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Liu X, Fang H, Liang D, Lei Q, Wang J, Xu F, Liang S, Liang D, Yang F, Li H, Chen J, Ni Y, Xie G, Zeng C. Advancing the application of the analytical renal pathology system in allograft IgA nephropathy patients. Ren Fail 2024; 46:2322043. [PMID: 38425049 PMCID: PMC10911252 DOI: 10.1080/0886022x.2024.2322043] [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: 01/17/2024] [Accepted: 02/16/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND The analytical renal pathology system (ARPS) based on convolutional neural networks has been used successfully in native IgA nephropathy (IgAN) patients. Considering the similarity of pathologic features, we aim to evaluate the performance of the ARPS in allograft IgAN patients and broaden its implementation. METHODS Biopsy-proven allograft IgAN patients from two different centers were enrolled for internal and external validation. We implemented the ARPS to identify glomerular lesions and intrinsic glomerular cells, and then evaluated its performance. Consistency between the ARPS and pathologists was assessed using intraclass correlation coefficients. The association of digital pathological features with clinical and pathological data was measured. Kaplan-Meier survival curve and cox proportional hazards model were applied to investigate prognosis prediction. RESULTS A total of 56 biopsy-proven allograft IgAN patients from the internal center and 17 biopsy-proven allograft IgAN patients from the external center were enrolled in this study. The ARPS was successfully applied to identify the glomerular lesions (F1-score, 0.696-0.959) and quantify intrinsic glomerular cells (F1-score, 0.888-0.968) in allograft IgAN patients rapidly and precisely. Furthermore, the mesangial hypercellularity score was positively correlated with all mesangial metrics provided by ARPS [Spearman's correlation coefficient (r), 0.439-0.472, and all p values < 0.001]. Besides, a higher allograft survival was noticed among patients in the high-level groups of the maximum and ratio of endothelial cells, as well as the maximum and density of podocytes. CONCLUSION We propose that the ARPS could be implemented in future clinical practice with outstanding capability.
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Affiliation(s)
- Xumeng Liu
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Huiwen Fang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Dongmei Liang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Qunjuan Lei
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | | | - Feng Xu
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Shaoshan Liang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Dandan Liang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Fan Yang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Heng Li
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China
| | - Jianghua Chen
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China
| | - Yuan Ni
- Ping An Healthcare Technology, Shanghai, China
| | - Guotong Xie
- Ping An Healthcare Technology, Shanghai, China
| | - Caihong Zeng
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
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Rodrigo E, Quintana LF, Vázquez-Sánchez T, Sánchez-Fructuoso A, Buxeda A, Gavela E, Cazorla JM, Cabello S, Beneyto I, López-Oliva MO, Diekmann F, Gómez-Ortega JM, Calvo Romero N, Pérez-Sáez MJ, Sancho A, Mazuecos A, Espí-Reig J, Jiménez C, Hernández D. Tubulo-interstitial inflammation increases the risk of graft loss after the recurrence of IgA nephropathy. Clin Kidney J 2024; 17:sfad259. [PMID: 38186867 PMCID: PMC10768752 DOI: 10.1093/ckj/sfad259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Indexed: 01/09/2024] Open
Abstract
Background Immunoglobulin A nephropathy (IgAN) is the most frequent recurrent disease in kidney transplant recipients and its recurrence contributes to reducing graft survival. Several variables at the time of recurrence have been associated with a higher risk of graft loss. The presence of clinical or subclinical inflammation has been associated with a higher risk of kidney graft loss, but it is not precisely known how it influences the outcome of patients with recurrent IgAN. Methods We performed a multicentre retrospective study including kidney transplant recipients with biopsy-proven recurrence of IgAN in which Banff and Oxford classification scores were available. 'Tubulo-interstitial inflammation' (TII) was defined when 't' or 'i' were ≥2. The main endpoint was progression to chronic kidney disease (CKD) stage 5 or to death censored-graft loss (CKD5/DCGL). Results A total of 119 kidney transplant recipients with IgAN recurrence were included and 23 of them showed TII. Median follow-up was 102.9 months and 39 (32.8%) patients reached CKD5/DCGL. TII related to a higher risk of CKD5/DCGL (3 years 18.0% vs 45.3%, log-rank 7.588, P = .006). After multivariate analysis, TII remained related to the risk of CKD5/DCGL (HR 2.344, 95% CI 1.119-4.910, P = .024) independently of other histologic and clinical variables. Conclusions In kidney transplant recipients with IgAN recurrence, TII contributes to increasing the risk of CKD5/DCGL independently of previously well-known variables. We suggest adding TII along with the Oxford classification to the clinical variables to identify recurrent IgAN patients at increased risk of graft loss who might benefit from intensified immunosuppression or specific IgAN therapies.
