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Friedmann J, Schuster A, Reichelt-Wurm S, Banas B, Bergler T, Steines L. Serum IL-6 predicts risk of kidney transplant failure independently of immunological risk. Transpl Immunol 2024; 84:102043. [PMID: 38548029 DOI: 10.1016/j.trim.2024.102043] [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: 11/23/2023] [Revised: 03/23/2024] [Accepted: 03/25/2024] [Indexed: 04/07/2024]
Abstract
Interleukin-6 (IL-6) is an important immune mediator and a target for novel antibody therapies. In this study, we aimed to determine whether serum IL-6 levels are associated with immunological risk, allograft rejection and outcomes in kidney transplant (Ktx) patients. We retrospectively analyzed the data of 104 patients who underwent Ktx at our center between 2011 and 2015. The patients were divided into high- and low-risk groups (n = 52 per group) based on panel reactive antibody (PRA) percentage ≥ 35%, the existence of pre-Ktx donor-specific antibodies (DSA), or a previous transplant. IL-6 concentrations were measured before and at 3 months, 12 months, and 3 years after Ktx. Serum IL-6 levels tended to be higher in high-risk patients than in low-risk patients prior to Ktx and at 12 months after Ktx; however, the difference did not reach statistical significance (pre-Ktx, high-risk: 1.995 ± 2.79 pg/ml vs. low-risk: 1.43 ± 1.76 pg/ml, p = 0.051; 12 mo. high-risk: 1.16 ± 1.87 pg/ml vs. low-risk: 0.78 ± 1.13 pg/ml, p = 0.067). IL-6 levels were correlated with the types (no rejection, T cell mediated rejection (TCMR), antibody-mediated rejection (ABMR), or both) and time (<1 year vs. >1 year after Ktx) of rejection, as well as patient and graft survival. Patients with both TCMR and ABMR had significantly higher IL-6 levels at 3 months (14.1 ± 25.2 pg/ml) than patients with ABMR (3.4 ± 4.8 pg/ml, p = 0.017), with TCMR (1.7 ± 1.3 pg/ml, p < 0.001), and without rejection (1.7 ± 1.4 pg/ml, p < 0.001). Three years after Ktx, patients with AMBR had significantly higher IL-6 levels (5.30 ± 7.66 pg/ml) than patients with TCMR (1.81 ± 1.61 pg/ml, p = 0.009) and patients without rejection (1.19 ± 0.95 pg/ml; p = 0.001). Moreover, three years after Ktx IL-6 levels were significantly higher in patients with late rejections (3.5 ± 5.4 pg/ml) than those without rejections (1.2 ± 1.0 pg/ml) (p = 0.006). The risk of death-censored graft failure was significantly increased in patients with elevated IL-6 levels at 12 months (IL-6 level > 1.396 pg/ml, HR 4.61, p = 0.007) and 3 years (IL-6 level > 1.976 pg/ml, HR 6.75, p = 0.003), but elevated IL-6 levels were not associated with a higher risk of death. Overall, our study highlights IL-6 as a risk factor for allograft failure and confirms that IL-6 levels are higher in patients developing ABMR compared to TCMR alone or no rejection.
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Affiliation(s)
- Julius Friedmann
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Antonia Schuster
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | | | - Bernhard Banas
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Tobias Bergler
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany; Department of Nephrology, Hospital Ingolstadt, Ingolstadt, Germany
| | - Louisa Steines
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany.
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Elsayed NS, Wolfe AJ, Burk RD. Urine microbiome in individuals with an impaired immune system. Front Cell Infect Microbiol 2024; 13:1308665. [PMID: 38274734 PMCID: PMC10808152 DOI: 10.3389/fcimb.2023.1308665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/21/2023] [Indexed: 01/27/2024] Open
Abstract
With the advent of next generation sequencing, it is now appreciated that human urine is not sterile. Recent investigations of the urinary microbiome (urobiome) have provided insights into several urological diseases. Urobiome dysbiosis, defined as non-optimal urine microbiome composition, has been observed in many disorders; however, it is not clear whether this dysbiosis is the cause of urinary tract disorders or a consequence. In addition, immunologically altered disorders are associated with higher rates of urinary tract infections. These disorders include immunoproliferative and immunodeficiency diseases, cancer, and immunosuppressant therapy in transplant recipients. In this review, we examine the current state of knowledge of the urobiome in immunologically altered diseases, its composition and metabolomic consequences. We conclude that more data are required to describe the urobiome in immune altered states, knowledge that could facilitate understanding the role of the urobiome and its pathophysiological effects on urinary tract infections and other disorders of the urinary tract.
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Affiliation(s)
- Noha S. Elsayed
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Alan J. Wolfe
- Department of Microbiology and Immunology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, United States
| | - Robert D. Burk
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, United States
- Departments of Microbiology and Immunology, Epidemiology and Population Health, and Obstetrics & Gynecology and Women’s Health, Albert Einstein College of Medicine, Bronx, NY, United States
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Khalil M, Gadelkareem RA, Abdallah MA, Sayed MAB, Elanany FG, Fornara P, Mohammed N. Predictors of graft function and survival in second kidney transplantation: A single center experience. World J Transplant 2023; 13:331-343. [PMID: 38174152 PMCID: PMC10758684 DOI: 10.5500/wjt.v13.i6.331] [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: 08/16/2023] [Revised: 10/19/2023] [Accepted: 11/03/2023] [Indexed: 12/15/2023] Open
Abstract
BACKGROUND The increasing kidney retransplantation rate has created a parallel field of research, including the risk factors and outcomes of this advanced form of renal replacement therapy. The presentation of experiences from different kidney transplantation centers may help enrich the literature on kidney retransplantation, as a specific topic in the field of kidney transplantation. AIM To identify the risk factors affecting primary graft function and graft survival rates after second kidney transplantation (SKT). METHODS The records of SKT cases performed between January 1977 and December 2014 at a European tertiary-level kidney transplantation center were retrospectively reviewed and analyzed. Beside the descriptive characteristics, the survivals of patients and both the first and second grafts were described using Kaplan-Meier curves. In addition, Kaplan-Meier analyses were also used to estimate the survival probabilities at 1, 3, 5, and 10 post-operative years, as well as at the longest follow-up duration available. Moreover, bivariate associations between various predictors and the categorical outcomes were assessed, using the suitable biostatistical tests, according to the predictor type. RESULTS Out of 1861 cases of kidney transplantation, only 48 cases with SKT were eligible for studying, including 33 men and 15 women with a mean age of 42.1 ± 13 years. The primary non-function (PNF) graft occurred in five patients (10.4%). In bivariate analyses, a high body mass index (P = 0.009) and first graft loss due to acute rejection (P = 0.025) were the only significant predictors of PNF graft. The second graft survival was reduced by delayed graft function in the first (P = 0.008) and second (P < 0.001) grafts. However, the effect of acute rejection within the first year after the first transplant did not reach the threshold of significance (P = 0.053). The mean follow-up period was 59.8 ± 48.6 mo. Censored graft/patient survival rates at 1, 3, 5 and 10 years were 90.5%/97.9%, 79.9%/95.6%, 73.7%/91.9%, and 51.6%/83.0%, respectively. CONCLUSION Non-immediate recovery modes of the first and second graft functions were significantly associated with unfavorable second graft survival rates. Patient and graft survival rates of SKT were similar to those of the first kidney transplantation.
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Affiliation(s)
- Mahmoud Khalil
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Assiut, Egypt
| | - Rabea Ahmed Gadelkareem
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Assiut, Egypt
| | - Medhat Ahmed Abdallah
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Assiut, Egypt
| | - Mohamed Abdel-Basir Sayed
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Assiut, Egypt
| | - Fathy Gaber Elanany
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Assiut, Egypt
| | - Paolo Fornara
- Department of Urology and Kidney Transplantation, Martin Luther University, Halle (Saale) 71515, Germany
| | - Nasreldin Mohammed
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Assiut, Egypt
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Granata S, La Russa D, Stallone G, Perri A, Zaza G. Inflammasome pathway in kidney transplantation. Front Med (Lausanne) 2023; 10:1303110. [PMID: 38020086 PMCID: PMC10663322 DOI: 10.3389/fmed.2023.1303110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 10/25/2023] [Indexed: 12/01/2023] Open
Abstract
Kidney transplantation is the best available renal replacement therapy for patients with end-stage kidney disease and is associated with better quality of life and patient survival compared with dialysis. However, despite the significant technical and pharmaceutical advances in this field, kidney transplant recipients are still characterized by reduced long-term graft survival. In fact, almost half of the patients lose their allograft after 15-20 years. Most of the conditions leading to graft loss are triggered by the activation of a large immune-inflammatory machinery. In this context, several inflammatory markers have been identified, and the deregulation of the inflammasome (NLRP3, NLRP1, NLRC4, AIM2), a multiprotein complex activated by either whole pathogens (including fungi, bacteria, and viruses) or host-derived molecules, seems to play a pivotal pathogenetic role. However, the biological mechanisms leading to inflammasome activation in patients developing post-transplant complications (including, ischemia-reperfusion injury, rejections, infections) are still largely unrecognized, and only a few research reports, reviewed in this manuscript, have addressed the association between abnormal activation of this pathway and the onset/development of major clinical effects. Finally, the regulation of the inflammasome machinery could represent in future a valuable therapeutic target in kidney transplantation.
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Affiliation(s)
- Simona Granata
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Daniele La Russa
- Department of Biology, Ecology and Earth Sciences, University of Calabria, Rende, Italy
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Anna Perri
- Department of Experimental and Clinical Medicine, University of Catanzaro "Magna Græcia", Catanzaro, Italy
| | - Gianluigi Zaza
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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Benning L, Morath C, Fink A, Rudek M, Speer C, Kälble F, Nusshag C, Beimler J, Schwab C, Waldherr R, Zeier M, Süsal C, Tran TH. Donor-Derived Cell-Free DNA (dd-cfDNA) in Kidney Transplant Recipients With Indication Biopsy-Results of a Prospective Single-Center Trial. Transpl Int 2023; 36:11899. [PMID: 38020751 PMCID: PMC10654198 DOI: 10.3389/ti.2023.11899] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023]
Abstract
Donor-derived cell-free DNA (dd-cfDNA) identifies allograft injury and discriminates active rejection from no rejection. In this prospective study, 106 kidney transplant recipients with 108 clinically indicated biopsies were enrolled at Heidelberg University Hospital between November 2020 and December 2022 to validate the clinical value of dd-cfDNA in a cohort of German patients. dd-cfDNA was quantified at biopsy and correlated to histopathology. Additionally, dd-cfDNA was determined on days 7, 30, and 90 post-biopsy and analyzed for potential use to monitor response to anti-rejection treatment. dd-cfDNA levels were with a median (IQR) % of 2.00 (0.48-3.20) highest in patients with ABMR, followed by 0.92 (0.19-11.25) in patients with TCMR, 0.44 (0.20-1.10) in patients with borderline changes and 0.20 (0.11-0.53) in patients with no signs of rejection. The AUC for dd-cfDNA to discriminate any type of rejection including borderline changes from no rejection was at 0.72 (95% CI 0.62-0.83). In patients receiving anti-rejection treatment, dd-cfDNA levels significantly decreased during the 7, 30, and 90 days follow-up compared to levels at the time of biopsy (p = 0.006, p = 0.002, and p < 0.001, respectively). In conclusion, dd-cfDNA significantly discriminates active rejection from no rejection. Decreasing dd-cfDNA following anti-rejection treatment may indicate response to therapy. Clinical Trial Registration: https://drks.de/search/de/trial/DRKS00023604, identifier DRKS00023604.
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Affiliation(s)
- Louise Benning
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Morath
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Annette Fink
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Rudek
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Claudius Speer
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Florian Kälble
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Nusshag
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jörg Beimler
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Constantin Schwab
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Rüdiger Waldherr
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Zeier
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Caner Süsal
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
- Transplant Immunology Research Center of Excellence, Koç University Hospital, Istanbul, Türkiye
| | - Thuong Hien Tran
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
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Ciancio G, Gaynor JJ, Guerra G, Tabbara MM, Roth D, Kupin W, Mattiazzi A, Moni L, Burke GW. Long-term effects of average calcineurin inhibitor trough levels (over time) on renal function in a prospectively followed cohort of 150 kidney transplant recipients. Clin Transl Sci 2023; 16:2382-2393. [PMID: 37817405 PMCID: PMC10651634 DOI: 10.1111/cts.13639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 09/01/2023] [Indexed: 10/12/2023] Open
Abstract
More favorable clinical outcomes with medium-term follow-up have been reported among kidney transplant recipients receiving maintenance therapy consisting of "reduced-tacrolimus (TAC) dosing," mycophenolate mofetil (MMF), and low-dose corticosteroids. However, it is not clear whether long-term maintenance therapy with reduced-calcineurin inhibitor (CNI) dosing still leads to reduced renal function. A prospectively followed cohort of 150 kidney transplant recipients randomized to receive TAC/sirolimus (SRL) versus TAC/MMF versus cyclosporine microemulsion (CSA)/SRL, plus low-dose maintenance corticosteroids, now has 20 years of post-transplant follow-up. Average CNI trough levels over time among patients who were still alive with functioning grafts at 60, 120, and 180 months post-transplant were determined and ranked from smallest-to-largest for both TAC and CSA. Stepwise linear regression was used to determine whether these ranked average trough levels were associated with the patient's estimated glomerular filtration rate (eGFR) at those times, particularly after controlling for other significant multivariable predictors. Experiencing biopsy-proven acute rejection (BPAR) and older donor age were the two most significant multivariable predictors of poorer eGFR at 60, 120, and 180 months post-transplant (p < 000001 and 0.000003 for older donor age at 60 and 120 months; p = 0.00008 and <0.000001 for previous BPAR at 60 and 120 months). Assignment to CSA also implied a significantly poorer eGFR (but with less magnitudes of effect) in multivariable analysis at 60 and 120 months (p = 0.01 and 0.002). Higher ranked average CNI trough levels had no association with eGFR at any timepoint in either univariable or multivariable analysis (p > 0.70). Long-term maintenance therapy with reduced-CNI dosing does not appear to cause reduced renal function.
