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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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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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3
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Imanifard Z, Liguori L, Remuzzi G. TMA in Kidney Transplantation. Transplantation 2023; 107:2329-2340. [PMID: 36944606 DOI: 10.1097/tp.0000000000004585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Thrombotic microangiopathy (TMA) is a rare and devastating complication of kidney transplantation, which often leads to graft failure. Posttransplant TMA (PT-TMA) may occur either de novo or as a recurrence of the disease. De novo TMA can be triggered by immunosuppressant drugs, antibody-mediated rejection, viral infections, and ischemia/reperfusion injury in patients with no evidence of the disease before transplantation. Recurrent TMA may occur in the kidney grafts of patients with a history of atypical hemolytic uremic syndrome (aHUS) in the native kidneys. Studies have shown that some patients with aHUS carry genetic abnormalities that affect genes that code for complement regulators (CFH, MCP, CFI) and components (C3 and CFB), whereas in 10% of patients (mostly children), anti-FH autoantibodies have been reported. The incidence of aHUS recurrence is determined by the underlying genetic or acquired complement abnormality. Although treatment of the causative agents is usually the first line of treatment for de novo PT-TMA, this approach might be insufficient. Plasma exchange typically resolves hematologic abnormalities but does not improve kidney function. Targeted complement inhibition is an effective treatment for recurrent TMA and may be effective in de novo PT-TMA as well, but it is necessary to establish which patients can benefit from different therapeutic options and when and how these can be applied.
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Affiliation(s)
- Zahra Imanifard
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Italy
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4
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Michael M, Bagga A, Sartain SE, Smith RJH. Haemolytic uraemic syndrome. Lancet 2022; 400:1722-1740. [PMID: 36272423 DOI: 10.1016/s0140-6736(22)01202-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/16/2022] [Accepted: 06/16/2022] [Indexed: 11/05/2022]
Abstract
Haemolytic uraemic syndrome (HUS) is a heterogeneous group of diseases that result in a common pathology, thrombotic microangiopathy, which is classically characterised by the triad of non-immune microangiopathic haemolytic anaemia, thrombocytopenia, and acute kidney injury. In this Seminar, different causes of HUS are discussed, the most common being Shiga toxin-producing Escherichia coli HUS. Identifying the underlying thrombotic microangiopathy trigger can be challenging but is imperative if patients are to receive personalised disease-specific treatment. The quintessential example is complement-mediated HUS, which once carried an extremely high mortality but is now treated with anti-complement therapies with excellent long-term outcomes. Unfortunately, the high cost of anti-complement therapies all but precludes their use in low-income countries. For many other forms of HUS, targeted therapies are yet to be identified.
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Affiliation(s)
- Mini Michael
- Division of Pediatric Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | - Arvind Bagga
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sarah E Sartain
- Pediatrics-Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Richard J H Smith
- Department of Otolaryngology, Pediatrics and Molecular Physiology & Biophysics, The University of Iowa, Iowa City, IA, USA
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5
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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: 19] [Impact Index Per Article: 9.5] [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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6
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Rejection-associated Phenotype of De Novo Thrombotic Microangiopathy Represents a Risk for Premature Graft Loss. Transplant Direct 2021; 7:e779. [PMID: 34712779 PMCID: PMC8547913 DOI: 10.1097/txd.0000000000001239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/19/2021] [Accepted: 09/08/2021] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. Background. Thrombotic microangiopathy (TMA) significantly affects kidney graft survival, but its pathophysiology remains poorly understood. Methods. In this multicenter, retrospective, case–control paired study designed to control for donor-associated risks, we assessed the recipients’ risk factors for de novo TMA development and its effects on graft survival. The study group consists of patients with TMA found in case biopsies from 2000 to 2019 (n = 93), and the control group consists of recipients of paired kidney grafts (n = 93). Graft follow-up was initiated at the time of TMA diagnosis and at the same time in the corresponding paired kidney graft. Results. The TMA group displayed higher peak panel-reactive antibodies, more frequent retransplantation status, and longer cold ischemia time in univariable analysis. In the multivariable regression model, longer cold ischemia times (odds ratio, 1.18; 95% confidence interval [CI], 1.01-1.39; P = 0.043) and higher peak pretransplant panel-reactive antibodies (odds ratio, 1.03; 95% CI, 1.01-1.06; P = 0.005) were found to be associated with increased risk of de novo TMA. The risk of graft failure was higher in the TMA group at 5 y (hazard ratio [HR], 3.99; 95% CI, 2.04-7.84; P < 0.0001). Concomitant rejection significantly affected graft prognosis at 5 y (HR, 6.36; 95% CI, 2.92-13.87; P < 0.001). De novo TMA associated with the active antibody-mediated rejection was associated with higher risk of graft failure at 5 y (HR, 3.43; 95% CI, 1.69-6.98; P < 0.001) compared with other TMA. Conclusions. Longer cold ischemia and allosensitization play a role in de novo TMA development, whereas TMA as a part of active antibody-mediated rejection was associated with the highest risk for premature graft loss.
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Saikumar Doradla LP, Lal H, Kaul A, Bhaduaria D, Jain M, Prasad N, Thammishetti V, Gupta A, Patel M, Sharma RK. Clinical profile and outcomes of De novo posttransplant thrombotic microangiopathy. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2021; 31:160-168. [PMID: 32129209 DOI: 10.4103/1319-2442.279936] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Thrombotic microangiopathy (TMA) after kidney transplant is rather uncommon but an important reversible cause of graft loss. This retrospective study of biopsy-proven posttransplant TMA was done to identify the important etiological factors, clinical features, and outcomes of post transplant TMA in a tertiary care referral hospital in northern India. This retrospective study was conducted among all renal transplant recipients who presented with graft dysfunction between 1989 and 2015. All the cases were looked for their etiology, clinical course, treatment modalities, and renal outcomes. The study was conducted in accord with prevailing ethical principles and reviewed by our own institutional review board. Seventeen patients out of 2000 (0.008%) transplants done during the study period had posttransplant TMA, out of which all the patients had de novo TMA, and the median time of presentation after transplantation was four months. Systemic TMA was noted in only four patients. Biopsy revealed associated rejection in five patients and associated calcineurin inhibitor (CNI) toxicity in 12 patients. Patients with TMA due to CNI toxicity were managed with CNI reduction or switching to alternate CNI or mammalian target of rapamycin inhibitors. In addition, antithymocyte globulin and plasma exchange were used in rejection-associated TMA. While four out of 12 patients (33%) in CNI-related TMA developed end-stage renal disease (ESRD), all patients in rejection-associated TMA developed ESRD. The overall one-year graft survival was 47%, whereas five- and 10-year survival was 35%. There was no significant difference in graft survival between localized and systemic TMAs (P = 0.4). Posttransplant TMA should be suspected even if there are no systemic features of hemolysis and early graft biopsy and prompt action is needed. The occurrence of TMA in the setting of rejection is associated with grave prognosis.
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Affiliation(s)
- L P Saikumar Doradla
- Departmenta of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - H Lal
- Departmenta of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anupma Kaul
- Departmenta of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - D Bhaduaria
- Departmenta of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - M Jain
- Departmenta of Pathology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - N Prasad
- Departmenta of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - V Thammishetti
- Departmenta of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - A Gupta
- Departmenta of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - M Patel
- Departmenta of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - R K Sharma
- Departmenta of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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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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Portoles J, Huerta A, Arjona E, Gavela E, Agüera M, Jiménez C, Cavero T, Marrero D, Rodríguez de Córdoba S, Diekmann F. Characteristics, management and outcomes of atypical haemolytic uraemic syndrome in kidney transplant patients: a retrospective national study. Clin Kidney J 2020; 14:1173-1180. [PMID: 33841863 PMCID: PMC8023214 DOI: 10.1093/ckj/sfaa096] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 05/04/2020] [Indexed: 02/07/2023] Open
Abstract
Background Kidney transplantation (KTx) is a strong trigger for the development of either recurrent or de novo atypical haemolytic uraemic syndrome (aHUS). According to previous studies, eculizumab (ECU) is effective for prophylaxis and for treatment of recurrence. Methods We evaluated the experiences of Spanish patients with recurrent and de novo aHUS associated with KTx, treated or not treated with ECU. In the de novo group, we classified patients as having early de novo (during the first month) or late de novo aHUS (subsequent onset). Results We analysed 36 cases of aHUS associated with KTx. All of the 14 patients with pre-KTx diagnosis of aHUS were considered to have high or moderate risk of recurrence. Despite receiving grafts from suboptimal donors, prophylactic ECU was effective for avoiding recurrence. The drug was stopped only in two cases with low–moderate risk of recurrence and was maintained in high-risk patients with no single relapse. There were 22 de novo aHUS cases and 16 belonged to the early de novo group. The median time of onset in the late group was 3.4 years. The early group had a better response to ECU than the late group, probably due to earlier diagnosis and use of the drug. No genetic pathogenic variant was detected in de novo aHUS cases, suggesting a secondary profile of the disease. ECU was stopped in all de novo patients with no relapses. ECU was well tolerated in all cases. Conclusions Both groups (pre-aHUS and de novo) presented different clinical profiles, management approaches and outcomes. One should consider aHUS regardless of time after KTx. Genetic studies are crucial to stratify risks of relapse and to determine necessary lengths of treatment. We suggest short ECU treatment for de novo cases without pathogenic mutation and that ECU treatment be considered pre-emptively for patients with moderate or high risk of recurrence.
