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Kim HD, Bae H, Kang H, Lee H, Eum SH, Yang CW, Choi YJ, Chung BH, Oh EJ. Donor-derived cell-free DNA predicted allograft rejection and severe microvascular inflammation in kidney transplant recipients. Front Immunol 2024; 15:1433918. [PMID: 39044817 PMCID: PMC11263016 DOI: 10.3389/fimmu.2024.1433918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 06/25/2024] [Indexed: 07/25/2024] Open
Abstract
Introduction The aim of this study is to investigate the clinical validity of donor-derived cell-free DNA (dd-cfDNA) in comparison with that of donor specific anti-HLA antibody (DSA) for predicting biopsy-proven rejection (BPR)and severe microvascular inflammation (severe MVI) in kidney transplant recipients (KTRs). Methods In this prospective observational investigation, 64 KTRs who underwent the indicated biopsies were included. Blood samples collected prior to biopsy were tested for dd-cfDNA and DSA. Biopsy specimens were classified by a renal pathologist according to the Banff classification. The predictive performance of dd-cfDNA and DSA for histological allograft diagnosis was assessed. Results KTRs were categorized into the high and low dd-cfDNA groups based on a level of 0.4%. Eighteen patients (28.1%) had positive DSA at biopsy, exhibiting higher dd-cfDNA levels than the DSA-negative patients. BPR and severe MVI incidences were elevated in the high dd-cfDNA group (BPR: 42.9% vs. 3.4%, P <0.001; severe MVI: 37.1% vs. 3.4%, P = 0.001). Also, elevated glomerulitis and MVI scores were observed in the high dd-cfDNA group. DSA showed the highest predictive value for BPR (AUC = 0.880), whereas dd-cfDNA alone excelled in predicting severe MVI (AUC = 0.855). Combination of DSA and dd-cfDNA (>0.4%) yielded sensitivities of 80.0% and 50.0% with specificities of 90.7% and 88.0% for antibody-mediated rejection and severe MVI detection, respectively. Conclusion The dd-cfDNA test is a predictive tool for BPR and severe MVI, and it can improve the performance, especially when combined with DSA for BPR.
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Affiliation(s)
- Hyung Duk Kim
- Division of Nephrology, Department of Internal Medicine, Eunpyeoung St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyunjoo Bae
- Department of Biomedicine & Health Sciences, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyunhye Kang
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Research and Development Institute for In Vitro Diagnostic Medical Devices of Catholic University of Korea, Seoul, Republic of Korea
| | - Hanbi Lee
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Hun Eum
- Division of Nephrology, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul Woo Yang
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yeong Jin Choi
- Department of Hospital Pathology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Byung Ha Chung
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun-Jee Oh
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Research and Development Institute for In Vitro Diagnostic Medical Devices of Catholic University of Korea, Seoul, Republic of Korea
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Lin WC, Wen MC, Hsu YC, Kuo CY, Chen TD. Banff-based histologic chronicity index is associated with graft failure but has poor interobserver reproducibility. Clin Transplant 2024; 38:e15335. [PMID: 38804610 DOI: 10.1111/ctr.15335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 04/16/2024] [Accepted: 05/01/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) often leads to chronic kidney allograft damage and is a critical cause of allograft failure. The Banff classification, used to diagnose AMR, has become complex and challenging for clinicians. A Banff-based histologic chronicity index (CI) was recently proposed as a simplified prognostic indicator. Its reliability and reproducibility have not been externally validated. METHODS This study investigated 71 kidney allograft biopsies diagnosed with AMR. Interobserver reproducibility of the recently proposed CI and its components (cg, cv, ct, and ci) were assessed. The association between CI and allograft failure was analyzed, and CI cut-off values were evaluated by Cox proportional hazards regression and Kaplan-Meier estimator with log-rank test. RESULTS The study confirmed the association of CI with allograft failure, but also revealed that the assessment of CI varied between pathologists, impacting its reproducibility as a prognostic tool. Only 49 (69.0%) of the biopsies showed complete agreement on the proposed cut-off value of CI < 4 or CI ≥ 4. Furthermore, this cut-off did not reliably stratify allograft failure. Notably, the cg score, which carries significant weight in the CI calculation, had the lowest agreement between observers (kappa = .281). CONCLUSIONS While a simplified prognostic indicator for AMR is needed, this study highlights the limitations of CI, particularly its poor interobserver reproducibility. Our findings suggest that clinicians should interpret CI cautiously and consider establishing their own cut-off values. This study underscores the need to address interobserver reproducibility before CI can be widely adopted for AMR management.