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Affiliation(s)
- Gaetano Ciancio
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
- Department of SurgeryLeonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
| | - Jeffrey J. Gaynor
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
- Department of SurgeryLeonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
| | - Giselle Guerra
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
- Division of Nephrology, Department of Medicine, Leonard M. Miller School of MedicineUniversity of MiamiMiamiFloridaUSA
| | - Marina M. Tabbara
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
| | - David Roth
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
- Division of Nephrology, Department of Medicine, Leonard M. Miller School of MedicineUniversity of MiamiMiamiFloridaUSA
| | - Warren Kupin
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
- Division of Nephrology, Department of Medicine, Leonard M. Miller School of MedicineUniversity of MiamiMiamiFloridaUSA
| | - Adela Mattiazzi
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
- Division of Nephrology, Department of Medicine, Leonard M. Miller School of MedicineUniversity of MiamiMiamiFloridaUSA
| | - Lissett Moni
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
- Department of SurgeryLeonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
| | - George W. Burke
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
- Department of SurgeryLeonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
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Heldal TF, Åsberg A, Ueland T, Reisæter AV, Pischke SE, Mollnes TE, Aukrust P, Reinholt F, Hartmann A, Heldal K, Jenssen TG. Systemic inflammation early after kidney transplantation is associated with long-term graft loss: a cohort study. Front Immunol 2023; 14:1253991. [PMID: 37849758 PMCID: PMC10577420 DOI: 10.3389/fimmu.2023.1253991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/11/2023] [Indexed: 10/19/2023] Open
Abstract
Background Early graft loss following kidney transplantation is mainly a result of acute rejection or surgical complications, while long-term kidney allograft loss is more complex. We examined the association between systemic inflammation early after kidney transplantation and long-term graft loss, as well as correlations between systemic inflammation scores and inflammatory findings in biopsies 6 weeks and 1 year after kidney transplantation. Methods We measured 21 inflammatory biomarkers 10 weeks after transplantation in 699 patients who were transplanted between 2009 and 2012 at Oslo University Hospital, Rikshospitalet, Norway. Low-grade inflammation was assessed with predefined inflammation scores based on specific biomarkers: one overall inflammation score and five pathway-specific scores. Surveillance or indication biopsies were performed in all patients 6 weeks after transplantation. The scores were tested in Cox regression models. Results Median follow-up time was 9.1 years (interquartile range 7.6-10.7 years). During the study period, there were 84 (12.2%) death-censored graft losses. The overall inflammation score was associated with long-term kidney graft loss both when assessed as a continuous variable (hazard ratio 1.03, 95% CI 1.01-1.06, P = 0.005) and as a categorical variable (4th quartile: hazard ratio 3.19, 95% CI 1.43-7.10, P = 0.005). In the pathway-specific analyses, fibrogenesis activity and vascular inflammation stood out. The vascular inflammation score was associated with inflammation in biopsies 6 weeks and 1 year after transplantation, while the fibrinogenesis score was associated with interstitial fibrosis and tubular atrophy. Conclusion In conclusion, a systemic inflammatory environment early after kidney transplantation was associated with biopsy-confirmed kidney graft pathology and long-term kidney graft loss. The systemic vascular inflammation score correlated with inflammatory findings in biopsies 6 weeks and 1 year after transplantation.
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Affiliation(s)
- Torbjørn F. Heldal
- Department of Internal Medicine, Telemark Hospital Trust, Skien, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Transplantation Medicine, Oslo University Hospital – Rikshospitalet, Oslo, Norway
| | - Anders Åsberg
- Department of Transplantation Medicine, Oslo University Hospital – Rikshospitalet, Oslo, Norway
- Norwegian Renal Registry, Oslo University Hospital – Rikshospitalet, Oslo, Norway
- Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Thor Ueland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- K.G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø, Tromsø, Norway
- Research Institute of Internal Medicine, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Anna V. Reisæter
- Department of Transplantation Medicine, Oslo University Hospital – Rikshospitalet, Oslo, Norway
- Norwegian Renal Registry, Oslo University Hospital – Rikshospitalet, Oslo, Norway
| | - Søren E. Pischke
- Department of Immunology, University of Oslo and Oslo University Hospital, Oslo, Norway
- Department of Anesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Tom E. Mollnes
- Department of Immunology, University of Oslo and Oslo University Hospital, Oslo, Norway
- Research Laboratory, Nordland Hospital Bodø, Bodø, Norway
| | - Pål Aukrust
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- K.G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø, Tromsø, Norway
- Research Institute of Internal Medicine, Oslo University Hospital - Rikshospitalet, Oslo, Norway
- Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital – Rikshospitalet, Oslo, Norway
| | - Finn Reinholt
- Department of Pathology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Anders Hartmann
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Transplantation Medicine, Oslo University Hospital – Rikshospitalet, Oslo, Norway
| | - Kristian Heldal
- Department of Internal Medicine, Telemark Hospital Trust, Skien, Norway
- Department of Transplantation Medicine, Oslo University Hospital – Rikshospitalet, Oslo, Norway
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Trond G. Jenssen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Transplantation Medicine, Oslo University Hospital – Rikshospitalet, Oslo, Norway
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Katwal S, Suwal S, Bhandari RM, Chataut D, Ansari MA, Lamichhane S. Prospective quantitative study: Doppler ultrasound in the evaluation of chronic renal allograft disease and correlation with histopathological finding. Ann Med Surg (Lond) 2023; 85:4811-4815. [PMID: 37811074 PMCID: PMC10553132 DOI: 10.1097/ms9.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/19/2023] [Indexed: 10/10/2023] Open
Abstract
Background and Objectives Renal allograft biopsy is the gold standard for diagnosing chronic allograft nephropathy, but noninvasive methods are needed to avoid unnecessary biopsies. Doppler ultrasonography, particularly the resistive index (RI), correlates with renal allograft dysfunction. This study aims to assess the relationship between renal sonographic parameters and biochemical parameters in diagnosing graft interstitial fibrosis. Methods The study evaluated 60 renal allograft recipients for sonographic renal morphological features and Doppler indices. The estimated glomerular filtration rate (eGFR) was calculated, and cortical fibrosis after the biopsy was determined using the Banff score. Continuous variables like mean and SD were calculated, and categorical variables were reported using frequencies and proportions. Associations were examined using independent sample t-tests, χ 2tests, and multivariate regression analysis. Results The mean eGFR was 75.23±25.45 ml/min/1.73 m2. A significant correlation of eGFR with RI (r=0.341, P=0.008) was seen. A significant difference in mean RI (F=10.167; df=2,57; P<0.001) was seen among the histological grades of fibrosis. Among the histological grades of fibrosis, significant differences in RI among mild and moderate (S.E. 0.033, P=0.043), mild and severe (S.E. 0.026, P=0.001) as well as moderate and severe (S.E. 0.036, P=0.029) was seen. Conclusion Doppler was able to noninvasively predict allograft fibrosis and could be used as a complementary imaging tool during the follow-up of renal allograft patients. Future research is needed to improve evidence, diagnostic criteria, guidelines, and long-term impact.
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Affiliation(s)
| | - Sundar Suwal
- Tribhuvan University Teaching Hospital, Maharajgunj
| | - Rajan M. Bhandari
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Hinrichs GR, Nielsen JR, Birn H, Bistrup C, Jensen BL. Amiloride evokes significant natriuresis and weight loss in kidney transplant recipients with and without albuminuria. Am J Physiol Renal Physiol 2023; 325:F426-F435. [PMID: 37560772 DOI: 10.1152/ajprenal.00108.2023] [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: 04/26/2023] [Revised: 07/14/2023] [Accepted: 08/03/2023] [Indexed: 08/11/2023] Open
Abstract
Albuminuria in kidney transplant recipients (KTRs) is associated with hypertension and aberrant glomerular filtration of serine proteases that may proteolytically activate the epithelial Na+ channel (ENaC). The present nonrandomized, pharmacodynamic intervention study aimed to investigate if inhibition of ENaC increases Na+ excretion and reduces extracellular volume in KTRs dependent on the presence of albuminuria. KTRs with and without albuminuria (albumin-to-creatinine ratio > 300 mg/g, n = 7, and <30 mg/g, n = 7, respectively) were included and ingested a diet with fixed Na+ content (150 mmol/day) for 5 days. On the last day, amiloride at 10 mg was administered twice. Body weight, 24-h urine electrolyte excretion, body water content, and ambulatory blood pressure as well as plasma renin, angiotensin II, and aldosterone concentrations were determined before and after amiloride. Amiloride led to a significant decrease in body weight, increase in 24-h urinary Na+ excretion, and decrease in 24-h urinary K+ excretion in both groups. Urine output increased in the nonalbuminuric group only. There was no change in plasma renin, aldosterone, and angiotensin II concentrations after amiloride, whereas a significant decrease in nocturnal systolic blood pressure and increase in 24-h urine aldosterone excretion was observed in albuminuric KTRs only. There was a significant correlation between 24-h urinary albumin excretion and amiloride-induced 24-h urinary Na+ excretion. In conclusion, ENaC activity contributes to Na+ and water retention in KTRs with and without albuminuria. ENaC is a relevant pharmacological target in KTRs; however, larger and long-term studies are needed to evaluate whether the magnitude of this effect depends on the presence of albuminuria.NEW & NOTEWORTHY Amiloride has a significant natriuretic effect in kidney transplant recipients (KTRs) that relates to urinary albumin excretion. The epithelial Na+ channel may be a relevant direct pharmacological target to counter Na+ retention and hypertension in KTRs. Epithelial Na+ channel blockers should be further investigated as a mean to mitigate Na+ and water retention and to potentially obtain optimal blood pressure control in KTRs.
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Affiliation(s)
- Gitte Rye Hinrichs
- Department of Molecular Medicine, Cardiovascular and Renal Research, University of Southern Denmark, Odense, Denmark
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Nephrology, University Hospital of Southern Denmark, Esbjerg, Denmark
| | | | - Henrik Birn
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Claus Bistrup
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Boye Lagerbon Jensen
- Department of Molecular Medicine, Cardiovascular and Renal Research, University of Southern Denmark, Odense, Denmark
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10
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Marinaki S, Vittoraki A, Tsiakas S, Kofotolios I, Darema M, Ioannou S, Vallianou K, Boletis J. Clinical Outcome of Kidney Transplant Recipients with C1q-Binding De Novo Donor Specific Antibodies: A Single-Center Experience. J Clin Med 2023; 12:4475. [PMID: 37445510 DOI: 10.3390/jcm12134475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 07/01/2023] [Accepted: 07/02/2023] [Indexed: 07/15/2023] Open
Abstract
Complement activation by HLA antibodies is a key component of immune-mediated graft injury. We examined the clinical outcomes of kidney transplant recipients with complement-fixing de novo donor-specific antibodies (dnDSA) who were followed in our center. The C1q-binding ability was retrospectively assessed in 69 patients with dnDSA and mean fluorescence intensity (MFI) values > 2000 out of the 1325 kidney transplant recipients who were screened for DSA between 2015 and 2019. Luminex IgG single antigen beads (SAB)and C1q-SAB assays (One Lambda) were used. C1q-binding dnDSA was identified in 32/69 (46.4%) of the patients. Significantly higher MFI values were observed in C1q-positive DSA (18,978 versus 5840, p < 0.001). Renal graft biopsies were performed in 43 of the kidney transplant recipients (62.3%) with allograft dysfunction. Antibody-mediated rejection (ABMR) was detected in 29/43 (67.4%) of the patients. The incidence of ABMR was similar among patients with C1q-binding and non-C1q-binding DSA (51.7% vs. 48.3%, p = 0.523). Graft loss occurred in 30/69 (43.5%) of the patients at a median time of 82.5 months (IQR 45-135) from DSA detection. C1q-binding DSA was present in more patients who experienced graft loss (53.1% vs. 35.1%, p = 0.152). Higher MFI values and inferior clinical outcomes occurred in most of the kidney transplant recipients with C1q-binding dnDSA.
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Affiliation(s)
- Smaragdi Marinaki
- Clinic of Nephrology and Renal Transplantation, National and Kapodistrian University of Athens Medical School, Laiko Hospital, 11527 Athens, Greece
| | - Angeliki Vittoraki
- Immunology Department, National Tissue Typing Center, General Hospital of Athens "G. Gennimatas", 11527 Athens, Greece
| | - Stathis Tsiakas
- Clinic of Nephrology and Renal Transplantation, National and Kapodistrian University of Athens Medical School, Laiko Hospital, 11527 Athens, Greece
| | - Ioannis Kofotolios
- Clinic of Nephrology and Renal Transplantation, National and Kapodistrian University of Athens Medical School, Laiko Hospital, 11527 Athens, Greece
| | - Maria Darema
- Clinic of Nephrology and Renal Transplantation, National and Kapodistrian University of Athens Medical School, Laiko Hospital, 11527 Athens, Greece
| | - Sofia Ioannou
- Immunology Department, National Tissue Typing Center, General Hospital of Athens "G. Gennimatas", 11527 Athens, Greece
| | - Kalliopi Vallianou
- Clinic of Nephrology and Renal Transplantation, National and Kapodistrian University of Athens Medical School, Laiko Hospital, 11527 Athens, Greece
| | - John Boletis
- Clinic of Nephrology and Renal Transplantation, National and Kapodistrian University of Athens Medical School, Laiko Hospital, 11527 Athens, Greece
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11
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Schold JD. The promise and reality of machine-learning models in kidney transplantation. Kidney Int 2023; 103:835-836. [PMID: 37085256 DOI: 10.1016/j.kint.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 02/15/2023] [Indexed: 04/23/2023]
Abstract
There have been numerous advances in statistical methods and computing technologies over the past decades, including the use of machine-learning models. In the current study, Truchot et al. rigorously evaluated the performance of different machine-learning models compared with traditional Cox proportional hazard models. Results of the study indicated that a Cox model had equivalent or superior performance than machine-learning models and can be relied on for predicting graft survival in kidney transplantation.