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Affiliation(s)
- Emilio Rodrigo
- Nephrology Department, Hospital Universitario Marqués de Valdecilla/IDIVAL, Santander, SpainRD21/0005/0010 (ISCIII RICORS2040)
| | - Luis F Quintana
- Nephrology and Renal Transplantation Department, Hospital Clinic, Barcelona, Spain
| | - Teresa Vázquez-Sánchez
- Nephrology Department, Hospital Universitario Regional de Málaga, Málaga, SpainRD21/0005/0010 (ISCIII RICORS2040)
| | - Ana Sánchez-Fructuoso
- Nephrology Department, Hospital Clínico San Carlos, Facultad de Medicina Universidad Complutense, Madrid, Spain
| | - Anna Buxeda
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Eva Gavela
- Nephrology Department, Hospital Universitari Dr Peset, FISABIO, Valencia, Spain
| | - Juan M Cazorla
- Nephrology Department, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - Sheila Cabello
- Nephrology Department, Hospital Universitario Son Espases, Mallorca, Spain
| | - Isabel Beneyto
- Kidney Transplant Unit, Nephrology Department, Hospital Universitario La Fe, Valencia, Spain
| | | | - Fritz Diekmann
- Nephrology and Renal Transplantation Department, Hospital Clinic, Barcelona, Spain
| | - José M Gómez-Ortega
- Pathology Department, Hospital Universitario Marqués de Valdecilla/IDIVAL, Santander, Spain
| | - Natividad Calvo Romero
- Nephrology Department, Hospital Clínico San Carlos, Facultad de Medicina Universidad Complutense, Madrid, Spain
| | | | - Asunción Sancho
- Nephrology Department, Hospital Universitari Dr Peset, FISABIO, Valencia, Spain
| | | | - Jordi Espí-Reig
- Kidney Transplant Unit, Nephrology Department, Hospital Universitario La Fe, Valencia, Spain
| | - Carlos Jiménez
- Nephrology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Domingo Hernández
- Nephrology Department, Hospital Universitario Regional de Málaga, Málaga, SpainRD21/0005/0010 (ISCIII RICORS2040)
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Bednarova K, Mjøen G, Hruba P, Modos I, Voska L, Kollar M, Viklicky O. A novel prognostic nomogram predicts premature failure of kidney allografts with IgA nephropathy recurrence. Nephrol Dial Transplant 2023; 38:2627-2636. [PMID: 37202220 PMCID: PMC10660147 DOI: 10.1093/ndt/gfad097] [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: 11/07/2022] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND Recurrence of immunoglobulin A nephropathy (IgAN) limits graft survival in kidney transplantation. However, predictors of a worse outcome are poorly understood. METHODS Among 442 kidney transplant recipients (KTRs) with IgAN, 83 (18.8%) KTRs exhibited biopsy-proven IgAN recurrence between 1994 and 2020 and were enrolled in the derivation cohort. A multivariable Cox model predicting allograft loss based on clinical data at the biopsy and a web-based nomogram were developed. The nomogram was externally validated using an independent cohort (n = 67). RESULTS Patient age <43 years {hazard ratio [HR] 2.20 [95% confidence interval (CI) 1.41-3.43], P < .001}, female gender [HR 1.72 (95% CI 1.07-2.76), P = .026] and retransplantation status [HR 1.98 (95% CI 1.13-3.36), P = .016] were identified as independent risk factors for IgAN recurrence. Patient age <43 years [HR 2.77 (95% CI 1.17-6.56), P = .02], proteinuria >1 g/24 hours [HR 3.12 (95% CI 1.40-6.91), P = .005] and C4d positivity [HR 2.93 (95% CI 1.26-6.83), P = .013] were found to be associated with graft loss in patients with IgAN recurrence. A nomogram predicting graft loss was constructed based on clinical and histological variables, with a C statistic of 0.736 for the derivation cohort and 0.807 for the external validation cohort. CONCLUSIONS The established nomogram identified patients with recurrent IgAN at risk for premature graft loss with good predictive performance.
