNI-treated patients, respectively (P = 0.037). Graft dimensions and function were similar between the groups. Late adverse events were comparable. CONCLUSIONS These results suggest that de novo heart transplant patients randomized to everolimus and low-dose CNI followed by CNI-free therapy maintain significantly better long-term renal function as well as significantly reduced CAV than patients randomized to standard CNI treatment. Increased BPAR in the everolimus group during year 1 did not impair long-term graft function.
Collapse
|
31
|
El Ters M, Bobart SA, Cornell LD, Leung N, Bentall A, Sethi S, Fidler M, Grande J, Hernandez LH, Cosio FG, Zand L, Amer H, Fervenza FC, Nasr SH, Alexander MP. Recurrence of DNAJB9-Positive Fibrillary Glomerulonephritis After Kidney Transplantation: A Case Series. Am J Kidney Dis 2020; 76:500-510. [PMID: 32414663 DOI: 10.1053/j.ajkd.2020.01.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 01/26/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Fibrillary glomerulonephritis (FGN) is a rare glomerular disease that often progresses to kidney failure requiring kidney replacement therapy. We have recently identified a novel biomarker of FGN, DnaJ homolog subfamily B member 9 (DNAJB9). In this study, we used sequential protocol allograft biopsies and DNAJB9 staining to help characterize a series of patients with native kidney FGN who underwent kidney transplantation. STUDY DESIGN Case series. SETTING & PARTICIPANTS Between 1996 and 2016, kidney transplantation was performed on 19 patients with a reported diagnosis of FGN in their native/transplant kidneys. Using standard diagnostic criteria and DNAJB9 staining, we excluded 5 patients (4 atypical cases diagnosed as possible FGN and 1 donor-derived FGN). Protocol allograft biopsies had been performed at 4, 12, 24, 60, and 120 months posttransplantation. DNAJB9 immunohistochemistry was performed using an anti-DNAJB9 rabbit polyclonal antibody. Pre- and posttransplantation demographic and clinical characteristics were collected. Summary statistical analysis was performed, including nonparametric statistical tests. OBSERVATIONS The 14 patients with FGN had a median posttransplantation follow-up of 5.7 (IQR, 2.9-13.8) years. 3 (21%) patients had recurrence of FGN, detected on the 5- (n=1) and 10-year (n=2) allograft biopsies. Median time to recurrence was 10.2 (IQR, 5-10.5) years. Median levels of proteinuria and iothalamate clearance at the time of recurrence were 243mg/d and 56mL/min. The remaining 11 patients had no evidence of histologic recurrence on the last posttransplantation biopsy, although the median time of follow-up was significantly less at 4.4 (IQR, 2.9-14.4) years. 3 (21%) patients had a monoclonal protein detectable in serum obtained pretransplantation; none of these patients had recurrent FGN. LIMITATIONS Small study sample and shorter follow-up time in the nonrecurrent versus recurrent group. CONCLUSIONS In this series, FGN had an indolent course in the kidney allograft in that detectable histologic recurrence did not appear for at least 5 years posttransplantation.
Collapse
Affiliation(s)
- Mireille El Ters
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; William von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Shane A Bobart
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Lynn D Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Andrew Bentall
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; William von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Mary Fidler
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Joseph Grande
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Fernando G Cosio
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; William von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Ladan Zand
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Hatem Amer
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; William von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | | | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Mariam P Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN.
| |
Collapse
|
32
|
Dao M, Pouliquen C, Duquesne A, Posseme K, Mussini C, Durrbach A, Guettier C, François H, Ferlicot S. Usefulness of morphometric image analysis with Sirius Red to assess interstitial fibrosis after renal transplantation from uncontrolled circulatory death donors. Sci Rep 2020; 10:6894. [PMID: 32327683 PMCID: PMC7181605 DOI: 10.1038/s41598-020-63749-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 03/19/2020] [Indexed: 11/12/2022] Open
Abstract
Early interstitial fibrosis (IF) correlates with long-term renal graft dysfunction, highlighting the need for accurate quantification of IF. However, the currently used Banff classification exhibits some limitations. The aim of our study was to precisely describe the progression of IF after renal transplantation using a new morphometric image analysis method relying of Sirius Red staining. The morphometric analysis we developed showed high inter-observer and intra-observer reproducibility, with ICC [95% IC] of respectively 0.75 [0.67–0.81] (n = 151) and 0.88 [0.72–0.95] (n = 21). We used this method to assess IF (mIF) during the first year after the kidney transplantation from 66 uncontrolled donors after circulatory death (uDCD). Both mIF and interstitial fibrosis (ci) according to the Banff classification significantly increased the first three months after transplantation. From M3 to M12, mIF significantly increased whereas Banff classification failed to highlight increase of ci. Moreover, mIF at M12 (p = 0.005) correlated with mean time to graft function recovery and was significantly associated with increase of creatininemia at M12 and at last follow-up. To conclude, the new morphometric image analysis method we developed, using a routine and cheap staining, may provide valuable tool to assess IF and thus to evaluate new sources of grafts.