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Affiliation(s)
- Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
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12
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Silva BDPC, Lasmar MF, Nascimento E, Fabreti-Oliveira RA. Impact of early blood transfusion after kidney transplantation on the clinical outcomes and allograft survival. Transpl Immunol 2023; 77:101807. [PMID: 36842568 DOI: 10.1016/j.trim.2023.101807] [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: 10/04/2022] [Revised: 02/21/2023] [Accepted: 02/21/2023] [Indexed: 02/26/2023]
Abstract
INTRODUCTION Anemia in chronic kidney disease is of great concern regarding blood transfusions and the possibility of allosensitization for future kidney transplants and the occurrence of rejection and allograft loss in the post-transplant period. The aim of this study was to evaluate the effect of early blood transfusion on the occurrence of rejections, allograft function and survival in the first year after transplantation. MATERIAL AND METHODS This retrospective study was carried out with 445 patients submitted to kidney transplant allocated to two groups. The first group received early blood transfusions after transplant (n = 125, 28.09%), and the second group did not receive blood transfusions (n = 320, 71.91%). The patient outcomes were evaluated during a 1-year follow-up. RESULTS 14 patients given blood transfusion (11.2%) lost their allograft in the first year in comparison with 8 (2.5%) without transfusion (p < 0.001). There were 9 deaths in each group, which corresponded to 7.2% of the patients who received blood transfusions and 2.81% of those who did not (p < 0.035). Patient hospitalization lasted 15 days in transfusion group and 8.5 days in non-transfusion group (p < 0.001). Creatinine levels were higher in the patients who received blood transfusion than in those without transfusion in the first and third months after transplantation (p = 0.012 and 0.038, respectively). During the first year, the patients who received blood products experienced more antibody-mediated rejection (ABMR) (13.60%) than patients who did not (4.38%) (p < 0.001). Those who received blood transfusions also developed de novo DSA in higher proportion than those without transfusion against both class I and class II HLA (p < 0.001). CONCLUSION This study showed that blood transfusions in the first month after transplantation had a negative impact on kidney function, graft survival, and contributed to the development of de novo DSA, an increased risk of ABMR and infections.
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Affiliation(s)
- Bernardo D P C Silva
- Faculty of Medical Sciences, Belo Horizonte, Minas Gerais, Brazil; University Hospital of the Faculty of Medical Sciences, Belo Horizonte, Minas Gerais, Brazil.
| | - Marcus Faria Lasmar
- Faculty of Medical Sciences, Belo Horizonte, Minas Gerais, Brazil; University Hospital of the Faculty of Medical Sciences, Belo Horizonte, Minas Gerais, Brazil
| | - Evaldo Nascimento
- IMUNOLAB - Laboratory of Histocompatibility, Belo Horizonte, Minas Gerais, Brazil; Institute of Research and Education of the Hospital Santa Casa, Belo Horizonte, Minas Gerais, Brazil..
| | - Raquel A Fabreti-Oliveira
- Faculty of Medical Sciences, Belo Horizonte, Minas Gerais, Brazil; IMUNOLAB - Laboratory of Histocompatibility, Belo Horizonte, Minas Gerais, Brazil.
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13
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Moein M, Gao SX, Martin SJ, Farkouh KM, Li BW, Ball AS, Dvorai RH, Saidi RF. Conversion to Belatacept in kidney transplant recipients with chronic antibody-mediated rejection (CAMR). Transpl Immunol 2023; 76:101737. [PMID: 36379374 DOI: 10.1016/j.trim.2022.101737] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/20/2022] [Accepted: 11/05/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND The costimulatory inhibitor Belatacept (Bela) has been shown to be an effective alternative in several clinical situations, including chronic antibody-mediated rejection, calcineurin toxicity, and de novo alloantibody formation. To further explore the usefulness of Belatacept under various clinical scenarios, we performed a retrospective analysis of a prospective database of all recipients who had a BPAR diagnosis of CAMR and were converted to a Belatacept maintenance immunosuppression regimen after kidney transplantation. MATERIAL AND METHOD We conducted a retrospective analysis of a prospectively collected database of all kidney transplants adult patients at SUNY Upstate Medical Hospital from 1 January 2013 to 31 December 2021. Our inclusion criteria were the patients who have been diagnosed with CAMR according to their renal biopsy based on the 2013 Banff criteria. The primary objective was to compare the kidney viability and function using GFR between the two interest groups and finally compare the outcomes. RESULTS A total of 48 patients met our inclusion criteria based on the kidney biopsy result, which showed chronic antibody-mediated graft rejection (CAMR). Nineteen patients (39.6%) were converted to the Belatacept, and we continued the previous immunosuppression regimen in 29 patients (60.4%). The mean time from the transplant date to the diagnosis of CAMR was 1385 days in the Belatacept group and 914 days for the non-Belatacept group (P = 0.15). The mean GFR comparison at each time point between the groups did not show a significant difference, and Belatacept did not show superiority compared to the standard immunosuppression regimen in terms of kidney function preservation. 1 (5.2%) patient from the Belatacept group and 1 (3.4%) patient from the non-Belatacept group had a biopsy-proven acute rejection (BPAR) after CAMR confirmation, and it was comparable (P = 0.76). De novo synthesis of the DSA rate was 12.5% in the Belatacept group and 15% In the non-Belatacept group, which was comparable. (P = 0.90). The patient survival rate was 100% in both groups. CONCLUSIONS We conclude that compared to the standard Tacrolimus/MMF/Prednisone regimen, Belatacept did not significantly benefit in preserving the GFR in long-term follow-ups and stabilizing the DSA production, which is one of the main factors resulting in chronic graft failure.
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Affiliation(s)
- Mahmoudreza Moein
- Department of Surgery, Division of Transplantation, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Shuqi X Gao
- Department of Surgery, Division of Transplantation, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Samuel J Martin
- Department of Surgery, Division of Transplantation, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Katie M Farkouh
- Department of Surgery, Division of Transplantation, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Benson W Li
- Department of Surgery, Division of Transplantation, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Angela S Ball
- Department of Surgery, Division of Transplantation, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Reut Hod Dvorai
- Department of Pathology and Laboratory Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Reza F Saidi
- Department of Surgery, Division of Transplantation, SUNY Upstate Medical University, Syracuse, NY, USA.
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14
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Tawhari I, Hallak P, Bin S, Yamani F, Safar-Boueri M, Irshad A, Leventhal J, Ansari MJ, Cravedi P, Gallon L. Early calcineurin-inhibitor to belatacept conversion in steroid-free kidney transplant recipients. Front Immunol 2022; 13:1096881. [PMID: 36601111 PMCID: PMC9806416 DOI: 10.3389/fimmu.2022.1096881] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022] Open
Abstract
Background Belatacept (Bela) was developed to reduce nephrotoxicity and cardiovascular risk that are associated with the chronic use of Calcineurin inhibitors (CNIs) in kidney transplant recipients. The use of Bela with early steroid withdrawal (ESW) and simultaneous CNI avoidance has not been formally evaluated. Methods At 3 months post-transplant, stable kidney transplant recipients with ESW on Tacrolimus (Tac) + mycophenolate (MPA) were randomized 1:1:1 to: 1) Bela+MPA, 2) Bela+low-dose Tac (trough goal <5 ng/mL), or 3) continue Tac+MPA. All patients underwent surveillance graft biopsies at enrollment and then at 12, and 24 months post-transplant. Twenty-seven recipients were included; 9 underwent conversion to Bela+MPA, 8 to Bela+low-dose Tac and 10 continued Tac+MPA. Serial blood samples were collected for immune phenotyping and gene expression analyses. Results The Bela+MPA arm was closed early due to high rate of biopsy proven acute rejection (BPAR). The incidence of BPAR was 4/9 in Bela+MPA, 0/8 in Bela+low dose Tac and 2/10 in Tac+MPA, P= 0.087. The Bela+low-dose Tac regimen was associated with +8.8 mL/min/1.73 m2 increase in eGFR compared to -0.38 mL/min/1.73 m2 in Tac+MPA, P= 0.243. One graft loss occurred in the Bela+MPA group. Immunophenotyping of peripheral blood monocyte count (PBMC) showed that CD28+CD4+ and CD28+CD8+ T cells were higher in Bela+MPA patients with acute rejection compared to patients without rejection, although the difference did not reach statistical significance. Conclusions Our data indicate that, in steroid free regimens, low-dose Tac maintenance is needed to prevent rejection when patients are converted to Bela, at least when the maneuver is done early after transplant.
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Affiliation(s)
- Ibrahim Tawhari
- Department of Medicine, Nephrology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States,Department of Medicine, Nephrology, King Khalid University College of Medicine, Abha, Saudi Arabia
| | - Patrick Hallak
- Department of Medicine, Nephrology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Sofia Bin
- Department of Medicine, Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, United States,Nephrology, Dialysis and Renal Transplant Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Fatmah Yamani
- Department of Medicine, Nephrology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Maria Safar-Boueri
- Department of Medicine, Nephrology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Aazib Irshad
- Department of Medicine, Nephrology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Joseph Leventhal
- Department of Medicine, Nephrology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Mohammed Javeed Ansari
- Department of Medicine, Nephrology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Paolo Cravedi
- Department of Medicine, Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Lorenzo Gallon
- Department of Medicine, Nephrology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States,*Correspondence: Lorenzo Gallon,
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15
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Effect of Maintaining Immunosuppression After Kidney Allograft Failure on Mortality and Retransplantation. Transplant Direct 2022; 9:e1415. [DOI: 10.1097/txd.0000000000001415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/11/2022] [Indexed: 12/12/2022] Open
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16
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Wahl AK, Andersen MH, Ødemark J, Reisaether A, Urstad KH, Engebretsen E. The importance of shared meaning-making for sustainable knowledge translation and health literacy. J Eval Clin Pract 2022; 28:828-834. [PMID: 35466469 PMCID: PMC9790374 DOI: 10.1111/jep.13690] [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: 08/30/2021] [Revised: 02/23/2022] [Accepted: 04/02/2022] [Indexed: 12/30/2022]
Abstract
The aim of the present paper is to describe and discuss how recent theories about translation, bridging medical and humanistic understandings of knowledge translation, in the medical humanities can bring about a new understanding of health literacy in the context of patient education. We argue that knowledge translation must be understood as active engagement with contextual meaning, considering the understandings, interpretation, and expertise of both patient and health care provider (deconstruction of the distinction between biomedical and cultural knowledge). To illustrate our points, we will describe the case of Jim, a kidney transplant recipient who received standard patient education but lost the graft (the new kidney). If we apply Kristeva's view to this context, graft function is not merely biology but a complex biocultural fact. In this perspective, graft function is seen as a phenomenon that embraces translation between health as a biomedical phenomenon and healing as lived experience, and that opens for shared meaning-making processes between the patient and the health care provider. In Jim's case, this means that we need to rethink the approach to patient education in a way that encourages the patient's idiosyncratic way of thinking and experiencing, and to transform health information into a means for sustaining Jim's singular life - not biological life "in general." The patient education programme did not take into consideration the singularities of Jim's biographical temporality, with its changes in everyday life, priorities, attitudes, and values. Hence, we claim that health literacy should involve a simultaneous interrogation of the patients and the health professional's constructions of knowledge.
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Affiliation(s)
- Astrid K Wahl
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,Department of Interdisciplinary Health Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Marit H Andersen
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,Department of Interdisciplinary Health Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - John Ødemark
- Faculty of Humanities, IKOS, University of Oslo, Oslo, Norway
| | - Anna Reisaether
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Kristin H Urstad
- Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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17
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Abstract
Liver transplantation (LT) for children results in excellent short- and long-term patient and graft survival. LT is a lifesaving procedure in children with acute or chronic liver disease, hepatic tumors, and select genetic metabolic diseases in which it can significantly improve quality of life. In this article, the authors discuss the unique aspects of pediatric LT, including the indications, appropriate patient selection and evaluation, allocation of organs, transplant surgery including the use of variant grafts, posttransplant care including immunosuppression management, prognosis, and transition of care.
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Affiliation(s)
- Sara Kathryn Smith
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Johns Hopkins School of Medicine, 600 N Wolfe Street, Baltimore, MD 21287, USA.
| | - Tamir Miloh
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Miami, Highland Professional Building, 1801 Northwest 9th Avenue, Miami, FL 33136, USA
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18
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Prevalence Rate of Proteinuria and Metabolic Acidosis Among Kidney Transplant Recipients in a Tertiary Teaching Hospital and Its Relationship to Dietary Intake. Transplant Proc 2022; 54:355-361. [DOI: 10.1016/j.transproceed.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/02/2021] [Accepted: 12/29/2021] [Indexed: 11/20/2022]
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19
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Yahyazadeh SR, Naderi G, Zadeh SST, Saatchi M, Khatami F, Aghamir SMK. Comparative study of the outcomes of the second kidney transplantation from the young deceased donors versus living-unrelated donors. Transpl Immunol 2022; 71:101527. [PMID: 34998989 DOI: 10.1016/j.trim.2022.101527] [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: 10/30/2021] [Revised: 01/01/2022] [Accepted: 01/01/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE To compare the kidney graft function and survival in patients who had second kidney transplantation from living donors versus those who had a second transplant from young deceased donors. METHODS In this retrospective cohort study, a total of 86 patients who underwent second kidney transplantation in Shariati hospital from 2001 until 2017 were enrolled. Baseline clinical data on the age, sex, type of kidney donor (living unrelated or deceased), duration of pretransplant dialysis, and the length of hospitalization were recorded. As the indicators of the graft function, we used the serum creatinine level and estimated glomerular filtration rate (eGFR) at time intervals during the study. The 1, 5, and 10-year graft survival rates were reported using life tables and the relative hazard ratios of the graft failure were calculated using the forward stepwise Cox proportional hazard model. RESULTS Forty-six of our patients were men (53.5%), with a mean ± SD age of 44.3 ± 12.3 years at the time of transplantation. The majority of the enrolled patients received the kidney from living unrelated donors (50 vs. 36 patients). In terms of serum creatinine and eGFR, at time intervals, no significant difference was found between the two recipient groups. In the living donor group, the 1, 5, and 10-year graft survival rates of the second transplant were 91% (95%CI: 73-96%), 87% (95%CI: 69-95%), and 82% (95%CI: 59-92%), and for the deceased donor group were 95% (95% CI: 69-99%), 95% (95%CI: 69-99%), and 79% (95%CI: 31-95%), respectively. CONCLUSION Considering the long-term outcomes of the second kidney transplantation, in our experience, the graft function and survival, either from the living or deceased donors, were favorable; and the type of organ donation had no significant effect on the risk of graft failure.
