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Yoo D, Divard G, Raynaud M, Cohen A, Mone TD, Rosenthal JT, Bentall AJ, Stegall MD, Naesens M, Zhang H, Wang C, Gueguen J, Kamar N, Bouquegneau A, Batal I, Coley SM, Gill JS, Oppenheimer F, De Sousa-Amorim E, Kuypers DRJ, Durrbach A, Seron D, Rabant M, Van Huyen JPD, Campbell P, Shojai S, Mengel M, Bestard O, Basic-Jukic N, Jurić I, Boor P, Cornell LD, Alexander MP, Toby Coates P, Legendre C, Reese PP, Lefaucheur C, Aubert O, Loupy A. A Machine Learning-Driven Virtual Biopsy System For Kidney Transplant Patients. Nat Commun 2024; 15:554. [PMID: 38228634 DOI: 10.1038/s41467-023-44595-z] [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: 06/26/2023] [Accepted: 12/21/2023] [Indexed: 01/18/2024] Open
Abstract
In kidney transplantation, day-zero biopsies are used to assess organ quality and discriminate between donor-inherited lesions and those acquired post-transplantation. However, many centers do not perform such biopsies since they are invasive, costly and may delay the transplant procedure. We aim to generate a non-invasive virtual biopsy system using routinely collected donor parameters. Using 14,032 day-zero kidney biopsies from 17 international centers, we develop a virtual biopsy system. 11 basic donor parameters are used to predict four Banff kidney lesions: arteriosclerosis, arteriolar hyalinosis, interstitial fibrosis and tubular atrophy, and the percentage of renal sclerotic glomeruli. Six machine learning models are aggregated into an ensemble model. The virtual biopsy system shows good performance in the internal and external validation sets. We confirm the generalizability of the system in various scenarios. This system could assist physicians in assessing organ quality, optimizing allograft allocation together with discriminating between donor derived and acquired lesions post-transplantation.
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Affiliation(s)
- Daniel Yoo
- Université Paris Cité, INSERM U970 PARCC, Paris Institute for Transplantation and Organ Regeneration, F-75015, Paris, France
| | - Gillian Divard
- Université Paris Cité, INSERM U970 PARCC, Paris Institute for Transplantation and Organ Regeneration, F-75015, Paris, France
- Kidney Transplant Department, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Marc Raynaud
- Université Paris Cité, INSERM U970 PARCC, Paris Institute for Transplantation and Organ Regeneration, F-75015, Paris, France
| | | | | | | | - Andrew J Bentall
- Division of Nephrology and Hypertension, Mayo Clinic Transplant Center, Rochester, MN, USA
| | | | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Huanxi Zhang
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Changxi Wang
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Juliette Gueguen
- Néphrologie-Immunologie Clinique, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Paul Sabatier University, INSERM, Toulouse, France
| | - Antoine Bouquegneau
- Department of Nephrology-Dialysis-Transplantation, Centre hospitalier universitaire de Liège, Liège, Belgium
| | - Ibrahim Batal
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, USA
| | - Shana M Coley
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, USA
| | - John S Gill
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Federico Oppenheimer
- Kidney Transplant Department, Hospital Clínic i Provincial de Barcelona, Barcelona, Spain
| | - Erika De Sousa-Amorim
- Kidney Transplant Department, Hospital Clínic i Provincial de Barcelona, Barcelona, Spain
| | - Dirk R J Kuypers
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Antoine Durrbach
- Department of Nephrology, AP-HP Hôpital Henri Mondor, Créteil, Île de France, France
| | - Daniel Seron
- Nephrology Department, Hospital Vall d'Hebrón, Autonomous University of Barcelona, Barcelona, Spain
| | - Marion Rabant
- Department of Pathology, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Jean-Paul Duong Van Huyen
- Université Paris Cité, INSERM U970 PARCC, Paris Institute for Transplantation and Organ Regeneration, F-75015, Paris, France
- Department of Pathology, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Patricia Campbell
- Faculty of Medicine & Dentistry - Laboratory Medicine & Pathology Dept, University of Alberta, Edmonton, AB, Canada
| | - Soroush Shojai
- Faculty of Medicine & Dentistry - Laboratory Medicine & Pathology Dept, University of Alberta, Edmonton, AB, Canada
| | - Michael Mengel
- Faculty of Medicine & Dentistry - Laboratory Medicine & Pathology Dept, University of Alberta, Edmonton, AB, Canada
| | - Oriol Bestard
- Nephrology Department, Hospital Vall d'Hebrón, Autonomous University of Barcelona, Barcelona, Spain
| | - Nikolina Basic-Jukic
- Department of nephrology, arterial hypertension, dialysis and transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Ivana Jurić
- Department of nephrology, arterial hypertension, dialysis and transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Peter Boor
- Institute of Pathology, RWTH Aachen University Hospital, Aachen, Germany
| | - Lynn D Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Mariam P Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - P Toby Coates
- Department of Renal and Transplantation, University of Adelaide, Royal Adelaide Hospital Campus, Adelaide, SA, Australia
| | - Christophe Legendre
- Université Paris Cité, INSERM U970 PARCC, Paris Institute for Transplantation and Organ Regeneration, F-75015, Paris, France
- Department of Kidney Transplantation, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Peter P Reese
- Université Paris Cité, INSERM U970 PARCC, Paris Institute for Transplantation and Organ Regeneration, F-75015, Paris, France
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadephia, PA, USA
| | - Carmen Lefaucheur
- Université Paris Cité, INSERM U970 PARCC, Paris Institute for Transplantation and Organ Regeneration, F-75015, Paris, France
- Kidney Transplant Department, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Olivier Aubert
- Université Paris Cité, INSERM U970 PARCC, Paris Institute for Transplantation and Organ Regeneration, F-75015, Paris, France
- Department of Kidney Transplantation, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Alexandre Loupy
- Université Paris Cité, INSERM U970 PARCC, Paris Institute for Transplantation and Organ Regeneration, F-75015, Paris, France.
- Department of Kidney Transplantation, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.
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Sedej I, Štalekar M, Tušek Žnidarič M, Goričar K, Kojc N, Kogovšek P, Dolžan V, Arnol M, Lenassi M. Extracellular vesicle-bound DNA in urine is indicative of kidney allograft injury. J Extracell Vesicles 2022; 11:e12268. [PMID: 36149031 PMCID: PMC9503341 DOI: 10.1002/jev2.12268] [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: 04/06/2022] [Revised: 07/29/2022] [Accepted: 09/09/2022] [Indexed: 11/11/2022] Open
Abstract
Extracellular vesicle‐bound DNA (evDNA) is an understudied extracellular vesicle (EV) cargo, particularly in cancer‐unrelated research. Although evDNA has been detected in urine, little is known about its characteristics, localization, and biomarker potential for kidney pathologies. To address this, we enriched EVs from urine of well‐characterized kidney transplant recipients undergoing allograft biopsy, characterized their evDNA and its association to allograft injury. The SEC‐based method enriched pure EVs from urine of kidney transplant recipients, regardless of the allograft injury. Urinary evDNA represented up to 29.2 ± 8% (mean ± SD) of cell‐free DNA (cfDNA) and correlated with cfDNA in several characteristics but was less fragmented (P < 0.001). Importantly, using DNase treatment and immunogold labelling TEM, we demonstrated that evDNA was bound to the surface of urinary EVs. Normalised evDNA yield (P = 0.042) and evDNA copy number (P = 0.027) significantly differed between patients with normal histology, rejection injury and non‐rejection injury, the later groups having significantly larger uEVs (mean diameter, P = 0.045) and more DNA bound per uEV. ddDNA is detectable in uEV samples of kidney allograft recipients, but its quantity is highly variable. In a proof‐of‐principle study, several evDNA characteristics correlated with clinical and histological parameters (P = 0.040), supporting that the potential of evDNA as a biomarker for kidney allograft injury should be further investigated.
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Affiliation(s)
- Ivana Sedej
- Department of Nephrology, Division of Internal Medicine, University Medical Center Ljubljana, Ljubljana, Slovenia.,Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Maja Štalekar
- Department of Biotechnology and Systems Biology, National Institute of Biology, Ljubljana, Slovenia
| | - Magda Tušek Žnidarič
- Department of Biotechnology and Systems Biology, National Institute of Biology, Ljubljana, Slovenia
| | - Katja Goričar
- Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Nika Kojc
- Institute of Pathology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Polona Kogovšek
- Department of Biotechnology and Systems Biology, National Institute of Biology, Ljubljana, Slovenia
| | - Vita Dolžan
- Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Miha Arnol
- Department of Nephrology, Division of Internal Medicine, University Medical Center Ljubljana, Ljubljana, Slovenia.,Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Metka Lenassi
- Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Steggerda JA, Pizzo H, Garrison J, Zhang X, Haas M, Kim IK, Jordan SC, Puliyanda DP. Use of a donor-derived cell-free DNA assay to monitor treatment response in pediatric renal transplant recipients with allograft rejection. Pediatr Transplant 2022; 26:e14258. [PMID: 35340104 DOI: 10.1111/petr.14258] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/09/2022] [Accepted: 02/08/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Detection of donor-derived cell-free DNA (dd-cfDNA) reliably identifies allograft rejection in pediatric and adult kidney transplant (KT) recipients. Here, we evaluate the utility of dd-cfDNA for monitoring response to treatment among pediatric renal transplant recipients suffering graft rejection. METHODS 58 pediatric transplant recipients were enrolled between April 2018 and March 2020 and underwent initial dd-cfDNA testing to monitor for rejection. Allograft biopsy was performed for dd-cfDNA scores >1.0%. Patients with histologically proven rejection formed the study cohort and underwent appropriate treatment. Results of dd-cfDNA, serum creatinine (SCr), biopsy findings, and treatment outcomes were evaluated. Standard statistical analyses were applied. RESULTS Nineteen of 58 (31%) patients had dd-cfDNA score >1.0%, of which 18 (94.7%) had biopsy-proven rejection. Median dd-cfDNA value was 1.90% (interquartile range 1.43%-3.23%), and biopsy results showed 11 patients (61.1%) with antibody-mediated rejection (AMR), 2 patients (11.1%) with T-cell mediated rejection (TCMR), and 5 patients (27.7%) with mixed AMR/TCMR. SCr at time of biopsy was 1.28 ± 1.09 mg/dl. Following treatment, dd-cfDNA scores decreased for all types of rejection but still remained >1.0% in both AMR (1.50% [0.90%-3.10%]) and mixed (1.40% [0.95%-4.15%]) groups. Repeat dd-cfDNA values were <1.0% for patients with TCMR (0.20%-0.28%). SCr showed minimal change from pre-treatment levels regardless of rejection subtype. CONCLUSIONS Patients with TCMR may be reliably followed by dd-cfDNA; however, it remains unclear whether persistently elevated dd-cfDNA levels in AMR is a reflection of ongoing subclinical rejection or an inherent limitation of the assay's utility.