Collapse
Affiliation(s)
- Myriam Dao
- AP-HP, Service de Néphrologie adulte, Hôpital Necker, 75015, Paris, France.,Inserm UMR_S 1155, Hôpital Tenon, 75020, Paris, France
| | | | - Alyette Duquesne
- Service de Néphrologie, CHI André Grégoire, 93100, Montreuil, France
| | - Katia Posseme
- AP-HP, Service d'Anatomie et de Cytologie Pathologiques, Hôpital de Bicêtre, 94270 Le Kremlin Bicêtre, France, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Charlotte Mussini
- AP-HP, Service d'Anatomie et de Cytologie Pathologiques, Hôpital de Bicêtre, 94270 Le Kremlin Bicêtre, France, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Antoine Durrbach
- AP-HP, Service de Néphrologie, Hôpital de Bicêtre, 94270 Le Kremlin Bicêtre, France, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Catherine Guettier
- AP-HP, Service d'Anatomie et de Cytologie Pathologiques, Hôpital de Bicêtre, 94270 Le Kremlin Bicêtre, France, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Hélène François
- Inserm UMR_S 1155, Hôpital Tenon, 75020, Paris, France. .,AP-HP, Unité de Néphrologie et de Transplantation rénale, Hôpital Tenon, 4 rue de la Chine, 75020 Paris, Sorbonne Université, Paris, France.
| | - Sophie Ferlicot
- AP-HP, Service d'Anatomie et de Cytologie Pathologiques, Hôpital de Bicêtre, 94270 Le Kremlin Bicêtre, France, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France
| |
Collapse
|
33
|
Naik AS, Afshinnia F, Aqeel J, Cibrik DM, Samaniego M, Wickman L, Wang SQ, Chowdhury M, Wiggins RC. Accelerated podocyte detachment early after kidney transplantation is related to long-term allograft loss of function. Nephrol Dial Transplant 2020; 34:1232-1239. [PMID: 30500951 DOI: 10.1093/ndt/gfy350] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Kidney allograft half-life has not improved despite excellent short-term survival. Recent long-term surveillance biopsy studies identify accumulating glomerulosclerosis (GS) to be associated with late allograft loss. While podocyte depletion is well known to drive proteinuria and GS in animal models and human glomerular diseases, its role in renal allograft loss of function is generally not recognized. METHODS To address these questions, we collected urine from 125 kidney allograft recipients in the first posttransplant year for urine pellet messenger RNA (mRNA) and protein analysis, with a median follow up of 4.5 years. RESULTS Using multivariable linear models adjusted for proteinuria, transplant, recipient and donor factors, we observed that the average urine pellet podocin mRNA normalized to urine creatinine (UPodCR) in the first posttransplant year was significantly associated with an estimated glomerular filtration rate (eGFR) decline (P = 0.001). The relationship between UPodCR and eGFR decline persisted even among recipients who were nonproteinuric and who had no recurrent or de novo glomerular disease identified on 1-year protocol biopsy. Finally, we identified recipient, donor and recipient:donor body surface area mismatch ratio to be independently associated with UPodCR early after transplantation. A larger donor was protective, while a larger recipient and increased recipient:donor size mismatch ratio were associated with increased UPodCR. CONCLUSIONS These findings support the concept that in kidney allografts, accelerated podocyte loss precedes proteinuria and is associated with inferior long-term allograft outcomes as measured by eGFR decline and may be initiated by recipient:donor size mismatch. Modulating factors driving early podocyte detachment after kidney transplantation may help improve long-term outcomes.
Collapse
Affiliation(s)
- Abhijit S Naik
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Farsad Afshinnia
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jawad Aqeel
- College of Literature, Science, and the Arts, University of Michigan, Ann Arbor, MI, USA
| | - Diane M Cibrik
- Department of Internal Medicine, University of Kansas, Kansas City, KS, USA
| | | | - Larysa Wickman
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - Su Q Wang
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Mahboob Chowdhury
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Roger C Wiggins
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
34
|
The Causes of Kidney Allograft Failure: More Than Alloimmunity. A Viewpoint Article. Transplantation 2020; 104:e46-e56. [DOI: 10.1097/tp.0000000000003012] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
35
|
Conversion to Everolimus was Beneficial and Safe for Fast and Slow Tacrolimus Metabolizers After Renal Transplantation. J Clin Med 2020; 9:jcm9020328. [PMID: 31979381 PMCID: PMC7074544 DOI: 10.3390/jcm9020328] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 01/14/2020] [Accepted: 01/20/2020] [Indexed: 12/17/2022] Open
Abstract
Fast tacrolimus (TAC) metabolism (concentration/dose (C/D) ratio <1.05 ng/mL/mg) is a risk factor for inferior outcomes after renal transplantation (RTx) as it fosters, e.g., TAC-related nephrotoxicity. TAC minimization or conversion to calcineurin-inhibitor free immunosuppression are strategies to improve graft function. Hence, we hypothesized that especially patients with a low C/D ratio profit from a switch to everolimus (EVR). We analyzed data of 34 RTx recipients (17 patients with a C/D ratio <1.05 ng/mL/mg vs. 17 patients with a C/D ratio ≥1.05 ng/mL/mg) who were converted to EVR within 24 months after RTx. The initial immunosuppression consisted of TAC, mycophenolate, prednisolone, and basiliximab induction. During an observation time of 36 months after changing immunosuppression from TAC to EVR, renal function, laboratory values, and adverse effects were compared between the groups. Fast TAC metabolizers were switched to EVR 4.6 (1.5–21.9) months and slow metabolizers 3.3 (1.8–23.0) months after RTx (p = 0.838). Estimated glomerular filtration rate (eGFR) did not differ between the groups at the time of conversion (baseline). Thereafter, the eGFR in all patients increased noticeably (fast metabolizers eGFR 36 months: + 11.0 ± 11.7 (p = 0.005); and slow metabolizers eGFR 36 months: + 9.4 ± 15.9 mL/min/1.73 m2 (p = 0.049)) vs. baseline. Adverse events were not different between the groups. After the switch, eGFR values of all patients increased statistically noticeably with a tendency towards a higher increase in fast TAC metabolizers. Since conversion to EVR was safe in a three-year follow-up for slow and fast TAC metabolizers, this could be an option to protect fast metabolizers from TAC-related issues.