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Affiliation(s)
- Seyed Reza Yahyazadeh
- Shariati Hospital, Department of Urology, Tehran University of Medical Sciences, Tehran, Iran
| | - Gholamhossein Naderi
- Shariati Hospital, Department of Urology, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mohammad Saatchi
- Department of Epidemiology and Biostatistics, School of Public Health(,) Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Khatami
- Urology Research Center, Tehran University of Medical Sciences, Tehran, Iran
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20
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Tantisattamo E, Kalantar-Zadeh K, Molnar MZ. Nutritional and dietary interventions to prolong renal allograft survival after kidney transplantation. Curr Opin Nephrol Hypertens 2022; 31:6-17. [PMID: 34750333 DOI: 10.1097/mnh.0000000000000757] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Diet plays an important role in slowing progression of chronic kidney disease in native and transplanted kidneys. There is limited evidence on the association on dietary intake with renal allograft function. Mechanisms of major nutrients and dietary patterns with focusing on a plant-based diet related to kidney transplant health and longevity are reviewed. RECENT FINDINGS High dietary protein intake may adversely affect renal allograft. Low protein plant-focused diets such as Dietary Approaches to Stop Hypertension, plant-dominant low-protein diet and Mediterranean diets appear associated with favorable outcomes in slowing renal allograft function decline. The mechanism may be related to a change in renal hemodynamic by decreasing glomerular hyperfiltration from low dietary protein intake and plant-based ingredients. Recent observational studies of association between dietary protein intake and kidney allograft outcomes are conflicting. Although strong evidence is still lacking, a low protein diet of 0.6-0.8 g/kg/day with at least 50% of the protein source from plant-based components in kidney transplant recipients with stable kidney allograft function should be considered as the dietary target. SUMMARY Dietary intervention with low-protein plant-focused meals may improve outcomes in kidney transplant recipients, but the evidence remains limited and further studies are warranted.
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Affiliation(s)
- Ekamol Tantisattamo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, University of California Irvine School of Medicine, Orange.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, Veterans Affairs Long Beach Healthcare System, Long Beach, California.,Multi-Organ Transplant Center, Section of Nephrology, Department of Internal Medicine, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, University of California Irvine School of Medicine, Orange.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, Veterans Affairs Long Beach Healthcare System, Long Beach, California.,Lundquist Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Miklos Z Molnar
- Division of Nephrology and Hypertension, Department of Medicine, University of Utah, Utah, USA
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21
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Gonzales HM, Fleming JN, Gebregziabher M, Posadas Salas MA, McGillicuddy JW, Taber DJ. A Critical Analysis of the Specific Pharmacist Interventions and Risk Assessments During the 12-Month TRANSAFE Rx Randomized Controlled Trial. Ann Pharmacother 2021; 56:685-690. [PMID: 34496669 DOI: 10.1177/10600280211044792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Medication safety issues have detrimental implications on long-term outcomes in the high-risk kidney transplant (KTX) population. Medication errors, adverse drug events, and medication nonadherence are important and modifiable mechanisms of graft loss. OBJECTIVE To describe the frequency and types of interventions made during a pharmacist-led, mobile health-based intervention in KTX recipients and the impact on patient risk levels. METHODS This was a secondary analysis of data collected during a 12-month, parallel-arm, 1:1 randomized clinical controlled trial including 136 KTX recipients. Participants were randomized to receive either usual care or supplemental, pharmacist-driven medication therapy monitoring and management using a smartphone-enabled app integrated with telemonitoring of blood pressure and glucose (when applicable) and risk-based televisits. The primary outcome was pharmacist intervention type. Secondary outcomes included frequency of interventions and changes in risk levels. RESULTS A total of 68 patients were randomized to the intervention and included in this analysis. The mean age at baseline was 50.2 years; 51.5% of participants were male, and 58.8% were black. Primary pharmacist intervention types were medication reconciliation and patient education, followed by medication changes. Medication reconciliation remained high throughout the study period, whereas education and medication changes trended downward. From baseline to month 12, we observed an approximately 15% decrease in high-risk patients and a corresponding 15% increase in medium- or low-risk patients. CONCLUSION AND RELEVANCE A pharmacist-led mHealth intervention may enhance opportunities for pharmacological and nonpharmacological interventions and mitigate risk levels in KTX recipients.
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Affiliation(s)
| | | | | | | | | | - David J Taber
- Medical University of South Carolina, Charleston, SC, USA
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22
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Poggio ED, Augustine JJ, Arrigain S, Brennan DC, Schold JD. Long-term kidney transplant graft survival-Making progress when most needed. Am J Transplant 2021; 21:2824-2832. [PMID: 33346917 DOI: 10.1111/ajt.16463] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 11/23/2020] [Accepted: 12/15/2020] [Indexed: 02/06/2023]
Abstract
Current short-term kidney post-transplant survival rates are excellent, but longer-term outcomes have historically been unchanged. This study used data from the national Scientific Registry of Transplant Recipients (SRTR) and evaluated 1-year and 5-year graft survival and half-lives for kidney transplant recipients in the US. All adult (≥18 years) solitary kidney transplants (n = 331,216) from 1995 to 2017 were included in the analysis. Mean age was 49.4 years (SD +/-13.7), 60% male, and 25% Black. The overall (deceased and living donor) adjusted hazard of graft failure steadily decreased from 0.89 (95%CI: 0.88, 0.91) in era 2000-2004 to 0.46 (95%CI: 0.45, 0.47) for era 2014-2017 (1995-1999 as reference). Improvements in adjusted hazards of graft failure were more favorable for Blacks, diabetics and older recipients. Median survival for deceased donor transplants increased from 8.2 years in era 1995-1999 to an estimated 11.7 years in the most recent era. Living kidney donor transplant median survival increased from 12.1 years in 1995-1999 to an estimated 19.2 years for transplants in 2014-2017. In conclusion, these data show continuous improvement in long-term outcomes with more notable improvement among higher-risk subgroups, suggesting a narrowing in the gap for those disadvantaged after transplantation.
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Affiliation(s)
- Emilio D Poggio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Joshua J Augustine
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Susana Arrigain
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel C Brennan
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland
| | - Jesse D Schold
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
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23
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Martin K, Cantwell L, Barraclough KA, Lian M, Masterson R, Hughes PD, Chow KV. Prolonged immunosuppression does not improve risk of sensitisation or likelihood of re-transplantation after kidney transplant graft failure. Transpl Int 2021; 34:2353-2362. [PMID: 34320262 DOI: 10.1111/tri.13998] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 07/20/2021] [Accepted: 07/23/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The optimum approach toward immunosuppression withdrawal following kidney transplant failure is unclear. Prolonged weaning may be associated with reduced sensitisation, less graft nephrectomy and greater likelihood of re-transplantation, but conversely increased risk of infection, malignancy and death. METHODS We conducted a single centre retrospective analysis of patients experiencing graft failure between 2007-2017, comparing rates of sensitisation, re-transplantation, nephrectomy, infection, malignancy and death between patients who had immunosuppression weaned over <90 vs. 90-180 vs. >180 days. RESULTS Patient survival after immunosuppression withdrawal over <90 vs. 90-180 vs. >180 days was 73.3%, 72.1% and 80.4% respectively (p=0.35), with no differences in cPRA (80.06 vs. 81.21 vs. 85.42, p=0.66) or re-transplantation rate (24/31 (77.4%) vs. 21/35 (60.0%) vs. 22/36 (61.1%), p=0.13). There was significantly less nephrectomy after late immunosuppression cessation (10/42 (23.8%) vs. 7/42 (16.7%) vs. 3/43 (7.0%), p=0.01) but no differences in infections or malignancy. On competing risk regression (death as competing risk) controlling for cofactors including age, nephrectomy and rejection, prolonged immunosuppression did not predict likelihood of re-transplantation (SHR 1.000, p=0.88). CONCLUSIONS Prolonged immunosuppression withdrawal does not reduce sensitisation or improve re-transplantation rates but is associated with less nephrectomy. Immunosuppression withdrawal should be tailored to individual circumstances after graft failure.
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Affiliation(s)
- Kylie Martin
- Department of Nephrology, Royal Melbourne Hospital, Victoria, Australia
| | - Linda Cantwell
- Victorian Transplantation and Immunogenetics Service, Australian Red Cross Life Blood, Victoria, Australia
| | - Katherine A Barraclough
- Department of Nephrology, Royal Melbourne Hospital, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Michael Lian
- Department of Nephrology, Royal Melbourne Hospital, Victoria, Australia
| | - Rosemary Masterson
- Department of Nephrology, Royal Melbourne Hospital, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Peter D Hughes
- Department of Nephrology, Royal Melbourne Hospital, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Kevin V Chow
- Department of Nephrology, Royal Melbourne Hospital, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
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24
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Urinary Carnosinase-1 Excretion is Associated with Urinary Carnosine Depletion and Risk of Graft Failure in Kidney Transplant Recipients: Results of the TransplantLines Cohort Study. Antioxidants (Basel) 2021; 10:antiox10071102. [PMID: 34356335 PMCID: PMC8301129 DOI: 10.3390/antiox10071102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/26/2021] [Accepted: 07/06/2021] [Indexed: 11/16/2022] Open
Abstract
Carnosine affords protection against oxidative and carbonyl stress, yet high concentrations of the carnosinase-1 enzyme may limit this. We recently reported that high urinary carnosinase-1 is associated with kidney function decline and albuminuria in patients with chronic kidney disease. We prospectively investigated whether urinary carnosinase-1 is associated with a high risk for development of late graft failure in kidney transplant recipients (KTRs). Carnosine and carnosinase-1 were measured in 24 h urine in a longitudinal cohort of 703 stable KTRs and 257 healthy controls. Cox regression was used to analyze the prospective data. Urinary carnosine excretions were significantly decreased in KTRs (26.5 [IQR 21.4–33.3] µmol/24 h versus 34.8 [IQR 25.6–46.8] µmol/24 h; p < 0.001). In KTRs, high urinary carnosinase-1 concentrations were associated with increased risk of undetectable urinary carnosine (OR 1.24, 95%CI [1.06–1.45]; p = 0.007). During median follow-up for 5.3 [4.5–6.0] years, 84 (12%) KTRs developed graft failure. In Cox regression analyses, high urinary carnosinase-1 excretions were associated with increased risk of graft failure (HR 1.73, 95%CI [1.44–2.08]; p < 0.001) independent of potential confounders. Since urinary carnosine is depleted and urinary carnosinase-1 imparts a higher risk for graft failure in KTRs, future studies determining the potential of carnosine supplementation in these patients are warranted.
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25
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Chandran S, Leung J, Hu C, Laszik ZG, Tang Q, Vincenti FG. Interleukin-6 blockade with tocilizumab increases Tregs and reduces T effector cytokines in renal graft inflammation: A randomized controlled trial. Am J Transplant 2021; 21:2543-2554. [PMID: 33331082 DOI: 10.1111/ajt.16459] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/11/2020] [Accepted: 12/11/2020] [Indexed: 01/25/2023]
Abstract
Interleukin-6 (IL-6) is a proinflammatory cytokine and key regulator of Treg: T effector cell (Teff) balance. We hypothesized that IL-6 blockade with tocilizumab, a monoclonal antibody to IL-6R, would increase Tregs, dampen Teff function, and control graft inflammation. We conducted a randomized controlled clinical trial (2014-2018) of clinically stable kidney transplant recipients on calcineurin inhibitor, mycophenolate mofetil, and prednisone, with subclinical graft inflammation noted on surveillance biopsies during the first year posttransplant. Subjects received tocilizumab (8 mg/kg IV every 4 weeks; 6 doses; n = 16) or no treatment (controls; n = 14) on top of usual maintenance immunosuppression. Kidney biopsies pre- and post-treatment were analyzed using Banff criteria. Blood was analyzed for serum cytokines, Treg frequencies, and T cell effector molecule expression (IFN-γ, IL-17, granzyme B) post-stimulation ex vivo. Tocilizumab-treated subjects were more likely to show improved Banff ti-score (62.5% vs. 21.4%, p = .03), increased Treg frequency (7.1% ± 5.55% vs. 3.6% ± 1.7%, p = .0168), and a blunted Teff cytokine response compared to controls. Changes in Banff i- and t-scores were not significantly different. The treatment was relatively well tolerated with no patient deaths or graft loss. Blockade of IL-6 is a novel and promising treatment option to regulate the T cell alloimmune response in kidney transplant recipients. NCT02108600.
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Affiliation(s)
- Sindhu Chandran
- Department of Medicine, University of California, San Francisco, California, USA
| | - Joey Leung
- Department of Surgery, University of California, San Francisco, California, USA
| | - Crystal Hu
- Department of Surgery, University of California, San Francisco, California, USA
| | - Zoltan G Laszik
- Department of Pathology, University of California, San Francisco, California, USA
| | - Qizhi Tang
- Department of Surgery, University of California, San Francisco, California, USA
| | - Flavio G Vincenti
- Department of Medicine, University of California, San Francisco, California, USA.,Department of Surgery, University of California, San Francisco, California, USA
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26
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Song SH, Choi HY, Kim HY, Nam CM, Jeong HJ, Kim MS, Kim SII, Kim YS, Huh KH, Kim BS. Effects of bisphosphonates on long-term kidney transplantation outcomes. Nephrol Dial Transplant 2021; 36:722-729. [PMID: 33367861 DOI: 10.1093/ndt/gfaa371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Bisphosphonates are administered to post-transplantation patients with mineral and bone disorders; however, the association between bisphosphonate therapy and long-term renal graft survival remains unclear. METHODS This nested case-control study investigated the effects of bisphosphonates on long-term graft outcomes after kidney transplantation. We enrolled 3836 kidney transplant recipients treated from April 1979 to June 2016 and matched patients with graft failure to those without (controls). Annual post-transplant bone mineral density assessments were performed and recipients with osteopenia or osteoporosis received bisphosphonate therapy. The associations between bisphosphonate use and long-term graft outcomes and graft survival were analyzed using conditional logistic regression and landmark analyses, respectively. RESULTS A landmark analysis demonstrated that death-censored graft survival was significantly higher in bisphosphonate users than in non-users in the entire cohort (log-rank test, P < 0.001). In the nested case-control matched cohort, bisphosphonate users had a significantly reduced risk of graft failure than did non-users (odds ratio = 0.38; 95% confidence interval 0.30-0.48). Bisphosphonate use, increased cumulative duration of bisphosphonate use >1 year and increased cumulative bisphosphonate dose above the first quartile were associated with a reduced risk of graft failure, after adjustments. CONCLUSIONS Bisphosphonates may improve long-term graft survival in kidney transplant recipients.