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Affiliation(s)
- Justin A Steggerda
- Cedars Sinai Medical Center, Pediatric Nephrology, Los Angeles, California, USA
| | - Helen Pizzo
- Cedars Sinai Medical Center, Pediatric Nephrology, Los Angeles, California, USA
| | - Jonathan Garrison
- Cedars Sinai Medical Center, Pediatric Nephrology, Los Angeles, California, USA
| | - Xiaohai Zhang
- Cedars Sinai Medical Center, Pediatric Nephrology, Los Angeles, California, USA
| | - Mark Haas
- Cedars Sinai Medical Center, Pediatric Nephrology, Los Angeles, California, USA
| | - Irene K Kim
- Cedars Sinai Medical Center, Pediatric Nephrology, Los Angeles, California, USA
| | - Stanley C Jordan
- Cedars Sinai Medical Center, Pediatric Nephrology, Los Angeles, California, USA
| | - Dechu P Puliyanda
- Cedars Sinai Medical Center, Pediatric Nephrology, Los Angeles, California, USA
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Lim WH, Ooi E, Pilmore HL, Johnson DW, McDonald SP, Clayton P, Hawley C, Mulley WR, Francis R, Collins MG, Jaques B, Larkins NG, Davies CE, Wyburn K, Chadban SJ, Wong G. Interactions Between Donor Age and 12-Month Estimated Glomerular Filtration Rate on Allograft and Patient Outcomes After Kidney Transplantation. Transpl Int 2022; 35:10199. [PMID: 35185379 PMCID: PMC8842263 DOI: 10.3389/ti.2022.10199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/12/2022] [Indexed: 11/25/2022]
Abstract
Reduced estimated glomerular filtration rate (eGFR) at 12-months after kidney transplantation is associated with increased risk of allograft loss, but it is uncertain whether donor age and types modify this relationship. Using Australia and New Zealand registry data, multivariable Cox proportional modelling was used to examine the interactive effects between donor age, types and 12-month eGFR on overall allograft loss. We included 11,095 recipients (4,423 received live-donors). Recipients with lowest 12-month eGFR (<30 ml/min/1.73 m2) experienced the greatest risk of allograft loss, with adjusted HR [95% CI) of 2.65 [2.38–2.95] compared to eGFR of 30–60 ml/min/1.73 m2; whereas the adjusted HR for highest eGFR (>60 ml/min/1.73 m2) was 0.67 [0.62–0.74]. The association of 12-month eGFR and allograft loss was modified by donor age (but not donor types) where a higher risk of allograft loss in recipients with lower compared with higher 12-month eGFR being most pronounced in the younger donor age groups (p < 0.01). Recipients with eGFR <30 ml/min/1.73 m2 12-months after transplantation experienced ≥2.5-fold increased risk of overall allograft loss compared to those with eGFR of >60 ml/min/1.73 m2, and the magnitude of the increased risk is most marked among recipients with younger donors. Careful deliberation of other factors including donor age when considering eGFR as a surrogate for clinical endpoints is warranted.
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Affiliation(s)
- Wai H. Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
- Medical School, University of Western Australia, Perth, WA, Australia
- *Correspondence: Wai H. Lim,
| | - Esther Ooi
- Medical School, University of Western Australia, Perth, WA, Australia
- School of Biomedical Sciences, University of Western Australia, Perth, WA, Australia
| | - Helen L. Pilmore
- Department of Renal Medicine, Auckland City Hospital, Auckland, New Zealand
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - David W. Johnson
- Metro South Integrated Nephrology and Transplant Services, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- Faculty of Medicine, University of Queensland, St Lucia, QLD, Australia
- Translational Research Institute, Brisbane, QLD, Australia
| | - Stephen P. McDonald
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, SA, Australia
- Central and Northern Adelaide Renal and Transplantation Services, Adelaide, SA, Australia
- South Australia Health and Medical Research Institute, Adelaide, SA, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Philip Clayton
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, SA, Australia
- Central and Northern Adelaide Renal and Transplantation Services, Adelaide, SA, Australia
- South Australia Health and Medical Research Institute, Adelaide, SA, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Carmel Hawley
- Metro South Integrated Nephrology and Transplant Services, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- Faculty of Medicine, University of Queensland, St Lucia, QLD, Australia
- Translational Research Institute, Brisbane, QLD, Australia
| | - William R. Mulley
- Department of Nephrology, Monash Medical Centre, Melbourne, VIC, Australia
- Department of Medicine, Monash University, Melbourne, VIC, Australia
| | - Ross Francis
- Metro South Integrated Nephrology and Transplant Services, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- Faculty of Medicine, University of Queensland, St Lucia, QLD, Australia
| | - Michael G. Collins
- School of Biomedical Sciences, University of Western Australia, Perth, WA, Australia
- Department of Renal Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Bryon Jaques
- Western Australia Liver and Kidney Transplant Service, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Nicholas G. Larkins
- Medical School, University of Western Australia, Perth, WA, Australia
- Department of Nephrology, Perth Children’s Hospital, Perth, WA, Australia
| | - Christopher E. Davies
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, SA, Australia
- South Australia Health and Medical Research Institute, Adelaide, SA, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Kate Wyburn
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Renal Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Steve J. Chadban
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Renal Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Germaine Wong
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, NSW, Australia
- Department of Renal Medicine and National Pancreas Transplant Unit, Westmead Hospital, Sydney, NSW, Australia
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Protocol Biopsies on de novo Renal-Transplants at 3 Months after Surgery: Impact on 5-Year Transplant Survival. J Clin Med 2021; 10:jcm10163635. [PMID: 34441931 PMCID: PMC8397165 DOI: 10.3390/jcm10163635] [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: 07/19/2021] [Revised: 08/14/2021] [Accepted: 08/16/2021] [Indexed: 12/02/2022] Open
Abstract
Background: In many centers, a protocol kidney biopsy (PKB) is performed at 3 months post-transplantation (M3), without a demonstrated benefit on death-censored graft survival (DCGS). In this study, we compared DCGS between kidney transplant recipients undergoing a PKB or without such biopsy while accounting for the obvious indication bias. Methods: In this retrospective, single-center study conducted between 2007 and 2013, we compared DCGS with respect to the availability and features of a PKB. We built a propensity score (PS) to account for PKB indication likelihood and adjusted the DCGS analysis on PKB availability and the PS. Results: A total of 615 patients were included: 333 had a PKB, 282 did not. In bivariate Kaplan–Meier survival analysis, adjusting for the availability of a PKB and for the PS, a PKB was associated with a better 5-year DCGS independently of the PS (p < 0.001). Among the PKB+ patients, 87 recipients (26%) had IF/TA > 0. Patients with an IF/TA score of 3 had the worst survival. A total of 144 patients (44%) showed cv lesions. Patients with cv2 and cv3 lesions had the worst 5-year DCGS. Conclusions: A M3 PKB was associated with improved graft survival independently of potential confounders. These results could be explained by the early treatment of subclinical immunological events. It could be due to better management of the immunosuppressive regimen.
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Clinical Relevance of Corticosteroid Withdrawal on Graft Histological Lesions in Low-Immunological-Risk Kidney Transplant Patients. J Clin Med 2021; 10:jcm10092005. [PMID: 34067039 PMCID: PMC8125434 DOI: 10.3390/jcm10092005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/30/2021] [Accepted: 05/03/2021] [Indexed: 12/14/2022] Open
Abstract
The impact of corticosteroid withdrawal on medium-term graft histological changes in kidney transplant (KT) recipients under standard immunosuppression is uncertain. As part of an open-label, multicenter, prospective, phase IV, 24-month clinical trial (ClinicalTrials.gov, NCT02284464) in low-immunological-risk KT recipients, 105 patients were randomized, after a protocol-biopsy at 3 months, to corticosteroid continuation (CSC, n = 52) or corticosteroid withdrawal (CSW, n = 53). Both groups received tacrolimus and MMF and had another protocol-biopsy at 24 months. The acute rejection rate, including subclinical inflammation (SCI), was comparable between groups (21.2 vs. 24.5%). No patients developed dnDSA. Inflammatory and chronicity scores increased from 3 to 24 months in patients with, at baseline, no inflammation (NI) or SCI, regardless of treatment. CSW patients with SCI at 3 months had a significantly increased chronicity score at 24 months. HbA1c levels were lower in CSW patients (6.4 ± 1.2 vs. 5.7 ± 0.6%; p = 0.013) at 24 months, as was systolic blood pressure (134.2 ± 14.9 vs. 125.7 ± 15.3 mmHg; p = 0.016). Allograft function was comparable between groups and no patients died or lost their graft. An increase in chronicity scores at 2-years post-transplantation was observed in low-immunological-risk KT recipients with initial NI or SCI, but CSW may accelerate chronicity changes, especially in patients with early SCI. This strategy did, however, improve the cardiovascular profiles of patients.
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Yang X, Hou FL, Zhao C, Jiang CY, Li XM, Yu N. The role of real-time shear wave elastography in the diagnosis of idiopathic nephrotic syndrome and evaluation of the curative effect. Abdom Radiol (NY) 2020; 45:2508-2517. [PMID: 32107581 DOI: 10.1007/s00261-020-02460-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE To evaluate the use of real-time shear wave elastography (SWE) in the assessment of renal elasticity and the efficacy of steroid treatment in adult idiopathic nephrotic syndrome (INS). METHODS This study included 120 patients with INS. Patients were divided into steroid-sensitive and steroid-resistant groups. Renal biopsy was performed. Thirty healthy subjects were recruited as controls. Young's modulus (YM) of the renal parenchyma was measured by SWE. The YM values in each group were compared using glomerular sclerosis index (GI) and renal interstitial fibrosis (RIF). RESULTS The YM values were significantly different between the INS and control groups, as well as between the steroid-sensitive and steroid-resistant groups (P < 0.05). Higher YM values were associated with steroid sensitivity. The area under the receiver operating characteristic curve for the YM value in the INS group vs. control group was 0.871 (95% CI 0.815-0.927) and in the steroid-resistant group vs. control, and steroid-sensitive groups was 0.836 (95% CI 0.765-0.908). The corresponding cut-off values were 7.96 and 10.73 m/s, with 81.7% and 86.0% sensitivities, 93.3% and 77.9% specificities, and Youden index 0.750 and 0.639, respectively. Spearman correlation analysis showed that the YM value in the renal parenchyma was positively correlated with GI (r = 0.631, P < 0.05) and RIF (r = 0.606, P < 0.05). CONCLUSION SWE technology is a potential method for non-invasive quantitative measurement of renal parenchyma stiffness to determine the pathological changes of INS renal parenchyma and evaluate the effectiveness of steroid therapy.