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Affiliation(s)
- José Portoles
- Nephrology Department, University Hospital Puerta de Hierro, Madrid, Spain.,RedInRen 16/009, RTYC ISCIII, Madrid, Spain
| | - Ana Huerta
- Nephrology Department, University Hospital Puerta de Hierro, Madrid, Spain.,RedInRen 16/009, RTYC ISCIII, Madrid, Spain
| | - Emilia Arjona
- Center for Biological Research and CIBER of Rare Diseases, Madrid, Spain
| | - Eva Gavela
- RedInRen 16/009, RTYC ISCIII, Madrid, Spain.,Nephrology Department, University Hospital Peset, Valencia, Spain
| | - Marisa Agüera
- RedInRen 16/009, RTYC ISCIII, Madrid, Spain.,Nephrology Department, University Hospital Reina Sofía, Cordoba, Spain
| | - Carlos Jiménez
- RedInRen 16/009, RTYC ISCIII, Madrid, Spain.,Nephrology Department, University Hospital La Paz, Madrid, Spain
| | - Teresa Cavero
- RedInRen 16/009, RTYC ISCIII, Madrid, Spain.,Nephrology Department, University Hospital Doce de Octubre, Madrid, Spain
| | - Domingo Marrero
- RedInRen 16/009, RTYC ISCIII, Madrid, Spain.,Nephrology Department, University Hospital Canarias, Canarias, Spain
| | | | - Fritz Diekmann
- RedInRen 16/009, RTYC ISCIII, Madrid, Spain.,Nephrology Department, University Hospital Clinic, Barcelona, Spain
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Lee H, Kang E, Kang HG, Kim YH, Kim JS, Kim HJ, Moon KC, Ban TH, Oh SW, Jo SK, Cho H, Choi BS, Hong J, Cheong HI, Oh D. Consensus regarding diagnosis and management of atypical hemolytic uremic syndrome. Korean J Intern Med 2020; 35:25-40. [PMID: 31935318 PMCID: PMC6960041 DOI: 10.3904/kjim.2019.388] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 12/04/2019] [Indexed: 12/13/2022] Open
Abstract
Thrombotic microangiopathy (TMA) is defined by specific clinical characteristics, including microangiopathic hemolytic anemia, thrombocytopenia, and pathologic evidence of endothelial cell damage, as well as the resulting ischemic end-organ injuries. A variety of clinical scenarios have features of TMA, including infection, pregnancy, malignancy, autoimmune disease, and medications. These overlapping manifestations hamper differential diagnosis of the underlying pathogenesis, despite recent advances in understanding the mechanisms of several types of TMA syndrome. Atypical hemolytic uremic syndrome (aHUS) is caused by a genetic or acquired defect in regulation of the alternative complement pathway. It is important to consider the possibility of aHUS in all patients who exhibit TMA with triggering conditions because of the incomplete genetic penetrance of aHUS. Therapeutic strategies for aHUS are based on functional restoration of the complement system. Eculizumab, a monoclonal antibody against the terminal complement component 5 inhibitor, yields good outcomes that include prevention of organ damage and premature death. However, there remain unresolved challenges in terms of treatment duration, cost, and infectious complications. A consensus regarding diagnosis and management of TMA syndrome would enhance understanding of the disease and enable treatment decision-making.
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Affiliation(s)
- Hajeong Lee
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Eunjeong Kang
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hee Gyung Kang
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children’s Hospital, Seoul, Korea
| | - Young Hoon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee-Jin Kim
- Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Chul Moon
- Department of Pathology, Seoul National University Hospital, Seoul, Korea
| | - Tae Hyun Ban
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Se Won Oh
- Division of Nephrology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Sang Kyung Jo
- Division of Nephrology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Heeyeon Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Bum Soon Choi
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Junshik Hong
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hae Il Cheong
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children’s Hospital, Seoul, Korea
| | - Doyeun Oh
- Department of Internal Medicine, CHA University School of Medicine, Seongnam, Korea
- Correspondence to Doyeun Oh, M.D. Department of Internal Medicine, CHA University School of Medicine, 59 Yatap-ro, Bundang-gu, Seongnam 13496, Korea Tel: +82-31-780-5217, Fax: +82-31-780-5221, E-mail:
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11
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Vilayur E, de Malmanche J, Trevillian P, Ferreira D. Metastatic lung adenocarcinoma- associated thrombotic microangiopathy in a renal transplant recipient. BMJ Case Rep 2018; 11:11/1/e226707. [PMID: 30567242 DOI: 10.1136/bcr-2018-226707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Thrombotic microangiopathy (TMA) after renal transplantation can be a diagnostic challenge. TMA can occur with calcineurin inhibitors, allograft rejection, infection, mutations in complement regulatory proteins and autoimmunity. A 52-year-old male renal transplant recipient presented with extensive deep vein thrombosis. He developed transfusion-dependent microangiopathic haemolytic anaemia with thrombocytopenia. He did not respond calcineurin inhibitor cessation, eculizumab or plasma exchange. ADAMTS13 and complement levels were normal. Infection and autoimmune screens were negative. A diagnosis of metastatic adenocarcinoma was made on bone marrow biopsy. This represents a rare case of malignancy-associated TMA in a renal transplant recipient. Early diagnosis can facilitate the prompt initiation of chemotherapy which is the only treatment option.
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Affiliation(s)
- Eswari Vilayur
- School of Epidemiology and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Newcastle Transplant Unit, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Jillian de Malmanche
- Haematology Department, Calvary Mater Hospital, Newcastle, New South Wales, Australia
| | - Paul Trevillian
- School of Epidemiology and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Newcastle Transplant Unit, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - David Ferreira
- Medical Department, Liverpool Hospital, Sydney, New South Wales, Australia.,School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
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12
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Abstract
Renal complications are common following heart and/or lung transplantation and lead to increased morbidity and mortality. Renal dysfunction is also associated with increased mortality for patients on the transplant wait list. Dialysis dependence is a relative contraindication for heart or lung transplantation at most centers, and such patients are often listed for a simultaneous kidney transplant. Several factors contribute to the impaired renal function in patients undergoing heart and/or lung transplantation, including the interplay between cardiopulmonary and renal hemodynamics, complex perioperative issues, and exposure to nephrotoxic medications, mainly calcineurin inhibitors.
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13
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Özdemir BH, Ok Atılgan A, Yılmaz Akçay E, Özdemir G, Ayvazoğlu Soy E, Akdur A, Haberal M. De Novo Thrombotic Microangiopathy in Renal Transplant Patients. EXP CLIN TRANSPLANT 2018. [PMID: 29528010 DOI: 10.6002/ect.tond-tdtd2017.p27] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Thrombotic microangiopathy is a form of renal capillary injury possibly associated with calcineurin inhibitor toxicity, acute humoral rejection, infections, and recurrent diseases. Here, we examined its incidence in patients diagnosed with acute and chronic active humoral rejection, polyomavirus nephropathy, acute cellular rejection, and immunoglobulin A recurrence. MATERIALS AND METHODS In total, 272 renal allograft recipients who met the inclusion criteria were reevaluated for presence of renal thrombotic microangiopathy. Thrombotic microangiopathy diagnosis was established by clinical, laboratory, and histologic features. C4d expression in peritubular capillaries was determined. Clinical data were collected from medical records. RESULTS Of 272 patients (mean age of 42.8 ± 12.7 years), only 74 patients (27.2%) had de novo thrombotic microangiopathy, which was found in 30/90 patients (33.3%) with acute humoral rejection, 9/51 (17.6%) with acute cellular rejection, 22/53 (41.5%) with chronic active humoral rejection, 10/55 (18.2%) with polyomavirus nephropathy, and 3/23 (13%) with immunoglobulin A nephropathy. Significant differences were shown between therapy type and thrombotic microangiopathy development (P = .02). Patients who received cyclosporine (38.5%) tended to show higher incidence of thrombotic microangiopathy than patients who received tacrolimus (20.7%) or sirolimus (7.7%). Patients with C4d-positive acute humoral (97.6% vs 2.4%) and chronic active humoral rejection (68.2% vs 31.8%) had greater incidence of thrombotic microangiopathy versus those who were C4d-negative. Graft loss was significantly higher in C4d-positive than in C4d-negative thrombotic microangiopathy groups (P < .001). Overall 1-, 3-, and 5-year graft survival was 94%, 85%, and 85% versus 83%, 51%, and 51% in thrombotic microangiopathy-negative versus thrombotic microangiopathy-positive patients (P < .001). CONCLUSIONS Acute humoral rejection and chronic active humoral rejection were the most common and therefore most important causes of de novo thrombotic microangiopathy in renal transplant patients. Its presence in the renal allograft biopsy should arouse suspicion for underlying acute or chronic active humoral rejection.