Collapse
|
36
|
The Use of GLP1R Agonists for the Treatment of Type 2 Diabetes in Kidney Transplant Recipients. Transplant Direct 2020; 6:e524. [PMID: 32095510 PMCID: PMC7004635 DOI: 10.1097/txd.0000000000000971] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 11/25/2019] [Indexed: 12/16/2022] Open
Abstract
Glucagon-like peptide-1 receptor agonists (GLP1RA) have been shown to improve glucose control and diabetes-related comorbidities in patients without solid organ transplants. The effectiveness, safety, and tolerability of GLP1RA after kidney transplantation have not been adequately studied.
Collapse
|
37
|
Khan AR, Raza A, Firasat S, Abid A. CYP3A5 gene polymorphisms and their impact on dosage and trough concentration of tacrolimus among kidney transplant patients: a systematic review and meta-analysis. THE PHARMACOGENOMICS JOURNAL 2020; 20:553-562. [PMID: 31902947 DOI: 10.1038/s41397-019-0144-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 11/29/2019] [Accepted: 12/18/2019] [Indexed: 12/11/2022]
Abstract
Tacrolimus is an immunosuppressive drug widely used in kidney transplantation. Cytochrome P450 3A5 (CYP3A5) protein is involved in tacrolimus metabolism. Single nucleotide polymorphism in the CYP3A5 gene (6986A>G) results in alteration in metabolic activity of CYP3A5 protein which eventually affects the tacrolimus concentration. Patients with CYP3A5 expresser genotypes (A/A *1/*1 and A/G *1/*3) metabolize tacrolimus more rapidly than CYP3A5 nonexpressers (G/G *3/*3). We performed meta-analysis to estimate the effect of CYP3A5 polymorphism on the trough concentration-dose ratio (Co/D) and risk of renal allograft rejection with similar post-transplant periods and Asian vs. European populations. Our results showed that the tacrolimus Co/D ratio is significantly lower in CYP3A5 expresser group as compared with nonexpresser in Asian as well as in European populations at any post-transplant period (p < 0.00001). No significant association was found with renal allograft rejection episodes between expressers and nonexpressers in European populations (OR: 1.12; p = 0.47). Interestingly, Asian population (with expresser genotypes) and patients after 3 years post-transplantation (with expresser genotypes) have a higher risk of rejection (OR: 1.62; p < 0.05), (OR: 1.68; p < 0.05), respectively. This could be due to high prevalence of expresser genotypes in Asian population. Few tacrolimus-based studies are identified with long-term graft survival. There is a need to have more studies looking for long-term graft survival in expresser as well as no-expresser groups especially in Asian populations who have high frequency of CYP3A5 functional genotype.
Collapse
Affiliation(s)
- Abdul Rafay Khan
- Centre for Human Genetics and Molecular Medicine, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Ali Raza
- Centre for Human Genetics and Molecular Medicine, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Sadaf Firasat
- Centre for Human Genetics and Molecular Medicine, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Aiysha Abid
- Centre for Human Genetics and Molecular Medicine, Sindh Institute of Urology and Transplantation, Karachi, Pakistan.
| |
Collapse
|
38
|
Reindl-Schwaighofer R, Heinzel A, Gualdoni GA, Mesnard L, Claas FHJ, Oberbauer R. Novel insights into non-HLA alloimmunity in kidney transplantation. Transpl Int 2019; 33:5-17. [PMID: 31650645 PMCID: PMC6972536 DOI: 10.1111/tri.13546] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 08/26/2019] [Accepted: 10/23/2019] [Indexed: 12/14/2022]
Abstract
Recognition of non‐self structures on donor cells represents the main immunological barrier in solid organ transplantation. The human leukocyte antigens (HLA) are considered the most important non‐self (allo)antigens in transplantation. Long‐term graft attrition is mainly caused by the formation of alloreactive antibodies that are directed against non‐self structures (i.e., epitopes) on cell surface proteins. Recently published data provided evidence for a similar importance of non‐HLA mismatches between donors and recipients in acute rejection as well as long‐term kidney allograft survival. These data suggest a broader concept of immunological non‐self that goes beyond HLA incompatibility and expands the current concept of polymorphic non‐self epitopes on cell surface molecules from HLA to non‐HLA targets. Amino acid substitutions caused by single nucleotide variants in protein‐coding genes or complete loss of gene expression represent the basis for polymorphic residues in both HLA and non‐HLA molecules. To better understand these novel insights in non‐HLA alloimmunity, we will first review basic principles of the alloimmune response with a focus on the HLA epitope concept in donor‐specific antibody formation before discussing key publications on non‐HLA antibodies.