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Affiliation(s)
- Xue Yang
- Department of Ultrasound, The Affiliated Hospital of Qingdao University, Qingdao, 266071, Shandong, China
| | - Fang-Lin Hou
- Department of Outpatient, The Qingdao Hiser Medical Center, Qingdao, 266071, Shandong, China
| | - Cheng Zhao
- Department of Ultrasound, The Affiliated Hospital of Qingdao University, Qingdao, 266071, Shandong, China
| | - Cai-Yun Jiang
- Department of Ultrasound, The Affiliated Hospital of Qingdao University, Qingdao, 266071, Shandong, China
| | - Xiu-Mei Li
- Department of Ultrasound, The Affiliated Hospital of Qingdao University, Qingdao, 266071, Shandong, China
| | - Ning Yu
- Department of Ultrasound, The Affiliated Hospital of Qingdao University, Qingdao, 266071, Shandong, China.
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Clinical Significance of Renal Allograft Protocol Biopsies: A Single Tertiary Center Experience in Malaysia. J Transplant 2019; 2019:9153875. [PMID: 31186948 PMCID: PMC6521333 DOI: 10.1155/2019/9153875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 02/15/2019] [Accepted: 03/17/2019] [Indexed: 11/18/2022] Open
Abstract
Background The role of protocol renal allograft biopsy in kidney transplantation is controversial due to the concern with procedural-related complications; however, its role is slowly evolving. Recent evidence suggests that protocol biopsy is useful in detecting subclinical renal pathology. Early recognition and treatment of renal pathologies can improve long-term outcomes of renal allografts. Methodology A total of 362 renal allograft protocol biopsies were performed in adult recipients of kidney transplantation between 2012 and 2017. After excluding those with poor quality or those performed with a baseline serum creatinine level >200 umol/L, we analyzed 334 (92.3%) biopsies. Histology reports were reviewed and categorized into histoimmunological and nonimmunological changes. The immunological changes were subcategorized into the following: (1) no acute rejection (NR), (2) borderline changes (BC), and (3) subclinical rejection (SCR). Nonimmunological changes were subcategorized into the following: (1) chronicity including interstitial fibrosis/tubular atrophy (IFTA), chronic T-cell-mediated rejection (TCMR), unspecified chronic lesions, and arterionephrosclerosis, (2) de novo glomerulopathy/recurrence of primary disease (RP), and (3) other clinically unsuspected lesions (acute pyelonephritis, calcineurin inhibitors toxicity, postinfective glomerulonephritis, and BK virus nephropathy). Risk factors associated with SCR were assessed. Results For the histoimmunological changes, 161 (48.2%) showed NR, 145 (43.4%) were BC, and 28 (8.4%) were SCR. These clinical events were more pronounced for the first 5 years; our data showed BC accounted for 59 (36.4%), 64 (54.2%), and 22 (40.7%) biopsies within <1 year, 1-5 years, and > 5 years, respectively (p = 0.011). Meanwhile, the incidence for SCR was 6 (3.7%) biopsies in <1 year, 18 (15.3%) in 1-5 years, and 4 (7.4%) in >5 years after transplantation (p=0.003). For the nonimmunological changes, chronicity, de novo glomerulopathy/RP, and other clinically unsuspected lesions were seen in 40 (12%), 10 (3%), and 12 (3.6%) biopsies, respectively. Living-related donor recipients were associated with decreased SCR (p=0.007). Conclusions Despite having a stable renal function, our transplant recipients had a significant number of subclinical rejection on renal allograft biopsies.
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Naesens M. The special relativity of noninvasive biomarkers for acute rejection. Am J Transplant 2019; 19:5-8. [PMID: 30125470 DOI: 10.1111/ajt.15078] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/10/2018] [Accepted: 08/12/2018] [Indexed: 01/25/2023]
Affiliation(s)
- Maarten Naesens
- Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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10
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Yang X, Yu N, Yu J, Wang H, Li X. Virtual Touch Tissue Quantification for Assessing Renal Pathology in Idiopathic Nephrotic Syndrome. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:1318-1326. [PMID: 29650267 DOI: 10.1016/j.ultrasmedbio.2018.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 02/05/2018] [Accepted: 02/22/2018] [Indexed: 06/08/2023]
Abstract
The aim of this study was to evaluate Virtual Touch tissue quantification in assessing renal interstitial fibrosis in patients with idiopathic nephrotic syndrome. Ninety patients with idiopathic nephrotic syndrome were assigned to mild, moderate and severe groups depending on the degree of renal interstitial fibrosis on histopathologic examination of renal biopsy specimens. Thirty healthy patients were also selected as the control group. Virtual Touch tissue quantification was performed to measure the shear wave velocity of the renal parenchyma. There was no statistically significant difference in shear wave velocity between the mild and control groups (p > 0.05); however, the moderate and severe groups did significantly differ compared with the control (p <0.001). The area under the receiver operating characteristic curve value for the shear wave velocity of renal interstitial fibrosis in the moderate group versus the control and mild groups together was 0.869 (95% confidence interval: 0.791-0.947) and that in the severe group versus the control, mild and moderate groups together was 0.954 (95% confidence interval: 0.917-0.998). The corresponding best cutoff points were 2.41 and 2.77 m/s, with sensitivities of 91.7% and 86.8%, specificities of 78.0% and 92.0%, negative predictive values 0.907 and 0.907, positive predictive values 0.800 and 0.971 and Youden index values of 0.697 and 0.788, respectively. Virtual Touch tissue quantification may non-invasively and quantitatively estimate the degree of renal interstitial fibrosis in patients with idiopathic nephrotic syndrome as a baseline for monitoring progression and treatment response.
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Affiliation(s)
- Xue Yang
- Department of Ultrasound, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Ning Yu
- Department of Ultrasound, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China.
| | - Jing Yu
- Department of Ultrasound, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Hongqiao Wang
- Department of Ultrasound, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Xiumei Li
- Department of Ultrasound, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
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11
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Eisenberger U, Budde K, Lehner F, Sommerer C, Reinke P, Witzke O, Wüthrich RP, Stahl R, Heller K, Suwelack B, Mühlfeld A, Hauser IA, Nadalin S, Porstner M, Arns W. Histological findings to five years after early conversion of kidney transplant patients from cyclosporine to everolimus: an analysis from the randomized ZEUS study. BMC Nephrol 2018; 19:154. [PMID: 29954336 PMCID: PMC6025714 DOI: 10.1186/s12882-018-0950-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 06/17/2018] [Indexed: 01/05/2023] Open
Abstract
Background Conversion from calcineurin inhibitor (CNI) therapy to everolimus within 6 months after kidney transplantation improves long-term graft function but can increase the risk of mild biopsy-proven acute cellular rejection (BPAR). We performed a post-hoc analysis of histological data from a randomized trial in order to further analyze histologic information obtained from indication and protocol biopsies up to 5 years after transplantation. Methods Biopsy samples obtained up to 5 years post-transplant were analyzed from the randomized ZEUS study, in which kidney transplant patients were randomized at month 4.5 to switch to everolimus (n = 154) or remain on cyclosporine (CsA)-based immunosuppression (n = 146). All patients received mycophenolate and steroids. Results At least one investigator-initiated biopsy was undertaken in 53 patients in each group between randomization and year 5, with a mean (SD) of 2.6 (1.7) and 2.2 (1.4) biopsies per patient in the everolimus and CsA groups, respectively. In the everolimus and CsA groups, investigator-initiated biopsies showed (i) BPAR in 12.3 and 7.5% (p = 0.182) of patients, respectively, with episodes graded mild in 22/24 and 18/20 cases (ii) CsA toxicity lesions in 4.5 and 10.3% of patients (p = 0.076) (iii) antibody-mediated rejection in 0.6 and 2.7% of patients (p = 0.204), respectively. Conclusions This analysis of histological findings in the ZEUS study to 5 years after kidney transplantation shows no increase in antibody-mediated rejection under everolimus-based therapy with a lower rate of CNI-related toxicity compared to a conventional CsA-based regimen, and confirms the preponderance of mild BPAR seen in the main study after the early switch to CsA-free everolimus therapy. Trial registration ClinicalTrials.gov NCT00154310. Date of registration: September 12, 2005. Electronic supplementary material The online version of this article (10.1186/s12882-018-0950-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ute Eisenberger
- Department of Nephrology and Hypertension, University of Bern, Inselspital, Bern, Switzerland. .,Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, Hufelandstr, 55, 45147, Essen, Germany.
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Frank Lehner
- Department of General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Claudia Sommerer
- Department of Nephrology, University Hospital Heidelberg, Heidelberg, Germany
| | - Petra Reinke
- Department of Nephrology and Intensive Care, Charité Campus Virchow, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | | | - Rolf Stahl
- Division of Nephrology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katharina Heller
- Department of Nephrology and Hypertension, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Barbara Suwelack
- Department of Internal Medicine - Transplant Nephrology, University Hospital of Münster, Münster, Germany
| | - Anja Mühlfeld
- Division of Nephrology and Immunology, University Hospital RWTH Aachen, Aachen, Germany
| | - Ingeborg A Hauser
- Med. Klinik III, Department of Nephrology, UKF, Goethe University, Frankfurt, Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany
| | | | - Wolfgang Arns
- Department of Nephrology and Transplantation, Cologne Merheim Medical Center, Cologne, Germany
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12
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Joelsons G, Domenico T, Gonçalves L, Manfro R. Non-invasive messenger RNA transcriptional evaluation in human kidney allograft dysfunction. Braz J Med Biol Res 2018; 51:e6904. [PMID: 29791589 PMCID: PMC5972022 DOI: 10.1590/1414-431x20186904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 03/19/2018] [Indexed: 11/21/2022] Open
Abstract
The aim of the present study was to evaluate messenger RNA expression in kidney allograft recipients. Forty-four kidney transplant recipients were evaluated up to three months after grafting. After transplantation, peripheral blood samples were drawn sequentially for real-time polymerase chain reaction analyses of perforin and TIM-3 genes. Biopsies were obtained to evaluate acute graft dysfunction and interpreted according to the Banff classification. Eight patients presented episodes of acute rejection. Recipients with rejection had significantly higher levels of TIM-3 mRNA transcripts compared to those without rejection (median gene expression 191.2 and 36.9 mRNA relative units, respectively; P<0.0001). Also, perforin gene expression was higher in patients with rejection (median gene expression 362.0 and 52.8 mRNA relative units; P<0.001). Receiver operating characteristic curves showed that the area under the curve (AUC) for the TIM-3 gene was 0.749 (95%CI: 0.670-0.827). Perforin gene mRNA expression provided an AUC of 0.699 (95%CI: 0.599 to 0.799). Overall accuracy of gene expression was 67.9% for the TIM-3 gene and 63.6% for the perforin gene. Combined accuracy was 76.8%. Negative predictive values were 95.3% for the TIM-3 gene, 95.5% for the perforin gene, and 95.4% in the combined analyses. Gene expression was significantly modulated by rejection treatment decreasing 64.1% (TIM-3) and 90.9% (perforin) compared to the median of pre-rejection samples. In conclusion, the longitudinal approach showed that gene profiling evaluation might be useful in ruling out the diagnosis of acute rejection and perhaps evaluating the efficacy of treatment.