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Affiliation(s)
- Kamila Bednarova
- Department of Nephrology, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- 1st Medical Faculty, Charles University, Prague, Czech Republic
| | - Geir Mjøen
- Department of Nephrology, Oslo University Hospital, Oslo, Norway
| | - Petra Hruba
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Istvan Modos
- Department of Informatics, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ludek Voska
- Clinical and Transplant Pathology Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Marek Kollar
- Clinical and Transplant Pathology Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ondrej Viklicky
- Department of Nephrology, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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Alachkar N, Delsante M, Greenberg RS, Koirala A, Alhamad T, Abdalla B, Anand M, Boonpheng B, Blosser C, Maggiore U, Bagnasco SM. Evaluation of the Modified Oxford Score in Recurrent IgA Nephropathy in North American Kidney Transplant Recipients: The Banff Recurrent Glomerulonephritis Working Group Report. Transplantation 2023; 107:2055-2063. [PMID: 37202854 DOI: 10.1097/tp.0000000000004640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
BACKGROUND The modified Oxford classification mesangial and endocapillary hypercellularity, segmental sclerosis, interstitial fibrosis/tubular atrophy, and the presence of crescents (MEST-C) of immunoglobulin A nephropathy (IgAN) was recently shown to be a predictor of graft failure in Asians with recurrent IgAN. We aimed to validate these findings in a cohort from North American centers participating in the Banff Recurrent Glomerulopathies Working Group. METHODS We examined 171 transplant recipients with end-stage kidney disease because of IgAN; 100 of them with biopsy-proven recurrent IgAN (57 of them had complete MEST-C scores) and 71 with no recurrence. RESULTS IgAN recurrence, which was associated with younger age at transplantation ( P = 0.012), strongly increased the risk of death-censored graft failure (adjusted hazard ratio, 5.10 [95% confidence interval (CI), 2.26-11.51]; P < 0.001). Higher MEST-C score sum was associated with death-censored graft failure (adjusted hazard ratio, 8.57 [95% CI, 1.23-59.85; P = 0.03] and 61.32 [95% CI, 4.82-779.89; P = 0.002] for score sums 2-3 and 4-5 versus 0, respectively), and so were the single components endocapillary hypercellularity, interstitial fibrosis/tubular atrophy, and crescents ( P < 0.05 each). Overall, most of the pooled adjusted hazard ratio estimates associated with each MEST-C component were consistent with those from the Asian cohort (heterogeneity I2 close to 0%, and P > 0.05). CONCLUSIONS Our findings may validate the prognostic usefulness of the Oxford classification for recurrent IgAN and support the inclusion of the MEST-C score in allograft biopsies diagnostic reports.
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Affiliation(s)
- Nada Alachkar
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marco Delsante
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Ross S Greenberg
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Abbal Koirala
- Department of Medicine, University of Washington, Seattle, WA
| | - Tarek Alhamad
- Department of Medicine, Washington University, St Louis, MO
| | - Basmah Abdalla
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Manish Anand
- Department of Medicine, Division of Nephrology, University of Cincinnati, Cincinnati, OH
| | - Ben Boonpheng
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Umberto Maggiore
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Serena M Bagnasco
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD
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Vasconcelos ADS, Mazzali M, de Sousa MV. IgA nephropathy and kidney transplantation according to the Oxford classification. J Bras Nefrol 2023; 45:350-356. [PMID: 36626310 PMCID: PMC10697166 DOI: 10.1590/2175-8239-jbn-2022-0051en] [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: 03/17/2022] [Accepted: 11/09/2022] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION IgA nephropathy (IgAN) is the most common glomerular disease globally, and its susceptibility and the risk for the development of end-stage kidney disease are related to genetic and environmental factors. IgAN recurrence after kidney transplantation is relatively common, impacting graft function and survival. This study evaluated the risk factors and the clinical, laboratory, and histological characteristics of post-transplant IgAN recurrence based on the Oxford classification. MATERIAL AND METHODS Retrospective single-center cohort study including kidney transplant recipients with biopsy-proven pre-transplantation IgAN, with analysis of risk factors and clinical, laboratory, and histological characteristics of the IgAN recurrence cases. RESULTS 53 patients fulfilled the inclusion criteria and were included in the study. The majority was male, white, eutrophic, with a mean age of 27 ± 9 years at IgAN diagnosis. Systemic arterial hypertension and proteinuria were frequent in the pretransplant period. Four recipients (7.5%) presented IgAN recurrence in a period of 6 to 122 months post-transplant. According to the Oxford classification, they had high scores of mesangial hypercellularity and segmental glomerulosclerosis in the native kidney biopsies and there was mesangial hypercellularity in all analyzed graft biopsies. None of these patients had received induction immunosuppression and all of them presented graft failure in the follow-up. CONCLUSIONS In this series, there was a high prevalence of mesangial hypercellularity and segmental glomerulosclerosis on native kidney biopsies, and mesangial hypercellularity occurred in all IgAN recurrence graft biopsies. Despite the lower incidence of recurrence of IgAN post-transplant compared to previous reports, progression to graft loss was of 100%.