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Affiliation(s)
- Wei-Chou Lin
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - Mei-Chin Wen
- Department of Pathology, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Yong-Chen Hsu
- Department of Pathology and Laboratory Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chien-Yi Kuo
- Department of Anatomic Pathology, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
| | - Tai-Di Chen
- Department of Anatomic Pathology, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
- School of Medicine, National Tsing Hua University, Hsinchu, Taiwan
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Sasaki H, Tanabe T, Tsuji T, Hotta K. Mechanism and treatment for chronic antibody-mediated rejection in kidney transplant recipients. Int J Urol 2023; 30:624-633. [PMID: 37306194 DOI: 10.1111/iju.15197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 04/11/2023] [Indexed: 06/13/2023]
Abstract
Chronic antibody-mediated rejection of kidney transplantation is a major cause of late-stage graft loss. Donor-specific antibodies are the main cause of antibody-mediated rejection; in particular, de novo donor-specific antibodies are a risk factor for chronic active antibody-mediated rejection. The level of de novo donor-specific antibodies tends to increase with time throughout long-term graft survival. Donor-specific antibodies induce humoral rejection through complement activation, which results in tissue injury and coagulation. Additionally, complement activation promotes the migration of inflammatory cells through the innate immune response, causing endothelial injury. This inflammatory response may cause persistent glomerulitis and peritubular capillaritis, leading to fixed pathological lesions that impair graft function. No treatment has been established for chronic antibody-mediated rejection, a condition in which antibody-mediated rejection becomes irreversible. Thus, antibody-mediated rejection must be detected and treated while it is still reversible. In this review, we discuss the development of de novo donor-specific antibodies and the mechanisms leading to chronic antibody-mediated rejection and summarize the current treatment options and the latest biomarkers for detecting chronic antibody-mediated rejection at an earlier stage.
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Affiliation(s)
- Hajime Sasaki
- Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University Hospital, Shimotsuke, Japan
- Department of Kidney Transplant Surgery, Sapporo City General Hospital, Sapporo, Japan
| | - Tatsu Tanabe
- Department of Kidney Transplant Surgery, Sapporo City General Hospital, Sapporo, Japan
| | - Takahiro Tsuji
- Department of Pathology, Sapporo City General Hospital, Sapporo, Japan
| | - Kiyohiko Hotta
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
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4
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Haas M, Mirocha J, Huang E, Najjar R, Peng A, Sethi S, Vo A, Anglicheau D, Jordan SC, Rabant M. A Banff-based histologic chronicity index is associated with graft loss in patients with a kidney transplant and antibody-mediated rejection. Kidney Int 2023; 103:187-195. [PMID: 36332728 DOI: 10.1016/j.kint.2022.09.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/19/2022] [Accepted: 09/16/2022] [Indexed: 11/15/2022]
Abstract
Antibody-mediated rejection (AMR) is the major cause of graft loss in kidney transplant recipients. The Banff classification defines two classes of AMR, active and chronic active but over time this classification has become increasingly complex. To simplify the approach to AMR, we developed activity and chronicity indices based on kidney transplant biopsy findings and examined their association with graft survival in 147 patients with active or chronic active AMR, all of whom had donor-specific antibodies and were treated for AMR. The activity index was determined as the sum of Banff glomerulitis (g), peritubular capillaritis (ptc), arteritis (v) and C4d scores, with a maximum score of 12. The chronicity index was the sum of interstitial fibrosis (ci), tubular atrophy (ct), chronic vasculopathy (cv), and chronic glomerulopathy (cg) scores, the latter doubled, with a maximum score of 15. While the activity index was generally not associated with graft loss, the chronicity index was significantly associated with graft loss with an optimal threshold value of 4 or greater for predicting graft loss. The association of the chronicity index of 4 or greater with graft loss was independent of other parameters associated with graft loss, including the estimated glomerular filtration rate at the time of biopsy, chronic active (versus active) AMR, AMR with de novo (versus persistent/rebound) donor-specific antibodies, Banff (g+ptc) scores, concurrent T cell-mediated rejection and donor-specific antibody reduction post-biopsy. The association of the chronicity index of 4 or greater with graft loss was confirmed in an independent cohort of 61 patients from Necker Hospital, Paris. Thus, our findings suggest that the chronicity index may be valuable as a simplified approach to decision-making in patients with AMR.