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Affiliation(s)
- G. Joelsons
- Programa de Pós-Graduação em Medicina: Ciências Médicas,
Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre,
RS, Brasil
| | - T. Domenico
- Programa de Pós-Graduação em Medicina: Ciências Médicas,
Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre,
RS, Brasil
| | - L.F. Gonçalves
- Programa de Pós-Graduação em Medicina: Ciências Médicas,
Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre,
RS, Brasil
- Serviço de Nefrologia, Hospital de Clínicas de Porto Alegre,
Porto Alegre, RS, Brasil
| | - R.C. Manfro
- Programa de Pós-Graduação em Medicina: Ciências Médicas,
Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre,
RS, Brasil
- Serviço de Nefrologia, Hospital de Clínicas de Porto Alegre,
Porto Alegre, RS, Brasil
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13
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The utility of surveillance biopsies in pediatric kidney transplantation. Pediatr Nephrol 2018; 33:889-895. [PMID: 29260318 DOI: 10.1007/s00467-017-3864-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 12/02/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Surveillance biopsies (SBs) are performed in some pediatric kidney transplant programs, based on data obtained in earlier immunosuppressive eras that the treatment of subclinical acute rejection results in better graft survival. The benefit of SBs for patients on modern immunosuppression regimens is unclear. We have therefore evaluated the clinical utility of SBs in a population of children receiving a kidney transplant. METHODS We have performed SBs at 3, 6 and 12 months post-transplantation as standard of care at our institution since 2013 in patients on a regimen of rabbit anti-thymocyte globulin, tacrolimus, mycophenolate and rapid steroid taper (RST; steroids maintained in some exceptions). We reviewed pathology reports of 82 SBs from 34 transplants in 34 children for all abnormal findings and adequacy of specimens. Clinical records were reviewed for changes in management resulting from SB findings and for significant procedure complications. RESULTS Of the 82 biopsies, 41 (50%) had abnormal findings separate from fibrosis, including five Banff Grade I rejections, ten borderline rejections, six calcineurin-inhibitor nephrotoxicity, four BK-virus nephropathy, five recurrent disease and three acute pyelonephritis. Moderate or more fibrosis was present in nine of the 82 (11%) biopsies. Management changes due to SB findings occurred in nine cases (11.0%). The proportion of abnormal findings or management changes did not differ between the RST or steroid-based groups. Patients performing clean intermittent catheterization showed inflammatory changes often read as rejection, but were managed differently. Three biopsies were deemed inadequate. No significant complications occurred. CONCLUSIONS A high percentage of the SBs performed under modern immunosuppression showed abnormal findings even when fibrosis was excluded. However, management changes due to the SB findings were less frequent, although they occurred in a clinically meaningful percentage of cases. Complications or inadequate specimens were rare.
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14
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Deltombe C, Gillaizeau F, Anglicheau D, Morelon E, Trébern-Launay K, Le Borgne F, Rimbert M, Guérif P, Malard-Castagnet S, Foucher Y, Giral M. Is pre-transplant sensitization against angiotensin II type 1 receptor still a risk factor of graft and patient outcome in kidney transplantation in the anti-HLA Luminex era? A retrospective study. Transpl Int 2017; 30:1150-1160. [DOI: 10.1111/tri.13009] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 07/08/2016] [Accepted: 07/04/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Clement Deltombe
- Institute for Transplantation, Urology and Nephrology (ITUN); Nantes University Hospital; Nantes France
| | - Florence Gillaizeau
- Institute for Transplantation, Urology and Nephrology (ITUN); Nantes University Hospital; Nantes France
- Inserm U1064; Nantes University Hospital; Nantes France
- EA 4275 SPHERE; Nantes University; Nantes France
- LabEx Transplantex; Nantes France
| | - Daniel Anglicheau
- LabEx Transplantex; Nantes France
- Thematic Research and Care Network RTRS “Centaure”; Université de Strasbourg; Strasbourg France
- Department of Kidney Transplantation; Necker University Hospital; AP-HP; Paris France
| | - Emmanuel Morelon
- Thematic Research and Care Network RTRS “Centaure”; Université de Strasbourg; Strasbourg France
- Department of Transplantation and Clinical Immunology; Hospices Civils de Lyon; Hopital Edouard Herriot; Lyon France
| | - Katy Trébern-Launay
- Institute for Transplantation, Urology and Nephrology (ITUN); Nantes University Hospital; Nantes France
- Inserm U1064; Nantes University Hospital; Nantes France
- Thematic Research and Care Network RTRS “Centaure”; Université de Strasbourg; Strasbourg France
| | | | - Marie Rimbert
- Plateforme CIMNA; CHU Nantes; Nantes France
- Biotherapy Clinical Investigation; Center Nantes University Hospital; Nantes France
| | - Pierrick Guérif
- Institute for Transplantation, Urology and Nephrology (ITUN); Nantes University Hospital; Nantes France
| | | | | | - Magali Giral
- Institute for Transplantation, Urology and Nephrology (ITUN); Nantes University Hospital; Nantes France
- Inserm U1064; Nantes University Hospital; Nantes France
- EA 4275 SPHERE; Nantes University; Nantes France
- LabEx Transplantex; Nantes France
- Thematic Research and Care Network RTRS “Centaure”; Université de Strasbourg; Strasbourg France
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15
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A Systematic Review about an Advance in Cyclosporine Monitoring in Kidney Transplant Recipients. Nephrourol Mon 2017. [DOI: 10.5812/numonthly.24989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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16
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Decreased Kidney Graft Survival in Low Immunological Risk Patients Showing Inflammation in Normal Protocol Biopsies. PLoS One 2016; 11:e0159717. [PMID: 27532630 PMCID: PMC4988662 DOI: 10.1371/journal.pone.0159717] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 07/07/2016] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The pros and cons for implementing protocol biopsies (PB) after kidney transplantation are still a matter of debate. We aimed to address the frequency of pathological findings in PB, to analyze their impact on long-term graft survival (GS) and to analyze the risk factors predicting an abnormal histology. METHODS We analyzed 946 kidney PB obtained at a median time of 6.5 (±2.9) months after transplantation. Statistics included comparison between groups, Kaplan-Meier and multinomial logistic regression analysis. RESULTS AND DISCUSSION PB diagnosis were: 53.4% normal; 46% IFTA; 12.3% borderline and 4.9% had subclinical acute rejection (SCAR). Inflammation had the strongest negative impact on GS. Therefore we split the cases into: "normal without inflammation", "normal with inflammation", "IFTA without inflammation", "IFTA with inflammation" and "rejection" (including SCAR and borderline). 15-year GS in PB diagnosed normal with inflammation was significantly decreased in a similar fashion as in rejection cases. Among normal biopsies, inflammation increased significantly the risk of 15-y graft loss (P = 0.01). Variables that predicted an abnormal biopsy were proteinuria, previous AR and DR-mismatch. CONCLUSION We conclude that inflammation in normal PB is associated with a significantly lower 15-y GS, comparable to rejection or IFTA with inflammation.
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17
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Moes DJAR, Press RR, Ackaert O, Ploeger BA, Bemelman FJ, Diack C, Wessels JAM, van der Straaten T, Danhof M, Sanders JSF, Homan van der Heide JJ, Guchelaar HJ, de Fijter JW. Exploring genetic and non-genetic risk factors for delayed graft function, acute and subclinical rejection in renal transplant recipients. Br J Clin Pharmacol 2016; 82:227-37. [PMID: 27334415 DOI: 10.1111/bcp.12946] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 03/22/2016] [Accepted: 03/23/2016] [Indexed: 01/05/2023] Open
Abstract
AIMS This study aimed at identifying pharmacological factors such as pharmacogenetics and drug exposure as new predictive biomarkers for delayed graft function (DGF), acute rejection (AR) and/or subclinical rejection (SCR). METHODS Adult renal transplant recipients (n = 361) on cyclosporine-based immunosuppression were followed for the first 6 months after transplantation. The incidence of DGF and AR were documented as well as the prevalence of SCR at 6 months in surveillance biopsies. Demographic, transplant-related factors, pharmacological and pharmacogenetic factors (ABCB1, CYP3A5, CYP3A4, CYP2C8, NR1I2, PPP3CA and PPP3CB) were analysed in a combined approach in relation to the occurrence of DGF, AR and prevalence of SCR at month 6 using a proportional odds model and time to event model. RESULTS Fourteen per cent of the patients experienced at least one clinical rejection episode and only DGF showed a significant effect on the time to AR. The incidence of DGF correlated with a deceased donor kidney transplant (27% vs. 0.6% of living donors). Pharmacogenetic factors were not associated with risk for DGF, AR or SCR. A deceased donor kidney and acute rejection history were the most important determinants for SCR, resulting in a 52% risk of SCR at 6 months (vs. 11% average). In a sub-analysis of the patients with AR, those treated with rejection treatment including ATG, significantly less frequent SCR was found in the 6-month biopsy (13% vs. 50%). CONCLUSIONS Transplant-related factors remain the most important determinants of DGF, AR and SCR. Furthermore, rejection treatment with depleting antibodies effectively prevented SCR in 6-month surveillance biopsies.
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Affiliation(s)
- Dirk Jan A R Moes
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Rogier R Press
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Oliver Ackaert
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics (LAP&P Consultants BV), Leiden, The Netherlands
| | - Bart A Ploeger
- Leiden Academic Center for Drug Research (LACDR), Leiden, The Netherlands.,Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics (LAP&P Consultants BV), Leiden, The Netherlands
| | | | - Cheikh Diack
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics (LAP&P Consultants BV), Leiden, The Netherlands
| | - Judith A M Wessels
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tahar van der Straaten
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Meindert Danhof
- Leiden Academic Center for Drug Research (LACDR), Leiden, The Netherlands
| | | | | | - Henk Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Johan W de Fijter
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
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18
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Escobedo-Villarreal MM, Mercado-Moreira AB, Muñoz-Espinosa LE, Gamboa-Esparza M, Pérez-Rodríguez E, Cordero-Pérez P. [Urinary protein detection by iTRAQ® associated with renal transplant complications and its modification with therapy]. CIR CIR 2015; 83:393-401. [PMID: 26148981 DOI: 10.1016/j.circir.2015.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 03/23/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND After renal transplant, surgical, infection complications, as well as graft rejection may occur; early detection through non-invasive markers is the key to change therapy and avoid biopsy. OBJECTIVE The aime of the study is to determine urine protein profiles in patients undergoing renal transplant with complications and detect its variation when therapy is modified. MATERIAL AND METHODS Urine samples were collected from patients prior the transplant and various postoperative stages. Urinary protein profiles were obtained by peptide labeling using isobaric isotopes for relative quantification (iTRAQ(®)). RESULTS A total of 22 patients were included, of whom 12 developed post-transplant complication: 2 with graft rejection (one male and one female) and 10 (6 males and 4 females) in the group of post-transplant infections. Using iTRAQ(®) 15/345 and 28/113 proteins were identified and fulfilled the acceptance criteria, in graft rejection and post-transplant infections group, respectively. CONCLUSIONS Albumin was the only protein found in both groups, the remaining proteins were different. The 5 proteins with higher scores in graft rejection were: alpha-1-microglobulin, 5'-nucleotidase cytosolic III, retinol-binding protein 4, membrane protein palmitoylated 4, and serine carboxypeptidase, while post-transplant infections were: mitochondrial acetyl-coenzyme A synthetase, putative adenosyl homocysteinase 2, zinc finger protein GLIS1, putative protein FAM157B, and zinc finger protein 615. It remains to elucidate the involvement of each of these in patients with renal transplantation.