Collapse
Affiliation(s)
- Roman Reindl-Schwaighofer
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Andreas Heinzel
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Guido A Gualdoni
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Laurent Mesnard
- Sorbonne Université, Urgences Néphrologiques et Transplantation Rénale, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Tenon, Paris, France
| | - Frans H J Claas
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Centre, Leiden, The Netherlands
| | - Rainer Oberbauer
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
39
|
Denic A, Morales MC, Park WD, Smith BH, Kremers WK, Alexander MP, Cosio FG, Rule AD, Stegall MD. Using computer-assisted morphometrics of 5-year biopsies to identify biomarkers of late renal allograft loss. Am J Transplant 2019; 19:2846-2854. [PMID: 30947386 PMCID: PMC8214914 DOI: 10.1111/ajt.15380] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/20/2019] [Accepted: 03/28/2019] [Indexed: 01/25/2023]
Abstract
The current Banff scoring system was not developed to predict graft loss and may not be ideal for use in clinical trials aimed at improving allograft survival. We hypothesized that scoring histologic features of digitized renal allograft biopsies using a continuous, more objective, computer-assisted morphometric (CAM) system might be more predictive of graft loss. We performed a nested case-control study in kidney transplant recipients with a surveillance biopsy obtained 5 years after transplantation. Patients that developed death-censored graft loss (n = 67) were 2:1 matched on age, gender, and follow-up time to controls with surviving grafts (n = 134). The risk of graft loss was compared between CAM-based models vs a model based on Banff scores. Both Banff and CAM identified chronic lesions associated with graft loss (chronic glomerulopathy, arteriolar hyalinosis, and mesangial expansion). However, the CAM-based models predicted graft loss better than the Banff-based model, both overall (c-statistic 0.754 vs 0.705, P < .001), and in biopsies without chronic glomerulopathy (c-statistic 0.738 vs 0.661, P < .001) where it identified more features predictive of graft loss (% luminal stenosis and % mesangial expansion). Using 5-year renal allograft surveillance biopsies, CAM-based models predict graft loss better than Banff models and might be developed into biomarkers for future clinical trials.
Collapse
Affiliation(s)
- Aleksandar Denic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Martha C. Morales
- Department of Surgery and Immunology, Mayo Clinic, Rochester, Minnesota
| | - Walter D. Park
- Department of Surgery and Immunology, Mayo Clinic, Rochester, Minnesota
| | - Byron H. Smith
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Walter K. Kremers
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Mariam P. Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Fernando G. Cosio
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Andrew D. Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Mark D. Stegall
- Department of Surgery and Immunology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
40
|
Regulation of Endothelial-to-Mesenchymal Transition by MicroRNAs in Chronic Allograft Dysfunction. Transplantation 2019; 103:e64-e73. [PMID: 30907855 DOI: 10.1097/tp.0000000000002589] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Fibrosis is a universal finding in chronic allograft dysfunction, and it is characterized by an accumulation of extracellular matrix. The precise source of the myofibroblasts responsible for matrix deposition is not understood, and pharmacological strategies for prevention or treatment of fibrosis remain limited. One source of myofibroblasts in fibrosis is an endothelial-to-mesenchymal transition (EndMT), a process first described in heart development and involving endothelial cells undergoing a phenotypic change to become more like mesenchymal cells. Recently, lineage tracing of endothelial cells in mouse models allowed studies of EndMT in vivo and reported 27% to 35% of myofibroblasts involved in cardiac fibrosis and 16% of isolated fibroblasts in bleomycin-induced pulmonary fibrosis to be of endothelial origin. Over the past decade, mature microRNAs (miRNAs) have increasingly been described as key regulators of biological processes through repression or degradation of targeted mRNA. The stability and abundance of miRNAs in body fluids make them attractive as potential biomarkers, and progress is being made in developing miRNA targeted therapeutics. In this review, we will discuss the evidence of miRNA regulation of EndMT from in vitro and in vivo studies and the potential relevance of this to heart, lung, and kidney allograft dysfunction.
Collapse
|
41
|
Carminatti M, Tedesco-Silva H, Silva Fernandes NM, Sanders-Pinheiro H. Chronic kidney disease progression in kidney transplant recipients: A focus on traditional risk factors. Nephrology (Carlton) 2019; 24:141-147. [PMID: 30159972 DOI: 10.1111/nep.13483] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2018] [Indexed: 12/31/2022]
Abstract
Kidney transplant recipients are a subset of patients with chronic kidney disease (CKD) that remain at high risk for progression to dialysis and mortality. Recent advances in immunosuppression have only partially improved long-term graft and patient survival. Discovery of new immunosuppressive regimens is a slow and resource-intensive process. Hence, recognition and management of modifiable allogeneic and non-allogeneic risk factors for progression to CKD among kidney transplant recipients is of major interest for improving long-term outcomes. Graft survival is mainly determined by the quality of the allograft and by the patient's alloimmune response, which is influenced by human leukocyte antigen matching and the presence of donor-specific antibodies. Alloimmune responses manifest as acute and chronic forms of cell- and antibody-mediated rejection, which can be worsened by patient non-adherence or under-immunosuppression. However, donor and patient ages, glomerular disease recurrence, time on dialysis, pre-existing cardiovascular burden, medication side-effects and traditional risk factors, such as hypertension, proteinuria, anaemia, dyslipidaemia, diabetes and bone mineral disorder, which can ultimately lead to severe endothelial derangement, also contribute to graft loss and mortality. These traditional risk factors, common to pre-dialysis patients, often are considered of secondary importance when compared to alloimmunity and immunosuppression concerns. In this review article, we focus on the epidemiological, pathophysiological and therapeutic features of non-allogeneic traditional risk factors for CKD. We also discuss the benefit of adopting a multidisciplinary approach to pursue the same therapeutic targets recommended for pre-dialysis patients.