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Affiliation(s)
- B Handan Özdemir
- From the Department of Pathology, Başkent University Faculty of Medicine, Ankara, Turkey
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14
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de Nattes T, Lelandais L, Etienne I, Laurent C, Guerrot D, Bertrand D. Antithymocyte globulin-induced hemolytic anemia and thrombocytopenia after kidney transplantation. Immunotherapy 2018; 10:737-742. [PMID: 30008258 DOI: 10.2217/imt-2017-0135] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Antithymocyte globulin is the most widely used lymphocyte-depleting treatment in kidney transplantation. In spite of the frequency of side effects, including anemia and thrombocytopenia, their pathophysiological mechanisms are not clearly established. Here, we report the case of a 21-year-old patient who had a first kidney transplantation and received induction immunosuppressive therapy by thymoglobulin. Immediately after kidney transplantation, he developed a severe hemolytic anemia and thrombocytopenia with a subsequent perirenal hematoma, which lead to a second surgical procedure and a transfer to the intensive care unit. Our patients' anemia and thrombocytopenia had heteroimmune characteristics, and thymoglobulin therapy was suspected to be the cause, via an interaction with a common Fc-receptor epitope in the different cell lines.
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Affiliation(s)
- T de Nattes
- Nephrology - Kidney Transplant Unit, Rouen University Hospital, 76031 Rouen, France
| | - L Lelandais
- Nephrology - Kidney Transplant Unit, Rouen University Hospital, 76031 Rouen, France
| | - I Etienne
- Nephrology - Kidney Transplant Unit, Rouen University Hospital, 76031 Rouen, France
| | - C Laurent
- Nephrology - Kidney Transplant Unit, Rouen University Hospital, 76031 Rouen, France
| | - D Guerrot
- Nephrology - Kidney Transplant Unit, Rouen University Hospital, 76031 Rouen, France
| | - D Bertrand
- Nephrology - Kidney Transplant Unit, Rouen University Hospital, 76031 Rouen, France
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15
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Kawanishi T, Hasegawa J, Kono M, Ishiwatari A, Ogawa T, Abe Y, Endo M, Ishigooka H, Okumi M, Tanabe K, Wakai S, Shirakawa H. Thrombotic microangiopathy after kidney transplantation successfully treated with eculizumab: A case report. TRANSPLANTATION REPORTS 2018. [DOI: 10.1016/j.tpr.2018.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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16
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De Novo Atypical Haemolytic Uremic Syndrome after Kidney Transplantation. Case Rep Nephrol 2018; 2018:1727986. [PMID: 29732228 PMCID: PMC5872611 DOI: 10.1155/2018/1727986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/23/2018] [Accepted: 02/14/2018] [Indexed: 11/29/2022] Open
Abstract
De novo thrombotic microangiopathy (TMA) can occur after kidney transplantation. An abnormality of the alternative pathway of complement must be suspected and searched for, even in presence of a secondary cause. We report the case of a 23-year-old female patient who was transplanted with a kidney from her mother for end-stage renal disease secondary to Hinman syndrome. Early after transplantation, she presented with 2 episodes of severe pyelonephritis, associated with acute kidney dysfunction and biological and histological features of TMA. Investigations of the alternative pathway of the complement system revealed atypical haemolytic uremic syndrome secondary to complement factor I mutation, associated with mutations in CD46 and complement factor H related protein genes. Plasma exchanges followed by eculizumab injections allowed improvement of kidney function without, however, normalization of creatinine.
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17
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Leal R, Tsapepas D, Crew RJ, Dube GK, Ratner L, Batal I. Pathology of Calcineurin and Mammalian Target of Rapamycin Inhibitors in Kidney Transplantation. Kidney Int Rep 2018; 3:281-290. [PMID: 30276344 PMCID: PMC6161639 DOI: 10.1016/j.ekir.2017.10.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 10/15/2017] [Accepted: 10/23/2017] [Indexed: 12/26/2022] Open
Abstract
The recent evolution in immunosuppression therapy has led to significant improvement in short-term kidney allograft outcomes; however, this progress did not translate into similar improvement in long-term graft survival. The latter, at least in part, is likely to be attributed to immunosuppressant side effects. In this review, we focus on the histologic manifestations of calcineurin inhibitor and mammalian target of rapamycin inhibitor toxicity. We discuss the pathologic features attributed to such toxicity and allude to the lack of highly specific pathognomonic lesions. Finally, we highlight the importance of clinicopathologic correlation to achieve a meaningful pathologic interpretation.
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Affiliation(s)
- Rita Leal
- Department of Nephrology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Department of Pathology and Cell Biology, Columbia University, College of Physicians and Surgeons, New York, New York, USA
| | - Demetra Tsapepas
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Russell J. Crew
- Department of Medicine, Division of Nephrology, Columbia University, College of Physicians and Surgeons, New York, New York, USA
| | - Geoffrey K. Dube
- Department of Medicine, Division of Nephrology, Columbia University, College of Physicians and Surgeons, New York, New York, USA
| | - Lloyd Ratner
- Department of Surgery, Division of Transplantation, Columbia University, College of Physicians and Surgeons, New York, New York, USA
| | - Ibrahim Batal
- Department of Pathology and Cell Biology, Columbia University, College of Physicians and Surgeons, New York, New York, USA
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18
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Abstract
Thrombotic microangiopathy can manifest in a diverse range of diseases and is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and organ injury, including AKI. It can be associated with significant morbidity and mortality, but a systematic approach to investigation and prompt initiation of supportive management and, in some cases, effective specific treatment can result in good outcomes. This review considers the classification, pathology, epidemiology, characteristics, and pathogenesis of the thrombotic microangiopathies, and outlines a pragmatic approach to diagnosis and management.
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Affiliation(s)
- Vicky Brocklebank
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne, Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; and
| | - Katrina M. Wood
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne, Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; and
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19
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Brocklebank V, Kavanagh D. Complement C5-inhibiting therapy for the thrombotic microangiopathies: accumulating evidence, but not a panacea. Clin Kidney J 2017; 10:600-624. [PMID: 28980670 PMCID: PMC5622895 DOI: 10.1093/ckj/sfx081] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 06/21/2017] [Indexed: 02/07/2023] Open
Abstract
Thrombotic microangiopathy (TMA), characterized by organ injury occurring consequent to severe endothelial damage, can manifest in a diverse range of diseases. In complement-mediated atypical haemolytic uraemic syndrome (aHUS) a primary defect in complement, such as a mutation or autoantibody leading to over activation of the alternative pathway, predisposes to the development of disease, usually following exposure to an environmental trigger. The elucidation of the pathogenesis of aHUS resulted in the successful introduction of the complement inhibitor eculizumab into clinical practice. In other TMAs, although complement activation may be seen, its role in the pathogenesis remains to be confirmed by an interventional trial. Although many case reports in TMAs other than complement-mediated aHUS hint at efficacy, publication bias, concurrent therapies and in some cases the self-limiting nature of disease make broader interpretation difficult. In this article, we will review the evidence for the role of complement inhibition in complement-mediated aHUS and other TMAs.
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Affiliation(s)
- Vicky Brocklebank
- The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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20
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Epperla N, Hemauer K, Hamadani M, Friedman KD, Kreuziger LB. Impact of treatment and outcomes for patients with posttransplant drug-associated thrombotic microangiopathy. Transfusion 2017; 57:2775-2781. [PMID: 28836275 DOI: 10.1111/trf.14263] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 06/17/2017] [Accepted: 06/17/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Drug-induced transplant-associated thrombotic microangiopathy (DTA-TMA) is a rare but serious complication that can occur after hematopoietic cell transplantation (HCT) or solid organ transplantation (SOT) without guidelines for optimal management of this condition. STUDY DESIGN AND METHODS Given the ambiguity surrounding the treatment for DTA-TMA, we conducted a retrospective review to evaluate the impact of different treatment strategies in DTA-TMA patients. Our primary endpoint was to determine the overall response rate (ORR) for DTA-TMA based on the type of treatment modality chosen while secondary endpoints included the time to response, relapse rates, and overall survival for DTA-TMA cases. RESULTS There were a total of 14 DTA-TMA patients of whom nine were post-HCT and five were post-SOT. Most of the DTA-TMA cases were due to tacrolimus (n = 11) with a minority related to sirolimus (n = 3). A total of nine of 14 patients demonstrated response and five had no response to therapy. The ORR among the DTA-TMA patients after HCT and SOT who received plasma exchange (PLEX) were 25 and 100%, respectively. The ORRs among the patients (includes HCT and SOT) who received rituximab (n = 3) and eculizumab (n = 5) were 67 and 60%, respectively. There were two relapses noted in our study and both were in the HCT group. CONCLUSION While discontinuation of the offending agent may be sufficient for treatment of DTA-TMA after HCT, PLEX may be a reasonable option for DTA-TMA after SOT. Although the results are encouraging with rituximab and eculizumab in the treatment of DTA-TMA, larger prospective studies are needed to validate our findings.