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Affiliation(s)
- Miguel Mariano Escobedo-Villarreal
- Servicio de Trasplantes, Departamento de Cirugía, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Amanda Berenice Mercado-Moreira
- Unidad de Hígado, Departamento de Medicina Interna, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Linda Elsa Muñoz-Espinosa
- Unidad de Hígado, Departamento de Medicina Interna, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Mariana Gamboa-Esparza
- Unidad de Hígado, Departamento de Medicina Interna, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Edelmiro Pérez-Rodríguez
- Servicio de Trasplantes, Departamento de Cirugía, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Paula Cordero-Pérez
- Unidad de Hígado, Departamento de Medicina Interna, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México.
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19
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Viero RM, da Silva MG, dos Santos DC, de Carvalho MFC, de Andrade LGM. The role of renin-angiotensin system in the chronic allograft nephropathy: an immunohistochemical study. Ren Fail 2015; 37:827-34. [PMID: 25782922 DOI: 10.3109/0886022x.2015.1024563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Evidences suggest a role of renin-angiotensin system (RAS) in the development of chronic allograft injury. METHODS We correlated intrarenal angiotensin-converting enzyme, angiotensin II (Angio II) and transforming growth factor β1 (TGFβ1) expression in 58 biopsies-proven chronic allograft nephropathy (CAN) with tissue injury and allograft survival. RESULTS The biopsies with CAN were graded according to Banff classification as I (22 cases), II (17) and III (19); 27 biopsies also showed a mononuclear inflammatory infiltrate in scarred areas. There were increased expression of angiotensin converting-enzyme (ACE), Angio II and TGFβ1 mainly in tubulointerstitial compartment in the group with CAN; there was no association of Angio II and TGFβ1 expression with interstitial fibrosis. There were no significant differences of ACE, Angio II and TGFβ1 expression between the patients treated and untreated with RAS blockade, and with the graft outcome. Interstitial inflammatory infiltrate had positive correlation with interstitial fibrosis and significant impact on graft survival at 8 years. CONCLUSIONS Our study showed in a group of cases with CAN a high percentage of inflammatory infiltrate that correlated with interstitial fibrosis and graft outcome. The chronic inflammatory changes in these cases did not show significant association with local RAS expression.
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Affiliation(s)
- Rosa Marlene Viero
- a Department of Pathology , Botucatu Medical School, São Paulo State University (UNESP) , Botucatu , São Paulo , Brazil and
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20
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Bestard O, Sarwal MM. Antibody-mediated rejection in young kidney transplant recipients: the dilemma of noncompliance and insufficient immunosuppression. Pediatr Nephrol 2015; 30:397-403. [PMID: 25503324 DOI: 10.1007/s00467-014-3020-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 11/09/2014] [Accepted: 11/10/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Antibody-mediated rejection (ABMR) is a recognized cause of late kidney allograft loss. Although ABMR may occur despite appropriate chronic immunosuppressive therapy, non-adherence both facilitates and accelerates the activation of the effector phase of the humoral immune response against the donor tissue, leading in turn to progressive kidney allograft rejection. Given the poor efficacy of rescue therapies for both acute and chronic late ABMR, establishing appropriate preventive strategies at different times before and after transplantation is a critical management goal. CASE-DIAGNOSIS/TREATMENT In this report, we discuss the differential diagnoses and management of ABMR based on the clinical case report of a young kidney transplant recipient with progressive ABMR due to poor immunosuppressive adherence. In the absence of sensitive and specific non-invasive monitoring tools for alloimmune activation, the clinical dilemma in the management of the adolescent patient lies in differentiating between suboptimal prescribed immunosuppression and deliberate non-adherence to adequate immunosuppression dosing. Despite the advent of therapies to reduce ABMR injury, the graft is destined for untimely functional loss. CONCLUSIONS New biomarkers and tools for the accurate characterization of alloimmune risk before and after transplantation, and serial testing for de novo changes in circulating donor-specific alloantibodies, are urgently needed to support the delivery of optimized immunosuppression exposure.
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Affiliation(s)
- Oriol Bestard
- Renal Transplant Unit, Nephrology Department, Bellvitge University Hospital, IDIBELL, Barcelona, Spain,
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21
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Uslu A, Hür E, Şen Ç, Şen S, Akgün A, Taşlı FA, Nart A, Yilmaz M, Töz H. To what extent estimated or measured GFR could predict subclinical graft fibrosis: a comparative prospective study with protocol biopsies. Transpl Int 2015; 28:575-81. [PMID: 25639483 DOI: 10.1111/tri.12534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 09/26/2014] [Accepted: 01/25/2015] [Indexed: 11/29/2022]
Abstract
Monitoring of allograft function entails methods more accurate than serum creatinine and creatinine-based GFR equations (eGFR). This prospective trial aimed at investigating the diagnostic accuracy of creatinine- and cystatin C-based eGFR with measured GFR (mGFR) and compared them with graft fibrosis detected by protocol biopsies (PBx). Forty-four kidney transplant recipients were enrolled. PBx were obtained postengraftment and at 6th and 12th months. GFR was measured by Tc-99m DTPA at 3th, 6th, and 12th months after transplantation. Significant correlation existed between eGFR and mGFR at 3, 6, and 12 months (P < 0.0001). Cystatin C-based Hoek and Larsson equations had the lowest bias and highest accuracy. The sum of interstitial fibrosis and tubular atrophy score increased from implantation to 6th and 12th months (0.52 ± 0.79, 0.84 ± 0.88, 1.50 ± 1.35). This was accompanied by reduction of mGFR from 54.1 ± 15.2 to 49.9 ± 15.2 and 46.8 ± 16.5 ml/min/1.73 m(2) , while serum creatinine, cystatin C, and eGFR remained stable. Neither creatinine- nor cystatin C-based GFR equations are reliable for detecting insidious graft fibrosis. In the first year after transplantation, mGFR, with its best proximity to histopathology, can be used to monitor allograft function and insidious graft fibrosis.
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Affiliation(s)
- Adam Uslu
- Department of General Surgery, İzmir Bozyaka Education and Research Hospital, İzmir, Turkey
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Tanabe T. The value of long-term protocol biopsies after kidney transplantation. Nephrology (Carlton) 2015; 19 Suppl 3:2-5. [PMID: 24842813 DOI: 10.1111/nep.12253] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2014] [Indexed: 01/04/2023]
Abstract
Protocol biopsies for the detection and treatment of subclinical rejection in the early period after kidney transplantation are useful for preventing allograft dysfunction. However, little has been reported on the relationship between subclinical rejection and long-term protocol biopsies. In this review, we examine the potential benefits associated with long-term allograft biopsies focusing on the issue of immunological and non-immunological factors. Early detection and treatment of subclinical rejection improves outcome. However, the benefit of long-term allograft biopsies is largely unproved, and the strategy is yet to be widely implemented. The procurement of long-term protocol biopsies for the sole purpose of detecting subclinical rejection may be unwarranted. On the other hand, the early detection of IgA nephropathy using long-term protocol biopsy may improve graft survival. In addition, assessment of long-term protocol biopsies is useful not only for detection of calcineurin inhibitor nephrotoxicity, but also for follow-up after withdrawal of calcineurin inhibitor regimens. Also, identifying normal histology on a protocol biopsy may inform us about the safety of reducing overall immunosuppression. Thus, the potential benefit of long-term protocol biopsy may be of clinical significance for the detection of graft dysfunction as a result of non-immune factors, such as recurrence of glomerulonephritis and calcineurin inhibitor nephrotoxicity, rather than subclinical rejection.
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Affiliation(s)
- Tatsu Tanabe
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
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Lee C, Park JH, Suh JH, Kim HW, Moon KC. C4d immunoreactivity of intraoperative zero-hour biopsy in renal allograft. Transplant Proc 2014; 46:3367-70. [PMID: 25498053 DOI: 10.1016/j.transproceed.2014.08.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 07/16/2014] [Accepted: 08/19/2014] [Indexed: 11/20/2022]
Abstract
C4d deposition in the peritubular capillaries is known to be correlated with antibody-mediated rejection (AMR) in renal allografts. An intraoperative zero-hour biopsy during transplantation is considered an indicator to indirectly determine the status of the donor kidney. In this study, we investigated the relationship between C4d immunoreactivity of intraoperative zero-hour biopsy in renal allograft, thought to be due to donor condition, and acute rejection episodes during follow-up. We collected 147 renal transplantation cases examining intraoperative zero-hour biopsy with C4d immunohistochemical staining. All cases were from the Seoul National University Hospital between 2010 and 2011. Of the 147 cases, 24 (16.3%) showed strong C4d staining in the glomeruli, 38 (25.9%) showed weak staining, and the remainder (57.8%) showed negative staining. Nine cases (6.1%) showed positive C4d staining in the arterioles, and the remainder (93.9%) were negative. There were no significant differences between acute T-cell-mediated rejection and acute AMR episodes in the renal allograft specimens during follow-up according to the glomerular or arteriolar C4d immunoreactivity of the intraoperative zero-hour biopsy specimens.
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Affiliation(s)
- C Lee
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - J H Park
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - J H Suh
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - H W Kim
- Department of Pathology, Good Moonhwa Hospital, Busan, Korea
| | - K C Moon
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea.
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Broecker V, Mengel M. The significance of histological diagnosis in renal allograft biopsies in 2014. Transpl Int 2014; 28:136-43. [PMID: 25205033 DOI: 10.1111/tri.12446] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 06/26/2014] [Accepted: 09/01/2014] [Indexed: 01/20/2023]
Abstract
In 2014, the renal allograft biopsy still represents the best available diagnostic 'gold' standard to assess reasons for allograft dysfunction. However, it is well recognized that histological lesion observed in the biopsy is of limited diagnostic specificity and that the Banff classification as the international diagnostic standard represents mere expert consensus. Here, we review the role of the renal allograft biopsy in different clinical and diagnostic settings. To increase diagnostic accuracy and to compensate for lack of specificity, the interpretation of biopsy pathology needs to be within the clinical context, primarily defined by time post-transplantation and patient-specific risk profile. With this in mind, similar histopathological patterns will lead to different conclusions with regard to diagnosis, disease grading and staging and thus to patient-specific clinical decision-making. Consensus generation for such integrated diagnostic approach, preferably including new molecular tools, represents the next challenge to the transplant community on its way to precision medicine in transplantation.