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Affiliation(s)
- André de Sá Vasconcelos
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas,
Departamento de Clínica Médica, Divisão de Nefrologia, Unidade de Transplante Renal,
Laboratório de Investigação em Transplante, Campinas, SP, Brasil
| | - Marilda Mazzali
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas,
Departamento de Clínica Médica, Divisão de Nefrologia, Unidade de Transplante Renal,
Laboratório de Investigação em Transplante, Campinas, SP, Brasil
| | - Marcos Vinicius de Sousa
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas,
Departamento de Clínica Médica, Divisão de Nefrologia, Unidade de Transplante Renal,
Laboratório de Investigação em Transplante, Campinas, SP, Brasil
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6
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Vasconcelos ADS, Mazzali M, de Sousa MV. Nefropatia por IgA e transplante renal segundo a classificação de Oxford. J Bras Nefrol 2023. [DOI: 10.1590/2175-8239-jbn-2022-0051pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Resumo Introdução: Nefropatia por IgA (NIgA) é a doença glomerular mais comum mundialmente. Sua suscetibilidade e risco para desenvolvimento de doença renal em fase terminal estão relacionados a fatores genéticos e ambientais. A recidiva de NIgA pós-transplante é relativamente comum, impactando na função e sobrevida do enxerto. Este estudo avaliou fatores de risco e características clínicas, laboratoriais e histológicas da recidiva de NIgA pós-transplante, com base na classificação de Oxford. Material e métodos: Estudo de coorte retrospectivo de centro único, incluindo receptores de transplante renal com NIgA pré-transplante comprovada por biópsia, com análise dos fatores de risco e características clínicas, laboratoriais e histológicas dos casos de recidiva de NIgA. Resultados: 53 pacientes preencheram critérios de inclusão e foram incluídos no estudo. A maioria era homem, branco, eutrófico, com idade média de 27 ± 9 anos no diagnóstico de NIgA. Hipertensão arterial sistêmica e proteinúria foram frequentes no período pré-transplante. Quatro receptores (7,5%) apresentaram recidiva de NIgA entre 6-122 meses pós-transplante. Segundo a classificação de Oxford, eles apresentaram altos escores de hipercelularidade mesangial e glomeruloesclerose segmentar nas biópsias de rins nativos. Houve hipercelularidade mesangial em todas as biópsias de enxerto analisadas. Nenhum destes pacientes recebeu imunossupressão de indução. Todos apresentaram falência do enxerto no acompanhamento. Conclusões: Nesta série, houve alta prevalência de hipercelularidade mesangial e glomeruloesclerose segmentar em biópsias de rins nativos, e hipercelularidade mesangial ocorreu em todas as biópsias do enxerto de recidiva da NIgA. Apesar da menor incidência de recidiva de NIgA pós-transplante comparada a relatos anteriores, a progressão para perda do enxerto foi de 100%.
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Kavanagh CR, Zanoni F, Leal R, Jain NG, Stack MN, Vasilescu ER, Serban G, Shaut C, Kamal J, Kudose S, Martinho A, Alves R, Santoriello D, Canetta PA, Cohen D, Radhakrishnan J, Appel GB, Stokes MB, Markowitz GS, D’Agati VD, Kiryluk K, Andeen NK, Batal I. Clinical Predictors and Prognosis of Recurrent IgA Nephropathy in the Kidney Allograft. GLOMERULAR DISEASES 2022; 2:42-53. [PMID: 35450416 PMCID: PMC9017582 DOI: 10.1159/000519834] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Introduction Although IgA nephropathy (IgAN) is the most common recurrent glomerulonephritis encountered in the kidney allograft, the clinical and immunogenetic characteristics remain poorly understood. We sought to study determinants and prognosis of recurrent IgAN with special focus on HLA antigens. Materials and Methods Between 2005 and 2019, we identified 282 transplanted patients with failure secondary to IgAN from two North American and one European Medical Centers, including 80 with recurrent IgAN and 202 without recurrence. Prevalence of HLA antigens was compared to external healthy controls of European ancestry (n=15,740). Graft survival was assessed by Kaplan-Meier method and log rank test. Cox proportional hazards were used for multivariable analyses. Results Compared to external controls of European ancestry, kidney transplant recipients of European ancestry with kidney failure secondary to IgAN had higher frequency of HLA-DQ5 (42% vs. 30%, OR=1.68, P=0.002) and lower frequency of HLA-DR15 (15% vs. 28%, OR=0.46, P<0.001) and HLA-DQ6 (32% vs. 45%, OR=0.59, P=0.003); however, the frequency of these HLA antigens were similar in recurrent versus non-recurring IgAN. Younger recipient age at transplantation was an independent predictor of recurrence. HLA-matching was an independent predictor for recurrent IgAN only in recipients of living-related but not deceased or living unrelated transplants. Recurrent IgAN was an independent predictor of allograft failure, along with acute rejection. In patients with recurrent IgAN, serum creatinine at biopsy, degree of proteinuria, and concurrent acute rejection were associated with inferior allograft survival. Discussion/ Conclusion Recurrent IgAN negatively affects allograft survival. Younger recipient age at transplantation is an independent predictor of recurrent IgAN, while the presence of HLA antigens associated with IgAN in the native kidney and HLA-matching in recipients of deceased or living unrelated transplants are not.
