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Dessaix K, Bontoux C, Aubert O, Grünenwald A, Sberro Soussan R, Zuber J, Duong Van Huyen JP, Anglicheau D, Legendre C, Fremeaux Bacchi V, Rabant M. De novo thrombotic microangiopathy after kidney transplantation in adults: Interplay between complement genetics and multiple endothelial injury. Am J Transplant 2024; 24:1205-1217. [PMID: 38320731 DOI: 10.1016/j.ajt.2024.01.029] [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: 09/08/2023] [Revised: 01/26/2024] [Accepted: 01/30/2024] [Indexed: 02/24/2024]
Abstract
De novo thrombotic microangiopathy (dnTMA), after renal transplantation may significantly alter graft outcomes. However, its pathogenesis and the role of complement alternative pathway dysregulation remain elusive. We studied all consecutive adult patients with a kidney allograft biopsy performed between January 2004 and March 2016 displaying dnTMA. Ninety-two patients were included. The median time of occurrence was 166 (IQR 25-811) days. The majority (82.6 %) had TMA localized only in the graft. Calcineurin inhibitor toxicity and antibody-mediated rejection (ABMR) were the 2 most frequent causes (54.3% and 37.0%, respectively). However, etiological factors were multiple in 37% patients. Interestingly, pathogenic variants in the genes of complement alternative pathway were significantly more frequent in the 42 tested patients than in healthy controls (16.7% vs 3.7% respectively, P < .008). The overall graft survival after biopsy was 66.0% at 5 years and 23.4% at 10 years, significantly worse than a matched cohort without TMA. Moreover, graft survival of patients with TMA and ABMR was worse than a matched cohort with ABMR without TMA. The 2 main prognostic factors were a positive C4d staining and a lower estimated glomerular filtration rate at diagnosis. DnTMA is a severe and multifactorial disease, induced by 1 or several endothelium-insulting conditions, mostly calcineurin inhibitor toxicity and ABMR.
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Affiliation(s)
- Kathleen Dessaix
- Service des Maladies du Rein et du Métabolisme, Transplantation et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France
| | - Christophe Bontoux
- Laboratoire d'Anatomie et Cytologie Pathologiques, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France; Laboratory of Clinical and Experimental Pathology, Hospital-Integrated Biobank (BB-0033-00025), Team 4, Institute of Research on Cancer and Aging of Nice, InsermU1081, CNRS UMR7284, FHU OncoAge, Institut Hospitalo-Universitaire RespirERA, Université Côte d'Azur, Hôpital Pasteur, CHU de Nice, CEDEX 1, Nice, France
| | - Olivier Aubert
- Service des Maladies du Rein et du Métabolisme, Transplantation et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France; INSERM, PARCC, Paris Translational Reseach for Organ Transplantation, Université Paris Cité, Paris, France
| | - Anne Grünenwald
- INSERM, UMRS 1138, Inflammation, Complement and Cancer Team, Centre de recherche des Cordeliers, Sorbonne Universités, Université Paris Cité, Paris, France
| | - Rebecca Sberro Soussan
- Service des Maladies du Rein et du Métabolisme, Transplantation et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France
| | - Julien Zuber
- Service des Maladies du Rein et du Métabolisme, Transplantation et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France
| | - Jean-Paul Duong Van Huyen
- Laboratoire d'Anatomie et Cytologie Pathologiques, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France; INSERM, PARCC, Paris Translational Reseach for Organ Transplantation, Université Paris Cité, Paris, France
| | - Dany Anglicheau
- Service des Maladies du Rein et du Métabolisme, Transplantation et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France; Necker-Enfants Malades Institute, INSERM U1151, Université de Paris Cité, Paris, France
| | - Christophe Legendre
- Service des Maladies du Rein et du Métabolisme, Transplantation et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France
| | - Veronique Fremeaux Bacchi
- INSERM, UMRS 1138, Inflammation, Complement and Cancer Team, Centre de recherche des Cordeliers, Sorbonne Universités, Université Paris Cité, Paris, France; Service d'Immunologie, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Université Paris Cité, Paris, France
| | - Marion Rabant
- Laboratoire d'Anatomie et Cytologie Pathologiques, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France; Necker-Enfants Malades Institute, INSERM U1151, Université de Paris Cité, Paris, France.