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Affiliation(s)
- Seung Hwan Song
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Surgery, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Hoon Young Choi
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ha Yan Kim
- Department of Biomedical Systems Informatics, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chung Mo Nam
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyeon Joo Jeong
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Pathology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Myoung Soo Kim
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Transplantation Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soon I I Kim
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Transplantation Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yu Seun Kim
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Transplantation Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyu Ha Huh
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Transplantation Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Beom Seok Kim
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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27
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Gregorini M, Del Fante C, Pattonieri EF, Avanzini MA, Grignano MA, Cassaniti I, Baldanti F, Comolli G, Nocco A, Ramondetta M, Viarengo G, Sepe V, Libetta C, Klersy C, Perotti C, Rampino T. Photopheresis Abates the Anti-HLA Antibody Titer and Renal Failure Progression in Chronic Antibody-Mediated Rejection. BIOLOGY 2021; 10:biology10060547. [PMID: 34207225 PMCID: PMC8234140 DOI: 10.3390/biology10060547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/03/2021] [Accepted: 06/15/2021] [Indexed: 12/28/2022]
Abstract
Simple Summary The most common cause of late allograft failure is chronic active antibody-mediated rejection (ABMR), but no effective therapy is available. Different immunosuppressive drugs in combination with procedures that remove serum antibodies have been used and the results have not shown to improve graft and patient outcome, but only an increased risk of adverse events. Extracorporeal pho-topheresis (ECP) is leukapheresis-based immunomodulatory therapy not associated with adverse effect, in which lymphocytes treat-ed with 8-methoxypsoralen (8-MOP) are irradiated with ultraviolet-A (UVA) ex vivo and re-infused into the patient. In this study we investigated therapeutic long-term effect of ECP in patients with biopsy proved chronic ABMR. Abstract Objective: Chronic renal antibody-mediated rejection (ABMR) is a common cause of allograft failure, but an effective therapy is not available. Extracorporeal photopheresis (ECP) has been proven successful in chronic lung and heart rejection, and graft versus host disease. The aim of this study was to evaluate the effectiveness of ECP in chronic ABMR patients. Patients and Methods: We investigated ECP treatment in 14 patients with biopsy-proven chronic ABMR and stage 2–3 chronic renal failure. The primary aim was to e valuate the eGFR lowering after 1 year of ECP therapy. The ECP responders (R) showed eGFR reduction greater than 20% vs the basal levels. We also evaluated the effectiveness of ECP on proteinuria, anti-HLA antibodies (HLAab), interleukin 6 (IL-6) serum levels, and CD3, CD4, CD8, CD19, NK, Treg and T helper 17 (Th17) circulating cells. Results: Three patients dropped out of the study. The R patients were eight (72.7%) out of the 11 remaining patients. Because ECP was not associated with any adverse reaction, the R patients continued such treatment for up to 3 years, showing a persisting eGFR stabilization. Twenty four hour proteinuria did not increase in the R patients over the follow-up when compared to the non-responder patients (NR). In the R patients, the HLAab levels were reduced and completely cleared in six out of eight patients when compared with the NR patients. The NR HLAab levels also increased after the discontinuation of the ECP. The ECP in the R patients showed a decrease in CD3, CD4, CD8, CD19, and NK circulating cells. The ECP treatment in the R patients also induced Tregs and Th17 cell increases, and a decrease of the IL-6 serum levels. Conclusions: ECP abates the HLAab titer and renal failure progression in patients with chronic renal ABMR, modulating the immune cellular and humoral responses.
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Affiliation(s)
- Marilena Gregorini
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100 Pavia, Italy;
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (E.F.P.); (M.A.G.); (V.S.); (T.R.)
- Correspondence: ; Tel.: +39-0382-502591; Fax: +39-0382-503666
| | - Claudia Del Fante
- Immunohematology and Transfusion Service, IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (C.D.F.); (G.V.); (C.P.)
| | - Eleonora Francesca Pattonieri
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (E.F.P.); (M.A.G.); (V.S.); (T.R.)
| | - Maria Antonietta Avanzini
- Immunology and Transplantation Laboratory, Cell Factory, Pediatric Hematology Oncology, Fondazione IRCCS Policlinico S. Matteo, 27100 Pavia, Italy;
| | - Maria Antonietta Grignano
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (E.F.P.); (M.A.G.); (V.S.); (T.R.)
| | - Irene Cassaniti
- Molecular Virology Unit, Department of Microbiology and Virology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.C.); (F.B.); (G.C.)
| | - Fausto Baldanti
- Molecular Virology Unit, Department of Microbiology and Virology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.C.); (F.B.); (G.C.)
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Giuditta Comolli
- Molecular Virology Unit, Department of Microbiology and Virology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.C.); (F.B.); (G.C.)
- Experimental Research Laboratories, Biotechnology Area, Fondazione IRCCS Policlinico S. Matteo, 27100 Pavia, Italy
| | - Angela Nocco
- Laboratory of Transplant Immunology, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico Milano, 20122 Milano, Italy; (A.N.); (M.R.)
| | - Miriam Ramondetta
- Laboratory of Transplant Immunology, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico Milano, 20122 Milano, Italy; (A.N.); (M.R.)
| | - Gianluca Viarengo
- Immunohematology and Transfusion Service, IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (C.D.F.); (G.V.); (C.P.)
| | - Vincenzo Sepe
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (E.F.P.); (M.A.G.); (V.S.); (T.R.)
| | - Carmelo Libetta
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100 Pavia, Italy;
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (E.F.P.); (M.A.G.); (V.S.); (T.R.)
| | - Catherine Klersy
- Clinical Epidemiology and Biometry Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Cesare Perotti
- Immunohematology and Transfusion Service, IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (C.D.F.); (G.V.); (C.P.)
| | - Teresa Rampino
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (E.F.P.); (M.A.G.); (V.S.); (T.R.)
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28
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Gonzales HM, Fleming JN, Gebregziabher M, Posadas-Salas MA, Su Z, McGillicuddy JW, Taber DJ. Pharmacist-Led Mobile Health Intervention and Transplant Medication Safety: A Randomized Controlled Clinical Trial. Clin J Am Soc Nephrol 2021; 16:776-784. [PMID: 33931415 PMCID: PMC8259471 DOI: 10.2215/cjn.15911020] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 02/24/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Medication safety events are predominant contributors to suboptimal graft outcomes in kidney transplant recipients. The goal of this study was to examine the efficacy of improving medication safety through a pharmacist-led, mobile health-based intervention. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This was a 12-month, single-center, prospective, parallel, two-arm, single-blind, randomized controlled trial. Adult kidney recipients 6-36 months post-transplant were eligible. Participants randomized to intervention received supplemental clinical pharmacist-led medication therapy monitoring and management via a mobile health-based application, integrated with risk-guided televisits and home-based BP and glucose monitoring. The application provided an accurate medication regimen, timely reminders, and side effect surveys. Both the control and intervention arms received usual care, including serial laboratory monitoring and regular clinic visits. The coprimary outcomes were to assess the incidence and severity of medication errors and adverse events. RESULTS In total, 136 kidney transplant recipients were included, 68 in each arm. The mean age was 51 years, 57% were male, and 64% were Black individuals. Participants receiving the intervention experienced a significant reduction in medication errors (61% reduction in the risk rate; incident risk ratio, 0.39; 95% confidence interval, 0.28 to 0.55; P<0.001) and a significantly lower incidence risk of Grade 3 or higher adverse events (incident risk ratio, 0.55, 95% confidence interval, 0.30 to 0.99; P=0.05). For the secondary outcome of hospitalizations, the intervention arm demonstrated significantly lower rates of hospitalizations (incident risk ratio, 0.46; 95% confidence interval, 0.27 to 0.77; P=0.005). CONCLUSIONS We demonstrated a significant reduction in medication errors, adverse events, and hospitalizations using a pharmacist-led, mobile health-based intervention.
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Affiliation(s)
- Haley M. Gonzales
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - James N. Fleming
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | | | - Zemin Su
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - John W. McGillicuddy
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - David J. Taber
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
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29
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Liu Y, Liu X, Zhou S, Xu R, Hu J, Liao G, Liao J, Guo Z, Li Y, Yang S, Li S, Chen H, Guo Y, Li M, Fan L, Li L, Zhao M, Liu D. Single-Cell Profiling of Kidney Transplant Recipients With Immunosuppressive Treatment Reveals the Dynamic Immune Characteristics. Front Immunol 2021; 12:639942. [PMID: 33959124 PMCID: PMC8093626 DOI: 10.3389/fimmu.2021.639942] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/31/2021] [Indexed: 11/17/2022] Open
Abstract
Kidney transplantation is currently the first choice of treatment for various types of end-stage renal failure, but there are major limitations in the application of immunosuppressive protocols after kidney transplantation. When the dose of immunosuppressant is too low, graft rejection occurs easily, while a dose that is too high can lead to graft loss. Therefore, it is very important to explore the immune status of patients receiving immunosuppressive agents after kidney transplantation. To compare the immune status of the recipient’s whole peripheral blood before and after receipt of immunosuppressive agents, we used single-cell cytometry by time-of-flight (CyTOF) to detect the peripheral blood immune cells in five kidney transplant recipients (KTRs) from the Department of Organ Transplantation of Zhujiang Hospital of Southern Medical University before and after receiving immunosuppressive agents. Based on CyTOF analysis, we detected 363,342 live single immune cells. We found that the immune cell types of the KTRs before and after receipt of immunosuppressive agents were mainly divided into CD4+ T cells, CD8+ T cells, B cells, NK cells/γδ T cells, monocytes/macrophages, granulocytes, and dendritic cells (DCs). After further reclustering of the above cell types, it was found that the immune cell subclusters in the peripheral blood of patients underwent major changes after receipt of immunosuppressants. After receiving immunosuppressive therapy, the peripheral blood of KTRs had significantly increased levels of CD57+NK cells and significantly decreased levels of central memory CD4+ T cells, follicular helper CD4+ T cells, effector CD8+ T cells, effector memory CD8+ T cells and naive CD8+ T cells. This study used CyTOF to classify immune cells in the peripheral blood of KTRs before and after immunosuppressive treatment, further compared differences in the proportions of the main immune cell types and immune cell subgroups before and after receipt of immunosuppressants, and provided relatively accurate information for assessment and treatment strategies for KTRs.
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Affiliation(s)
- Yongguang Liu
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaoyou Liu
- Department of Organ Transplantation, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Song Zhou
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Ruiquan Xu
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Jianmin Hu
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Guorong Liao
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Jun Liao
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Zefeng Guo
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yuzhu Li
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Siqiang Yang
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Shichao Li
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Hua Chen
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Ying Guo
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Min Li
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Lipei Fan
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Liuyang Li
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Ming Zhao
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Ding Liu
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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30
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Yepes‐Calderón M, Sotomayor CG, Pena M, Eisenga MF, Gans ROB, Berger SP, Moers C, Sugaya T, Doekharan D, Navis GJ, van den Born J, Bakker SJL. Urinary liver-type fatty acid-binding protein is independently associated with graft failure in outpatient kidney transplant recipients. Am J Transplant 2021; 21:1535-1544. [PMID: 32946659 PMCID: PMC8048636 DOI: 10.1111/ajt.16312] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 08/16/2020] [Accepted: 09/07/2020] [Indexed: 01/25/2023]
Abstract
Urinary liver-type fatty acid-binding protein (uL-FABP) is a biomarker of kidney hypoxia and ischemia, and thus offers a novel approach to identify early kidney insults associated with increased risk of graft failure in outpatient kidney transplant recipients (KTR). We investigated whether uL-FABP is associated with graft failure and whether it improves risk prediction. We studied a cohort of 638 outpatient KTR with a functional graft ≥1-year. During a median follow-up of 5.3 years, 80 KTR developed graft failure. uL-FABP (median 2.11, interquartile range 0.93-7.37 µg/24"/>h) was prospectively associated with the risk of graft failure (hazard ratio 1.75; 95% confidence interval 1.27-2.41 per 1-SD increment; P = .001), independent of potential confounders including estimated glomerular filtration rate and proteinuria. uL-FABP showed excellent discrimination ability for graft failure (c-statistic of 0.83) and its addition to a prediction model composed by established clinical predictors of graft failure significantly improved the c-statistic to 0.89 (P for F-test <.001). These results were robust to several sensitivity analyses. Further validation studies are warranted to evaluate the potential use of a risk-prediction model including uL-FABP to improve identification of outpatient KTR at high risk of graft failure in clinical care.