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Affiliation(s)
- Verena Broecker
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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A comparative study on renal biopsy before and after long-term calcineurin inhibitors therapy: an insight for pathogenesis of its toxicity. Hum Pathol 2014; 46:34-9. [PMID: 25449629 DOI: 10.1016/j.humpath.2014.09.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 09/10/2014] [Accepted: 09/17/2014] [Indexed: 12/25/2022]
Abstract
Calcineurin inhibitors (CNIs) are effective immunosuppressive agents for the successful treatment of childhood steroid-resistant nephrotic syndrome (SRNS). Because these patients require long-term treatment, the identification of early markers of CNI-induced nephrotoxicity (CNIN) is imperative. The monitoring of CNI trough levels, serum creatinine, and glomerular filtration rate is not an accurate marker of CNIN. The present study has been undertaken to identify early markers of CNIN in SRNS patients. Twenty-four pediatric SRNS patients were included with paired renal biopsies, before initiation (time zero biopsy) and at least 1 year after CNI therapy (protocol renal biopsy) with standard dosage. Semiquantitative morphologic grading of the histologic features was done for assessing CNIN. Immunohistochemical markers for oxidative stress (nitrotyrosine [NT]), fibrogenic cytokine (transforming growth factor β1 [TGF-β1]), and endothelial injury (endothelial nitric oxide synthase [eNOS]) were evaluated. In addition, ultrastructural study was done to assess mitochondrial injury in endothelial and tubular epithelial cells. The protocol renal biopsies in comparison with time zero biopsies showed significant increase in glomerulosclerosis, juxtaglomerular apparatus hyperplasia, tubular atrophy, interstitial fibrosis, arteriolar hyalinosis, and smooth muscle vacuolization (P < .05 - P < .001). Significantly higher immunoexpression of eNOS (91.6%), NT (71%), and TGF-β1 (87.5%) was noted in posttreatment biopsies. Mean mitochondrial injury grade among post-CNI cases in endothelial cells and proximal tubular cells was 2.28 and 1.4, whereas in pre-CNI, it was 0.28 and 0.27, respectively. We propose that immunohistochemical overexpression of NT, eNOS, and TGF-β1 is an early marker of CNIN. Endothelial and proximal tubular mitochondrial injury may play an important role in the pathogenesis of CNIN.
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Bröcker V, Mengel M. Histopathological diagnosis of acute and chronic rejection in pediatric kidney transplantation. Pediatr Nephrol 2014; 29:1939-49. [PMID: 24141526 DOI: 10.1007/s00467-013-2640-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 09/05/2013] [Accepted: 09/13/2013] [Indexed: 01/05/2023]
Abstract
ABO-compatible as well as ABO-incompatible kidney transplantation are well established in the pediatric population. There are particularities in the histopathological evaluation of pediatric kidney transplant biopsies as for example the recurrence of certain diseases different from the adult population. Furthermore, the challenging transition of pediatric renal transplant recipients to adulthood is associated with an increased rate of non-adherence triggered rejection episodes. With modern immunosuppressive drugs, T-cell-mediated rejection of renal allografts is well controlled. In contrast, antibody-mediated rejection (AMR) is increasingly recognized as one of the major reasons for allograft loss. However, the 2001 diagnostic Banff criteria for antibody-mediated rejection require further refinement, as the morphological spectrum of AMR expands while effective therapeutic strategies are lacking. For example, endarteritis, which traditionally has been attributed to T-cell-mediated rejection, has recently been shown to be part of the AMR spectrum in some cases. Many findings in transplant renal biopsies are not specific for a certain disease but need consideration of differential diagnoses. To use the term "chronic allograft nephropathy" as a diagnostic entity is no longer appropriate. Therefore, the precise identification of specific diseases is paramount in the assessment of transplant renal biopsies in order to enable tailored therapeutic management.
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Affiliation(s)
- Verena Bröcker
- Department of Histopathology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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27
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Antibody-mediated allograft rejection: morphologic spectrum and serologic correlations in surveillance and for cause biopsies. Transplantation 2013; 95:128-36. [PMID: 23222897 DOI: 10.1097/tp.0b013e3182777f28] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Subclinical antibody-mediated allograft rejection (AMR) has been characterized in serial biopsies from presensitized recipients but has not been systematically studied in conventional renal transplants. METHODS We evaluated 1101 consecutive kidney transplant biopsies (400 surveillance biopsies [SBx] and 701 for cause biopsies [FCBx]) with concurrent donor-specific antibody (DSA) studies, C4d staining, and ultrastructural examination. RESULTS A comparison of AMR-related features (DSA and DSA class, C4d staining, and microvascular injury) demonstrated that these were qualitatively and quantitatively associated with each other and with graft dysfunction. A major difference between SBx and FCBx was that the complete AMR phenotype was more common in FCBx. Among SBx, 8.5% showed complete or incomplete AMR with predominance of an incomplete phenotype (according to the Banff schema, these were acute AMR [23.5%], chronic active AMR [14.7%], suspicious for acute AMR [41.1%], suspicious for chronic active AMR [2.9%], and only microvascular injury insufficient to consider AMR [17.5%]). Persistence or worsening of AMR in a subsequent biopsy occurred in 38.2% of cases independently of the strength of AMR findings in the first biopsy (e.g., progression to chronic AMR occurred also in cases with suspicious or nondiagnostic findings). Temporal progression from subclinical to clinically evident AMR is consistent with the fact that, overall, the biopsies with incomplete phenotype (DSA±C4d) occurred between 14.52 and 20.86 months, whereas the complete phenotype occurred much later (36.71 months). CONCLUSION An accurate diagnostic interpretation of the potentially important but incomplete, subclinical, AMR phenotype represents a serious challenge that may impact clinical management.
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Sommerer C, Scharf M, Seitz C, Millonig G, Seitz HK, Zeier M, Mueller S. Assessment of renal allograft fibrosis by transient elastography. Transpl Int 2013; 26:545-51. [PMID: 23383606 DOI: 10.1111/tri.12073] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 09/13/2012] [Accepted: 01/07/2013] [Indexed: 01/06/2023]
Affiliation(s)
- Claudia Sommerer
- Department of Nephrology; University Hospital Heidelberg; Heidelberg; Germany
| | - Michael Scharf
- Department of Nephrology; University Hospital Heidelberg; Heidelberg; Germany
| | - Christoph Seitz
- Department of Nephrology; University Hospital Heidelberg; Heidelberg; Germany
| | - Gunda Millonig
- Department of Medicine; Salem Medical Center and Alcohol Research Center; University of Heidelberg; Heidelberg; Germany
| | - Helmut K. Seitz
- Department of Medicine; Salem Medical Center and Alcohol Research Center; University of Heidelberg; Heidelberg; Germany
| | - Martin Zeier
- Department of Nephrology; University Hospital Heidelberg; Heidelberg; Germany
| | - Sebastian Mueller
- Department of Medicine; Salem Medical Center and Alcohol Research Center; University of Heidelberg; Heidelberg; Germany
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29
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The role of mesenchymal stromal cells in chronic transplant rejection after solid organ transplantation. Curr Opin Organ Transplant 2013; 18:44-50. [DOI: 10.1097/mot.0b013e32835c2939] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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30
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Hirt-Minkowski P, Roth M, Hönger G, Amico P, Hopfer H, Schaub S. Soluble CD30 correlates with clinical but not subclinical renal allograft rejection. Transpl Int 2012; 26:75-83. [DOI: 10.1111/j.1432-2277.2012.01578.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Surveillance biopsies in children post-kidney transplant. Pediatr Nephrol 2012; 27:753-60. [PMID: 21792611 PMCID: PMC3315641 DOI: 10.1007/s00467-011-1969-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 06/29/2011] [Accepted: 07/05/2011] [Indexed: 01/05/2023]
Abstract
Surveillance biopsies are increasingly used in the post-transplant monitoring of pediatric renal allograft recipients. The main justification for this procedure is to diagnose early and presumably modifiable acute and chronic renal allograft injury. Pediatric recipients are theoretically at increased risk for subclinical renal allograft injury due to their relatively large adult-sized kidneys and their higher degree of immunological responsiveness. The safety profile of this procedure has been well investigated. Patient morbidity is low, with macroscopic hematuria being the most common adverse event. No patient deaths have been attributed to this procedure. Longitudinal surveillance biopsy studies have revealed a substantial burden of subclinical immunological and non-immunological injury, including acute cellular rejection, interstitial fibrosis and tubular atrophy, microvascular lesions and transplant glomerulopathy. The main impediment to the implementation of surveillance biopsies as the standard of care is the lack of demonstrable benefit of early histological detection on long-term outcome. The considerable debate surrounding this issue highlights the need for multicenter, prospective, and randomized studies.
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33
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Williams WW, Taheri D, Tolkoff-Rubin N, Colvin RB. Clinical role of the renal transplant biopsy. Nat Rev Nephrol 2012; 8:110-21. [PMID: 22231130 DOI: 10.1038/nrneph.2011.213] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Percutaneous needle core biopsy is the definitive procedure by which essential diagnostic and prognostic information on acute and chronic renal allograft dysfunction is obtained. The diagnostic value of the information so obtained has endured for over three decades and has proven crucially important in shaping strategies for therapeutic intervention. This Review provides a broad outline of the utility of performing kidney graft biopsies after transplantation, highlighting the relevance of biopsy findings in the immediate and early post-transplant period (from days to weeks after implantation), the first post-transplant year, and the late period (beyond the first year). We focus on how biopsy findings change over time, and the wide variety of pathological features that characterize the major clinical diagnoses facing the clinician. This article also includes a discussion of acute cellular and humoral rejection, the toxic effects of calcineurin inhibitors, and the widely varying etiologies and characteristics of chronic lesions. Emerging technologies based on gene expression analyses and proteomics, the in situ detection of functionally relevant molecules, and new bioinformatic approaches that hold the promise of improving diagnostic precision and developing new, refined molecular pathways for therapeutic intervention are also presented.