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2
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Mour GK, Ninan J, Butterfield D, Zhang N, Nair SS, Smith M, Ryan M, Reddy K, Heilman RL. Outcomes of Early Thrombotic Microangiopathy in Renal Transplantation. Clin Transplant 2024; 38:e15373. [PMID: 39023085 DOI: 10.1111/ctr.15373] [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: 01/24/2024] [Revised: 05/02/2024] [Accepted: 05/23/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Alternate complement dysregulation postrenal transplantation can result in thrombotic microangiopathy (TMA). There is a scarcity of data regarding outcomes based on the timing of TMA post-transplant, coupled with a lack of follow-up biopsy findings post TMA diagnosis. This study aims to assess allograft and patient outcomes in individuals developing early TMA, defined within 4 months post-transplantation, and explore any differences in follow-up surveillance biopsies compared to a non-TMA group. DESIGN This is a single center retrospective study between January 1, 2002 and October 10, 2019. Patients who developed TMA within 4 months post-transplantation were compared to a propensity matched non-TMA group. RESULTS Thirty-one patients developed TMA within 4 months of renal transplantation. Index TMA biopsy featured noticeable glomerular, and vascular lesions along with acute tubular injury. Four-month surveillance biopsy showed significant glomerulitis, transplant glomerulopathy and chronic interstitial fibrosis as compared to non-TMA group. However, at 1 year, these differences were no longer significant. There was no significant difference in patient survival (TMA vs. non-TMA, p = 0.083); however, death censored graft survival was significantly lower in the TMA group (p < 0.001). TMA patients had a significantly lower estimated glomerular filtration rate at 4 months and at 1 year as compared to the non-TMA group. CONCLUSION Early onset TMA post renal transplant leads to decreased renal function and lower graft survival. Early recognition and prompt treatment may help in reducing the adverse outcomes.
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Affiliation(s)
- Girish K Mour
- Division of Nephrology, Mayo Clinic, Phoenix, Arizona, USA
| | - Jacob Ninan
- Division of Nephrology, Mayo Clinic College of Medicine and Science, Phoenix, Arizona, USA
| | - Duke Butterfield
- Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, Arizona, USA
| | - Nan Zhang
- Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, Arizona, USA
| | - Sumi S Nair
- Division of Nephrology, Mayo Clinic, Phoenix, Arizona, USA
| | - Maxwell Smith
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Arizona, USA
| | - Margaret Ryan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Arizona, USA
| | - Kunam Reddy
- Division Chair, Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
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3
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Mubarak M, Raza A, Rashid R, Sapna F, Shakeel S. Thrombotic microangiopathy after kidney transplantation: Expanding etiologic and pathogenetic spectra. World J Transplant 2024; 14:90277. [PMID: 38576763 PMCID: PMC10989473 DOI: 10.5500/wjt.v14.i1.90277] [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: 11/29/2023] [Revised: 01/28/2024] [Accepted: 03/04/2024] [Indexed: 03/15/2024] Open
Abstract
Thrombotic microangiopathy (TMA) is an uncommon but serious complication that not only affects native kidneys but also transplanted kidneys. This review is specifically focused on post-transplant TMA (PT-TMA) involving kidney transplant recipients. Its reported prevalence in the latter population varies from 0.8% to 14% with adverse impacts on both graft and patient survival. It has many causes and associations, and the list of etiologic agents and associations is growing constantly. The pathogenesis is equally varied and a variety of patho genetic pathways lead to the development of microvascular injury as the final common pathway. PT-TMA is categorized in many ways in order to facilitate its management. Ironically, more than one causes are contributory in PT-TMA and it is often difficult to pinpoint one particular cause in an individual case. Pathologically, the hallmark lesions are endothelial cell injury and intravascular thrombi affecting the microvasculature. Early diagnosis and classification of PT-TMA are imperative for optimal outcomes but are challenging for both clinicians and pathologists. The Banff classification has addressed this issue and has developed minimum diagnostic criteria for pathologic diagnosis of PT-TMA in the first phase. Management of the condition is also challenging and still largely empirical. It varies from simple maneuvers, such as plasmapheresis, drug withdrawal or modification, or dose reduction, to lifelong complement blockade, which is very expensive. A thorough understanding of the condition is imperative for an early diagnosis and quick treatment when the treatment is potentially effective. This review aims to increase the awareness of relevant stakeholders regarding this important, potentially treatable but under-recognized cause of kidney allograft dysfunction.