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Affiliation(s)
- Manuela Yepes‐Calderón
- Division of NephrologyUniversity Medical Center GroningenUniversity of GroningenGroningenthe Netherlands
| | - Camilo G. Sotomayor
- Division of NephrologyUniversity Medical Center GroningenUniversity of GroningenGroningenthe Netherlands
| | - Michelle Pena
- Departmant of Clinical Pharmacy and PharmacologyUniversity Medical Center GroningenUniversity of GroningenGroningenthe Netherlands
| | - Michele F. Eisenga
- Division of NephrologyUniversity Medical Center GroningenUniversity of GroningenGroningenthe Netherlands
| | - Rijk O. B. Gans
- Department of Internal MedicineUniversity Medical Center GroningenUniversity of GroningenGroningenthe Netherlands
| | - Stefan P. Berger
- Division of NephrologyUniversity Medical Center GroningenUniversity of GroningenGroningenthe Netherlands
| | - Cyril Moers
- Division of Transplantation SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenthe Netherlands
| | - Takeshi Sugaya
- Department of MedicineSt. Marianna University School of MedicineKawasakiJapan
| | | | - Gerjan J. Navis
- Division of NephrologyUniversity Medical Center GroningenUniversity of GroningenGroningenthe Netherlands
| | - Jaap van den Born
- Division of NephrologyUniversity Medical Center GroningenUniversity of GroningenGroningenthe Netherlands
| | - Stephan J. L. Bakker
- Division of NephrologyUniversity Medical Center GroningenUniversity of GroningenGroningenthe Netherlands
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Sahman M, Mugosa S, Rancic N. Utilization of Mycophenolic Acid, Azathioprine, Tacrolimus, Cyclosporin, Sirolimus, and Everolimus: Multinational Study. Front Public Health 2021; 9:671316. [PMID: 33869136 PMCID: PMC8044364 DOI: 10.3389/fpubh.2021.671316] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Organ transplantations are difficult, complicated and very expensive interventions. In order to preserve the transplanted organs, it is necessary to provide medical care to the patients in terms of immunosuppression. According to the guidelines, the first-line therapy choices for achieving immunosuppression after transplantation are tacrolimus, cyclosporine, mycophenolic acid, azathioprine, sirolimus, everolimus„ and corticosteroids. The aim of our study was to examine the utilization of this drugs in Montenegro and to compare the results with the ones from Finland, Croatia, and Serbia. Methods: In our investigation we used Anatomical Therapeutic Chemical/Defined Daily Dose (ATC/DDD) methodology. Prices per DDD of drugs are presented in euros (€). Results: In all observed countries, there is a positive trend in the consumption of all 6 drugs during the analyzed period. The prices per DDD of these drugs generally show a negative trend. Tacrolimus and mycophenolic acid in Montenegro recorded the largest reduction in the price per DDD. Price per one DDD of tacrolimus decreased from €13.28 in 2009 to €5.11 in 2019, thus by about 260%, and as regards mycophenolic acid, the price per one DDD decreased from €9.59 in 2009 to € 3.36 in 2019, thus by almost 300%. Conclusion: Despite the reduction in the price per DDD, drugs that are used as immunosuppressants are showing increasing costs from year to year. Since these drugs are expensive, they participate in a significant percentage in the budget for medicines in each country.
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Affiliation(s)
- Majda Sahman
- Department for Pharmacology, Faculty of Medicine, University of Montenegro, Podgorica, Montenegro.,Institute for Medicines and Medical Devices of Montenegro, Podgorica, Montenegro
| | - Snezana Mugosa
- Department for Pharmacology, Faculty of Medicine, University of Montenegro, Podgorica, Montenegro.,Institute for Medicines and Medical Devices of Montenegro, Podgorica, Montenegro
| | - Nemanja Rancic
- Center for Clinical Pharmacology, Military Medical Academy, Belgrade, Serbia.,Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia
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32
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Law JP, Borrows R, McNulty D, Sharif A, Ferro CJ. Early renal function trajectories, cytomegalovirus serostatus and long-term graft outcomes in kidney transplant recipients. BMC Nephrol 2021; 22:102. [PMID: 33743617 PMCID: PMC7981965 DOI: 10.1186/s12882-021-02285-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 03/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improved recognition of factors influencing graft survival has led to better short-term kidney transplant outcomes. However, efforts to prevent long-term graft decline and improve graft survival have seen more modest improvements. The adoption of electronic health records has enabled better recording and identification of donor-recipient factors through the use of modern statistical techniques. We have previously shown in a prevalent renal transplant population that episodes of rapid deterioration are associated with graft loss. METHODS Estimated glomerular filtration rates (eGFR) between 3 and 27 months after transplantation were collected from 310 kidney transplant recipients. We utilised a Bayesian approach to estimate the most likely eGFR trajectory as a smooth curve from an average of 10,000 Monte Carlo samples. The probability of having an episode of rapid deterioration (decline greater than 5 ml/min/1.73 m2 per year in any 1-month period) was calculated. Graft loss and mortality data was collected over a median follow-up period of 8 years. Factors associated with having an episode of rapid deterioration and associations with long-term graft loss were explored. RESULTS In multivariable Cox Proportional Hazard analysis, a probability greater than 0.8 of rapid deterioration was associated with long-term death-censored graft loss (Hazard ratio 2.17; 95% Confidence intervals [CI] 1.04-4.55). In separate multivariable logistic regression models, cytomegalovirus (CMV) serostatus donor positive to recipient positive (Odds ratio [OR] 3.82; 95%CI 1.63-8.97), CMV donor positive (OR 2.06; 95%CI 1.15-3.68), and CMV recipient positive (OR 2.03; 95%CI 1.14-3.60) were associated with having a greater than 0.8 probability of an episode of rapid deterioration. CONCLUSIONS Early episodes of rapid deterioration are associated with long-term death-censored graft loss and are associated with cytomegalovirus seropositivity. Further study is required to better manage these potentially modifiable risks factors and improve long-term graft survival.
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Affiliation(s)
- Jonathan P Law
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, Edgbaston, Birmingham, B15 2TT, UK
- Department of Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK
| | - Richard Borrows
- Department of Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK
| | - David McNulty
- Department of Medical Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK
| | - Adnan Sharif
- Department of Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK
| | - Charles J Ferro
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, Edgbaston, Birmingham, B15 2TT, UK.
- Department of Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK.
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33
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Paul RS, Almokayad I, Collins A, Raj D, Jagadeesan M. Donor-derived Cell-free DNA: Advancing a Novel Assay to New Heights in Renal Transplantation. Transplant Direct 2021; 7:e664. [PMID: 33564715 PMCID: PMC7862009 DOI: 10.1097/txd.0000000000001098] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/09/2020] [Accepted: 10/13/2020] [Indexed: 02/07/2023] Open
Abstract
Despite advances in transplant immunosuppression, long-term renal allograft outcomes remain suboptimal because of the occurrence of rejection, recurrent disease, and interstitial fibrosis with tubular atrophy. This is largely due to limitations in our understanding of allogeneic processes coupled with inadequate surveillance strategies. The concept of donor-derived cell-free DNA as a signal of allograft stress has therefore rapidly been adopted as a noninvasive monitoring tool. Refining it for effective clinical use, however, remains an ongoing effort. Furthermore, its potential to unravel new insights in alloimmunity through novel molecular techniques is yet to be realized. This review herein summarizes current knowledge and active endeavors to optimize cell-free DNA-based diagnostic techniques for clinical use in kidney transplantation. In addition, the integration of DNA methylation and microRNA may unveil new epigenetic signatures of allograft health and is also explored in this report. Directing research initiatives toward these aspirations will not only improve diagnostic precision but may foster new paradigms in transplant immunobiology.
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Affiliation(s)
- Rohan S. Paul
- Division of Kidney Disease & Hypertension, George Washington University, Washington, DC
| | - Ismail Almokayad
- Division of Kidney Disease & Hypertension, George Washington University, Washington, DC
| | - Ashte Collins
- Division of Kidney Disease & Hypertension, George Washington University, Washington, DC
| | - Dominic Raj
- Division of Kidney Disease & Hypertension, George Washington University, Washington, DC
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34
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Telkes G, Piros L, Szabó J, Huszty G, Eitler K, Kóbori L. Outcomes of first versus third kidney transplantations: propensity score matching and paired subgroup analysis-a single-centre experience. Langenbecks Arch Surg 2021; 406:863-871. [PMID: 33454840 PMCID: PMC8106582 DOI: 10.1007/s00423-020-02063-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/15/2020] [Indexed: 11/25/2022]
Abstract
Background In the Eurotransplant, 12.6% of kidney transplantations are a repeat procedure. Third transplants are significantly more complex than first and second ones. We compared the results of first (PRT) versus third (TRT) transplantations. Methods Between 2011 and 2016, we performed 779 deceased donor adult kidney transplantations, 14.2% out of them were second, 2.6% (20) third, and 0.3% fourth. We compared the pre-, intra-, and postoperative data, kidney function, and survival rate. Results Recipients of TRT were younger (53.4 vs. 47.3 p = 0.02). HCV infection rate (20%, p = 0.00) is ten times higher. The operation time is longer (132 vs. 152 min, p = 0.02), and delayed graft function is much more frequent (22.4% vs. 60%, p = 0.00). Induction therapy was given to every TRT (7.9% vs.100%), but as a result, the rejection rate was the same (~ 15%). Hospital stay is a week longer. Patient’s survival at 1, 3, and 5 years for PRT is 96.4%, 93.9%, and 91.2% and for TRT is 90%, 85%, and 78.4%, respectively (p = 0.023). TRT’s odds ratio of fatal outcome is 4.35 (1.5–12.5). Graft survival at 1, 3, and 5 years for PRT is 93.1%, 91.4%, and 90.3% and for TRT is 75%, 75%, and 75%, respectively (p = 0.020). TRT’s odds ratio of graft loss is 3.14 (1.1–8.9). Of PRT 85.76%, out of PRT 85.76%, while out of TRT 60% live with a functioning graft, p=0.00149. Conclusion In a third transplant, both graft and patient survival are significantly inferior to primer ones. Careful selection is required to minimize the patient risk and graft loss.
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Affiliation(s)
- Gábor Telkes
- Department of Transplantation and Surgery, Semmelweis University, VIII. Baross u. 23, Budapest, H-1082, Hungary.
| | - László Piros
- Department of Transplantation and Surgery, Semmelweis University, VIII. Baross u. 23, Budapest, H-1082, Hungary
| | - József Szabó
- Department of Transplantation and Surgery, Semmelweis University, VIII. Baross u. 23, Budapest, H-1082, Hungary
| | - Gergely Huszty
- Department of Transplantation and Surgery, Semmelweis University, VIII. Baross u. 23, Budapest, H-1082, Hungary
| | - Katalin Eitler
- Department of Transplantation and Surgery, Semmelweis University, VIII. Baross u. 23, Budapest, H-1082, Hungary
| | - László Kóbori
- Department of Transplantation and Surgery, Semmelweis University, VIII. Baross u. 23, Budapest, H-1082, Hungary
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Urinary vitronectin identifies patients with high levels of fibrosis in kidney grafts. J Nephrol 2020; 34:861-874. [PMID: 33275196 PMCID: PMC8192319 DOI: 10.1007/s40620-020-00886-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 10/08/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND In kidney transplantation, fibrosis represents the final and irreversible consequence of the pathogenic mechanisms that lead to graft failure, and in the late stages it irremediably precedes the loss of renal function. The invasiveness of kidney biopsy prevents this condition from being frequently monitored, while clinical data are rather unspecific. The objective of this study was to find noninvasive biomarkers of kidney rejection. METHODS We carried out proteomic analysis of the urinary Extracellular Vesicles (uEVs) from a cohort of kidney transplant recipients (n = 23) classified according to their biopsy-based diagnosis and clinical parameters as interstitial fibrosis and tubular atrophy (IFTA), acute cellular rejection (ACR), calcineurin inhibitors toxicity (CNIT) and normal kidney function (NKF). RESULTS Shotgun mass spectrometry of uEV-proteins identified differential expression of several proteins among these different groups. Up to 23 of these proteins were re-evaluated using targeted proteomics in a new independent cohort of patients (n = 41) classified in the same diagnostic groups. Among other results, we found a differential expression of vitronectin (VTN) in patients displaying chronic interstitial and tubular lesions (ci and ct mean > 2 according to Banff criteria). These results were further confirmed by a pilot study using enzyme-linked immunosorbent assay (ELISA). CONCLUSION Urinary vitronectin levels are a potential stand-alone biomarker to monitor fibrotic changes in kidney transplant recipients in a non-invasive fashion.
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36
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Post A, Said MY, Gomes-Neto AW, Minović I, Groothof D, Swarte JC, Boer T, Kema IP, Heiner-Fokkema MR, Franssen CFM, Bakker SJL. Urinary 3-hydroxyisovaleryl carnitine excretion, protein energy malnutrition and risk of all-cause mortality in kidney transplant recipients: Results from the TransplantLines cohort studies. Clin Nutr 2020; 40:2109-2120. [PMID: 33071013 DOI: 10.1016/j.clnu.2020.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 08/17/2020] [Accepted: 09/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Leucine is an essential amino acid and a potent stimulator of muscle protein synthesis. Since muscle wasting is a major risk factor for mortality in kidney transplant recipients (KTR), dietary leucine intake might be linked to long-term mortality. Urinary 3-hydroxyisovaleryl carnitine (3-HIC) excretion, a functional marker of marginal biotin deficiency, may also serve as a marker for dietary leucine intake. OBJECTIVE In this study we aimed to investigate the cross-sectional determinants of urinary 3-HIC excretion and to prospectively investigate the association of urinary 3-HIC excretion with all-cause mortality in KTR. DESIGN Urinary 3-HIC excretion and plasma biotin were measured in a longitudinal cohort of 694 stable KTR. Cross-sectional and prospective analyses were performed using ordinary least squares linear regression analyses and Cox regression analyses, respectively. RESULTS In KTR (57% male, 53 ± 13 years, estimated glomerular filtration rate 45 ± 19 mL/min/1.73 m2), urinary 3-HIC excretion (0.80 [0.57-1.16] μmol/24 h) was significantly associated with plasma biotin (std. β = -0.17; P < 0.001). Subsequent adjustment for potential covariates revealed urinary creatinine excretion (std. β = 0.24; P < 0.001) and urinary urea excretion (std. β = 0.53; P < 0.001) as the primary determinant of urinary 3-HIC excretion. Whereas plasma biotin explained only 1% of the variance in urinary 3-HIC excretion, urinary urea excretion explained >45%. During median follow-up for 5.4 [4.8-6.1] years, 150 (22%) patients died. Log2-transformed urinary 3-HIC excretion was inversely associated with all-cause mortality (HR: 0.52 [0.43-0.63]; P < 0.001). This association was independent of potential confounders. CONCLUSIONS Urinary 3-HIC excretion more strongly serves as a marker of leucine intake than of biotin status. A higher urinary 3-HIC excretion is associated with a lower risk of all-cause mortality. Future studies are warranted to explore the underlying mechanism. TRIAL REGISTRATION ID NCT02811835. TRIAL REGISTRATION URL: https://clinicaltrials.gov/ct2/show/NCT02811835.
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Affiliation(s)
- Adrian Post
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, 9713 GZ, Groningen, the Netherlands.
| | - M Yusof Said
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, 9713 GZ, Groningen, the Netherlands.
| | - Antonio W Gomes-Neto
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, 9713 GZ, Groningen, the Netherlands.
| | - Isidor Minović
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - Dion Groothof
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, 9713 GZ, Groningen, the Netherlands.
| | - J Casper Swarte
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, 9713 GZ, Groningen, the Netherlands.
| | - Theo Boer
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - Ido P Kema
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - M Rebecca Heiner-Fokkema
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - Casper F M Franssen
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, 9713 GZ, Groningen, the Netherlands.
| | - Stephan J L Bakker
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, 9713 GZ, Groningen, the Netherlands.