Collapse
Affiliation(s)
- Moisés Carminatti
- Nephrology Division, Interdisciplinary Nucleus of Studies and Research in Nephrology (NIEPEN), Renal Transplantation Unit, Juiz de Fora, Brazil
| | - Hélio Tedesco-Silva
- Nephrology Division, Hospital do Rim, Federal University of São Paulo UNIFESP, São Paulo, Brazil
| | - Natália Maria Silva Fernandes
- Nephrology Division, Interdisciplinary Nucleus of Studies and Research in Nephrology (NIEPEN), Renal Transplantation Unit, Juiz de Fora, Brazil
| | - Helady Sanders-Pinheiro
- Nephrology Division, Interdisciplinary Nucleus of Studies and Research in Nephrology (NIEPEN), Renal Transplantation Unit, Juiz de Fora, Brazil
| |
Collapse
|
42
|
Coemans M, Van Loon E, Lerut E, Gillard P, Sprangers B, Senev A, Emonds MP, Van Keer J, Callemeyn J, Daniëls L, Sichien J, Verbeke G, Kuypers D, Mathieu C, Naesens M. Occurrence of Diabetic Nephropathy After Renal Transplantation Despite Intensive Glycemic Control: An Observational Cohort Study. Diabetes Care 2019; 42:625-634. [PMID: 30765434 DOI: 10.2337/dc18-1936] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 01/14/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The kinetics and risk factors of diabetic nephropathy after kidney transplantation remain unclear. This study investigated the posttransplant occurrence of diabetic nephropathy and the contribution of posttransplant glycemic control. RESEARCH DESIGN AND METHODS We performed a single-center prospective cohort study of 953 renal allograft recipients and 3,458 protocol-specified renal allograft biopsy specimens up to 5 years after transplantation. The effects of pretransplant diabetes and glycemic control (glycated hemoglobin levels) on the posttransplant histology were studied. RESULTS Before transplantation, diabetes was present in 164 (17.2%) renal allograft recipients, primarily type 2 (n = 146 [89.0%]). Despite intensive glycemic control (glycated hemoglobin 7.00 ± 1.34% [53 ± 14.6 mmol/mol], 6.90 ± 1.22% [52 ± 13.3 mmol/mol], and 7.10 ± 1.13% [54 ± 12.4 mmol/mol], at 1, 2, and 5 years after transplantation), mesangial matrix expansion reached a cumulative incidence of 47.7% by 5 years in the pretransplant diabetes group versus 27.1% in patients without diabetes, corresponding to a hazard ratio of 1.55 (95% CI 1.07-2.26; P = 0.005). Mesangial matrix expansion was not specific for diabetic nephropathy and associated independently with increasing age. Pretransplant diabetes was associated with posttransplant proteinuria but not with estimated glomerular filtration rate, graft failure, or any other structural changes of the glomerular, vascular, or tubulointerstitial renal compartments. The occurrence of diabetic nephropathy was independent of posttransplant glycated hemoglobin levels. CONCLUSIONS Mesangial matrix expansion, an early indicator of diabetic nephropathy, can occur rapidly in patients with diabetes before transplantation, despite intensive glycemic control. Prevention of diabetic nephropathy requires more than pursuing low levels of glycated hemoglobin.
Collapse
Affiliation(s)
- Maarten Coemans
- Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.,Leuven Biostatistics and Statistical Bioinformatics Centre, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Elisabet Van Loon
- Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Evelyne Lerut
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium.,Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Gillard
- Clinical and Experimental Endocrinology, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium.,Department of Diabetes and Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Ben Sprangers
- Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Aleksandar Senev
- Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Histocompatibility and Immunogenetic Laboratory, Red Cross Flanders, Mechelen, Belgium
| | - Marie-Paule Emonds
- Histocompatibility and Immunogenetic Laboratory, Red Cross Flanders, Mechelen, Belgium
| | - Jan Van Keer
- Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Jasper Callemeyn
- Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Liesbeth Daniëls
- Clinical and Experimental Endocrinology, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Jeroen Sichien
- Leuven Biostatistics and Statistical Bioinformatics Centre, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Geert Verbeke
- Leuven Biostatistics and Statistical Bioinformatics Centre, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Dirk Kuypers
- Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium.,Department of Diabetes and Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Naesens
- Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium .,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
43
|
Stegall MD, Troy Somerville K, Everly MJ, Mannon RB, Gaber AO, First MR, Agashivala N, Perez V, Newell KA, Morris RE, Sudan D, Romero K, Eremenco S, Mattera M, Spear N, Porter AC, O'Doherty I. The importance of drug safety and tolerability in the development of new immunosuppressive therapy for transplant recipients: The Transplant Therapeutics Consortium's position statement. Am J Transplant 2019; 19:625-632. [PMID: 30549395 DOI: 10.1111/ajt.15214] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/21/2018] [Accepted: 11/21/2018] [Indexed: 01/25/2023]
Abstract
The Transplant Therapeutics Consortium (TTC) is a public-private partnership between the US Food and Drug Administration and the transplantation community including the transplantation societies and members of the biopharmaceutical industry. The TTC was formed to accelerate the process of developing new medical products for transplant patients. The initial goals of this collaboration are the following: (a) To define which aspects of the kidney transplant drug-development process have clear needs for improvement from an industry and regulatory perspective; (b) to define which of the unmet needs in the process could be positively impacted through the development of specific drug-development tools based on available data; and (c) to determine the most appropriate pathway to achieve regulatory acceptance of the proposed process-accelerating tools. The TTC has identified 2 major areas of emphasis: new biomarkers or endpoints for determining the efficacy of new therapies and new tools to assess the safety or tolerability of new therapies. This article presents the rationale and planned approach to develop new tools to assess safety and tolerability of therapies for transplant patients. We also discuss how similar efforts might support the continued development of patient-reported outcome measures in the future.