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Affiliation(s)
- Muhammed Mubarak
- Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
| | - Amber Raza
- Department of Nephrology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
| | - Rahma Rashid
- Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
| | - Fnu Sapna
- Department of Pathology, Montefiore Medical Center, The University Hospital for Albert Einstein School of Medicine, Bronx, NY 10461, United States
| | - Shaheera Shakeel
- Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
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Afrouzian M, Kozakowski N, Liapis H, Broecker V, Truong L, Avila-Casado C, Regele H, Seshan S, Ambruzs JM, Farris AB, Buob D, Chander PN, Cheraghvandi L, Clahsen-van Groningen MC, de Almeida Araujo S, Ertoy Baydar D, Formby M, Galesic Ljubanovic D, Herrera Hernandez L, Honsova E, Mohamed N, Ozluk Y, Rabant M, Royal V, Stevenson HL, Toniolo MF, Taheri D. Thrombotic Microangiopathy in the Renal Allograft: Results of the TMA Banff Working Group Consensus on Pathologic Diagnostic Criteria. Transpl Int 2023; 36:11590. [PMID: 37680648 PMCID: PMC10481335 DOI: 10.3389/ti.2023.11590] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 08/09/2023] [Indexed: 09/09/2023]
Abstract
The Banff community summoned the TMA Banff Working Group to develop minimum diagnostic criteria (MDC) and recommendations for renal transplant TMA (Tx-TMA) diagnosis, which currently lacks standardized criteria. Using the Delphi method for consensus generation, 23 nephropathologists (panelists) with >3 years of diagnostic experience with Tx-TMA were asked to list light, immunofluorescence, and electron microscopic, clinical and laboratory criteria and differential diagnoses for Tx-TMA. Delphi was modified to include 2 validations rounds with histological evaluation of whole slide images of 37 transplant biopsies (28 TMA and 9 non-TMA). Starting with 338 criteria in R1, MDC were narrowed down to 24 in R8 generating 18 pathological, 2 clinical, 4 laboratory criteria, and 8 differential diagnoses. The panelists reached a good level of agreement (70%) on 76% of the validated cases. For the first time in Banff classification, Delphi was used to reach consensus on MDC for Tx-TMA. Phase I of the study (pathology phase) will be used as a model for Phase II (nephrology phase) for consensus regarding clinical and laboratory criteria. Eventually in Phase III (consensus of the consensus groups) and the final MDC for Tx-TMA will be reported to the transplantation community.
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Affiliation(s)
- Marjan Afrouzian
- Department of Pathology, John Sealy School of Medicine, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | | | - Helen Liapis
- Department of Pathology and Immunology, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
- Department of Nephrology, Ludwig Maximilian University, Munich, Germany
| | - Verena Broecker
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Luon Truong
- Department of Pathology, The Houston Methodist Hospital, Houston, TX, United States
| | - Carmen Avila-Casado
- Laboratory Medicine Program, University Health Network (UHN), Toronto, ON, Canada
| | - Heinz Regele
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Surya Seshan
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, United States
| | | | - Alton Brad Farris
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, United States
| | - David Buob
- Department of Pathology, Université de Sorbonne, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Paris, France
| | | | - Lukman Cheraghvandi
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, United States
| | - Marian C Clahsen-van Groningen
- Department of Pathology and Clinical Bioinformatics, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
- Institute of Experimental Medicine and Systems Biology, RWTH Aachen University, Aachen, Germany
| | - Stanley de Almeida Araujo
- Departamento de Parasitologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Dilek Ertoy Baydar
- Department of Pathology, School of Medicine, Koç University, Sarıyer, Türkiye
| | - Mark Formby
- Department of Anatomical Pathology, NSW Health Pathology, Callaghan, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | | | | | - Eva Honsova
- AeskuLab Pathology and Department of Pathology, Charles University, Prague, Czechia
| | - Nasreen Mohamed
- Department of Pathology and Laboratory Medicine, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
| | - Yasemin Ozluk
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
| | - Marion Rabant
- Department of Pathology, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Virginie Royal
- Department of Pathology, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, QC, Canada
| | - Heather L Stevenson
- Department of Pathology, John Sealy School of Medicine, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Maria Fernanda Toniolo
- Kidney Pancreas Transplantation, Instituto de Nefrología-Nephrology, Buenos Aires, Argentina
| | - Diana Taheri
- Department of Pathology, Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Ponticelli C, Reggiani F, Moroni G. Delayed Graft Function in Kidney Transplant: Risk Factors, Consequences and Prevention Strategies. J Pers Med 2022; 12:jpm12101557. [PMID: 36294695 PMCID: PMC9605016 DOI: 10.3390/jpm12101557] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/17/2022] [Accepted: 09/18/2022] [Indexed: 11/24/2022] Open
Abstract
Background. Delayed graft function is a frequent complication of kidney transplantation that requires dialysis in the first week posttransplant. Materials and Methods. We searched for the most relevant articles in the National Institutes of Health library of medicine, as well as in transplantation, pharmacologic, and nephrological journals. Results. The main factors that may influence the development of delayed graft function (DGF) are ischemia–reperfusion injury, the source and the quality of the donated kidney, and the clinical management of the recipient. The pathophysiology of ischemia–reperfusion injury is complex and involves kidney hypoxia related to the duration of warm and cold ischemia, as well as the harmful effects of blood reperfusion on tubular epithelial cells and endothelial cells. Ischemia–reperfusion injury is more frequent and severe in kidneys from deceased donors than in those from living donors. Of great importance is the quality and function of the donated kidney. Kidneys from living donors and those with normal function can provide better results. In the peri-operative management of the recipient, great attention should be paid to hemodynamic stability and blood pressure; nephrotoxic medicaments should be avoided. Over time, patients with DGF may present lower graft function and survival compared to transplant recipients without DGF. Maladaptation repair, mitochondrial dysfunction, and acute rejection may explain the worse long-term outcome in patients with DGF. Many different strategies meant to prevent DGF have been evaluated, but only prolonged perfusion of dopamine and hypothermic machine perfusion have proven to be of some benefit. Whenever possible, a preemptive transplant from living donor should be preferred.