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Affiliation(s)
- Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA.
| | - James Mirocha
- General Clinical Research Center, Clinical & Translational Science Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Edmund Huang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Reiad Najjar
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Alice Peng
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Supreet Sethi
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ashley Vo
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dany Anglicheau
- Deparment of Nephrology and Kidney Transplantation, Necker-Enfants Malades Hospital, AP-HP, INSERM U1151, Université Paris Cite, Paris, France
| | - Stanley C Jordan
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Marion Rabant
- Department of Pathology, Necker-Enfants Malades Hospital, AP-HP, Université Paris Cite, Paris, France
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5
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Reis Pereira P, Ribeiro B, Oliveira J, Santos S, Pedroso S, Tafulo S, Almeida M, Dias L, Martins LS, Malheiro J. Antibody-Mediated Rejection in Kidney Transplantation: A Retrospective Study on the Impact of Donor-Specific Antibodies and on the Timing of Diagnosis. Cureus 2022; 14:e30296. [DOI: 10.7759/cureus.30296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2022] [Indexed: 11/07/2022] Open
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6
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Seitz A, Mounsey K, Hughes P, Cullen K, Welberry Smith M, Daga S, Carter C, Clark B, Baker R. Isolated Pre-existing HLA-DP Donor-Specific Antibodies are Associated With Poorer Outcomes in Renal Transplantation. Kidney Int Rep 2022; 7:2251-2263. [PMID: 36217531 PMCID: PMC9546735 DOI: 10.1016/j.ekir.2022.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 12/01/2022] Open
Abstract
Introduction The importance of donor-specific antibodies (DSAs) in renal transplantation has long been recognized, but the significance of human leukocyte antigen (HLA)-DP antibodies remains less clear. We performed a retrospective single center study of renal transplants with pre-existing isolated HLA-DP-DSAs to assess clinical outcomes. Methods Twenty-three patients with isolated HLA-DP-DSAs were compared with 3 control groups as follows: standard immunological risk (calculated reaction frequency [cRF] < 85%, no current or historical DSA, no repeat mismatched antigens with previous transplants, n = 46), highly sensitized (cRF > 85%, n = 27), and patients with HLA-DP antibodies that were not donor-specific (n = 18). Univariate and multivariate analyses were performed comparing antibody-mediated rejection (ABMR)-free and graft survival. Factors in the final multivariable models included patient group, % cRF, B-cell flow crossmatch (BFXM) positivity and regrafts. Results Over a median follow-up of 1197 days, 65% of HLA-DP-DSA patients had ABMR on indication biopsies, and 30% of HLA-DP-DSA patients lost their graft. Pre-existing HLA-DP DSAs remained the single factor associated with ABMR after multivariable analysis (hazard ratio [HR] = 9.578, P = 0.012). Patients with HLA-DP DSAs had increased microvascular scores (P = 0.0346) and worse transplant glomerulopathy (P = 0.015) on biopsy compared with the standard immunological risk group. Furthermore, flow crossmatch (FXM) positivity did not help inform on the risk of graft failure or ABMR in patients with preformed DP-DSA. Conclusion Transplants with pre-existing HLA-DP-DSAs should be considered high risk. Routine laboratory tests are unable to further risk stratify these patients. Recipients should be considered for intensified immunosuppression and closely monitored.
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Affiliation(s)
- Adrienne Seitz
- Renal Transplant Unit, St James’s University Hospital, Leeds, UK
- Transplant Immunology, St James’s University Hospital, Leeds, UK
- Correspondence: Adrienne Seitz, Renal Transplant Unit, St James's University Hospital, Leeds, UK.
| | | | - Pamela Hughes
- Transplant Immunology, St James’s University Hospital, Leeds, UK
| | - Katherine Cullen
- Transplant Immunology, St James’s University Hospital, Leeds, UK
| | | | - Sunil Daga
- Renal Transplant Unit, St James’s University Hospital, Leeds, UK
| | - Clive Carter
- Transplant Immunology, St James’s University Hospital, Leeds, UK
| | - Brendan Clark
- Transplant Immunology, St James’s University Hospital, Leeds, UK
| | - Richard Baker
- Renal Transplant Unit, St James’s University Hospital, Leeds, UK
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7
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Sazpinar O, Gaspert A, Sidler D, Rechsteiner M, Mueller TF. Histologic and Molecular Patterns in Responders and Non-responders With Chronic-Active Antibody-Mediated Rejection in Kidney Transplants. Front Med (Lausanne) 2022; 9:820085. [PMID: 35573002 PMCID: PMC9099145 DOI: 10.3389/fmed.2022.820085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/05/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionThere is no proven therapy for chronic-active antibody-mediated rejection (caABMR), the major cause of late kidney allograft failure. Histological and molecular patterns associated with possible therapy responsiveness are not known.MethodsBased on rigorous selection criteria this single center, retrospective study identified 16 out of 1027 consecutive kidney transplant biopsies taken between 2008 and 2016 with pure, unquestionable caABMR, without other pathologic features. The change in estimated GFR pre- and post-biopsy/treatment were utilized to differentiate subjects into responders and non-responders. Gene sets reflecting active immune processes of caABMR were defined a priori, including endothelial, inflammatory, cellular, interferon gamma (IFNg) and calcineurin inhibitor (CNI) related-genes based on the literature. Transcript measurements were performed in RNA extracted from stored, formalin-fixed, paraffin-embedded (FFPE) samples using NanoString™ technology. Histology and gene expression patterns of responders and non-responders were compared.ResultsA reductionist approach applying very tight criteria to identify caABMR and treatment response excluded the vast majority of clinical ABMR cases. Only 16 out of 139 cases with a written diagnosis of chronic rejection fulfilled the caABMR criteria. Histological associations with therapy response included a lower peritubular capillaritis score (p = 0.028) along with less glomerulitis. In contrast, no single gene discriminated responders from non-responders. Activated genes associated with NK cells and endothelial cells suggested lack of treatment response.ConclusionIn caABMR active microvascular injury, in particular peritubular capillaritis, differentiates treatment responders from non-responders. Transcriptome changes in NK cell and endothelial cell associated genes may further help to identify treatment response. Future prospective studies will be needed which include more subjects, who receive standardized treatment protocols to identify biomarkers for treatment response.Clinical Trial Registration[ClinicalTrials.gov], identifier [NCT03430414].