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Affiliation(s)
- Catherine R. Kavanagh
- Pediatric, Nephrology, Columbia University Irving Medical Center, Morgan Stanley Children's Hospital, New York, NY, USA
| | - Francesca Zanoni
- Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Rita Leal
- Nephrology department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal,Faculty of Medicine, University of Coimbra, Portugal
| | - Namrata G. Jain
- Pediatric, Nephrology, Columbia University Irving Medical Center, Morgan Stanley Children's Hospital, New York, NY, USA
| | - Megan Nicole Stack
- Medicine, Nephrology, Oregon Health & Science University, Portland, OR, USA
| | - Elena-Rodica Vasilescu
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Geo Serban
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Carley Shaut
- Medicine, Nephrology, Oregon Health & Science University, Portland, OR, USA
| | - Jeanne Kamal
- Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Satoru Kudose
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - António Martinho
- Centro de Histocompatibilidade do Centro, Instituto Português do Sangue da Transplantação, Coimbra, Portugal
| | - Rui Alves
- Nephrology department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal,Faculty of Medicine, University of Coimbra, Portugal
| | - Dominick Santoriello
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Pietro A Canetta
- Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - David Cohen
- Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Jai Radhakrishnan
- Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Gerald B. Appel
- Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Michael B. Stokes
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Glen S. Markowitz
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Vivette D. D’Agati
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Nicole K. Andeen
- Pathology, Oregon Health & Science University, Portland, OR, USA
| | - Ibrahim Batal
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
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8
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Maixnerova D, Hruba P, Neprasova M, Bednarova K, Slatinska J, Suchanek M, Kollar M, Novak J, Tesar V, Viklicky O. Outcome of 313 Czech Patients With IgA Nephropathy After Renal Transplantation. Front Immunol 2021; 12:726215. [PMID: 34659212 PMCID: PMC8515028 DOI: 10.3389/fimmu.2021.726215] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/03/2021] [Indexed: 11/13/2022] Open
Abstract
The recurrence of IgA nephropathy (IgAN) after kidney transplantation occurs in 20–35% of patients. The main aim of this study is to evaluate risk factors affecting the course of IgAN after renal biopsy of native kidney and kidney transplant. We evaluated clinical parameters and histological findings at the time of biopsy of native kidney and after kidney transplantation in 313 patients with IgAN with a follow-up of up to 36 years. Using hierarchical clustering method, patients with graft failure (n=50) were divided into two groups based on the mean time from kidney transplant to graft failure (11.2 versus 6.1 years). The time-to-graft failure corresponded well to the time from the renal biopsy of native kidney to end-stage renal disease (5.9 versus 0.4 years). Body mass index, proteinuria, microscopic hematuria, histological evaluation of fibrosis, and crescents at the time of renal biopsy of native kidney were the main variables for the differentiation of the two groups. Higher age of kidney-transplant donor, histological recurrence of IgAN, antibody-mediated rejection, and the onset of microscopic hematuria and proteinuria within 1 year after kidney transplant were also associated with worse graft survival in multivariate Cox regression analysis.