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Affiliation(s)
| | - Francesco Reggiani
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
- Correspondence:
| | - Gabriella Moroni
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
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Cerebral vascular injury in transplant-associated thrombotic microangiopathy. Blood Adv 2022; 6:4310-4319. [PMID: 35877136 PMCID: PMC9327538 DOI: 10.1182/bloodadvances.2022007453] [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: 03/01/2022] [Accepted: 05/27/2022] [Indexed: 11/20/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) and atypical hemolytic uremic syndrome (aHUS) are complement-mediated TMAs. The central nervous system (CNS) is the most common extrarenal organ affected by aHUS, and, despite mechanistic overlap between aHUS and TA-TMA, CNS involvement is rarely reported in TA-TMA, suggesting that CNS involvement in TA-TMA may be underdiagnosed and that these patients may benefit from complement blockers. In addition, there are no widely used histologic or radiologic criteria for the diagnosis of TMA in the brain. Thirteen recipients of pediatric hematopoietic cell transplants (HCTs) who had TA-TMA and who underwent autopsy were studied. Seven of 13 brains had vascular injury, and 2 had severe vascular injury. Neurologic symptoms correlated with severe vascular injury. Classic TMA histology was present and most often observed in the cerebellum, brainstem, and cerebral white matter. Abnormalities in similar anatomic regions were seen on imaging. Brain imaging findings related to TMA included hemorrhages, siderosis, and posterior reversible encephalopathy syndrome. We then studied 100 consecutive HCT recipients to identify differences in neurologic complications between patients with and those without TA-TMA. Patients with TA-TMA were significantly more likely to have a clinical concern for seizure, have an electroencephalogram performed, and develop altered mental status. In summary, our study confirms that TA-TMA involves the brains of recipients of HCT and is associated with an increased incidence of neurologic symptoms. Based on these findings, we propose that patients with low- or moderate-risk TA-TMA who develop neurologic complications should be considered for TA-TMA-directed therapy.
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Aguiar R, Bourmpaki E, Bunce C, Coker B, Delaney F, de Jongh L, Oliveira G, Weir A, Higgins F, Spiridou A, Hasan S, Smith J, Mulla A, Glampson B, Mercuri L, Montero R, Hernandez-Fuentes M, Roufosse CA, Simmonds N, Clatworthy M, McLean A, Ploeg R, Davies J, Várnai KA, Woods K, Lord G, Pruthi R, Breen C, Chowdhury P. Incidence, Risk Factors, and Effect on Allograft Survival of Glomerulonephritis Post-transplantation in a United Kingdom Population: Cohort Study. FRONTIERS IN NEPHROLOGY 2022; 2:923813. [PMID: 37675026 PMCID: PMC10479671 DOI: 10.3389/fneph.2022.923813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/17/2022] [Indexed: 09/08/2023]
Abstract
Background Post-transplant glomerulonephritis (PTGN) has been associated with inferior long-term allograft survival, and its incidence varies widely in the literature. Methods This is a cohort study of 7,623 patients transplanted between 2005 and 2016 at four major transplant UK centres. The diagnosis of glomerulonephritis (GN) in the allograft was extracted from histology reports aided by the use of text-mining software. The incidence of the four most common GN post-transplantation was calculated, and the risk factors for disease and allograft outcomes were analyzed. Results In total, 214 patients (2.8%) presented with PTGN. IgA nephropathy (IgAN), focal segmental glomerulosclerosis (FSGS), membranous nephropathy (MN), and membranoproliferative/mesangiocapillary GN (MPGN/MCGN) were the four most common forms of post-transplant GN. Living donation, HLA DR match, mixed race, and other ethnic minority groups were associated with an increased risk of developing a PTGN. Patients with PTGN showed a similar allograft survival to those without in the first 8 years of post-transplantation, but the results suggest that they do less well after that timepoint. IgAN was associated with the best allograft survival and FSGS with the worst allograft survival. Conclusions PTGN has an important impact on long-term allograft survival. Significant challenges can be encountered when attempting to analyze large-scale data involving unstructured or complex data points, and the use of computational analysis can assist.