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Affiliation(s)
- Onur Sazpinar
- Clinic of Nephrology, Department of Medicine, University Hospital Zürich, Zurich, Switzerland
| | - Ariana Gaspert
- Department of Pathology and Molecular Pathology, University Hospital Zürich, Zurich, Switzerland
| | - Daniel Sidler
- Department of Nephrology and Hypertension, University Hospital Bern, Bern, Switzerland
| | - Markus Rechsteiner
- Department of Pathology and Molecular Pathology, University Hospital Zürich, Zurich, Switzerland
| | - Thomas F. Mueller
- Clinic of Nephrology, Department of Medicine, University Hospital Zürich, Zurich, Switzerland
- *Correspondence: Thomas F. Mueller,
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Halloran PF, Einecke G, Sikosana MLN, Madill-Thomsen K. The Biology and Molecular Basis of Organ Transplant Rejection. Handb Exp Pharmacol 2022; 272:1-26. [PMID: 35091823 DOI: 10.1007/164_2021_557] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Allograft rejection is defined as tissue injury in a transplanted allogeneic organ produced by the effector mechanisms of the adaptive alloimmune response. Effector T lymphocytes and IgG alloantibodies cause two different types of rejection that can occur either individually or simultaneously: T cell-mediated rejection (TCMR) and antibody-mediated rejection (ABMR). In TCMR, cognate effector T cells infiltrate the graft and orchestrate an interstitial inflammatory response in the kidney interstitium in which effector T cells engage antigen-presenting myeloid cells, activating the T cells, antigen-presenting cells, and macrophages. The result is intense expression of IFNG and IFNG-induced molecules, expression of effector T cell molecules and macrophage molecules and checkpoints, and deterioration of parenchymal function. The diagnostic lesions of TCMR follow, i.e. interstitial inflammation, parenchymal deterioration, and intimal arteritis. In ABMR, HLA IgG alloantibodies produced by plasma cells bind to the donor antigens on graft microcirculation, leading to complement activation, margination, and activation of NK cells and neutrophils and monocytes, and endothelial injury, sometimes with intimal arteritis. TCMR becomes infrequent after 5-10 years post-transplant, probably reflecting adaptive mechanisms such as checkpoints, but ABMR can present even decades post-transplant. Some rejection is triggered by inadequate immunosuppression and non-adherence, challenging the clinician to target effective immunosuppression even decades post-transplant.