Collapse
Affiliation(s)
| | | | | | | | | | - M Roy First
- Transplant Genomics Inc., Mansfield, Massachusetts.,Comprehensive Transplant Center, Northwestern University, Chicago, Illinois
| | | | - Vanessa Perez
- Astellas Pharma Global Development, Inc., Northbrook, Illinois
| | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Seija M, Nin M, Santiago J, Apaza L, Castaño A, Poggi L, Urioste I, Chiossoni A, Fernandez A, Navarrine N, Garau M, Astesiano R, Ferrari MS, Noboa O. Being Overweight Is Related to Faster Decline in Annual Glomerular Filtration Rate in Kidney Transplant. Transplant Proc 2018; 50:3392-3396. [PMID: 30577211 DOI: 10.1016/j.transproceed.2018.04.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 03/08/2018] [Accepted: 04/12/2018] [Indexed: 01/02/2023]
Abstract
Few studies have examined the relationship between non-immunological factors and glomerular filtration rate (GFR) decline in kidney transplant. Correcting these factors in native kidneys slows the progression of chronic kidney disease. The aim of this study was to analyze the association between the control of non-immunological factors and the annual decline of GFR. METHODS A single-center, retrospective study was performed. We included 128 patients who received kidney transplants between 2000 and 2015, with at least 1-year post-transplant follow-up. Clinical records were reviewed. GFR was estimated by CKD-EPI. Three groups were defined according to the annual change in eGFR (ΔGFR 2016-1015): non-progressors (> -1 mL/min/1.73 m2), slow progressors (> -1 and < -5 mL/min/1.73 m2), and fast progressors (< -5 mL/min/1.73 m2). Percentage of achievement of KDIGO target was also analyzed. RESULTS The mean GFR was 62.5 mL/min/1.73 m2. Glomerulonephritis was the most common cause of kidney failure (36%). When the fast progressor group was compared with the non-progressor group, they differed significantly in age-patients were younger (40 ± 12.3 vs 45 ± 13.1 years)-post-transplant body mass index (27.4 ± 5.6 vs 25.2 x ± 5.9 kg/m2), and serum uric acid, which was significantly higher (6.4 ± 1.7 vs 5.5 ± 1.58 mg/dL). There were no differences between the groups with regard to blood pressure, dyslipidemia, proteinuria, or venous bicarbonate. Target systolic blood pressure was achieved by 45% of patients. Biopsy-proven acute rejection was higher in the fast progression group, although this was not statistically significant (13 [24.5%] vs 8 [13.1%]). CONCLUSIONS High body mass index was associated with a faster decline in glomerular filtration rate in this study. Target blood pressure <140/90 mm Hg was achieved in less than 50% of cases.
Collapse
Affiliation(s)
- M Seija
- Centro de Nefrología, Hospital de Clínicas, Facultad de Medicina, UdeLaR, Montevideo, Uruguay; Departamento de Fisiopatología, Hospital de Clínicas, Facultad de Medicina, UdeLaR, Montevideo, Uruguay.
| | - M Nin
- Centro de Nefrología, Hospital de Clínicas, Facultad de Medicina, UdeLaR, Montevideo, Uruguay
| | - J Santiago
- Centro de Nefrología, Hospital de Clínicas, Facultad de Medicina, UdeLaR, Montevideo, Uruguay
| | - L Apaza
- Hospital Obrero N°1, La Paz, Bolivia
| | - A Castaño
- Centro de Nefrología, Hospital de Clínicas, Facultad de Medicina, UdeLaR, Montevideo, Uruguay
| | - L Poggi
- Centro de Nefrología, Hospital de Clínicas, Facultad de Medicina, UdeLaR, Montevideo, Uruguay
| | - I Urioste
- Centro de Nefrología, Hospital de Clínicas, Facultad de Medicina, UdeLaR, Montevideo, Uruguay
| | - A Chiossoni
- Centro de Nefrología, Hospital de Clínicas, Facultad de Medicina, UdeLaR, Montevideo, Uruguay
| | - A Fernandez
- Centro de Nefrología, Hospital de Clínicas, Facultad de Medicina, UdeLaR, Montevideo, Uruguay
| | - N Navarrine
- Centro de Nefrología, Hospital de Clínicas, Facultad de Medicina, UdeLaR, Montevideo, Uruguay
| | - M Garau
- Departamento de Métodos Cuantitativos, Facultad de Medicina, UdeLaR, Montevideo, Uruguay
| | - R Astesiano
- Centro de Nefrología, Hospital de Clínicas, Facultad de Medicina, UdeLaR, Montevideo, Uruguay
| | - M S Ferrari
- Centro de Nefrología, Hospital de Clínicas, Facultad de Medicina, UdeLaR, Montevideo, Uruguay
| | - O Noboa
- Centro de Nefrología, Hospital de Clínicas, Facultad de Medicina, UdeLaR, Montevideo, Uruguay
| |
Collapse
|
45
|
Schinstock CA, Gandhi MJ. Maintaining the Health of the Renal Allograft: Laboratory and Histologic Monitoring After Kidney Transplantation. Clin Lab Med 2018; 38:607-621. [PMID: 30420056 DOI: 10.1016/j.cll.2018.07.003] [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] [Indexed: 11/18/2022]
Abstract
Advances in posttransplant care, including new immunosuppressive medications have led to excellent short-term renal allograft survival. However, there is a small therapeutic window within which the patient and the clinician must balance the risk of rejection, with side effects such as infection, malignancy, and toxicity. Laboratory testing plays a key role in this ongoing monitoring, which includes relatively simple tests, such as serum creatinine, to complex tests, such as solid-phase assays, used to monitor for donor-specific antibody and surveillance allograft biopsies. This article reviews the role of the laboratory tests and surveillance biopsies in posttransplant monitoring.