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Affiliation(s)
- Dita Maixnerova
- Department of Nephrology, General Teaching Hospital, 1st Faculty of Medicine, Prague, Czech Republic
| | - Petra Hruba
- Department of Nephrology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Michaela Neprasova
- Department of Nephrology, General Teaching Hospital, 1st Faculty of Medicine, Prague, Czech Republic
| | - Kamila Bednarova
- Department of Nephrology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Janka Slatinska
- Department of Nephrology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Miloslav Suchanek
- University of Jan Evangelista Purkyně in Ústí nad Labem, Ústí nad Labem, Czech Republic
| | - Marek Kollar
- Department of Pathology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jan Novak
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Vladimir Tesar
- Department of Nephrology, General Teaching Hospital, 1st Faculty of Medicine, Prague, Czech Republic
| | - Ondrej Viklicky
- Department of Nephrology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
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9
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Codina S, Manonelles A, Tormo M, Sola A, Cruzado JM. Chronic Kidney Allograft Disease: New Concepts and Opportunities. Front Med (Lausanne) 2021; 8:660334. [PMID: 34336878 PMCID: PMC8316649 DOI: 10.3389/fmed.2021.660334] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/10/2021] [Indexed: 12/12/2022] Open
Abstract
Chronic kidney disease (CKD) is increasing in most countries and kidney transplantation is the best option for those patients requiring renal replacement therapy. Therefore, there is a significant number of patients living with a functioning kidney allograft. However, progressive kidney allograft functional deterioration remains unchanged despite of major advances in the field. After the first post-transplant year, it has been estimated that this chronic allograft damage may cause a 5% graft loss per year. Most studies focused on mechanisms of kidney graft damage, especially on ischemia-reperfusion injury, alloimmunity, nephrotoxicity, infection and disease recurrence. Thus, therapeutic interventions focus on those modifiable factors associated with chronic kidney allograft disease (CKaD). There are strategies to reduce ischemia-reperfusion injury, to improve the immunologic risk stratification and monitoring, to reduce calcineurin-inhibitor exposure and to identify recurrence of primary renal disease early. On the other hand, control of risk factors for chronic disease progression are particularly relevant as kidney transplantation is inherently associated with renal mass reduction. However, despite progress in pathophysiology and interventions, clinical advances in terms of long-term kidney allograft survival have been subtle. New approaches are needed and probably a holistic view can help. Chronic kidney allograft deterioration is probably the consequence of damage from various etiologies but can be attenuated by kidney repair mechanisms. Thus, besides immunological and other mechanisms of damage, the intrinsic repair kidney graft capacity should be considered to generate new hypothesis and potential therapeutic targets. In this review, the critical risk factors that define CKaD will be discussed but also how the renal mechanisms of regeneration could contribute to a change chronic kidney allograft disease paradigm.
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Affiliation(s)
- Sergi Codina
- Department of Nephrology, Hospital Universitari Bellvitge, Barcelona, Spain
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Anna Manonelles
- Department of Nephrology, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Maria Tormo
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Anna Sola
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Josep M. Cruzado
- Department of Nephrology, Hospital Universitari Bellvitge, Barcelona, Spain
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
- Department of Clinical Sciences, University of Barcelona, Barcelona, Spain
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10
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Infante B, Rossini M, Leo S, Troise D, Netti GS, Ranieri E, Gesualdo L, Castellano G, Stallone G. Recurrent Glomerulonephritis after Renal Transplantation: The Clinical Problem. Int J Mol Sci 2020; 21:ijms21175954. [PMID: 32824988 PMCID: PMC7504691 DOI: 10.3390/ijms21175954] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 07/30/2020] [Accepted: 08/17/2020] [Indexed: 12/22/2022] Open
Abstract
Glomerulonephritis (GN) continues to be one of the main causes of end-stage kidney disease (ESKD) with an incidence rating from 10.5% to 38.2%. Therefore, recurrent GN, previously considered to be a minor contributor to graft loss, is the third most common cause of graft failure 10 years after renal transplantation. However, the incidence, pathogenesis, and natural course of recurrences are still not completely understood. This review focuses on the most frequent diseases that recur after renal transplantation, analyzing rate of recurrence, epidemiology and risk factors, pathogenesis and bimolecular mechanisms, clinical presentation, diagnosis, and therapy, taking into consideration the limited data available in the literature. First of all, the risk for recurrence depends on the type of glomerulonephritis. For example, recipient patients with anti-glomerular basement membrane (GBM) disease present recurrence rarely, but often exhibit rapid graft loss. On the other hand, recipient patients with C3 glomerulonephritis present recurrence in more than 50% of cases, although the disease is generally slowly progressive. It should not be forgotten that every condition that can lead to chronic graft dysfunction should be considered in the differential diagnosis of recurrence. Therefore, a complete workup of renal biopsy, including light, immunofluorescence and electron microscopy study, is essential to provide the diagnosis, excluding alternative diagnosis that may require different treatment. We will examine in detail the biomolecular mechanisms of both native and transplanted kidney diseases, monitoring the risk of recurrence and optimizing the available treatment options.