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Affiliation(s)
| | | | | | - Kenneth D Friedman
- Division of Hematology and Oncology.,BloodCenter of Wisconsin, Milwaukee, Wisconsin
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21
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Shochet L, Kanellis J, Simpson I, Ta J, Mulley W. De novo thrombotic microangiopathy following simultaneous pancreas and kidney transplantation managed with eculizumab. Nephrology (Carlton) 2017; 22 Suppl 1:23-27. [PMID: 28176480 DOI: 10.1111/nep.12936] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Thrombotic microangiopathy (TMA) is a well-recognised complication following transplantation, often due to an underlying genetic predisposition, medications or rejection. The use of eculizumab in these settings has been previously described, but its role still remains to be clarified. A 45-year-old man, with a history of type 1 diabetes mellitus and subsequent end-stage kidney failure, presented for a simultaneous pancreas-kidney transplant. Immunologically, he was well matched with the donor, and he received standard induction immunosuppression including tacrolimus. His early transplant course was complicated by Haemophilus parainfluenzae paronychia and a Pseudomonas aeruginosa catheter-associated urinary tract infection. Within 1 week, he developed thrombotic microangiopathy with significant renal dysfunction and eventual dialysis dependence, without evidence of transplant rejection on biopsy. He was also noted to have antiphospholipid antibodies in moderate titres. The TMA did not resolve despite cessation of tacrolimus, and he was subsequently commenced on eculizumab. The patient achieved a partial remission from TMA, with ongoing biochemical evidence of haemolysis, although now with stable graft function, despite significant damage. His transplanted pancreas remained seemingly unaffected by TMA, and continues to function well. This case describes an unusual presentation of TMA post-transplantation and is the only described case of eculizumab use following pancreas-kidney transplant. It remains unclear in this case what the likely precipitant for TMA was, although it seems to be, at least in part, controlled by ongoing use of eculizumab, presumably by terminal complement inhibition.
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Affiliation(s)
- Lani Shochet
- Department of Nephrology, Monash Health, Melbourne, Victoria, Australia
| | - John Kanellis
- Department of Nephrology, Monash Health, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ian Simpson
- Department of Anatomical Pathology, Monash Health, Melbourne, Victoria, Australia
| | - Joseph Ta
- Australian Red Cross Blood Service, Melbourne, Victoria, Australia
| | - William Mulley
- Department of Nephrology, Monash Health, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
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22
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Hayashi Y, Nagahara A, Kawashima A, Kakuta Y, Ujike T, Abe T, Fukuhara S, Fujita K, Uemura M, Kiuchi H, Imamura R, Miyagawa Y, Ichimaru N, Maeda T, Nonomura N. [A CASE OF SUCCESSFUL RECOVERY OF RENAL ALLOGRAFT FUNCTION FOLLOWING A DIAGNOSIS OF THROMBOTIC MICROANGIOPATHY CLINICALLY MADE IN THE IMMEDIATE POST-TRANSPLANT PERIOD]. Nihon Hinyokika Gakkai Zasshi 2017; 108:166-169. [PMID: 30033982 DOI: 10.5980/jpnjurol.108.166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
A 57-year-old female patient on hemodialysis with chronic renal failure due to chronic glomerular nephritis received deceased donor kidney transplantation. Induction immunosuppressive therapy was combination of tacrolimus, mycophenolate mofetil, everolimus, prednisolone, and basiliximab. She was diagnosed with secondary thrombotic microangiopathy (TMA) by clinical findings such as hemolytic anemia, thrombocytopenia and acute kidney injury not by pathological findings on the 4th post-operative date. Plasma exchange was performed with suspension of tacrolimus. General conditions recovered, and the graft function was preserved.
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Affiliation(s)
- Yujiro Hayashi
- Department of Urology, Osaka University Graduate School of Medicine
| | - Akira Nagahara
- Department of Urology, Osaka University Graduate School of Medicine
| | | | - Yoichi Kakuta
- Department of Urology, Osaka University Graduate School of Medicine
| | - Takeshi Ujike
- Department of Urology, Osaka University Graduate School of Medicine
| | - Toyofumi Abe
- Department of Urology, Osaka University Graduate School of Medicine
| | | | - Kazutoshi Fujita
- Department of Urology, Osaka University Graduate School of Medicine
| | - Motohide Uemura
- Department of Urology, Osaka University Graduate School of Medicine
| | - Hiroshi Kiuchi
- Department of Urology, Osaka University Graduate School of Medicine
| | - Ryoichi Imamura
- Department of Urology, Osaka University Graduate School of Medicine
| | - Yasushi Miyagawa
- Department of Urology, Osaka University Graduate School of Medicine
| | - Naotsugu Ichimaru
- Department of Advanced Technology for Transplantation, Osaka University Graduate School of Medicine
| | - Tetsuo Maeda
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine
| | - Norio Nonomura
- Department of Urology, Osaka University Graduate School of Medicine
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23
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Yun SH, Lee JH, Oh JS, Kim SM, Sin YH, Kim YJ, Kim JK. Overcome of Drug Induced Thrombotic Microangiopathy after Kidney Transplantation by Using Belatacept for Maintenance Immunosuppression. KOREAN JOURNAL OF TRANSPLANTATION 2016. [DOI: 10.4285/jkstn.2016.30.1.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Seong Han Yun
- Division of Nephrology, Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Jin Ho Lee
- Division of Nephrology, Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Joon Seok Oh
- Division of Nephrology, Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Seong Min Kim
- Division of Nephrology, Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Yong Hun Sin
- Division of Nephrology, Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Yong-Jin Kim
- Department of Pathology, Yeungnam University College of Medicine, Daegu, Korea
| | - Joong Kyung Kim
- Division of Nephrology, Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
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24
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Kawaguchi K, Kawanishi K, Sato M, Itabashi M, Fujii A, Kanetsuna Y, Huchinoue S, Ohashi R, Koike J, Honda K, Nagashima Y, Nitta K. Atypical hemolytic uremic syndrome diagnosed four years after ABO-incompatible kidney transplantation. Nephrology (Carlton) 2016; 20 Suppl 2:61-5. [PMID: 26031589 DOI: 10.1111/nep.12465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2015] [Indexed: 11/29/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS) in allograft kidney transplantation is caused by various factors including rejection, infection, and immunosuppressive drugs. We present a case of a 32 year old woman with aHUS four years after an ABO-incompatible kidney transplantation from a living relative. The primary cause of end-stage renal disease was unknown; however, IgA nephropathy (IgAN) was suspected from her clinical course. She underwent pre-emptive kidney transplantation from her 60 year old mother. The allograft preserved good renal function [serum creatinine (sCr) level 110-130 μmol/L] until a sudden attack of abdominal pain four years after transplant, with acute renal failure (sCr level, 385.3 μmol/L), decreasing platelet count, and hemolytic anemia with schizocytes. On allograft biopsy, there was thrombotic microangiopathy in the glomeruli, with a cellular crescent formation and mesangial IgA and C3 deposition. Microvascular inflammation, such as glomerulitis, peritubular capillaritis, and arteriole endarteritis were also detected. A disintegrin-like and metalloproteinase with thrombospondin type 1 motifs 13 (ADAMTS13) did not decrease and Shiga toxin was not detected. Donor-specific antibodies or autoantibodies, including anti-neutrophil cytoplasmic antibody and anti-glomerular basement membrane (anti-GBM) antibody, were negative. The patient was diagnosed with aHUS and received three sessions of plasmapheresis and methylprednisolone pulse therapy, followed by oral methylprednisolone (0.25-0.5 mg/kg) instead of tacrolimus. She temporarily required hemodialysis (sCr level, 658.3 μmol/L). Thereafter, her sCr level improved to 284.5 μmol/L without dialysis therapy. This case is clinically considered as aHUS after kidney transplantation, associated with various factors, including rejection, glomerulonephritis, and toxicity from drugs such as tacrolimus.