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Affiliation(s)
- Philip F Halloran
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
| | - Gunilla Einecke
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Majid L N Sikosana
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Ali AA, Almukhtar SE, Abd KH, Saleem ZSM, Sharif DA, Hughson MD. The causes and frequency of kidney allograft failure in a low-resource setting: observational data from Iraqi Kurdistan. BMC Nephrol 2021; 22:272. [PMID: 34364378 PMCID: PMC8349141 DOI: 10.1186/s12882-021-02486-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 07/28/2021] [Indexed: 12/18/2022] Open
Abstract
Background In the developing world, transplantation is the most common long-term treatment for patients with end-stage renal disease, but rates and causes of graft failure are uncertain. Methods This was a retrospective outcomes study of renal transplant patients seen in Iraqi Kurdistan nephrology clinics in the year 2019. In 2019, 871 renal transplant patients were registered and outcomes followed through 12/31/2020. Indicated renal biopsies were obtained on 431 patients at 1 day to 18 years post-transplantation. Outcomes were compared with United States Renal Data System (USRDS) living donor reports. Results All donors were living. The recipient age was 38.5 ± 13.3 years, 98.2% were < 65 years old, 3.7% had previous transplants, and 2.8% had pretransplant donor-specific antibodies (DSA). Gehan-Breslow estimated failure rates for all-cause, return to HD, and death with functional graft were 6.0, 4.2, and 1.9% at 1 year and 18.1, 13.7, and 5.1% at 5 years post-engraftment (USRDS 2000; 1 year: 7.0, 5.0, 2.6%; 5 year: 22.3, 15.2, 10.6%. USRDS 2010; 1 year: 3.7, 2.4, 1.4%; 5 year: 15.3, 9.6, 7.3%). The median graft survival was 15 years. Acute tubular injury (ATI), infarction, and acute T cell-mediated rejection accounted for 22.2% of graft loss, with > 75% of these failures taking place in the first year. Most graft failures occurred late, at a median post-transplant time of 1125 (interquartile range, 365–2555) days, and consisted of interstitial fibrosis and tubular atrophy (IF/TA) (23.8%), transplant glomerulopathy (13.7%), and acquired active antibody-mediated rejection (12.0%). The significant predictors of graft loss were C4d + biopsies (P < 0.01) and advanced IF/TA (P < 0.001). Conclusions Kurdistan transplant patients had graft failure rates similar to living donors reported by the USRDS for the year 2000 but higher than reported for 2010. Compared to USRDS 2010, Kurdistan patients had a moderate excess of HD failures at one and 5 years post-engraftment. Nevertheless, prolonged survival is the norm, with chronic disorders and acquired DSA being the leading causes of graft loss.
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Affiliation(s)
- Alaa Abbas Ali
- University of Sulaimani College of Medicine, Quirga Road, Sulaimani, Iraq
| | | | - Kais H Abd
- University of Dohuk College of Medicine, Dohuk, Iraq
| | | | - Dana A Sharif
- University of Sulaimani College of Medicine, Quirga Road, Sulaimani, Iraq
| | - Michael D Hughson
- University of Sulaimani College of Medicine, Quirga Road, Sulaimani, Iraq.
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10
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Codina S, Manonelles A, Tormo M, Sola A, Cruzado JM. Chronic Kidney Allograft Disease: New Concepts and Opportunities. Front Med (Lausanne) 2021; 8:660334. [PMID: 34336878 PMCID: PMC8316649 DOI: 10.3389/fmed.2021.660334] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/10/2021] [Indexed: 12/12/2022] Open
Abstract
Chronic kidney disease (CKD) is increasing in most countries and kidney transplantation is the best option for those patients requiring renal replacement therapy. Therefore, there is a significant number of patients living with a functioning kidney allograft. However, progressive kidney allograft functional deterioration remains unchanged despite of major advances in the field. After the first post-transplant year, it has been estimated that this chronic allograft damage may cause a 5% graft loss per year. Most studies focused on mechanisms of kidney graft damage, especially on ischemia-reperfusion injury, alloimmunity, nephrotoxicity, infection and disease recurrence. Thus, therapeutic interventions focus on those modifiable factors associated with chronic kidney allograft disease (CKaD). There are strategies to reduce ischemia-reperfusion injury, to improve the immunologic risk stratification and monitoring, to reduce calcineurin-inhibitor exposure and to identify recurrence of primary renal disease early. On the other hand, control of risk factors for chronic disease progression are particularly relevant as kidney transplantation is inherently associated with renal mass reduction. However, despite progress in pathophysiology and interventions, clinical advances in terms of long-term kidney allograft survival have been subtle. New approaches are needed and probably a holistic view can help. Chronic kidney allograft deterioration is probably the consequence of damage from various etiologies but can be attenuated by kidney repair mechanisms. Thus, besides immunological and other mechanisms of damage, the intrinsic repair kidney graft capacity should be considered to generate new hypothesis and potential therapeutic targets. In this review, the critical risk factors that define CKaD will be discussed but also how the renal mechanisms of regeneration could contribute to a change chronic kidney allograft disease paradigm.