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Affiliation(s)
- Barbara Infante
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto Luigi 251, 71122 Foggia, Italy; (B.I.); (S.L.); (D.T.); (G.S.)
| | - Michele Rossini
- Clinical Pathology Unit and Center of Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto, 71122 Foggia, Italy; (M.R.); (G.S.N.); (E.R.)
| | - Serena Leo
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto Luigi 251, 71122 Foggia, Italy; (B.I.); (S.L.); (D.T.); (G.S.)
| | - Dario Troise
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto Luigi 251, 71122 Foggia, Italy; (B.I.); (S.L.); (D.T.); (G.S.)
| | - Giuseppe Stefano Netti
- Clinical Pathology Unit and Center of Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto, 71122 Foggia, Italy; (M.R.); (G.S.N.); (E.R.)
| | - Elena Ranieri
- Clinical Pathology Unit and Center of Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto, 71122 Foggia, Italy; (M.R.); (G.S.N.); (E.R.)
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, 70124 Bari, Italy;
| | - Giuseppe Castellano
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto Luigi 251, 71122 Foggia, Italy; (B.I.); (S.L.); (D.T.); (G.S.)
- Correspondence: ; Tel.: +39-0881732610; Fax: +39-0881736001
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto Luigi 251, 71122 Foggia, Italy; (B.I.); (S.L.); (D.T.); (G.S.)
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11
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Infante B, Rossini M, Di Lorenzo A, Coviello N, Giuseppe C, Gesualdo L, Giuseppe G, Stallone G. Recurrence of immunoglobulin A nephropathy after kidney transplantation: a narrative review of the incidence, risk factors, pathophysiology and management of immunosuppressive therapy. Clin Kidney J 2020; 13:758-767. [PMID: 33123355 PMCID: PMC7577761 DOI: 10.1093/ckj/sfaa060] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/18/2020] [Indexed: 01/04/2023] Open
Abstract
Glomerulonephritis (GN) is the underlying cause of end-stage renal failure in 30–50% of kidney transplant recipients. It represents the primary cause of end-stage renal disease for 25% of the dialysis population and 45% of the transplant population. For patients with GN requiring renal replacement therapy, kidney transplantation is associated with superior outcomes compared with dialysis. Recurrent GN was previously considered to be a minor contributor to graft loss, but with the prolongation of graft survival, the effect of recurrent disease on graft outcome assumes increasing importance. Thus the extent of recurrence of original kidney disease after kidney transplantation has been underestimated for several reasons. This review aims to provide updated knowledge on one particular recurrent renal disease after kidney transplantation, immunoglobulin A nephropathy (IgAN). IgAN is one of the most common GNs worldwide. The pathogenesis of IgAN is complex and remains incompletely understood. Evidence to date is most supportive of a several hit hypothesis. Biopsy is mandatory not only to diagnose the disease in the native kidney, but also to identify and characterize graft recurrence of IgAN in the kidney graft. The optimal therapy for IgAN recurrence in the renal graft is unknown. Supportive therapy aiming to reduce proteinuria and control hypertension is the mainstream, with corticosteroids and immunosuppressive treatment tailored for certain subgroups of patients experiencing a rapidly progressive course of the disease with active lesions on renal biopsy and considering safety issues related to infectious complications.