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Ying T, Shi B, Kelly PJ, Pilmore H, Clayton PA, Chadban SJ. Death after Kidney Transplantation: An Analysis by Era and Time Post-Transplant. J Am Soc Nephrol 2020; 31:2887-2899. [PMID: 32908001 DOI: 10.1681/asn.2020050566] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/25/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Mortality risk after kidney transplantation can vary significantly during the post-transplant course. A contemporary assessment of trends in all-cause and cause-specific mortality at different periods post-transplant is required to better inform patients, clinicians, researchers, and policy makers. METHODS We included all first kidney-only transplant recipients from 1980 through 2018 from the Australia and New Zealand Dialysis and Transplant Registry. We compared adjusted death rates per 5-year intervals, using a piecewise exponential survival model, stratified by time post-transplant or time post-graft failure. RESULTS Of 23,210 recipients, 4765 died with a functioning graft. Risk of death declined over successive eras, at all periods post-transplant. Reductions in early deaths were most marked; however, recipients ≥10 years post-transplant were 20% less likely to die in the current era compared with preceding eras (2015-2018 versus 2005-2009, adjusted hazard ratio, 0.80; 95% confidence interval, 0.69 to 0.90). In 2015-2018, cardiovascular disease was the most common cause of death, particularly in months 0-3 post-transplant (1.18 per 100 patient-years). Cancer deaths were rare early post-transplant, but frequent at later time points (0.93 per 100 patient-years ≥10 years post-transplant). Among 3657 patients with first graft loss, 2472 died and were not retransplanted. Death was common in the first year after graft failure, and the cause was most commonly cardiovascular (50%). CONCLUSIONS Reductions in death early and late post-transplant over the past 40 years represent a major achievement. Reductions in cause-specific mortality at all time points post-transplant are also apparent. However, relatively greater reductions in cardiovascular death have increased the prominence of late cancer deaths.
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Affiliation(s)
- Tracey Ying
- Renal Medicine, Kidney Centre, Royal Prince Alfred Hospital, Camperdown, Australia .,Kidney Node, Charles Perkins Centre, The University of Sydney, Sydney, Australia.,Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Bree Shi
- Renal Medicine, Kidney Centre, Royal Prince Alfred Hospital, Camperdown, Australia .,Kidney Node, Charles Perkins Centre, The University of Sydney, Sydney, Australia.,Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Patrick J Kelly
- School of Public Health, The University of Sydney, Sydney, Australia
| | - Helen Pilmore
- Renal Department, Auckland City Hospital, Auckland, New Zealand
| | - Philip A Clayton
- Renal Medicine, Kidney Centre, Royal Prince Alfred Hospital, Camperdown, Australia.,Kidney Node, Charles Perkins Centre, The University of Sydney, Sydney, Australia.,Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, Adelaide, Australia.,Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Steven J Chadban
- Renal Medicine, Kidney Centre, Royal Prince Alfred Hospital, Camperdown, Australia.,Kidney Node, Charles Perkins Centre, The University of Sydney, Sydney, Australia.,Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
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Alfieri CM, Mattinzoli D, Ikehata M, Cresseri D, Moroni G, Vaira V, Ferri G, Ferrero S, Messa P. Laser capture microdissection on formalin-fixed and paraffin-embedded renal transplanted biopsies: Technical perspectives for clinical practice application. Exp Mol Pathol 2020; 116:104516. [PMID: 32853636 DOI: 10.1016/j.yexmp.2020.104516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 04/22/2020] [Accepted: 08/03/2020] [Indexed: 11/30/2022]
Abstract
Renal biopsy (RBx) is an essential tool in the diagnostic and therapeutic process of most native kidney diseases and in the renal transplanted graft. Laser capture microdissection (LCM), combined with molecular biology, might improve the diagnostic power of RBx. However, the limited amount of available renal tissue is often an obstacle for achieving a satisfactory qualitative and quantitative analysis. In our work we present a method which allows us to obtain good quality and quantity of RNA from formalin-fixed and paraffin-embedded (FFPE) renal tissue derived from RBx performed in transplanted patients. Histology, immunohistochemistry, LCM, pre-amplify system and qRT-PCR of biomarkers related to tubular damage, inflammation and fibrosis on FFPE RBx were performed. Glomeruli, tubules and interstitium of three RBx (RB-A: no alteration; RB-B and -C: the progressive rise of creatinine) were compared. The method proposed, could well be useful in future clinical practice. It is quick, easy to perform and allows the analyses of many biomarkers. In addition, it could be extended to all types of RBx without any limitation on the sample amount. Nevertheless, the need for a higher number of well-trained technicians might represent some limitation, counterbalanced by the opportunity to elaborate more accurate diagnosis and, consequently, more targeted therapies.
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Affiliation(s)
- Carlo Maria Alfieri
- Renal Research Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Unit of Nephrology, Dialysis and Renal Transplant, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Deborah Mattinzoli
- Renal Research Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Masami Ikehata
- Renal Research Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Donata Cresseri
- Unit of Nephrology, Dialysis and Renal Transplant, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gabriella Moroni
- Unit of Nephrology, Dialysis and Renal Transplant, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valentina Vaira
- Department of Pathophysiology and Transplantation, University of Milan, Divisions of Pathology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Ferri
- Renal Research Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Ferrero
- Department of Pathophysiology and Transplantation, University of Milan, Divisions of Pathology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Piergiorgio Messa
- Renal Research Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Unit of Nephrology, Dialysis and Renal Transplant, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
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Noguchi H, Tsuchimoto A, Ueki K, Kaku K, Okabe Y, Nakamura M. Reduced Recurrence of Primary IgA Nephropathy in Kidney Transplant Recipients Receiving Everolimus With Corticosteroid: A Retrospective, Single-Center Study of 135 Transplant Patients. Transplant Proc 2020; 52:3118-3124. [PMID: 32600641 DOI: 10.1016/j.transproceed.2020.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/27/2020] [Accepted: 05/12/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Long-term kidney allograft survival remains a major clinical challenge. Recurrent glomerulonephritis disease, including recurrence of IgA nephropathy (IgAN), is a significant barrier to long-term kidney allograft survival. We performed a retrospective, observational study to evaluate the role of everolimus (EVR) in the risk of recurrent IgAN. METHODS The study included data from 135 patients aged ≥16 years with biopsy-proven IgAN on native kidneys who underwent a kidney transplant (KT) between December 2002 and December 2018. RESULTS Patients who underwent de novo KT received mycophenolate mofetil (MMF) (n = 107) or EVR (n = 28). The mean recipient age in the MMF and EVR groups was 44.9 ± 13.7 and 41.1 ± 10.1, respectively. The median (interquartile range) follow-up period was 90.9 (64.9-115.3) and 21.2 (11.4-30.6) months, respectively (< .0001). All patients received continuous corticosteroid and tacrolimus therapy. The death-censored graft survival rate after KT and the recurrence-free survival rate did not differ significantly between the groups. Univariate and multivariate Cox regression analyses identified EVR for de novo KT as an independent predictive factor for recurrence-free survival (P = .024). CONCLUSIONS Our findings suggest that EVR-based regimens with tacrolimus and corticosteroid therapy for de novo KT reduce the recurrence of IgAN compared with MMF-based regimens with tacrolimus and corticosteroid therapy.
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Affiliation(s)
- Hiroshi Noguchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akihiro Tsuchimoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenji Ueki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keizo Kaku
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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40
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Mengozzi A, Tricò D, Natali A. A novel method for interpreting survival analysis data: description and test on three major clinical trials on cardiovascular prevention. Trials 2020; 21:578. [PMID: 32586346 PMCID: PMC7318394 DOI: 10.1186/s13063-020-04511-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 06/15/2020] [Indexed: 01/13/2023] Open
Abstract
Background Major results of randomized clinical trials on cardiovascular prevention are currently provided in terms of relative or absolute risk reductions, including also the number needed to treat (NNT), incorrectly implying that a treatment might prevent the occurrence of the outcome/s under investigation. Provided that these results are based on survival analysis, the primary measure of which is time-to-the outcome and not the outcome itself, we sought an alternative method to describe, analyse and interpret clinical trial results consistent with this assumption, so as to better define qualitative and quantitative heterogeneity of various therapeutic strategies in terms of their effects and costs. Methods The original Kaplan-Meier graphs of three major positive cardiovascular prevention trials (PROVE-IT, LIFE and HOPE) were captured from the PDF images of the article and then digitalized. We calculated the difference between the placebo and active treatment curves and plotted it as a function of time to describe the event-free time gain (Time-Gain) produced by the active treatment. By calculating the exposure to the active treatment in terms of months (MoT) as a function of time and dividing it for the corresponding time-dependent number of event-free years gained (i.e. months/12), we described the kinetics of the pharmaco-economic index MoT/y+. The same procedure was repeated replacing MoT with the actual number of patients being treated at each time point as a function of time to obtain the NNT to gain 1 event-free year (NNT/y+) curve. Results The Time-Gain curves depict the kinetics of the treatment-related effect over time and possess the peculiar feature of being smooth and accurately fitted by second-order polynomial functions (a*time2 + b*time); similarly, also the MoT/y+ and NNT/y+ curves can be accurately fitted by power functions (a*timeb). These curves and indices allow to fully appreciate the quantitative and qualitative heterogeneity, both in terms of effects and costs, of the different therapeutic strategies adopted in the three trials. Conclusions With our novel method, by exploiting original Kaplan-Meier curves from three major clinical trials on cardiovascular prevention, we generate new information on the actual consequences of choosing a therapeutic strategy vs another, thus ultimately providing the clinical gain in terms of time-dependent functions. Accurately assessing clinically and economic meaningful results from any intervention trial reporting positive results through this approach, facilitates objective comparisons and increases reliability in predicting survival among the various therapeutic options provided. Trial registration PROVE-IT (Pravastatin or Atorvastatin Evaluation and Infection Therapy (TIMI22), Clinical trial registration number: NCT00382460, date of registration: September 29, 2006, study start date: November 2000). LIFE (Losartan Intervention For Endpoint Reduction in Hypertension (LIFE) Study, Clinical trial registration number: NCT00338260, date of registration: June 20, 2006, study start date: June 1995). HOPE (Heart Outcomes Prevention Evaluation; we could not find Clinical trial registration number and date of registration).
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Affiliation(s)
- Alessandro Mengozzi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, Pisa, Italy.
| | - Domenico Tricò
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, Pisa, Italy.,Institute of Life Sciences, Sant'Anna School of Advanced Studies, Pisa, Italy
| | - Andrea Natali
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, Pisa, Italy
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41
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Kim BW, Kim SK, Heo KW, Bae KB, Jeong KH, Lee SH, Kim TH, Kim YH, Kang SW. Association between epidermal growth factor (EGF) and EGF receptor gene polymorphisms and end-stage renal disease and acute renal allograft rejection in a Korean population. Ren Fail 2020; 42:98-106. [PMID: 31906817 PMCID: PMC6968622 DOI: 10.1080/0886022x.2019.1710535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Purpose Epidermal growth factor (EGF) has been found to be associated with the development and repair mechanisms of several renal diseases. In this study, we hypothesized that single nucleotide polymorphisms (SNPs) in EGF or its receptor genes might have an association with end-stage renal disease (ESRD) or acute renal allograft rejection (AR) in a Korean population. Methods Three-hundred and forty seven recipients of the first renal transplants for ESRD, including 63 AR patients along with 289 healthy adults were included in the study. Five EGF gene SNPs (rs11568835, rs11568943, rs2237051, rs11569017, and rs3756261) and four EGFR gene SNPs (rs1140475, rs2293347, rs1050171, and rs6965469) were analyzed. The genotypes of these SNPs were analyzed using the AxiomTM genome-wide human assay. Statistical analysis was performed using SNPStats and Haploview version 4.2 software. Multiple logistic regression models (codominant, dominant, recessive, and Log-additive) were used to estimate the odds ratio (OR), 95% confidence interval (CI), and P value. Results One SNP (rs11569017) in the EGF gene showed significant association with ESRD but not with AR. Another SNP (rs11568835) in the EGF gene showed significant association with susceptibility to AR but not with ESRD. One SNP (rs1050171) in the EGFR gene showed significant association with susceptibility to AR but not with ESRD. Conclusion Our findings suggest that SNPs in the EGF and EGFR gene may be associated with the risk of ESRD and AR development in the Korean population.
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Affiliation(s)
- Byeong Woo Kim
- Department of Internal Medicine, Haeundae Bumin Hospital, Busan, Korea
| | - Su Kang Kim
- Kohwang Medical Research Institute, Kyung Hee University School of Medicine, Seoul, Korea
| | - Kyung Wook Heo
- Department of Otolaryngology, Inje University, Busan, Korea
| | - Ki Beom Bae
- Department of General Surgery, Inje University, Busan, Korea
| | - Kyung Hwan Jeong
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Korea
| | - Sang Ho Lee
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Korea
| | - Tae Hee Kim
- Division of Nephrology, Department of Internal Medicine, Inje University, Busan, Korea
| | - Yeong Hoon Kim
- Division of Nephrology, Department of Internal Medicine, Inje University, Busan, Korea
| | - Sun Woo Kang
- Division of Nephrology, Department of Internal Medicine, Inje University, Busan, Korea
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42
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Shaw BI, Cheng DK, Acharya CR, Ettenger RB, Lyerly HK, Cheng Q, Kirk AD, Chambers ET. An age-independent gene signature for monitoring acute rejection in kidney transplantation. Am J Cancer Res 2020; 10:6977-6986. [PMID: 32550916 PMCID: PMC7295062 DOI: 10.7150/thno.42110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/20/2020] [Indexed: 12/12/2022] Open
Abstract
Acute rejection (AR) remains a significant problem that negatively impacts long-term renal allograft survival. Numerous therapies are used to prevent AR that differ by center and recipient age. This variability confounds diagnostic methods. Methods: To develop an age-independent gene signature for AR effective across a broad array of immunosuppressive regimens, we compiled kidney transplant biopsy (n=1091) and peripheral blood (n=392) gene expression profiles from 12 independent public datasets. After removing genes differentially expressed in pediatric and adult patients, we compared gene expression profiles from biopsy and peripheral blood samples of patients with AR to those who were stable (STA), using Mann-Whitney U Tests with validation in independent testing datasets. We confirmed this signature in pediatric and adult patients (42 AR and 47 STA) from our institutional biorepository. Results: We identified a novel age-independent gene network that identified AR from both kidney and blood samples. We developed a 90-probe set signature targeting 76 genes that differentiated AR from STA and found an 8 gene subset (DIP2C, ENOSF1, FBXO21, KCTD6, PDXDC1, REXO2, HLA-E, and RAB31) that was associated with AR. Conclusion: We used publicly available datasets to create a gene signature of AR that identified AR irrespective of immunosuppression regimen or recipient age. This study highlights a novel model to screen and validate biomarkers across multiple treatment regimens.