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Affiliation(s)
- Rute Aguiar
- Department of Transplantation and Renal Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Elli Bourmpaki
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Catey Bunce
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Bola Coker
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Guy’s & St Thomas’ National Health Service (NHS) Foundation Trust and King’s College London, London, United Kingdom
| | - Florence Delaney
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Guy’s & St Thomas’ National Health Service (NHS) Foundation Trust and King’s College London, London, United Kingdom
| | - Leonardo de Jongh
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Guy’s & St Thomas’ National Health Service (NHS) Foundation Trust and King’s College London, London, United Kingdom
| | - Giovani Oliveira
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Guy’s & St Thomas’ National Health Service (NHS) Foundation Trust and King’s College London, London, United Kingdom
| | - Alistair Weir
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Guy’s & St Thomas’ National Health Service (NHS) Foundation Trust and King’s College London, London, United Kingdom
| | - Finola Higgins
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Guy’s & St Thomas’ National Health Service (NHS) Foundation Trust and King’s College London, London, United Kingdom
| | - Anastasia Spiridou
- Data Research, Innovation and Virtual Environments Unit (DRIVE), Great Ormond Street Hospital for Children National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Syed Hasan
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Guy’s & St Thomas’ National Health Service (NHS) Foundation Trust and King’s College London, London, United Kingdom
| | - Jonathan Smith
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Guy’s & St Thomas’ National Health Service (NHS) Foundation Trust and King’s College London, London, United Kingdom
| | - Abdulrahim Mulla
- National Institute for Health and Care Research (NIHR) Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare National Health Service (NHS) Trust, Hammersmith Hospital, London, United Kingdom
| | - Ben Glampson
- Research Informatics Team, Imperial College Healthcare National Health Service (NHS) Trust, London, United Kingdom
| | - Luca Mercuri
- National Institute for Health and Care Research (NIHR) Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare National Health Service (NHS) Trust, Hammersmith Hospital, London, United Kingdom
| | - Rosa Montero
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Guy’s & St Thomas’ National Health Service (NHS) Foundation Trust and King’s College London, London, United Kingdom
| | | | - Candice A. Roufosse
- Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Naomi Simmonds
- Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Menna Clatworthy
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Adam McLean
- Renal Section, Department of Medicine, Hammersmith Hospital Campus, Imperial College London, London, United Kingdom
| | - Rutger Ploeg
- Nuffield Department of Surgical Sciences, Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Jim Davies
- National Institute for Health and Care Research (NIHR) Oxford Biomedical Research Centre, Big Data Institute, University of Oxford, Oxford, Oxfordshire, United Kingdom
- Department of Computer Science, University of Oxford, Oxford, Oxfordshire, United Kingdom
| | - Kinga Anna Várnai
- National Institute for Health and Care Research (NIHR) Oxford Biomedical Research Centre, Big Data Institute, University of Oxford, Oxford, Oxfordshire, United Kingdom
- Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, Oxfordshire, United Kingdom
| | - Kerrie Woods
- National Institute for Health and Care Research (NIHR) Oxford Biomedical Research Centre, Big Data Institute, University of Oxford, Oxford, Oxfordshire, United Kingdom
- Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, Oxfordshire, United Kingdom
| | - Graham Lord
- Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Rishi Pruthi
- Department of Transplantation and Renal Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Cormac Breen
- Department of Transplantation and Renal Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Paramit Chowdhury
- Department of Transplantation and Renal Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
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8
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Wu Q, Tian X, Gong N, Zheng J, Liang D, Li X, Lu X, Xue W, Tian P, Wen J. Early graft loss due to acute thrombotic microangiopathy accompanied by complement gene variants in living-related kidney transplantation: case series report. BMC Nephrol 2022; 23:249. [PMID: 35836191 PMCID: PMC9284761 DOI: 10.1186/s12882-022-02868-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 06/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background Recently, early graft loss has become very rare in living-related kidney transplantation (LKT) as a result of decreased risk of hyperacute rejection and improvements in immunosuppressive regimens. Post-transplant acute thrombotic microangiopathy (TMA) is a rare, multi-factorial disease that often occurs shortly after kidney transplantation and is usually resistant to treatment with dismal renal outcomes. The complement genetic variants may accelerate the development of TMA. However, the complement genetic test was seldom performed in unknown native kidney disease recipients scheduled for LKT. Case presentation We reported three cases of unknown native kidney diseases who had fulminant TMA in the allograft shortly after LKT. Both the donors and the recipients were noted to carry complement genetic variants, which were identified by genetic testing after transplantation. However, all recipients were refractory to treatment and had allograft loss within 3 months after LKT. Conclusion This case series highlights the suggestion to screen complement gene variants in both the donors and the recipients with unknown native kidney diseases scheduled for LKT. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02868-7.