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Affiliation(s)
- Barbara Infante
- Department of Medical and Surgical Sciences, Nephrology, Dialysis and Transplantation Unit, University of Foggia, Foggia, Italy
| | - Michele Rossini
- Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplantation Unit, University of Bari "Aldo Moro", Bari, Italy
| | - Adelaide Di Lorenzo
- Department of Medical and Surgical Sciences, Nephrology, Dialysis and Transplantation Unit, University of Foggia, Foggia, Italy
| | - Nicola Coviello
- Department of Medical and Surgical Sciences, Nephrology, Dialysis and Transplantation Unit, University of Foggia, Foggia, Italy
| | - Castellano Giuseppe
- Department of Medical and Surgical Sciences, Nephrology, Dialysis and Transplantation Unit, University of Foggia, Foggia, Italy
| | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplantation Unit, University of Bari "Aldo Moro", Bari, Italy
| | | | - Giovanni Stallone
- Department of Medical and Surgical Sciences, Nephrology, Dialysis and Transplantation Unit, University of Foggia, Foggia, Italy
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12
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Park S, Baek CH, Go H, Kim YH, Min S, Ha J, Kim YC, Lee JP, Kim YS, Moon KC, Park SK, Lee H. Possible beneficial association between renin-angiotensin-aldosterone-system blockade usage and graft prognosis in allograft IgA nephropathy: a retrospective cohort study. BMC Nephrol 2019; 20:354. [PMID: 31510954 PMCID: PMC6737644 DOI: 10.1186/s12882-019-1537-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 08/27/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Although immunoglobulin A nephropathy (IgAN) is associated with an increased risk of renal allograft failure, evidences for its treatment, including renin-angiotensin-aldosterone system blockade (RAASB) usage, remain limited. METHODS In this bi-center retrospective cohort study, we included patients who were recently diagnosed with IgAN through allograft biopsies. We identified their 6-month antihypertensive medication prescriptions and investigated the association between the medication types, albuminuria changes, and risk of 5-year death-censored-graft-failure (DCGF). The mixed effect model and cox regression analysis were used. RESULTS A total of 464 allograft IgAN patients were included: 272, 38, 33, and 121 patients in the no antihypertensive medication, single agent RAASB, single agent beta blocker (BB)/calcium channel blocker (CCB), and combination therapy groups, respectively. High-degree albuminuria after 6 months of allograft IgAN diagnosis was an important prognostic parameter and a partial mediator for the association between the subgroups and 5-year DCGF. The usage of single RAASB was associated with decrement of albuminuria from allograft IgAN diagnosis (P for interaction = 0.03). The single BB/CCB group demonstrated significantly worse prognosis than the single RAASB group (adjusted hazard ratio, 2.76 [1.09-6.98]; P = 0.03). CONCLUSIONS In conclusion, RAASB may be beneficial for graft prognosis in early allograft IgAN patients who require single antihypertensive medication therapy, by means of reducing albuminuria. Further investigation of treatment strategy in allograft IgAN is warranted.
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Affiliation(s)
- Sehoon Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, South Korea
| | - Chung Hee Baek
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Heounjeong Go
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Young Hoon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sang–il Min
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Yong Chul Kim
- Kidney Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Jung Pyo Lee
- Kidney Research Institute, Seoul National University College of Medicine, Seoul, South Korea
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, South Korea
- Kidney Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung Chul Moon
- Department of Pathology, Seoul National University Hospital, Seoul, South Korea
| | - Su-Kil Park
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Kidney Research Institute, Seoul National University College of Medicine, Seoul, South Korea
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13
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Moroni G, Belingheri M, Frontini G, Tamborini F, Messa P. Immunoglobulin A Nephropathy. Recurrence After Renal Transplantation. Front Immunol 2019; 10:1332. [PMID: 31275309 PMCID: PMC6593081 DOI: 10.3389/fimmu.2019.01332] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 05/28/2019] [Indexed: 12/28/2022] Open
Abstract
IgA nephropathy (IgAN) is the most common primary glomerular disease worldwide. The disease generally runs an indolent course but may lead to ESRD in 20-30% of patients in 20 years or more after diagnosis. Patients with IgA nephropathy are ideal candidates for renal transplant because they are generally relatively young and with few comorbidities. Their graft survival is better or comparable to that of controls at 10 years, though few data are available after 10 years of follow-up. Recurrence of the original disease in the graft is a well-known complication of transplant in IgAN and is a significant cause of deterioration of graft function. Recurrent IgAN rarely manifests clinically before 3 years post transplantation. Recurrence rate is estimated to be around 30% with considerable differences among different series. Despite these factors there is no certain recurrence predictor, young age at renal transplant, rapid progression of the original disease and higher levels of circulating galactose-deficient IgA1 and IgA-IgG immune complexes are all associated with a higher rate of recurrence. Which pathogenetic mechanisms are responsible for the progression of the recurrence to graft function deterioration, and what therapy can prevent or slow down the progression of the disease in the graft, are open questions. The aim of this review is to describe the clinical outcome of renal transplantation in IgA patients with attention to the rate and the predictors of recurrence and to discuss the available therapeutic options for the management of recurrence.
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Affiliation(s)
- Gabriella Moroni
- Dialysis, and Renal Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mirco Belingheri
- Dialysis, and Renal Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Frontini
- Dialysis, and Renal Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Tamborini
- Dialysis, and Renal Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Piergiorgio Messa
- Dialysis, and Renal Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Science and Community, Università degli Studi di Milano, Milan, Italy
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