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Affiliation(s)
- Keiko Kawaguchi
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Kunio Kawanishi
- Department of Surgical Pathology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayo Sato
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Mitsuyo Itabashi
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Akiko Fujii
- Department of Surgical Pathology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yukiko Kanetsuna
- Department of Surgical Pathology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shouhei Huchinoue
- Department of Surgical Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Ryuji Ohashi
- Department of Surgical Pathology, Nippon Medical School Hospital, Tokyo, Japan
| | - Junki Koike
- Department of Pathology, Kawasaki Municipal Tama Hospital, Kawasaki, Kanagawa, Japan
| | - Kazuho Honda
- Department of Surgical Pathology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoji Nagashima
- Department of Surgical Pathology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kosaku Nitta
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
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25
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Okumi M, Omoto K, Unagami K, Ishida H, Tanabe K. Eculizumab for the treatment of atypical hemolytic uremic syndrome recurrence after kidney transplantation associated with complement factor H mutations: a case report with a 5-year follow-up. Int Urol Nephrol 2016; 48:817-8. [PMID: 26865178 DOI: 10.1007/s11255-016-1234-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 01/28/2016] [Indexed: 01/11/2023]
Affiliation(s)
- Masayoshi Okumi
- Department of Urology, Kidney Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan.
| | - Kazuya Omoto
- Department of Urology, Kidney Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
| | - Kohei Unagami
- Department of Internal Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Hideki Ishida
- Department of Urology, Kidney Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
| | - Kazunari Tanabe
- Department of Urology, Kidney Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
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26
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Ventura-Aguiar P, Campistol JM, Diekmann F. Safety of mTOR inhibitors in adult solid organ transplantation. Expert Opin Drug Saf 2016; 15:303-19. [PMID: 26667069 DOI: 10.1517/14740338.2016.1132698] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Mammalian target of rapamycin (mTOR) inhibitors (sirolimus and everolimus) are a class of immunosuppressive drugs approved for solid organ transplantation (SOT). By inhibiting the ubiquitous mTOR pathway, they present a peculiar safety profile. The increased incidence of serious adverse events in early studies halted the enthusiasm as a kidney sparing alternative to calcineurin inhibitors (CNI). AREAS COVERED Herein we review mTOR inhibitors safety profile for adult organ transplantation, ranging from acute side effects, such as lymphoceles, delayed wound healing, or cytopenias, to long-term ones which increase morbidity and mortality, such as cancer risk and metabolic profile. Infection, proteinuria, and cutaneous safety profiles are also addressed. EXPERT OPINION In the authors' opinion, mTOR inhibitors are a safe alternative to standard immunosuppression therapy with CNI and mycophenolate/azathioprine. Mild adverse events can be easily managed with an increased awareness and close monitoring of trough levels. Most serious side effects are dose- and organ-dependent. In kidney and heart transplantation mTOR inhibitors may be safely used as either low-dose de novo or through early-conversion. In the liver, conversion 4 weeks post-transplantation may reduce long-term chronic kidney disease secondary to calcineurin nephrotoxicity, without increasing hepatic artery/portal vein thrombosis.
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Affiliation(s)
- Pedro Ventura-Aguiar
- a Department of Nephrology and Renal Transplantation , Hospital Clínic , Villarroel, 170, E-08036 Barcelona , Spain
| | - Josep Maria Campistol
- a Department of Nephrology and Renal Transplantation , Hospital Clínic , Villarroel, 170, E-08036 Barcelona , Spain.,b August Pi i Sunyer Biomedical Research Institute (IDIBAPS) , University of Barcelona , Barcelona , Spain
| | - Fritz Diekmann
- a Department of Nephrology and Renal Transplantation , Hospital Clínic , Villarroel, 170, E-08036 Barcelona , Spain
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Canet E, Zafrani L, Azoulay É. The Critically Ill Kidney Transplant Recipient: A Narrative Review. Chest 2016; 149:1546-55. [PMID: 26836919 DOI: 10.1016/j.chest.2016.01.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 12/11/2015] [Accepted: 01/03/2016] [Indexed: 12/20/2022] Open
Abstract
Kidney transplantation is the most common solid organ transplantation performed worldwide. Up to 6% of kidney transplant recipients experience a life-threatening complication that requires ICU admission, chiefly in the late posttransplantation period (≥ 6 months). Acute respiratory failure and septic shock are the main reasons for ICU admission. Cardiac pulmonary edema, bacterial pneumonia, acute graft pyelonephritis, and bloodstream infections account for the vast majority of diagnoses in the ICU. Pneumocystis jirovecii pneumonia is the most common opportunistic infection, and one-half of the patients so infected require mechanical ventilation. The incidence of cytomegalovirus visceral infections in the era of preemptive therapy has dramatically decreased. Drug-related neutropenia, sirolimus-related pneumonitis, and posterior reversible encephalopathy syndrome are among the most common immunosuppression-associated toxic effects. Importantly, the impact of critical illness on graft function is worrisome. Throughout the ICU stay, acute kidney injury is common, and about 40% of the recipients require renal replacement therapy. One-half of the patients are discharged alive and free from dialysis. Hospital mortality can reach 30% and correlates with acute illness severity and reason for ICU admission. Transplant characteristics are not predictors of short-term survival. Graft survival depends on pre-ICU graft function, disease severity, and renal toxicity of ICU investigations and treatments.
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Affiliation(s)
- Emmanuel Canet
- Medical Intensive Care Unit Department, Saint-Louis University Hospital, Paris, France.
| | - Lara Zafrani
- Medical Intensive Care Unit Department, Saint-Louis University Hospital, Paris, France; Paris Diderot University, Sorbonne Paris Cité Paris, France
| | - Élie Azoulay
- Medical Intensive Care Unit Department, Saint-Louis University Hospital, Paris, France; Paris Diderot University, Sorbonne Paris Cité Paris, France
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Wu K, Budde K, Schmidt D, Neumayer HH, Lehner L, Bamoulid J, Rudolph B. The inferior impact of antibody-mediated rejection on the clinical outcome of kidney allografts that develop de novo thrombotic microangiopathy. Clin Transplant 2016; 30:105-17. [PMID: 26448478 DOI: 10.1111/ctr.12645] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) can induce and develop thrombotic microangiopathy (TMA) in renal allografts. A definitive AMR (dAMR) co-presents three diagnostic features. A suspicious AMR (sAMR) is designated when one of the three features is missing. METHODS Thirty-two TMA cases overlapping with AMR (AMR+ TMA) were studied, which involved 14 cases of sAMR+ TMA and 18 cases of dAMR+ TMA. Thirty TMA cases free of AMR features (AMR- TMA) were enrolled as control group. RESULTS The ratio of complete response to treatment was similar between AMR- TMA and AMR+ TMA group (23.3% vs. 12.5%, p = 0.33), or between sAMR+ TMA and dAMR+ TMA group (14.3% vs. 11.1%, p = 0.79). At eight yr post-transplantation, the death-censored graft survival (DCGS) rate of AMR- TMA group was 62.8%, which was significantly higher than 28.0% of AMR+ TMA group (p = 0.01), but similar between sAMR+ TMA and dAMR+ TMA group (30.0% vs. 26.7%, p = 0.92). Overall, the intimal arteritis and the broad HLA (Human leukocyte antigens) mismatches were closely associated with over time renal allograft failure. CONCLUSION The AMR+ TMA has inferior long-term graft survival, but grafts with sAMR+ TMA or dAMR+ TMA have similar characteristics and clinical courses.
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Affiliation(s)
- Kaiyin Wu
- Medizinische Klinik mit Schwerpunkt Nephrologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
| | - Klemens Budde
- Medizinische Klinik mit Schwerpunkt Nephrologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
| | - Danilo Schmidt
- Medizinische Klinik mit Schwerpunkt Nephrologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
| | - Hans-Hellmut Neumayer
- Medizinische Klinik mit Schwerpunkt Nephrologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
| | - Lukas Lehner
- Medizinische Klinik mit Schwerpunkt Nephrologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
| | - Jamal Bamoulid
- Medizinische Klinik mit Schwerpunkt Nephrologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
| | - Birgit Rudolph
- Institut für Pathologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
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Characteristics and Outcomes of Renal Transplant Recipients with Hemolytic Uremic Syndrome in the United States. Transplant Direct 2015; 1. [PMID: 26949736 PMCID: PMC4775084 DOI: 10.1097/txd.0000000000000555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Hemolytic uremic syndrome (HUS) accounts for <1% of renal transplants in the US. There are limited data on the characteristics and outcomes of HUS in pediatric and adult kidney transplant recipients in the US. METHODS This study included all renal transplant recipients identified with HUS (N=1,233) as a cause of end-stage renal disease between 1987 and 2013 using the UNOS/OPTN database. The cohort was divided into two age groups: pediatric (N=447) and adult (N=786). Main outcomes were acute rejection rate at one-year, allograft and patient survival, and recurrence of HUS post-transplant. Both age groups were then compared with a propensity score (1:2 ratio) matched control group with an alternative primary kidney disease (non-HUS cohort: pediatric [N= 829] and adult [N=1,547]). RESULTS In pediatric cohort, when compared to the PS matched controls, acute rejection, death censored allograft and patient survival was similar in the HUS group. However, in the adult cohort, the graft and patient survivals were significantly worse in the HUS group. HUS was associated with allograft loss (HR=1.40, 95%CI 1.14-1.71) in adult recipients. Patients with HUS recurrence had significantly lower allograft and patient survival rates compared to the non-recurrent group in both age groups. Acute rejection was one of the major predictor of HUS recurrence in adults (OR=2.64, 95%CI 1.25-5.60). Calcineurin inhibitors (CNI) were not associated HUS recurrence in both age groups. CONCLUSION Pediatric HUS-patients, unlike adult recipients, have similar outcomes compared to the PS matched controls. Recurrence of HUS is associated with poor allograft and patient survival in pediatric and adult patients. Use of CNIs seem to be safe as a part of maintenance immunosuppression post-transplantation. A comprehensive national registry is urgently needed.