Collapse
Affiliation(s)
- Carrie A Schinstock
- Department of Internal Medicine, Division of Nephrology and Hypertension, William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
| | - Manish J Gandhi
- Division of Transfusion Medicine, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| |
Collapse
|
46
|
Manonelles A, Guiteras R, Melilli E, Lazzeri E, Goma M, Crespo E, Bestard O, Sola A, Romagnani P, Cruzado JM. The Presence of Urinary Renal Progenitor Cells in Stable Kidney Transplant Recipients Anticipates Allograft Deterioration. Front Physiol 2018; 9:1412. [PMID: 30364198 PMCID: PMC6191504 DOI: 10.3389/fphys.2018.01412] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 09/18/2018] [Indexed: 12/18/2022] Open
Abstract
Long-term kidney transplant outcomes have reached mild improvements recently. Parietal epithelial cells (PECs) are progenitor cells located along the Bowman’s capsule that can be isolated in urine, and display the capability to replace podocytes, but in certain situations cause glomerulosclerosis. In this study, a cohort of stable kidney transplant recipients with 6 months protocol biopsy was divided in two groups depending on the presence (uPEC+; n = 41) or absence (uPEC-; n = 25) of PECs in urine and followed for 2 years. No differences were found between groups at 6 months after transplantation considering clinical variables, alloimmune response, renal function, albuminuria and graft pathology. However, uPEC+ group showed increased podocyturia and a higher rate of proliferating PECs along the Bowman’s capsule, without concomitant enhancement of the CD44 pro-sclerotic activation marker. Accordingly, 2 years follow up evidenced poorer outcomes in the uPEC+ group with worse renal function, increased albuminuria, wider mesangial expansion and more severe IFTA. In summary, chronic allograft damage can progress in certain stable-supposed grafts by podocyte detachment and reactive PECs proliferation, being the uPEC presence a biomarker of this process. This damage-response regenerative process, if sustained in time, might fail in preserve the allograft function and histology. Our study raises new prospects to overcome current limits on long-term allograft results.
Collapse
Affiliation(s)
- Anna Manonelles
- Nephrology Department, L'Hospitalet de Llobregat, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Roser Guiteras
- Experimental Nephrology, Department of Ciències Clíniques, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Universitat de Barcelona, Barcelona, Spain
| | - Edoardo Melilli
- Nephrology Department, L'Hospitalet de Llobregat, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Elena Lazzeri
- Excellence Centre for Research, Transfer and High Education for the Development of DE NOVO Therapies (DENOTHE), University of Florence, Florence, Italy
| | - Montse Goma
- Pathology Department, L'Hospitalet de Llobregat, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Elena Crespo
- Experimental Nephrology, Department of Ciències Clíniques, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Universitat de Barcelona, Barcelona, Spain
| | - Oriol Bestard
- Nephrology Department, L'Hospitalet de Llobregat, Hospital Universitari de Bellvitge, Barcelona, Spain.,Experimental Nephrology, Department of Ciències Clíniques, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Universitat de Barcelona, Barcelona, Spain
| | - Anna Sola
- Experimental Nephrology, Department of Ciències Clíniques, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Universitat de Barcelona, Barcelona, Spain
| | - Paola Romagnani
- Excellence Centre for Research, Transfer and High Education for the Development of DE NOVO Therapies (DENOTHE), University of Florence, Florence, Italy
| | - Josep M Cruzado
- Nephrology Department, L'Hospitalet de Llobregat, Hospital Universitari de Bellvitge, Barcelona, Spain.,Experimental Nephrology, Department of Ciències Clíniques, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Universitat de Barcelona, Barcelona, Spain
| |
Collapse
|
47
|
Association between post-transplant uric acid level and renal allograft fibrosis: Analysis using Banff pathologic scores from renal biopsies. Sci Rep 2018; 8:11601. [PMID: 30072753 PMCID: PMC6072792 DOI: 10.1038/s41598-018-29948-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 07/20/2018] [Indexed: 12/20/2022] Open
Abstract
Several experimental studies implicate uric acid in renal injury and fibrosis. The objective of this study was to examine the association between uric acid level and allograft fibrosis after kidney transplantation. 241 adult patients who underwent kidney transplantation between 2003 and 2014 were divided into three groups according to the sex specific tertiles of mean uric acid level within the first post-transplant year. The renal biopsies performed during 1 to 5 post-transplant year were analyzed to compare the degree of interstitial fibrosis and tubular atrophy (IF/TA). Mean interval between kidney transplantation and biopsy was similar between groups (23.7 ± 15.3 vs. 30.0 ± 18.6 vs. 27.5 ± 18.5 months, P = 0.072). The higher tertile uric acid level was, the more advanced grade of IF/TA was shown (P = 0.001). Multivariate analysis identified uric acid tertile was independent risk factor for severe IF/TA (odds ratio [95% confidence interval] was 3.16 [1.13-8.82] for tertile 2 and 3.70 [1.25-10.93] for tertile 3, versus tertile 1, respectively). Other independent factors were estimated glomerular filtration rate at 1year post-transplant (0.80 [CI 0.65-0.98]) and biopsy-proven rejection (2.34 [1.05-5.21]). Graft survival over 10 years was significantly lower in tertile 3 (P = 0.041). The results showed that higher uric acid level after kidney transplantation was associated with more severe IF/TA.