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Affiliation(s)
- Winfred W Williams
- Transplant Center, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA. wwwilliams@ partners.org
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34
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Thierry A, Thervet E, Vuiblet V, Goujon JM, Machet MC, Noel LH, Rioux-Leclercq N, Comoz F, Cordonnier C, François A, Marcellin L, Girardot-Seguin S, Touchard G. Long-term impact of subclinical inflammation diagnosed by protocol biopsy one year after renal transplantation. Am J Transplant 2011; 11:2153-61. [PMID: 21883902 DOI: 10.1111/j.1600-6143.2011.03695.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The long-term impact of subclinical acute rejection (SCAR) on renal graft function remains poorly understood. Furthermore, the interpretation of borderline lesions is difficult and their incidence is variable. The aim of this study was to analyze the characteristics of subclinical inflammation (SCI) in protocol biopsies performed 1-year after renal transplantation. SCI was defined as the presence of borderline lesions or SCAR according to the Banff 2005 classification. The patients included were a subpopulation of the CONCEPT study in which patients were randomized 3 months after transplantation to receive either sirolimus (SRL) or cyclosporine A (CsA) in combination with mycophenolate mofetil. At 1 year, we observed SCI in 37 of the 121 patients observed with an evaluable biopsy. The incidence was more frequent in the SRL group (SRL 45.2% vs. CsA 15.3%). At 30 months , SCI was associated with a significantly lower level of estimated glomerular filtration rate (mean MDRD 50.8 [±13.3] vs. 57.7 [±16.3] mL/min/1.73 m(2) , p = 0.035). In conclusion, SCI at 1-year posttransplantation is associated with worsening renal function and is more frequent in SRL-treated patients. Therefore, evaluation of SCI may be a valuable tool to allow the optimization of immunosuppressive regimens.
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Affiliation(s)
- A Thierry
- Department of Nephrology and Transplantation, University Hospital, Poitiers, France.
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Syversveen T, Brabrand K, Midtvedt K, Strøm EH, Hartmann A, Berstad AE. Non-invasive assessment of renal allograft fibrosis by dynamic sonographic tissue perfusion measurement. Acta Radiol 2011; 52:920-6. [PMID: 21873503 DOI: 10.1258/ar.2011.110215] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Chronic allograft nephropathy (CAN) characterized by interstitial fibrosis and tubular atrophy is a major cause of renal transplant failure. The diagnosis can currently only be verified by a graft biopsy. PURPOSE To evaluate whether non-invasive dynamic color Doppler sonographic parenchymal perfusion measurements are different in grafts with various degrees of biopsy proven renal transplant fibrosis. MATERIAL AND METHODS Forty-nine adult patients were prospectively included. Four patients were excluded. Color Doppler videos from the renal cortex were recorded. Perfusion in the renal cortex was evaluated using a software package which calculates color pixel area and flow velocity, encoded by each pixel inside a region of interest of a video sequence. The software calculates parameters that describe tissue perfusion numerically. Two of these, the perfusion intensity and tissue pulsatility index, were compared to grade of interstitial fibrosis (0-3) in biopsies. Observer agreement was evaluated in a subset of 12 patients. RESULTS Of the 45 patients analyzed, 18 patients had grade 0, 18 had grade 1, seven had grade 2 and two had grade 3 fibrosis. The mean perfusion intensity of grade 0 was significantly higher than that of grade 2 and 3 fibrosis in the proximal cortical layer (1.65 m/s vs. 0.84 m/s, P = 0.008). No significant difference was found between grade 0 and grade 1 fibrosis. Perfusion intensity was correlated to estimated glomerular filtration rate (Pearson r 0.51, P = 0.001, R(2) = 0.26 and 0.46, P = 0.001, R(2) = 0.22 in the distal and proximal cortex, respectively). Inter-observer agreement of the perfusion intensity, expressed as intraclass correlation coefficient was 0.69 in the proximal part of the cortex. Intra-observer agreement was 0.85 for observer 1 and 0.82 for observer 2. CONCLUSION Perfusion intensity assessed by dynamic color Doppler measurements is significantly reduced in allografts with grade 2 and 3 fibrosis compared to allografts without fibrosis. Further studies involving longitudinal assessment of allografts undergoing protocol biopsies would be of interest.
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Affiliation(s)
| | - Knut Brabrand
- Department of Radiology, Oslo University Hospital, Rikshospitalet
| | - Karsten Midtvedt
- Section of Nephrology, Medical Department, Oslo University Hospital, Rikshospitalet
| | - Erik H Strøm
- Department of Pathology, Oslo University Hospital, Rikshospitalet
| | - Anders Hartmann
- Section of Nephrology, Medical Department, Oslo University Hospital, Rikshospitalet
- Medical Faculty, University of Oslo, Oslo, Norway
| | - Audun Elnaes Berstad
- Department of Radiology, Oslo University Hospital, Rikshospitalet
- Medical Faculty, University of Oslo, Oslo, Norway
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Lorenzen JM, Volkmann I, Fiedler J, Schmidt M, Scheffner I, Haller H, Gwinner W, Thum T. Urinary miR-210 as a mediator of acute T-cell mediated rejection in renal allograft recipients. Am J Transplant 2011; 11:2221-7. [PMID: 21812927 DOI: 10.1111/j.1600-6143.2011.03679.x] [Citation(s) in RCA: 153] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
MicroRNAs (miRNAs) are small ribonucleotides regulating gene expression. Circulating miRNAs are remarkably stable in the blood. We tested whether miRNAs are also detectable in urine and may serve as new predictors of outcome in renal transplant patients with acute rejection. We profiled urinary miRNAs of stable transplant patients and transplant patients with acute rejection. The miR-10a, miR-10b and miR-210 were strongly deregulated in urine of the patients with acute rejection. We confirmed these data in urine of a validation cohort of 62 patients with acute rejection, 19 control transplant patients without rejection and 13 stable transplant patients with urinary tract infection by quantitative RT-PCR. The miR-10b and miR-210 were downregulated and miR-10a upregulated in patients with acute rejection compared to controls. Only miR-210 differed between patients with acute rejection when compared to stable transplant patients with urinary tract infection or transplant patients before/after rejection. Low miR-210 levels were associated with higher decline in GFR 1 year after transplantation. Selected miRNAs are strongly altered in urine of the patients with acute renal allograft rejection. The miR-210 levels identify patients with acute rejection and predict long-term kidney function. Urinary miR-210 may thus serve as a novel biomarker of acute kidney rejection.
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Affiliation(s)
- J M Lorenzen
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS) Department of Medicine/Division of Nephrology and Hypertension, Hannover Medical School, Hanover, Germany.
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Jackson JA, Kim EJ, Begley B, Cheeseman J, Harden T, Perez SD, Thomas S, Warshaw B, Kirk AD. Urinary chemokines CXCL9 and CXCL10 are noninvasive markers of renal allograft rejection and BK viral infection. Am J Transplant 2011; 11:2228-34. [PMID: 21812928 PMCID: PMC3184377 DOI: 10.1111/j.1600-6143.2011.03680.x] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Renal transplant recipients require periodic surveillance for immune-based complications such as rejection and infection. Noninvasive monitoring methods are preferred, particularly for children, for whom invasive testing is problematic. We performed a cross-sectional analysis of adult and pediatric transplant recipients to determine whether a urine-based chemokine assay could noninvasively identify patients with rejection among other common clinical diagnoses. Urine was collected from 110 adults and 46 children with defined clinical conditions: healthy volunteers, stable renal transplant recipients, and recipients with clinical or subclinical acute rejection (AR) or BK infection (BKI), calcineurin inhibitor (CNI) toxicity or interstitial fibrosis (IFTA). Urine was analyzed using a solid-phase bead-array assay for the interferon gamma-induced chemokines CXCL9 and CXCL10. We found that urine CXCL9 and CXCL10 were markedly elevated in adults and children experiencing either AR or BKI (p = 0.0002), but not in stable allograft recipients or recipients with CNI toxicity or IFTA. The sensitivity and specificity of these chemokine assays exceeded that of serum creatinine. Neither chemokine distinguished between AR and BKI. These data show that urine chemokine monitoring identifies patients with renal allograft inflammation. This assay may be useful for noninvasively distinguishing those allograft recipients requiring more intensive surveillance from those with benign clinical courses.
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Affiliation(s)
- J A Jackson
- Children's Healthcare of Atlanta, Atlanta, Georgia The Emory Transplant Center, Emory University, Atlanta, Georgia, USA
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38
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Amann K, Büttner M. [Evaluation of a renal biopsy: what information is important for nephrologists?]. DER PATHOLOGE 2011; 32 Suppl 2:361-9. [PMID: 21845359 DOI: 10.1007/s00292-011-1484-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A kidney biopsy is an important and frequently used diagnostic tool in routine nephrology. In order to obtain relevant clinical information from a renal biopsy close cooperation between clinicians and pathologists is mandatory. The better the information obtained from nephrologists and the better the understanding by nephrologists and the quality of the kidney biopsy, the more rewarding is the information from pathologists. The following paper will discuss some practical aspects regarding the interaction between nephrology and pathology which may not be known or poorly handled and may thus cause misunderstanding. In order to facilitate interaction between clinicians and pathologists some guidelines concerning the procedure and work-up of routine kidney biopsies have been established and will be discussed in detail.
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Affiliation(s)
- K Amann
- Abteilung Nephropathologie, Pathologisches Institut, Universität Erlangen-Nürnberg, Krankenhausstr. 12, 91054, Erlangen, Deutschland.
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39
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Servais A, Meas-Yedid V, Noël LH, Martinez F, Panterne C, Kreis H, Zuber J, Timsit MO, Legendre C, Olivo-Marin JC, Thervet E. Interstitial fibrosis evolution on early sequential screening renal allograft biopsies using quantitative image analysis. Am J Transplant 2011; 11:1456-63. [PMID: 21672152 DOI: 10.1111/j.1600-6143.2011.03594.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Screening renal biopsies (RB) may assess early changes of interstitial fibrosis (IF) after transplantation. The aim of this study was to quantify IF by automatic color image analysis on sequential RB. We analyzed RB performed at day (D) 0, month (M) 3 and M12 from 140 renal transplant recipients with a program of color segmentation imaging. The mean IF score was 19 ± 9% at D0, 27 ± 11% at M3 and 32 ± 11% at M12 with a 8% progression during the first 3 months and 5% between M3 and M12. IF at M3 was correlated with estimated glomerular rate (eGFR) at M3, 12 and 24 (p < 0.02) and IF at M12 with eGFR at M12 and 48 (p < 0.05). Furthermore, IF evolution between D0 and M3 (ΔIFM3-D0) was correlated with eGFR at M24, 36 and 48 (p < 0.03). IF at M12 was significantly associated with male donor gender and tacrolimus dose (p = 0.03). ΔIFM3-D0 was significantly associated with male donor gender, acute rejection episodes (p = 0.04) and diabetes mellitus (p = 0.02). Thus, significant IF is already present before transplantation. IF evolution is more important during the first 3 months and has some predictive ability for change in GFR. Intervention to decrease IF should be applied early, i.e. before 3 months, after transplantation.
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Affiliation(s)
- A Servais
- Department of Nephrology, Assistance publique-Hôpitaux de Paris, Necker-Enfants Malades Hospital, Paris, France.