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Affiliation(s)
- Sergi Codina
- Department of Nephrology, Hospital Universitari Bellvitge, Barcelona, Spain
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Anna Manonelles
- Department of Nephrology, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Maria Tormo
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Anna Sola
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Josep M. Cruzado
- Department of Nephrology, Hospital Universitari Bellvitge, Barcelona, Spain
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
- Department of Clinical Sciences, University of Barcelona, Barcelona, Spain
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11
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Zhang Q, Budde K, Schmidt D, Halleck F, Duerr M, Naik MG, Mayrdorfer M, Duettmann W, Klauschen F, Rudolph B, Wu K. Clinicopathologic Features and Risk Factors of Proteinuria in Transplant Glomerulopathy. Front Med (Lausanne) 2021; 8:666319. [PMID: 34277656 PMCID: PMC8283120 DOI: 10.3389/fmed.2021.666319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 06/01/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Transplant glomerulopathy (TG) is one of the main causes of post-transplant proteinuria (PU). The features and possible risk factors for proteinuria in TG patients are uncertain. Methods: We investigated all patients who had biopsy-proven TG from 2000 to 2018 in our center. The clinical and histological data were compared between two groups with or without PU (cut-off = 0.3 g/day). Spearman correlation analysis was used to evaluate the relationship between PU and pathological changes. The risk factors for PU in TG patients were determined by multivariable logistic regression analysis. Results: One hundred and twenty-five (75.76%) of all enrolled 165 TG patients had proteinuria ≥0.3 g/day at the time of biopsy. TG patients' PU level was significantly correlated with Banff lesion score cg (ρ = 0.247, P = 0.003), and mm (ρ = 0.257, P = 0.012). Systolic blood pressure ≥140 mmHg (OR 2.72, 95% CI 1.04–7.10, P = 0.041), diastolic blood pressure ≥90 mmHg (OR 4.84, 95% CI 1.39–16.82, P = 0.013), peak PRA ≥5% (OR 6.47, 95% CI 1.67–25.01, P = 0.007), positive C4d staining (OR 4.55, 95% CI 1.29–16.11, 0.019), tacrolimus-based regimen (OR 3.5, 95% CI 1.28–9.54, P = 0.014), and calcium channel blocker usage (OR 4.38, 95% CI 1.59–12.09, P = 0.004) were independent risk factors for PU. Conclusions: Proteinuria is common in TG patients. systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg, peak PRA ≥5%, positive C4d staining, tacrolimus-based regimen, and calcium channel blocker usage are associated with proteinuria in TG patients.
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Affiliation(s)
- Qiang Zhang
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Organ Transplant, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Danilo Schmidt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Duerr
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Marcel G Naik
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Manuel Mayrdorfer
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Wiebke Duettmann
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Frederick Klauschen
- Department of Pathology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Birgit Rudolph
- Department of Pathology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Kaiyin Wu
- Department of Pathology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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12
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Coemans M, Senev A, Van Loon E, Lerut E, Sprangers B, Kuypers D, Emonds MP, Verbeke G, Naesens M. The evolution of histological changes suggestive of antibody-mediated injury, in the presence and absence of donor-specific anti-HLA antibodies. Transpl Int 2021; 34:1824-1836. [PMID: 34197662 DOI: 10.1111/tri.13964] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/01/2021] [Accepted: 06/27/2021] [Indexed: 11/26/2022]
Abstract
The interplay between donor-specific anti-HLA antibodies (HLA-DSA), histology of active antibody-mediated rejection (aABMRh ), transplant glomerulopathy (cg) and graft failure in kidney transplantation remains insufficiently understood. We performed a single-center cohort study (n=1000) including 2761 protocol and 833 indication biopsies. Patients with pre-transplant HLA-DSA were more prone to develop aABMRh (OR 22.7, 95% CI, 11.8 - 43.7, p<0.001), cg (OR 5.76, 95% CI, 1.67 - 19.8, p=0.006) and aABMRh/cg (OR 19.5, 95% CI, 10.6 - 35.9, p<0.001). The negative impact of pre-transplant HLA-DSA on graft survival (HR 2.12, 95% CI, 1.41 - 3.20, p<0.001) was partially mediated through aABMRh and cg occurrence. When adjusted for time-dependent HLA-DSA (HR 4.03, 95% CI, 2.21 - 7.15, p=0.002), graft failure was only affected by aABMRh when cg was evident. In HLA-DSA negative patients, aABMRh was associated with impaired graft outcome only when evolving to cg (HR 1.32, 95% CI, 1.07 - 1.61, p=0.008). We conclude that the kinetics of HLA-DSA are important to estimate the rate of graft failure, and that histological follow-up is necessary to discover, often subclinical, ABMR and cg. In the absence of HLA-DSA, patients experience similar histological lesions and the evolution to transplant glomerulopathy associates with impaired graft outcome.