Collapse
|
48
|
Abstract
This review is focused on present and future biomarkers, along with pharmacogenomics used in clinical practice for kidney transplantation. It aims to highlight biomarkers that could potentially be used to improve kidney transplant early and long-term graft survival, but also potentially patient co-morbidity. Future directions for improving outcomes are discussed, which include immune tolerance and personalising immunosuppression regimens.
Collapse
|
49
|
Defining kidney allograft benefit from successful pancreas transplant: separating fact from fiction. Curr Opin Organ Transplant 2018; 23:448-453. [PMID: 29878910 DOI: 10.1097/mot.0000000000000547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW To define the natural history of kidney allograft loss related to recurrent diabetes following transplant, and to understand the potential benefit of pancreas transplantation upon kidney allograft survival. RECENT FINDINGS A postulated benefit of simultaneous pancreas kidney transplant is that, unlike kidney transplant alone, euglycemia from the added pancreas allograft may confer a nephroprotective benefit and prevent recurrent diabetic nephropathy in the renal allograft. Recent large database analyses and long-term histological assessments have been published that assist in quantifying the problem of recurrent diabetic nephropathy and answering the question of the potential benefits of euglycemia. Further data may be extrapolated from larger single-center series that follow the prognosis of early posttransplant diabetes mellitus as another barometer of risk from diabetic nephropathy and graft loss. SUMMARY Recurrent diabetic nephropathy following kidney transplant is a relatively rare, late occurrence and its clinical significance is significantly diminished by the competing risks of death and chronic alloimmune injury. Although there are hints of a protective effect upon kidney graft survival with pancreas transplant, these improvements are small and may take decades to appreciate. Clinical decision-making regarding pancreas transplant solely based upon nephroprotective effects of the kidney allograft should be avoided.
Collapse
|
50
|
Jouve T, Noble J, Rostaing L, Malvezzi P. Tailoring tacrolimus therapy in kidney transplantation. Expert Rev Clin Pharmacol 2018; 11:581-588. [PMID: 29779413 DOI: 10.1080/17512433.2018.1479638] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The prevalence of end-stage renal disease is increasing worldwide. The best treatment is kidney transplantation, although life-long immunosuppressive therapy is then mandatory. Currently, the cornerstone immunosuppressive therapy relies on tacrolimus (Tac), a calcineurin inhibitor that is nephrotoxic but whose exposition can be minimized in a delicate balance. Area covered: We addressed whether, in the setting of kidney transplantation, Tac-based therapy can be tailored to medical needs: to achieve this, we searched for suitable articles in PubMed. Expert commentary: Too over-minimization of Tac, when associated with mycophenolic acid (MPA), may cause the development of de novo donor-specific alloantibodies (DSA). However, Tac minimization, in the context of everolimus-associated therapy instead of MPA, does not increase DSA formation as demonstrated in the TRANSFORM study and, in addition, can prevent cytomegalovirus (CMV) infection/reactivation. Nonetheless, Tac therapy, regardless of its formulation (immediate or extended release) compared to cyclosporine A, increases the risk of posttransplant diabetes mellitus; this increase is not affected by steroid therapy. Tac-based immunosuppression remains the best immunosuppressive therapy in kidney-transplant recipients and can be tailored according to patients' need.
Collapse
Affiliation(s)
- Thomas Jouve
- a Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation , Centre Hospitalier Universitaire (CHU) Grenoble-Alpes , Grenoble , France.,b Health Department , Grenoble Alpes University , Grenoble , France
| | - Johan Noble
- a Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation , Centre Hospitalier Universitaire (CHU) Grenoble-Alpes , Grenoble , France.,b Health Department , Grenoble Alpes University , Grenoble , France
| | - Lionel Rostaing
- a Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation , Centre Hospitalier Universitaire (CHU) Grenoble-Alpes , Grenoble , France.,b Health Department , Grenoble Alpes University , Grenoble , France
| | - Paolo Malvezzi
- a Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation , Centre Hospitalier Universitaire (CHU) Grenoble-Alpes , Grenoble , France
| |
Collapse
|