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Koch M, Wiech T, Marget M, Peine S, Thude H, Achilles EG, Fischer L, Lehnhardt A, Thaiss F, Nashan B. De novomTOR inhibitor-based immunosuppression in ABO-incompatible kidney transplantation. Clin Transplant 2015; 29:1021-8. [DOI: 10.1111/ctr.12624] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2015] [Indexed: 01/05/2023]
Affiliation(s)
- Martina Koch
- Department of Hepatobiliary Surgery and Transplantation; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Thorsten Wiech
- Section Nephropathology; Institute of Pathology; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Matthias Marget
- HLA Laboratory; Institute of Transfusion Medicine; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Sven Peine
- HLA Laboratory; Institute of Transfusion Medicine; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Hansjörg Thude
- Department of Hepatobiliary Surgery and Transplantation; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Eike G. Achilles
- Department of Hepatobiliary Surgery and Transplantation; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Lutz Fischer
- Department of Hepatobiliary Surgery and Transplantation; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Anja Lehnhardt
- Department of Hepatobiliary Surgery and Transplantation; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Friedrich Thaiss
- III. Medical Clinic/Nephrology; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Bjoern Nashan
- Department of Hepatobiliary Surgery and Transplantation; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
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Bulut C, Oguz EG, Canbakan B, Ayli D. BK virus-related thrombotic microangiopathy in a kidney transplant recipient. INDIAN JOURNAL OF TRANSPLANTATION 2015. [DOI: 10.1016/j.ijt.2015.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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32
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Nava F, Cappelli G, Mori G, Granito M, Magnoni G, Botta C, Solazzo A, Fontana F, Baisi A, Bonucchi D. Everolimus, cyclosporine, and thrombotic microangiopathy: clinical role and preventive tools in renal transplantation. Transplant Proc 2015; 46:2263-8. [PMID: 25242766 DOI: 10.1016/j.transproceed.2014.07.062] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Thrombotic microangiopathy (TMA) is characterized by endothelial cell injury and formation of fibrin thrombi within capillary and arterioles. In renal allograft recipients, TMA mainly presents as hemolytic uremic syndrome. Its occurrence is rare, and diagnosis requires a high degree of suspicion. Drug toxicity, in particular from calcineurin inhibitors (CNIs) and mTOR inhibitors (mTORi), is the most common cause posttransplant and has recently been emphasized in the setting of lung transplantation. OBJECTIVE The goal of this study was to investigate the role of mTORi as an added risk factor in the development of TMA to propose strategies for modulation of immunosuppressive (IS) therapy. PATIENTS AND METHODS From a database of 496 renal graft recipients, we analyzed 350 renal graft biopsy specimens gathered at our center from 1998 to 2012. In patients undergoing combined therapy with mTORi and CNI, we compared drugs levels in TMA-affected and TMA-free groups, using mTORi and CNI TLC and the summation of [everolimus TLC+(cyclosporine C2/100)] (Σ) as a surrogate marker of combined exposition to 2 drugs. Receiver-operating characteristic analysis of association of EVL TLC+(C2/100) was performed for patients exposed to mTORi. RESULTS Histologic features of TMA were found in 36 patients (prevalence of 7.3%). The caseload was divided into 2 groups: not drug-related TMA (n=19) and drug-related TMA (n=17). Despite the prevalence of TMA in patients exposed to mTORi being greater (8 of 153; prevalence, 5.3%) compared with therapies without mTORi (9 of 324; prevalence, 2.8%), statistical difference was not reached. Patients treated with mTORi who developed de novo drug-related TMA had higher blood levels of IS drugs compared with those who did not develop TMA. Receiver-operating characteristic analysis found a significant threshold of 12.5 ng/mL (area under the curve, 0.803; P=.006). CONCLUSIONS Results confirm the pivotal role of IS drugs in the onset of de novo TMA. On the basis of literature, we could speculate a sequence of endothelial damage by CNI, on which everolimus fits hindering the repair of endothelial injury. Therefore, high blood levels of CNI and mTORi seem to predispose patients to posttransplant TMA. Combined monitoring of these 2 drugs might be used to prevent the complication. Σ [everolimus TLC + (cyclosporine C2/100)]>12.5 ng/mL should be avoided as a surrogate risk factor for adverse effects.
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Affiliation(s)
- F Nava
- Nephrology Dialysis and Kidney Transplantation, AOU Policlinico, Modena, Italy.
| | - G Cappelli
- Nephrology Dialysis and Kidney Transplantation, AOU Policlinico, Modena, Italy
| | - G Mori
- Nephrology Dialysis and Kidney Transplantation, AOU Policlinico, Modena, Italy
| | - M Granito
- Nephrology Dialysis and Kidney Transplantation, AOU Policlinico, Modena, Italy
| | - G Magnoni
- Nephrology Dialysis and Kidney Transplantation, AOU Policlinico, Modena, Italy
| | - C Botta
- Nephrology Dialysis and Kidney Transplantation, AOU Policlinico, Modena, Italy
| | - A Solazzo
- Nephrology Dialysis and Kidney Transplantation, AOU Policlinico, Modena, Italy
| | - F Fontana
- Nephrology Dialysis and Kidney Transplantation, AOU Policlinico, Modena, Italy
| | - A Baisi
- Nephrology Dialysis and Kidney Transplantation, AOU Policlinico, Modena, Italy
| | - D Bonucchi
- Nephrology Dialysis and Kidney Transplantation, AOU Policlinico, Modena, Italy
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Java A, Edwards A, Rossi A, Pandey R, Gaut J, Delos Santos R, Miller B, Klein C, Brennan D. Cytomegalovirus-induced thrombotic microangiopathy after renal transplant successfully treated with eculizumab: case report and review of the literature. Transpl Int 2015; 28:1121-5. [PMID: 25864519 DOI: 10.1111/tri.12582] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 03/09/2015] [Accepted: 04/07/2015] [Indexed: 01/28/2023]
Abstract
De novo thrombotic microangiopathy (TMA) after renal transplant is rare. Cytomegalovirus (CMV)-related post-transplant TMA has only been reported in 6 cases. We report an unusual case of a 75-year-old woman who developed de novo TMA in association with CMV viremia. The recurrence of TMA with CMV viremia, the resolution with treatment for CMV, and the lack of correlation with a calcineurin inhibitor (CNI) in our case support CMV as the cause of the TMA. What is unique is that the use of eculizumab without plasmapheresis led to prompt improvement in renal function. After a failure to identify a genetic cause for TMA and the clear association with CMV, eculizumab was discontinued. This case provides insight into the pathogenesis and novel treatment of de novo TMA, highlights the beneficial effects of complement inhibitors in this disease, and shows that they can be safely discontinued once the inciting etiology is addressed.
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Affiliation(s)
- Anuja Java
- Department of Transplant Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Angelina Edwards
- Department of Transplant Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ana Rossi
- Department of Transplant Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Richa Pandey
- Department of Transplant Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Joseph Gaut
- Department of Pathology, Washington University School of Medicine, St. Louis, MO, USA
| | - Rowena Delos Santos
- Department of Transplant Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Brent Miller
- Department of Transplant Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Christina Klein
- Department of Transplant Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel Brennan
- Department of Transplant Nephrology, Washington University School of Medicine, St. Louis, MO, USA
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34
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De novo thrombotic microangiopathy after non-renal solid organ transplantation. Blood Rev 2014; 28:269-79. [DOI: 10.1016/j.blre.2014.09.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 09/02/2014] [Indexed: 12/14/2022]
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A Case of Thrombotic Microangiopathy Associated With Antiphospholipid Antibody Syndrome Successfully Treated With Eculizumab. Transplantation 2014; 98:e17-8. [DOI: 10.1097/tp.0000000000000267] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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36
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Differing tales of two patients after receiving a kidney transplant from a donor with disseminated intravascular coagulation. Case Rep Transplant 2014; 2014:754256. [PMID: 25061532 PMCID: PMC4100278 DOI: 10.1155/2014/754256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/31/2014] [Accepted: 06/16/2014] [Indexed: 11/17/2022] Open
Abstract
In order to decrease the time on the deceased donor kidney wait list and to have more organs available, criteria for acceptable organs for transplant could be made less stringent. There are reports of successful recipient outcomes using kidney donors presenting with disseminated intravascular coagulation (DIC). We report a unique circumstance where two patients received kidneys from the same deceased donor who had DIC; one patient developed thrombotic microangiopathy (TMA) while the other did not. This difference in outcome may indicate that both donor and recipient factors contribute to the development of posttransplant TMA.
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37
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Sreedharanunni S, Joshi K, Duggal R, Nada R, Minz M, Sakhuja V. An analysis of transplant glomerulopathy and thrombotic microangiopathy in kidney transplant biopsies. Transpl Int 2014; 27:784-92. [PMID: 24684170 DOI: 10.1111/tri.12331] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 10/29/2013] [Accepted: 03/28/2014] [Indexed: 11/27/2022]
Abstract
Glomerular diseases of the transplanted kidney are the most important cause of poor long- term outcome. The estimation of the magnitude of this problem and an elucidation of pathogenic mechanism is essential for improvement of graft survival. This study from the Indian subcontinent aims (i) to determine the incidence of transplant glomerulopathy (TG) and thrombotic microangiopathy (TMA) in a large cohort of indicated renal transplant biopsies, (ii) to evaluate the histological and ultrastructural features of TG and TMA, and (iii) to assess the relationship between the two glomerular lesions. Of a total of 1792 indication renal transplant biopsies received over 5 years (2006-2010), 266 biopsies (of 249 patients) had significant glomerular pathology and were further analyzed along with immunofluorescence, electron microscopy (EM), and C4d immunohistochemistry. TG is the most common glomerular lesion followed by TMA seen in 5.97% and 5.08% of allograft biopsies, respectively, which constitutes 40.23% and 34.2% of biopsies with significant glomerular lesions. Pathologic antibody-mediated rejection (AMR) is associated with both TG and TMA in 71% and 46.5%, respectively. A coexistent TG was found in 18.4% of biopsies with TMA. Endothelial swelling with subendothelial widening, a feature of TMA, is also seen in early TG by EM. Our findings support the concept that TG evolves from a smoldering TMA of various causes.