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Affiliation(s)
- Maarten Coemans
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Leuven Biostatistics and Statistical Bioinformatics Centre (L-BioStat), Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Aleksandar Senev
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Elisabet Van Loon
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Evelyne Lerut
- Department of Imaging & Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Dirk Kuypers
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Marie-Paule Emonds
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Geert Verbeke
- Leuven Biostatistics and Statistical Bioinformatics Centre (L-BioStat), Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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13
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Gibson IW. Transplant Glomerulopathy: Importance of Ultrastructural Examination. GLOMERULAR DISEASES 2021; 1:68-81. [PMID: 36751426 PMCID: PMC9677739 DOI: 10.1159/000513522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 11/29/2020] [Indexed: 11/19/2022]
Abstract
Background Transplant glomerulopathy (TG) is a morphologic alteration in glomeruli of renal allografts, characterized by glomerular basement membrane reduplications. Summary TG is associated with progressive chronic allograft dysfunction and proteinuria and is a diagnostic feature of chronic antibody-mediated rejection (ABMR) in patients positive for donor-specific antibodies, according to the Banff schema for renal allograft pathology. It is a definitive endpoint in clinical trials and interventional studies for ABMR, but the lesion can also occur in the absence of definitive alloimmune injury, as a consequence of chronic thrombotic microangiopathy, and in some cases in association with hepatitis C infection. This review discusses the pathophysiology and clinical presentation of TG, the diagnostic features by light microscopy, and focuses on the sequential ultrastructural stages of the lesion. The differential diagnosis of TG, and Banff grading of the lesion, are reviewed. Clinicopathological indications for performing routine ultrastructural examination of renal allograft biopsies are discussed. Key Messages TG can be diagnosed at an early stage by electron microscopy, before histological features are apparent, emphasizing the importance of ultrastructural examination of renal allograft biopsies for an early diagnosis, when therapeutic intervention may be beneficial.
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Affiliation(s)
- Ian W. Gibson
- *Ian W. Gibson, Department of Pathology, MS-336C Electron Microscopy Lab, Health Sciences Centre, University of Manitoba, 820 Sherbrook Street, Winnipeg, MB R3A1R9 (Canada),
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14
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Hundemer GL, Srivastava A, Jacob KA, Krishnasamudram N, Ahmed S, Boerger E, Sharma S, Pokharel KK, Hirji SA, Pelletier M, Safa K, Kulvichit W, Kellum JA, Riella LV, Leaf DE. Acute kidney injury in renal transplant recipients undergoing cardiac surgery. Nephrol Dial Transplant 2021; 36:185-196. [PMID: 32892219 DOI: 10.1093/ndt/gfaa063] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a key risk factor for chronic kidney disease in the general population, but has not been investigated in detail among renal transplant recipients (RTRs). We investigated the incidence, severity and risk factors for AKI following cardiac surgery among RTRs compared with non-RTRs with otherwise similar clinical characteristics. METHODS We conducted a retrospective cohort study of RTRs (n = 83) and non-RTRs (n = 83) who underwent cardiac surgery at two major academic medical centers. Non-RTRs were matched 1:1 to RTRs by age, preoperative (preop) estimated glomerular filtration rate and type of cardiac surgery. We defined AKI according to Kidney Disease: Improving Global Outcomes criteria. RESULTS RTRs had a higher rate of AKI following cardiac surgery compared with non-RTRs [46% versus 28%; adjusted odds ratio 2.77 (95% confidence interval 1.36-5.64)]. Among RTRs, deceased donor (DD) versus living donor (LD) status, as well as higher versus lower preop calcineurin inhibitor (CNI) trough levels, were associated with higher rates of AKI (57% versus 33% among DD-RTRs versus LD-RTRs; P = 0.047; 73% versus 36% among RTRs with higher versus lower CNI trough levels, P = 0.02). The combination of both risk factors (DD status and higher CNI trough level) had an additive effect (88% AKI incidence among patients with both risk factors versus 25% incidence among RTRs with neither risk factor, P = 0.004). CONCLUSIONS RTRs have a higher risk of AKI following cardiac surgery compared with non-RTRs with otherwise similar characteristics. Among RTRs, DD-RTRs and those with higher preop CNI trough levels are at the highest risk.