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Herzenberg AM, Fogo AB, Reich HN, Troyanov S, Bavbek N, Massat AE, Hunley TE, Hladunewich MA, Julian BA, Fervenza FC, Cattran DC. Validation of the Oxford classification of IgA nephropathy. Kidney Int 2011; 80:310-7. [PMID: 21544062 DOI: 10.1038/ki.2011.126] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The Oxford classification of IgA nephropathy (IgAN) identified four pathological elements that were of prognostic value and additive to known clinical and laboratory variables in predicting patient outcome. These features are segmental glomerulosclerosis/adhesion, mesangial hypercellularity, endocapillary proliferation, and tubular atrophy/interstitial fibrosis. Here, we tested the Oxford results using an independent cohort of 187 adults and children with IgAN from 4 centers in North America by comparing the performance of the logistic regression model and the predictive value of each of the four lesions in both data sets. The cohorts had similar clinical and histological findings, presentations, and clinicopathological correlations. During follow-up, however, the North American cohort received more immunosuppressive and antihypertensive therapies. Identifying patients with a rapid decline in the rate of renal function using the logistic model from the original study in the validation data set was good (c-statistic 0.75), although less precise than in the original study (0.82). Individually, each pathological variable offered the same predictive value in both cohorts except mesangial hypercellularity, which was a weaker predictor. Thus, this North American cohort validated the Oxford IgAN classification and supports its utilization. Further studies are needed to determine the relationship to the impact of treatment and to define the value of the mesangial hypercellularity score.
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Affiliation(s)
- Andrew M Herzenberg
- Division of Nephrology, Toronto General Hospital, University of Toronto, Ontario, Canada
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Abstract
Despite the impressive reduction in early acute rejection rates over the past decades, chronic allograft dysfunction remains a key issue after renal transplantation. A number of factors, such as the quality of the original organ, ischemia/reperfusion injury, and/or (treated) acute rejection, will adversely affect renal structure, causing early (but often mild) tubular atrophy and interstitial fibrosis. It remains, however, controversial whether subclinical acute rejection or borderline changes imply a different functional prognosis with longer times of follow-up, if cases with late clinical acute rejection, inadequate dosing, and/or incompliance with drug prescription are excluded. Serum creatinine and immunosuppressant trough levels constitute the current standard biomarkers for assessing and renal function and systemic drug exposure, respectively. Serum creatinine is a notoriously unreliable marker for the glomerular filtration rate; changes in creatinine concentration occur late in disease progression and do not accurately represent the ongoing underlying renal damage. Trough level monitoring without information on the patient's absorption profile or the related systemic drug exposure is equally unreliable for guiding initial calcineurin inhibitor dosing or for controlling systemic drug exposure while tapering. Until more sophisticated biomarkers to guide clinical immunosupprression become available, protocol biopsies may prove to be most useful in patients with an increased risk for (late) acute rejection.
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Abstract
Chronic allograft dysfunction is associated with a variety of fibrosing/sclerosing changes in the allograft. Fibrosis is multifactorial, a final pathway following varying types of injury. Using a range of diagnostic criteria, the pathologist can and should define specific lesions enabling identification of pathogenic processes affecting the allograft. Although some cases remain 'interstitial fibrosis and tubular atrophy, no specific cause', specific diagnoses can be made in most cases. Drug toxicity, bacterial or viral infection, hypertension, obstruction, recurrent or de novo renal diseases, and acute and chronic cell- and/or antibody-mediated rejection can be diagnosed in this setting. Of particular concern is a combination of persistent inflammation and fibrosis, which has repeatedly been shown to be correlated with poor graft outcomes. Identification of ongoing activity, and the stage of evolution of fibrosis/sclerosis provides important diagnostic and therapeutic information for patient management. Histological, immunohistological, ultrastructural, and molecular studies may be needed to adequately assess the kidney in the setting of chronic allograft dysfunction. Protocol biopsies may provide diagnostic insights in early stages of late graft deterioration, or even before evident dysfunction develops.
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Halloran PF, de Freitas DG, Einecke G, Famulski KS, Hidalgo LG, MengeL M, Reeve J, Sellares J, Sis B. An integrated view of molecular changes, histopathology and outcomes in kidney transplants. Am J Transplant 2010; 10:2223-30. [PMID: 20931696 DOI: 10.1111/j.1600-6143.2010.03268.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Data-driven approaches to deteriorating kidney transplants, incorporating histologic, molecular and HLA antibody findings, have created a new understanding of transplant pathology and why transplants fail. Transplant dysfunction is best understood in terms of three elements: diseases, the active injury-repair response and the cumulative burden of injury. Progression to failure is mainly attributable to antibody-mediated rejection, nonadherence and glomerular disease. Antibody-mediated rejection usually develops late due to de novo HLA antibodies, particularly anti-class II, and is often C4d negative. Pure treated T cell-mediated rejection does not predispose to graft loss because it responds well, even with endothelialitis, but it may indicate nonadherence. The cumulative burden of injury results in atrophy-fibrosis (nephron loss), arterial fibrous intimal thickening and arteriolar hyalinosis, but these are not progressive without ongoing disease/injury, and do not explain progression. Calcineurin inhibitor toxicity has been overestimated because burden-of-injury lesions invite this default diagnosis when diseases such as antibody-mediated rejection are missed. Disease/injury triggers a stereotyped active injury-repair response, including de-differentiation, cell cycling and apoptosis. The active injury-repair response is the strongest correlate of organ function and future progression to failure, but should always prompt a search for the initiating injury or disease.
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Affiliation(s)
- P F Halloran
- Department of Medicine, Division of Nephrology & Immunology, University of Alberta, Edmonton, Canada.
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Park WD, Griffin MD, Cornell LD, Cosio FG, Stegall MD. Fibrosis with inflammation at one year predicts transplant functional decline. J Am Soc Nephrol 2010; 21:1987-97. [PMID: 20813870 DOI: 10.1681/asn.2010010049] [Citation(s) in RCA: 175] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Lack of knowledge regarding specific causes for late loss of kidney transplants hampers improvements in long-term allograft survival. Kidney transplants with both interstitial fibrosis and subclinical inflammation but not fibrosis alone after 1 year have reduced survival. This study tested whether fibrosis with inflammation at 1 year associates with decline of renal function in a low-risk cohort and characterized the nature of the inflammation. We studied 151 living-donor, tacrolimus/mycophenolate-treated recipients without overt risk factors for reduced graft survival. Transplants with normal histology (n = 86) or fibrosis alone (n = 45) on 1-year protocol biopsy had stable renal function between 1 and 5 years, whereas those with both fibrosis and inflammation (n = 20) exhibited a decline in GFR and reduced graft survival. Immunohistochemistry confirmed increased interstitial T cells and macrophages/dendritic cells in the group with both fibrosis and inflammation, and there was increased expression of transcripts related to innate and cognate immunity. Pathway- and pathologic process-specific analyses of microarray profiles revealed that potentially damaging immunologic activities were enriched among the overexpressed transcripts (e.g., Toll-like receptor signaling, antigen presentation/dendritic cell maturation, IFN-γ-inducible response, cytotoxic T lymphocyte-associated and acute rejection-associated genes). Therefore, the combination of fibrosis and inflammation in 1-year protocol biopsies associates with reduced graft function and survival as well as a rejection-like gene expression signature, even among recipients with no clinical risk factors for poor outcomes. Early interventions aimed at altering rejection-like inflammation may improve long-term survival of kidney allografts.
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Affiliation(s)
- Walter D Park
- Department of Surgery, Division of Transplantation Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Bia M, Adey DB, Bloom RD, Chan L, Kulkarni S, Tomlanovich S. KDOQI US commentary on the 2009 KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Kidney Dis 2010; 56:189-218. [PMID: 20598411 DOI: 10.1053/j.ajkd.2010.04.010] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Accepted: 04/26/2010] [Indexed: 12/14/2022]
Abstract
In response to recently published KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for the care of kidney transplant recipients (KTRs), the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) organized a working group of transplant nephrologists and surgeons to review these guidelines and comment on their relevance and applicability for US KTRs. The following commentaries on the KDIGO guidelines represent the consensus of our work group. The KDIGO transplant guidelines concentrated on aspects of transplant care most important to this population in the posttransplant period, such as immunosuppression, infection, malignancy, and cardiovascular care. Our KDOQI work group concurred with many of the KDIGO recommendations except in some important areas related to immunosuppression, in which decisions in the United States are largely made by transplant centers and are dependent in part on the specific patient population served. Most, but not all, KDIGO guidelines are relevant to US patients. However, implementation of many may remain a major challenge because of issues of limitation in resources needed to assist in the tasks of educating, counseling, and implementing and maintaining lifestyle changes. Although very few of the guidelines are based on evidence that is strong enough to justify their being used as the basis of policy or performance measures, they offer an excellent road map to navigate the complex care of KTRs.
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Affiliation(s)
- Margaret Bia
- Yale School of Medicine, New Haven, CT 06520-8029, USA
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Arndt R, Schmidt S, Loddenkemper C, Grünbaum M, Zidek W, van der Giet M, Westhoff TH. Noninvasive evaluation of renal allograft fibrosis by transient elastography--a pilot study. Transpl Int 2010; 23:871-7. [PMID: 20158692 DOI: 10.1111/j.1432-2277.2010.01057.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Chronic allograft injury (CAI) is the most common cause of graft failure after the first year of transplantation. To date, only protocol biopsies can reveal subclinical disease. Transient elastography (TE) is a novel noninvasive technique that has demonstrated high reliability in the assessment of liver fibrosis. This study evaluates the feasibility of TE for the assessment of renal allograft fibrosis. Fifty-seven patients underwent TE by the FibroScan device. Biopsies were performed in 20 patients. Measurement of parenchymal stiffness by TE was successful in 55 of 57 patients (96.5%). Stiffness was significantly correlated to the extent of interstitial fibrosis (Pearson r: 0.67, P: 0.002, R(2): 0.45) and inversely related to estimated glomerular filtration rate (eGFR) (Pearson r: -0.47, P: 0.0003, R(2): 0.22). Stiffness values of patients with an eGFR >50 ml/min were significantly lower than in patients with an eGFR < or = 50 ml/min (22.2 +/- 11.0 vs. 37.1 +/- 14.2 kPa, P: 0.0005). The stiffness values of CAI Banff grades 0-1 differed significantly from grade 2 (P: 0.008) and grade 3 (P: 0.046). Parenchymal stiffness measured by TE reflects interstitial fibrosis in kidney allografts. A longitudinal assessment of parenchymal stiffness might be a powerful tool to identify patients with CAI who benefit from biopsy and consequent adaptation of the immunosuppressive regime.
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Affiliation(s)
- Robert Arndt
- Department of Nephrology, Charité-Campus Benjamin Franklin, Berlin, Germany
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Ruiz P, Takahashi H, Delacruz V, Island E, Selvaggi G, Nishida S, Moon J, Smith L, Asaoka T, Levi D, Tekin A, Tzakis A. International Grading Scheme for Acute Cellular Rejection in Small-Bowel Transplantation: Single-Center Experience. Transplant Proc 2010; 42:47-53. [DOI: 10.1016/j.transproceed.2009.12.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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