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Affiliation(s)
- Sreejesh Sreedharanunni
- Department of Histopatholology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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De Ciuceis C, Flati V, Rossini C, Rufo A, Porteri E, Di Gregorio J, Petroboni B, La Boria E, Donini C, Pasini E, Agabiti Rosei E, Rizzoni D. Effect of antihypertensive treatments on insulin signalling in lympho-monocytes of essential hypertensive patients: A pilot study. Blood Press 2014; 23:330-8. [DOI: 10.3109/08037051.2014.901021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Ponticelli C, Moroni G, Glassock RJ. De novo glomerular diseases after renal transplantation. Clin J Am Soc Nephrol 2014; 9:1479-87. [PMID: 24700797 DOI: 10.2215/cjn.12571213] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Glomerular diseases developing in the kidney allograft are more often recurrences of the original disease affecting the native kidneys. However, in an undefined number of cases de novo, glomerular diseases unrelated to the original disease in the native kidneys can develop in the transplanted kidney. The clinical presentation and histologic features of de novo diseases are often similar to those features observed in patients with primary or secondary GN in the native kidneys. However, in transplanted kidneys, the glomerular, vascular, and tubulointerstitial changes are often intertwined with structural abnormalities already present at the time of transplant or caused by antibody- or cell-mediated allograft rejection, immunosuppressive drugs, or superimposed infection (most often of a viral nature). The pathophysiology of de novo glomerular diseases is quite variable. In rare cases of de novo minimal change disease, circulating factors increasing the glomerular permeability likely participate. Maladaptive hemodynamic changes and tissue fibrosis caused by calcineurin inhibitors or other factors may be involved in the pathogenesis of de novo FSGS. The exposure of cryptic podocyte antigens may favor the development of de novo membranous nephropathy. Many cases of de novo membranoproliferative GN are related to hepatitis C virus infection. Patients with Alport syndrome lacking antigenic epitopes in their glomerular basement membrane may develop antibodies against these glomerular basement membrane antigens expressed in the transplanted kidney. Infection may cause acute GN to have a heterogeneous clinical presentation and outcome. De novo pauci-immune GN in renal transplant is rare. Preexisting or acquired intolerance to glucose may, in the long term, cause diabetic nephropathy. The prognosis of de novo diseases depends on the type of GN, the severity of lesions caused by the alloimmune response, or the efficacy of immunosuppressive therapy. In most cases, the management of de novo glomerular diseases is empirical or elusive.
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Affiliation(s)
- Claudio Ponticelli
- Division of Nephrology, Humanitas Scientific Institute, Rozzano, Milan, Italy;
| | - Gabriella Moroni
- Division of Nephrology, Fondazione Ca' Granda Ospedale Maggiore Istituto Scientifico, Milan, Italy; and
| | - Richard J Glassock
- Department of Medicine, Geffen School of Medicine at the University of California at Los Angeles, Laguna Niguel, California
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40
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Matsuda D, Toshima T, Ikegami T, Harimoto N, Yamashita YI, Yoshizumi T, Soejima Y, Ikeda T, Shirabe K, Maehara Y. Thrombotic microangiopathy caused by severe graft dysfunction after living donor liver transplantation: report of a case. Clin J Gastroenterol 2014; 7:159-63. [DOI: 10.1007/s12328-013-0446-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 12/10/2013] [Indexed: 11/30/2022]
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41
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Peeters P, Van Laecke S, Vanholder R. Acute kidney injury in solid organ transplant recipients. Acta Clin Belg 2014; 62 Suppl 2:389-92. [PMID: 18284006 DOI: 10.1179/acb.2007.087] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Delayed and slow graft function (DGF/SGF) in de novo kidney transplantation endanger outcomes of graft and patient, while predisposing the patient to acute rejection and lesser graft function. Causes and work-up of DGF/SGF are described in the present paper. Also, the epidemiology and pathophysiology of chronic renal failure both in kidney graft recipients and in recipients of other solid organs is discussed, especially in relation to calcineurin inhibitor (CNI) immunosuppression. An acute kidney injury event will have a greater and faster impact on impaired renal reserve in case of chronic renal failure. Major causes of acute kidney injury (AKI) of the native kidneys of solid organ recipients and of the transplanted kidney are: severe infections, acute toxic kidney injury caused by CNI treatment concomitant CYP450 3A4 inhibiting medication, toxic and infectious events inducing haemolytic uraemic syndrome, toxic rhabdomyolysis, acute interstitial nephritis, rapid IV immunoglobulin infusion and exposure to other well-known nephrotoxins, such as NSAIDs, amphotericin and aminoglycosides.
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Affiliation(s)
- P Peeters
- Renal Division, Department of Internal Medicine, University Hospital Ghent, Belgium.
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42
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Reindl-Schwaighofer R, Oberbauer R. Blood disorders after kidney transplantation. Transplant Rev (Orlando) 2013; 28:63-75. [PMID: 24211181 DOI: 10.1016/j.trre.2013.10.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Revised: 09/21/2013] [Accepted: 10/01/2013] [Indexed: 02/07/2023]
Abstract
Post transplant anemia (PTA) is a common issue in kidney transplant recipients. Most importantly it is associated with an impaired allograft function. Other important factors associated with PTA are immunosuppressive drugs (MPA, AZA and SRL), iron deficiency, infections (Parvo B19), older donor age, rejection episodes, an increased inflammatory state, and erythropoietin hyporesponsiveness. As there are no adequately powered RCTs in the kidney transplant population on anemia treatment with ESA, we have to rely on what we know from the large RCTs in the CKD population. The recently published KDIGO guidelines do not recommend treatment with ESA if Hb is >10 g/dl. Repletion of iron stores is emphasized. Post transplant leukopenia (PTL) and thrombocytopenia (PTT) are frequent complications especially in the first six months after kidney transplantation. Myelosuppression caused by immunosuppressive agents (MPA, AZA, SRL, rATG), antimicrobial drugs (VGCV), and CMV infection is the predominant cause. There are no widely accepted guidelines on treatment strategies, but most often dose reduction or discontinuation of causative medication is done. Most clinicians tend to decrease MPA dose, but this is eventually associated with an increase in acute rejection episodes. VGCV dose reduction (preemptive treatment instead of CMV prophylaxis) may be a successful strategy. In severe cases G-CSF treatment is an important management option and seems to be safe.
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Affiliation(s)
| | - Rainer Oberbauer
- Department of Nephrology, KH Elisabethinen, Linz, Austria; Department of Nephrology, Medical University of Vienna, Vienna, Austria.
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Ellimoottil C, Brandt W, Bernardi K, Evans A, Mehta V, Picken MM, Phelan K, Heinrich L, Milner J, Wai PY, Asolati M, Kuo PC, Lu AD. Acute graft dysfunction after living-related renal transplant. Urology 2013; 82:764-7. [PMID: 23947990 DOI: 10.1016/j.urology.2013.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 06/02/2013] [Accepted: 06/16/2013] [Indexed: 11/18/2022]
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Glomerular mRNA expression of prothrombotic and antithrombotic factors in renal transplants with thrombotic microangiopathy. Transplantation 2013; 95:1242-8. [PMID: 23635876 DOI: 10.1097/tp.0b013e318291a298] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) in renal transplants (rTx-TMA) is a serious complication and is usually either recurrent TMA (RecTMA) due to humoral rejection (HR-TMA) or due to calcineurin inhibitor toxicity (CNI-TMA). Although the triggers are known, our knowledge about the thrombogenic transcriptome changes in the microvessels is rudimentary. METHODS We examined the expression of several prothrombotic and antithrombotic genes in 25 biopsies with rTx-TMA (6 RecTMA, 9 HR-TMA, and 10 CNI-TMA) and 8 controls. RNA from microdissected glomeruli of paraffin-embedded tissue was isolated and mRNA transcripts were quantified with real-time polymerase chain reaction after preamplification. Results were correlated with clinicopathologic parameters. RESULTS Glomerular mRNA expression of KLF2, KLF4, and tPA was lower and that of PAI-1 was higher in rTx-TMA than in the controls. Glomerular mRNA expression of KLF2 and KLF4 correlated with that of tPA and inversely with that of PAI-1 in rTx-TMA. The mRNA expression of complement regulators CD46 and CD59 were higher in rTx-TMA than in the controls. Only in HR-TMA were glomerular ADAMTS13 and CD55 down-regulated. CONCLUSIONS The glomerular capillary bed seems to contribute to all subtypes of rTx-TMA by down-regulation of the endothelial transcription factors KLF2 and KLF4, indicating dedifferentiation with subsequent up-regulation of PAI-1 and down-regulation of tPA, resulting in inhibition of local fibrinolysis. Decreased glomerular expression of ADAMTS13 and CD55 could be an additional pathway toward microthrombosis exclusively in HR-TMA.