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43
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Genome-wide non-HLA donor-recipient genetic differences influence renal allograft survival via early allograft fibrosis. Kidney Int 2020; 98:758-768. [PMID: 32454123 DOI: 10.1016/j.kint.2020.04.039] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 03/22/2020] [Accepted: 04/02/2020] [Indexed: 12/16/2022]
Abstract
Donor-recipient (D-R) differences at human leukocyte antigen (HLA) loci are currently incorporated into organ sharing, allocation and immunosuppression decisions. However, while acute rejection episodes have substantially diminished, progressive histologic damage occurs in allografts and improved long-term survival remains an unrealized goal among kidney recipients. Here we tested the hypothesis that non-HLA dependent, genome-wide D-R genetic differences could contribute to unchecked alloimmunity with histologic and functional consequences, culminating in long-term allograft failure. Genome-wide single nucleotide polymorphism (SNP) array data, excluding the HLA region, was utilized from 385 transplants to study the role of D-R differences upon serial histology and allograft survival. ADMIXTURE analysis was performed to quantitatively estimate ancestry in each D-R pair and PLINK was used to estimate the proportion of genome-shared identity-by-descent (pIBD) between D-R pairs. Subsequently, quantitative measures of recipient ancestry based on non-HLA SNPs was associated with death-censored allograft survival in adjusted Cox models. In D-R pairs of similar ancestry, pIBD was significantly associated with allograft survival independent of HLA mismatches in 224 transplants. Surprisingly, pIBD and recipient ancestry were not associated with clinical or subclinical rejection at any time post-transplant. Significantly, in multivariable analysis, pIBD inversely correlated with vascular intimal fibrosis in 160 biopsies obtained less than one year which in turn was significantly associated with allograft survival. Thus, our novel data show that non-HLA D-R differences associate with early vascular intimal fibrosis and allograft survival.
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44
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Lee KW. Mechanisms and clinical applications of immunosuppressive medications. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2020. [DOI: 10.5124/jkma.2020.63.5.251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Immunosuppressive medications and regimens have evolved with significant advancements in the understanding of the immunologic process after solid organ transplantation. Medications can block the communication between antigen-presenting cells and T-cells, the activation and proliferation of T-cells, antibody production by plasma cells, and the activation of the complement system by antibodies. T-cell depleting antibodies and interleukin-2 receptor blockers are commonly used during induction therapy. Calcineurin inhibitors, antimetabolites, antiproliferative agents, and corticosteroids are commonly used in maintenance therapy regimens. These medications decrease the rates of rejection episodes and markedly increase the survival rates of short-term grafts. However, in terms of the survival rate of long-term grafts, there is still room for improvement. Opportunistic infections, development of cancer, metabolic diseases, and calcineurin inhibitor toxicity are hurdles in the improvement in survival rates of long-term grafts. Therefore, many efforts are being taken to overcome these hurdles, such as the development of new drugs, individualization of immunosuppression, and induction of immune tolerance.
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45
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Sussell J, Silverstein AR, Goutam P, Incerti D, Kee R, Chen CX, Batty DS, Jansen JP, Kasiske BL. The economic burden of kidney graft failure in the United States. Am J Transplant 2020; 20:1323-1333. [PMID: 32020739 DOI: 10.1111/ajt.15750] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 11/13/2019] [Accepted: 12/04/2019] [Indexed: 01/25/2023]
Abstract
Despite improvements in outcomes for kidney transplant recipients in the past decade, graft failure continues to impose substantial burden on patients. However, the population-wide economic burden of graft failure has not been quantified. This study aims to fill that gap by comparing outcomes from a simulation model of kidney transplant patients in which patients are at risk for graft failure with an alternative simulation in which the risk of graft failure is assumed to be zero. Transitions through the model were estimated using Scientific Registry of Transplant Recipients data from 1987 to 2017. We estimated lifetime costs, overall survival, and quality-adjusted life-years (QALYs) for both scenarios and calculated the difference between them to obtain the burden of graft failure. We find that for the average patient, graft failure will impose additional medical costs of $78 079 (95% confidence interval [CI] $41 074, $112 409) and a loss of 1.66 QALYs (95% CI 1.15, 2.18). Given 17 644 kidney transplants in 2017, the total incremental lifetime medical costs associated with graft failure is $1.38B (95% CI $725M, $1.98B) and the total QALY loss is 29 289 (95% CI 20 291, 38 464). Efforts to reduce the incidence of graft failure or to mitigate its impact are urgently needed.
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Affiliation(s)
| | | | | | | | - Rebecca Kee
- Precision Health Economics, Los Angeles, California
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46
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Fan P, Zhang W, Liu Y. CYC1, SDHA, UQCRC1, UQCRQ, and SDHB might be important biomarkers in kidney transplant rejection. Clin Chim Acta 2020; 507:132-138. [PMID: 32302684 DOI: 10.1016/j.cca.2020.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/08/2020] [Accepted: 04/11/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Kidney transplant rejection is considered as a vital factor of kidney transplant failure. Therefore, it's necessary to search for effective biomarkers for kidney transplant surveillance. METHODS In this study, we conducted time-series gene expression profiles analysis of samples from kidney transplant patients with different post-transplant days through weighted gene co-expression network analysis (WGCNA). Associations between gene co-expression modules and days post-transplant were determined through spearman rank correlation analysis. Potential kidney transplant rejection-related modules were subjected to gene functional enrichment analysis through clusterProfiler and protein-protein interaction analysis via STRING database. RESULTS A total of 11 gene co-expression modules were identified, and the pink module which was mainly involved in "energy derivation by oxidation of organic compounds" and "Huntington disease" showed significant correlation with the phenotypic trait "days post-transplant". CYC1, SDHA, UQCRC1, UQCRQ, and SDHB in the pink module exhibited high scores in the protein-protein interaction network analysis. CONCLUSIONS We reported several potential genes may be associated with the kidney transplant rejection, which should provide novel biomarkers for kidney transplant surveillance.
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Affiliation(s)
- Pengfei Fan
- Organ Transplant Center, Tianjin First Central Hospital, Tianjin 300192, China
| | - Weiye Zhang
- Organ Transplant Center, Tianjin First Central Hospital, Tianjin 300192, China.
| | - Yi Liu
- Department of Critical Care Medicine, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300380, China
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47
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Lee EJ, Jeon J, Lee KW, Yoo H, Jang HR, Park JB, Lee JE, Kim K, Huh W. The combination of area under the curve and percentage change in estimated glomerular filtration rate predicts long-term outcome of kidney transplants. Am J Transplant 2020; 20:1056-1062. [PMID: 31733034 DOI: 10.1111/ajt.15711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/04/2019] [Accepted: 11/10/2019] [Indexed: 01/25/2023]
Abstract
The development of surrogate markers for long-term outcomes of kidney transplant (KT) is a focus of attention. We examined the possibility of using a combination of the area under the curve of estimated glomerular filtration rate (eGFR) for 2 years (AUCeGFR2yrs ) and percent change in eGFR between 1 and 2 years after KT (% changeeGFR1/2yr ) as a surrogate marker. We compared the predictive power of death-censored graft failure with various combinations. The combination of >2% vs ≤2% for % changeeGFR1/2yr and >1300 vs ≤1300 mL/min/month for AUCeGFR2yr had the highest Harrell C-index (0.647; 95% confidence interval [95% CI], 0.604-0.690). The death-censored graft survival rate of the group with ≤2% changeeGFR1/2yr and ≤1300 mL/min/month AUCeGFR2yr was significantly lower than those of other groups. The AUC/% change eGFR had comparable predictive power to the previously identified marker ≥30% decline in eGFR between years 1 and 3 after KT (≤-30% changeeGFR1/3yr ) (Harrell's C-index = 0.645 [95% CI 0.628-0.662] for ≤-30% changeeGFR1/3yr ). The proposed combination might be useful as a surrogate marker in KT trials because it requires a shorter surveillance period than the established marker while having comparable predictive power.
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Affiliation(s)
- Eun Jeong Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Junseok Jeon
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyo Won Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Heejin Yoo
- Statistics and Data Center, Samsung Medical Center, Research Institute for Future Medicine, Seoul, Korea
| | - Hye Ryoun Jang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Berm Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Eun Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyunga Kim
- Statistics and Data Center, Samsung Medical Center, Research Institute for Future Medicine, Seoul, Korea
| | - Wooseong Huh
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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48
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Farouk S, Zhang Z, Menon MC. Non-HLA donor-recipient mismatches in kidney transplantation-A stone left unturned. Am J Transplant 2020; 20:19-24. [PMID: 31550409 PMCID: PMC7898079 DOI: 10.1111/ajt.15612] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 08/28/2019] [Accepted: 09/17/2019] [Indexed: 01/25/2023]
Abstract
In kidney transplantation, short-term allograft survival has improved due to improvements in acute rejection episodes without corresponding improvements in long-term survival. Although current organ allocation algorithms take into account human leukocyte antigen (HLA) matching to reduce antidonor alloimmune responses, it is likely that genomic variation at non-HLA loci (ie, non-HLA donor-recipient [D-R] pair mismatches) play a role in the "non-self" responses and ultimately affect long-term allograft survival. Existing data from both animal models and human studies suggest an association between non-HLA D-R mismatches and kidney allograft outcomes. In this minireview, we examine existing and emerging data and discuss putative mechanisms on the role of non-HLA D-R mismatches on long-term allograft outcomes in kidney transplantation.
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Affiliation(s)
- Samira Farouk
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, NY,Recanati-Miller transplant institute, Icahn School of Medicine at Mount Sinai, NY
| | - Zhongyang Zhang
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY,Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, NY
| | - Madhav C Menon
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, NY,Recanati-Miller transplant institute, Icahn School of Medicine at Mount Sinai, NY
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49
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Nafar M, Kalantari S, Samavat S, Omrani MD, Arsang-Jang S, Taheri M, Ghafouri-Fard S. Downregulation of Protein Inhibitor of Activated STAT (PIAS) 1 Is Possibly Involved in the Process of Allograft Rejection. Transplant Proc 2019; 52:414-418. [PMID: 31870601 DOI: 10.1016/j.transproceed.2019.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 10/11/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Protein inhibitors of activated STAT (PIAS) proteins are regarded as negative regulators of cytokine-signaling and potent immunosuppressive proteins. However, their role in the process of organ transplant rejection has not been elucidated. METHODS In the current study, we compared transcript levels of PIAS1 to 4 in the peripheral blood of renal transplant recipients who experienced transplant rejection with those having normal transplant functions. Expression of PIAS1 was significantly higher in nonrejected group compared with the rejected group among male recipients; however, differences were insignificant among female recipients. Expressions of other PIAS genes were not different between study groups. Significant pairwise correlations were found between expression levels of PIAS genes in all study subgroups. The current investigation highlights the role of PIAS1 downregulation in the evolution of graft rejection and potentiates this gene as a predictive marker for transplant fate.
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Affiliation(s)
- Mohsen Nafar
- Chronic Kidney Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shiva Kalantari
- Chronic Kidney Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shiva Samavat
- Chronic Kidney Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mir Davood Omrani
- Urology and Nephrology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shahram Arsang-Jang
- Clinical Research Development Center (CRDU), Qom University of Medical Sciences, Qom, Iran
| | - Mohammad Taheri
- Urogenital Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Soudeh Ghafouri-Fard
- Department of Medical Genetics, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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50
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Karimi M, Ahmadpoor P, Nafar M, Pourrezagholi F, Jamali S, Eteghadi A, Yekaninejad MS, Amirzargar AA. Frequency of dendritic cell subsets and ILT3, ILT4 gene expression in two different immunosuppressive protocols in kidney transplant recipients. A cohort report. Mol Biol Rep 2019; 47:123-128. [PMID: 31833032 DOI: 10.1007/s11033-019-05113-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 09/26/2019] [Indexed: 11/24/2022]
Abstract
Dendritic cells (DCs) have a major role in the initiation of an immune response and Immunoglobulin-like transcript 3&4 (ILT3&ILT4) are inhibitory receptors that induce tolerance in DCs. Recent studies show that immunosuppressive agents affect frequency of DCs. Herein, we compared the effect of mycophenolate mofetil (MMF) and sirolimus (SRL) in tacrolimus (TAC)-based immunosuppression on DC subsets frequency and ILT3/ILT4 gene expression in kidney transplant recipients. We enrolled 24 adult transplant recipients who received MMF/TAC (n = 14) or SRL/TAC (n = 10). Peripheral blood samples were obtained from recipients, 24-48 h before transplantation and 4 months after transplantation. The frequency of DC subsets was analyzed by flow cytometry and gene expression of ILT3/ILT4 were estimated by real-time PCR. Our results showed that MMF vs. SRL treated recipient showed an increase in pDC % with increased in the expression of ILT3/ILT4 which is in favor of better allograft survival; However, for confirming the results of this preliminary study, a cohort study with larger sample size is necessary.
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Affiliation(s)
- Mozhdeh Karimi
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.,Molecular Immunology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Pedram Ahmadpoor
- Chronic Kidney Disease Research Center, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Nafar
- Chronic Kidney Disease Research Center, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Pourrezagholi
- Chronic Kidney Disease Research Center, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeideh Jamali
- Molecular Immunology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Atefeh Eteghadi
- Molecular Immunology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mir Saeed Yekaninejad
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Akbar Amirzargar
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. .,Molecular Immunology Research Center, Tehran University of Medical Sciences, Tehran, Iran.
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