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Affiliation(s)
- Qianqian Wu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Xiaohui Tian
- Department of Kidney Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Nianqiao Gong
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jin Zheng
- Department of Kidney Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Dandan Liang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Xue Li
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Xia Lu
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wujun Xue
- Department of Kidney Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Puxun Tian
- Department of Kidney Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China.
| | - Jiqiu Wen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China.
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9
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Wu K, Schmidt D, López del Moral C, Osmanodja B, Lachmann N, Halleck F, Choi M, Bachmann F, Ronicke S, Duettmann W, Naik M, Schrezenmeier E, Rudolph B, Budde K. Poor Outcomes in Patients With Transplant Glomerulopathy Independent of Banff Categorization or Therapeutic Interventions. Front Med (Lausanne) 2022; 9:889648. [PMID: 35646957 PMCID: PMC9133540 DOI: 10.3389/fmed.2022.889648] [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: 03/04/2022] [Accepted: 04/14/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundTransplant glomerulopathy (TG) may indicate different disease entities including chronic AMR (antibody-mediated rejection). However, AMR criteria have been frequently changed, and long-term outcomes of allografts with AMR and TG according to Banff 2017 have rarely been investigated.Methods282 kidney allograft recipients with biopsy-proven TG were retrospectively investigated and diagnosed according to Banff'17 criteria: chronic AMR (cAMR, n = 72), chronic active AMR (cAAMR, n = 76) and isolated TG (iTG, n = 134). Of which 25/72 (34.7%) patients of cAMR group and 46/76 (60.5%) of cAAMR group were treated with antihumoral therapy (AHT).ResultsUp to 5 years after indication biopsy, no statistically significant differences were detected among iTG, cAMR and cAAMR groups in annual eGFR decline (−3.0 vs. −2.0 vs. −2.8 ml/min/1.73 m2 per year), 5-year median eGFR (21.5 vs. 16.0 vs. 20.0 ml/min/1.73 m2), 5-year graft survival rates (34.1 vs. 40.6 vs. 31.8%) as well as urinary protein excretion during follow-up. In addition, cAMR and cAAMR patients treated with AHT had similar graft and patient survival rates in comparison with those free of AHT, and similar comparing with iTG group. The TG scores were not associated with 5-year postbiopsy graft failure; whereas the patients with higher scores of chronic allograft scarring (by mm-, ci- and ct-lesions) had significantly lower graft survival rates than those with mild scores. The logistic-regression analysis demonstrated that Banff mm-, ah-, t-, ci-, ct-lesions and the eGFR level at biopsy were associated with 5-year graft failure.ConclusionsThe occurrence of TG is closely associated with graft failure independent of disease categories and TG score, and the long-term clinical outcomes were not influenced by AHT. The Banff lesions indicating progressive scarring might be better suited to predict an unfavorable outcome.
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Affiliation(s)
- Kaiyin Wu
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
- *Correspondence: Kaiyin Wu
| | - Danilo Schmidt
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Covadonga López del Moral
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Bilgin Osmanodja
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Nils Lachmann
- HLA Laboratory, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, BIH, Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Mira Choi
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Friederike Bachmann
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Simon Ronicke
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Wiebke Duettmann
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Marcel Naik
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Eva Schrezenmeier
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Birgit Rudolph
- Institute of Pathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universitätzu Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
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10
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Kielar M, Gala-Błądzińska A, Dumnicka P, Ceranowicz P, Kapusta M, Naumnik B, Kubiak G, Kuźniewski M, Kuśnierz-Cabala B. Complement Components in the Diagnosis and Treatment after Kidney Transplantation-Is There a Missing Link? Biomolecules 2021; 11:biom11060773. [PMID: 34064132 PMCID: PMC8224281 DOI: 10.3390/biom11060773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/14/2021] [Accepted: 05/18/2021] [Indexed: 12/25/2022] Open
Abstract
Currently, kidney transplantation is widely accepted as the renal replacement therapy allowing for the best quality of life and longest survival of patients developing end-stage renal disease. However, chronic transplant rejection, recurrence of previous kidney disease or newly acquired conditions, or immunosuppressive drug toxicity often lead to a deterioration of kidney allograft function over time. Complement components play an important role in the pathogenesis of kidney allograft impairment. Most studies on the role of complement in kidney graft function focus on humoral rejection; however, complement has also been associated with cell mediated rejection, post-transplant thrombotic microangiopathy, the recurrence of several glomerulopathies in the transplanted kidney, and transplant tolerance. Better understanding of the complement involvement in the transplanted kidney damage has led to the development of novel therapies that inhibit complement components and improve graft survival. The analysis of functional complotypes, based on the genotype of both graft recipient and donor, may become a valuable tool for assessing the risk of acute transplant rejection. The review summarizes current knowledge on the pathomechanisms of complement activation following kidney transplantation and the resulting diagnostic and therapeutic possibilities.