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González-Roncero F, Suñer M, Bernal G, Cabello V, Toro M, Pereira P, Angel Gentil M. Eculizumab treatment of acute antibody-mediated rejection in renal transplantation: case reports. Transplant Proc 2013; 44:2690-4. [PMID: 23146495 DOI: 10.1016/j.transproceed.2012.09.038] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The occurrence of acute antibody-mediated rejection (AMR), especially in more severe cases, continues to be associated with a poor prognosis for implant survival. Here, we have reported the results of treatment of two patients who developed AMR associated with thrombotic microangiopathy immediately after transplantation. We used a single dose of eculizumab at an early stage jointly with conventional modalities of steroid boluses, plasmapheresis, intravenous immunoglobulin, and rituximab. In both cases, the clinical course was favorable. Eculizumab, a monoclonal antibody with a high affinity for complement protein C5, prevents generation of the final membrane attack complex, blocking this cascade. To date, there are a few reports of the usefulness of eculizumab in AMR. Eculizumab can help to stop endothelial damage, especially in severe cases that show a risk of progression to cortical necrosis, by providing a therapeutic window until the other modalities begin to control the immune response. In our experience, the use of eculizumab can be beneficial in the treatment of AMR.
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Affiliation(s)
- F González-Roncero
- Unidad Gestión Clínica de Nefrourología, Hospitales Universitarios Virgen del Rocío), Sevilla, Spain.
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Caires RA, Marques IDB, Repizo LP, Sato VAH, Carmo LPF, Machado DJB, de Paula FJ, Nahas WC, David-Neto E. De novo thrombotic microangiopathy after kidney transplantation: clinical features, treatment, and long-term patient and graft survival. Transplant Proc 2013; 44:2388-90. [PMID: 23026601 DOI: 10.1016/j.transproceed.2012.07.039] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Posttransplant thrombotic microangiopathy (TMA)/hemolytic uremic syndrome (HUS) can occur as a recurrent or de novo disease. METHODS A retrospective single-center observational study was applied in order to examine the incidence and outcomes of de novo TMA/HUS among transplantations performed between 2000 and 2010. Recurrent HUS or antibody-mediated rejections were excluded. RESULTS Seventeen (1.1%) among 1549 kidney transplant recipients fulfilled criteria for de novo TMA. The mean follow-up was 572 days (range, 69-1769). Maintenance immunosuppression was prednisone, tacrolimus (TAC), and mycophenolic acid in 14 (82%) patients. Mean age at onset was 40 ± 15 years, and serum creatinine was 6.1 ± 4.1 mg/dL. TMA occurred at a median of 25 days (range, 1-1755) after transplantation. Nine (53%) patients developed TMA within 1 month of transplantation and only 12% after 1 year. Clinical features were anemia (hemoglobin < 10 g/dL) in 9 (53%) patients, thrombocytopenia in 7 (41%), and increased lactate dehydrogenase in 12 (70%). Decreased haptoglobin was observed in 64% and schistocytes in 35%. Calcineurin inhibitor (CNI) withdrawal or reduction was the first step in the management of 10/15 (66%) patients, and 6 (35%) received fresh frozen plasma (FFP) and/or plasmapheresis. TAC was successfully reintroduced in six patients after a median of 17 days. Eight (47%) patients needed dialytic support after TMA diagnosis and 75% remained on dialysis. At 4 years of follow-up, death-censored graft survival was worse for TMA group (43.0% versus 85.6%, log-rank = 0.001; hazard ratio = 3.74) and there was no difference in patient survival (53.1% versus 82.2%, log-rank = 0.24). CONCLUSION De novo TMA after kidney transplantation is a rare but severe condition with poor graft outcomes. This syndrome may not be fully manifested, and clinical suspicion is essential for early diagnosis and treatment, based mainly in CNI withdrawal and FFP infusions and/or plasmapheresis.
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Affiliation(s)
- R A Caires
- Nephrology Division, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
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Devadoss CW, Vijaya V M, E M, Venkataramana S R, M S G. Tacrolimus associated localized thrombotic microangiopathy developing in early stage after renal transplantation. J Clin Diagn Res 2012; 6:1786-8. [PMID: 23373055 DOI: 10.7860/jcdr/2012/4535.2614] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Accepted: 10/22/2012] [Indexed: 11/24/2022]
Abstract
Calcineurin inhibitor induced thrombotic microangiopathy is a rare but well recognized complication of a renal transplantation that occurs in 1% of the patients who are on tacrolimus immunosuppression. Among the other aetiological factors of the "de-novo" Thrombotic Microangiopathy (TMA), the condition especially has to be differentiated from an antibody mediated rejection, as both have different pathogenesis, therapeutic connotations and outcomes.We report a case of a middle aged female renal transplant recipient treated with tacrolimus, who developed localised thrombotic microangiopathy in the early post transplantation period. Despite the normal trough levels of tacrolimus, a diagnosis of "Tacrolimus induced TMA" was rendered after excluding other causes of the "de-novo" TMA, which included an antibody mediated rejection, a meticulous clinico-pathological correlation and serological studies. The treatment included the substitution of tacrolimus by rapamycin, with the subsequent normalization of the renal function.
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Noone D, Al-Matrafi J, Tinckam K, Zipfel PF, Herzenberg AM, Thorner PS, Pluthero FG, Kahr WHA, Filler G, Hebert D, Harvey E, Licht C. Antibody mediated rejection associated with complement factor h-related protein 3/1 deficiency successfully treated with eculizumab. Am J Transplant 2012; 12:2546-53. [PMID: 22681773 DOI: 10.1111/j.1600-6143.2012.04124.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Antibody mediated rejection (AMR) activates the classical complement pathway and can be detrimental to graft survival. AMR can be accompanied by thrombotic microangiopathy (TMA). Eculizumab, a monoclonal C5 antibody prevents induction of the terminal complement cascade (TCC) and has recently emerged as a therapeutic option for AMR. We present a highly sensitized 13-year-old female with end-stage kidney disease secondary to spina bifida-associated reflux nephropathy, who developed severe steroid-, ATG- and plasmapheresis-resistant AMR with TMA 1 week post second kidney transplant despite previous desensitization therapy with immunoglobulin infusions. Eculizumab rescue therapy resulted in a dramatic improvement in biochemical (C3; creatinine) and hematological (platelets) parameters within 6 days. The patient was proven to be deficient in complement Factor H-related protein 3/1 (CFHR3/1), a plasma protein that regulates the complement cascade at the level of C5 conversion and has been involved in the pathogenesis of atypical hemolytic uremic syndrome caused by CFH autoantibodies (DEAP-HUS). CFHR1 deficiency may have worsened the severe clinical progression of AMR and possibly contributed to the development of donor-specific antibodies. Thus, screening for CFHR3/1 deficiency should be considered in patients with severe AMR associated with TMA.
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Affiliation(s)
- D Noone
- Division of Nephrology, The Hospital for Sick Children, University of Toronto, ON, Canada
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Shindoh J, Sugawara Y, Akamatsu N, Kaneko J, Tamura S, Yamashiki N, Aoki T, Sakamoto Y, Hasegawa K, Kokudo N. Thrombotic microangiopathy after living-donor liver transplantation. Am J Transplant 2012; 12:728-36. [PMID: 22070669 DOI: 10.1111/j.1600-6143.2011.03841.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Thrombotic microangiopathy (TMA) is an infrequent but severe life-threatening disorder in solid organ transplant recipients. Few studies of TMA in living donor liver transplant (LDLT) recipients, however, have been reported. We investigated the clinical characteristics and prognostic factors of TMA after LDLT. Among 393 adult LDLT recipients, 30 patients (7.6%) were identified to have TMA. The 1-, 3- and 5-year survival rates of these patients were lower (60.6%, 52.5% and 47.7%, respectively) than those of patients without TMA (93.0%, 89.0% and 87.3%, respectively). Multivariate analysis confirmed that reduced administration of fresh frozen plasma and sensitization against HLA are closely related with TMA (odds ratio [OR]: 2.6 and 16.1, respectively). However, a review of the cases revealed that individual responses to treatment varied considerably and the main etiologies were difficult to determine. A comparison of the clinical factors suggested that late onset (>30 days), poor response to treatment and delayed diagnosis and/or treatment are associated with a poor outcome. Because the prevention of TMA in LDLT patients is difficult, early diagnosis and initiation of intensive therapies may be crucial to improve the prognosis.
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Affiliation(s)
- J Shindoh
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Successful treatment of de novo posttransplant thrombotic microangiopathy with eculizumab. Transplantation 2011; 92:e42-3. [PMID: 21989273 DOI: 10.1097/tp.0b013e318230c0bd] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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