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Affiliation(s)
- Małgorzata Kielar
- St. Louis Regional Children’s Hospital, Medical Diagnostic Laboratory with a Bacteriology Laboratory, Strzelecka 2 St., 31-503 Kraków, Poland;
| | - Agnieszka Gala-Błądzińska
- Medical College of Rzeszów University, Institute of Medical Sciences, Kopisto 2A Avn., 35-310 Rzeszów, Poland;
| | - Paulina Dumnicka
- Jagiellonian University Medical College, Faculty of Pharmacy, Department of Medical Diagnostics, Medyczna 9 St., 30-688 Kraków, Poland;
| | - Piotr Ceranowicz
- Jagiellonian University Medical College, Faculty of Medicine, Department of Physiology, Grzegórzecka 16 St., 31-531 Kraków, Poland;
| | - Maria Kapusta
- Jagiellonian University Medical College, Faculty of Medicine, Chair of Clinical Biochemistry, Department of Diagnostics, Kopernika 15A St., 31-501 Kraków, Poland;
| | - Beata Naumnik
- Medical University of Białystok, Faculty of Medicine, 1st Department of Nephrology and Transplantation with Dialysis Unit, Żurawia 14 St., 15-540 Białystok, Poland;
| | - Grzegorz Kubiak
- Catholic University of Leuven, Department of Cardiovascular Diseases, 3000 Leuven, Belgium;
| | - Marek Kuźniewski
- Jagiellonian University Medical College, Faculty of Medicine, Chair and Department of Nephrology, Jakubowskiego 2 St., 30-688 Kraków, Poland;
| | - Beata Kuśnierz-Cabala
- Jagiellonian University Medical College, Faculty of Medicine, Chair of Clinical Biochemistry, Department of Diagnostics, Kopernika 15A St., 31-501 Kraków, Poland;
- Correspondence: ; Tel.: +48-12-424-83-65
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11
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Ávila A, Gavela E, Sancho A. Thrombotic Microangiopathy After Kidney Transplantation: An Underdiagnosed and Potentially Reversible Entity. Front Med (Lausanne) 2021; 8:642864. [PMID: 33898482 PMCID: PMC8063690 DOI: 10.3389/fmed.2021.642864] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/22/2021] [Indexed: 01/25/2023] Open
Abstract
Thrombotic microangiopathy is a rare but serious complication that affects kidney transplant recipients. It appears in 0.8–14% of transplanted patients and negatively affects graft and patient survival. It can appear in a systemic form, with hemolytic microangiopathic anemia, thrombocytopenia, and renal failure, or in a localized form, with progressive renal failure, proteinuria, or arterial hypertension. Post-transplant thrombotic microangiopathy is classified as recurrent atypical hemolytic uremic syndrome or de novo thrombotic microangiopathy. De novo thrombotic microangiopathy accounts for the majority of cases. Distinguishing between the 2 conditions can be difficult, given there is an overlap between them. Complement overactivation is the cornerstone of all post-transplant thrombotic microangiopathies, and has been demonstrated in the context of organ procurement, ischemia-reperfusion phenomena, immunosuppressive drugs, antibody-mediated rejection, viral infections, and post-transplant relapse of antiphospholipid antibody syndrome. Although treatment of the causative agents is usually the first line of treatment, this approach might not be sufficient. Plasma exchange typically resolves hematologic abnormalities but does not improve renal function. Complement blockade with eculizumab has been shown to be an effective therapy in post-transplant thrombotic microangiopathy, but it is necessary to define which patients can benefit from this therapy and when and how eculizumab should be used.
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Affiliation(s)
- Ana Ávila
- Nephrology Department, University Hospital Dr. Peset, Valencia, Spain
| | - Eva Gavela
- Nephrology Department, University Hospital Dr. Peset, Valencia, Spain
| | - Asunción Sancho
- Nephrology Department, University Hospital Dr. Peset, Valencia, Spain
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12
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Cherniak V, Demir KK, Sandal S, Cantarovich M, Podymow T, Naessens V, Ponette V, Wou K, Do AT, Malhamé I. Thrombotic Microangiopathy in a Pregnant Woman With Kidney Transplantation: A Case Report. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 43:874-878. [PMID: 33310162 DOI: 10.1016/j.jogc.2020.10.018] [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: 08/18/2020] [Revised: 10/28/2020] [Accepted: 10/28/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The differential diagnosis of thrombotic microangiopathy (TMA) in pregnancy includes common conditions, such as preeclampsia. In women with kidney transplantation, additional causes of TMA must be considered. CASE A 22-year-old primigravid woman with a transplanted kidney presented with fetal growth restriction, hypertension, acute kidney injury, and hemolysis at 28 weeks gestation. While her clinical presentation was initially consistent with preeclampsia, hemolysis persisted beyond 1 week postpartum. Diagnoses of TMA associated with tacrolimus and antibody-mediated rejection were considered. An elevated tacrolimus level likely contributed to her TMA and a decrease in dosage improved her clinical picture and laboratory markers. CONCLUSION We report the case of a pregnant kidney transplant recipient with TMA. A multidisciplinary approach is required to optimize the maternal health outcomes in this complex population.
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Affiliation(s)
- Vladimir Cherniak
- Department of Medicine, McGill University Health Centre, Montréal, QC
| | - Koray K Demir
- Department of Medicine, McGill University Health Centre, Montréal, QC
| | - Shaifali Sandal
- Department of Medicine, McGill University Health Centre, Montréal, QC
| | | | - Tiina Podymow
- Department of Medicine, McGill University Health Centre, Montréal, QC
| | | | - Vincent Ponette
- Department of Obstetrics and Gynaecology, McGill University Health Centre, Montréal, QC
| | - Karen Wou
- Department of Obstetrics and Gynaecology, McGill University Health Centre, Montréal, QC
| | - Anh Thu Do
- Department of Pharmacy, McGill University Health Centre, Montréal, QC
| | - Isabelle Malhamé
- Department of Medicine, McGill University Health Centre, Montréal, QC; Research Institute of the McGill University Health Centre, Montréal, QC.
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13
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Malyszko J, Basak G, Batko K, Capasso G, Capasso A, Drozd-Sokolowska J, Krzanowska K, Kulicki P, Matuszkiewicz-Rowinska J, Soler MJ, Sprangers B, Malyszko J. Haematological disorders following kidney transplantation. Nephrol Dial Transplant 2020; 37:409-420. [PMID: 33150431 DOI: 10.1093/ndt/gfaa219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Indexed: 01/19/2023] Open
Abstract
Transplantation offers cure for some haematological cancers, end-stage organ failure, but at the cost of long-term complications. Renal transplantation is the best-known kidney replacement therapy and it can prolong end-stage renal disease patient lives for decades. However, patients after renal transplantation are at a higher risk of developing different complications connected not only with surgical procedure but also with immunosuppressive treatment, chronic kidney disease progression and rejection processes. Various blood disorders can develop in post-transplant patients ranging from relatively benign anaemia through cytopenias to therapy-related myelodysplasia and acute myeloid leukaemia (AML) and post-transplant lymphoproliferative disorders followed by a rare and fatal condition of thrombotic microangiopathy and haemophagocytic syndrome. So far literature mainly focused on the post-transplant lymphoproliferative disease. In this review, a variety of haematological problems after transplantation ranging from rare disorders such as myelodysplasia and AML to relatively common conditions such as anaemia and iron deficiency are presented with up-to-date diagnosis and management.
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Affiliation(s)
| | - Grzegorz Basak
- Department of Hematology, Oncology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Batko
- Department of Nephrology, Collegium Medicum, Jagiellonian University, Cracow, Poland
| | - Giavambatista Capasso
- Department of Translational Medical Sciences, University Luigi Vanvitelli, Naples, Italy
| | - Anna Capasso
- Department of Oncology, Livestrong Cancer Institutes, Dell Medical School, The University of Texas, Austin, TX, USA
| | - Joanna Drozd-Sokolowska
- Department of Hematology, Oncology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Krzanowska
- Department of Nephrology, Collegium Medicum, Jagiellonian University, Cracow, Poland
| | - Pawel Kulicki
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | | | - Maria Jose Soler
- Department of Nephrology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ben Sprangers
- Department of Microbiology, Immunology, and Transplantation, Laboratory of Molecular Immunology, Rega Institute, Katholieke Universiteit Leuven, Belgium.,Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Jacek Malyszko
- 1st Department of Nephrology and Transplantology, Medical University of Bialystok, Bialystok, Poland
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