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Affiliation(s)
- Gregory L Hundemer
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Division of Nephrology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Anand Srivastava
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kirolos A Jacob
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Neeraja Krishnasamudram
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Salman Ahmed
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Emily Boerger
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shreyak Sharma
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kapil K Pokharel
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sameer A Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marc Pelletier
- Division of Cardiac Surgery, University Hospitals, Case Western Reserve University, Cleveland, OH, USA
| | - Kassem Safa
- Transplant Center and Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Win Kulvichit
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
| | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leonardo V Riella
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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15
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Senev A, Van Loon E, Lerut E, Callemeyn J, Coemans M, Van Sandt V, Kuypers D, Emonds MP, Naesens M. Risk factors, histopathological features, and graft outcome of transplant glomerulopathy in the absence of donor-specific HLA antibodies. Kidney Int 2021; 100:401-414. [PMID: 33675843 DOI: 10.1016/j.kint.2021.01.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 01/18/2021] [Accepted: 01/28/2021] [Indexed: 01/07/2023]
Abstract
Transplant glomerulopathy is established as a hallmark of chronic antibody-mediated rejection in kidney transplant patients with donor-specific HLA antibodies (HLA-DSA). The clinical importance of transplant glomerulopathy in the absence of HLA-DSA is not well established. To help define this, 954 patients (encompassing 3744 biopsies) who underwent kidney transplantation 2004-2013 were studied with retrospective high-resolution HLA genotyping of both donors and recipients. The risk factors, histopathological appearance and prognosis of cases with transplant glomerulopathy in the absence of HLA-DSA were compared to those cases with HLA-DSA, and the impact of the PIRCHE-II score and eplet mismatches on development of transplant glomerulopathy evaluated. In this cohort, 10.3% developed transplant glomerulopathy, on average 3.2 years post-transplant. At the time of glomerulopathy, 23.5% had persistent pre-transplant or de novo HLA-DSA, while 76.5% were HLA-DSA negative. Only HLA-DSA was identified as a risk factor for glomerulopathy development as eplet mismatches and the PIRCHE-II score did not associate. HLA-DSA negative biopsies with glomerulopathy had less interstitial inflammation, less glomerulitis, and less C4d deposition in the peritubular capillaries compared to the HLA-DSA positive biopsies with glomerulopathy. While graft function was comparable between the two groups, HLA-DSA positive glomerulopathy was associated with a significantly higher risk of graft failure compared to HLA-DSA negative glomerulopathy (Hazard Ratio 3.84; 95% confidence interval 1.94-7.59). Landmark analysis three-years post-transplant showed that HLA-DSA negative patients with glomerulopathy still had a significant increased risk of graft failure compared to patients negative for glomerulopathy (2.62; 1.46-4.72). Thus, transplant glomerulopathy often occurs in the absence of HLA-DSA, independent of HLA molecular mismatches, and represents a different phenotype with less concomitant inflammation and better graft survival compared to that developed in the presence of HLA-DSA.
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Affiliation(s)
- Aleksandar Senev
- KU Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven University, Leuven, Belgium; Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Elisabet Van Loon
- KU Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven University, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Evelyne Lerut
- Department of Imaging and Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Jasper Callemeyn
- KU Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven University, Leuven, Belgium
| | - Maarten Coemans
- KU Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven University, Leuven, Belgium
| | - Vicky Van Sandt
- Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Dirk Kuypers
- KU Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven University, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Marie-Paule Emonds
- KU Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven University, Leuven, Belgium; Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Maarten Naesens
- KU Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven University, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.
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16
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Okada M, Tomosugi T, Futamura K, Hiramitsu T, Goto N, Narumi S, Takeda A, Watarai Y. Mid-Term Outcomes After Treatment for Antibody-Mediated Rejection by De Novo Donor-Specific HLA Antibody in Renal Transplant Recipients: Does Early Treatment Lead to Better Outcomes? Transplant Proc 2020; 52:3051-3057. [PMID: 32694058 DOI: 10.1016/j.transproceed.2020.06.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/15/2020] [Accepted: 06/04/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND De novo donor-specific HLA antibody (DSA) and antibody-mediated rejection (ABMR) are strongly associated with late allograft loss in renal transplant recipients. However, the impact of therapeutic intervention with the current treatment options for ABMR remains unclear. This study aimed to elucidate the efficacy of treatment for ABMR. METHODS Sixty-seven patients who had de novo DSAs underwent diagnostic biopsy for ABMR, and these patients were classified into 3 groups: ABMR-free group (n = 40), clinical ABMR group (n = 15), and subclinical ABMR group (n = 12). The ABMR-positive groups were treated mainly with double-filtration plasmapheresis followed by rituximab and corticosteroid pulse. The patient characteristics and graft outcomes were compared between groups. RESULTS The clinical and subclinical ABMR groups were younger and had a higher number and mean fluorescence intensity (MFI) of de novo DSAs than the ABMR-free group. The graft survival in the clinical ABMR group was significantly lower than that in the ABMR-free group, but the subclinical ABMR group had a surprisingly good graft survival rate compared to the ABMR-free group (43.3% vs 100% vs 94.2% 5 years after diagnostic biopsy in the clinical ABMR, subclinical ABMR, and ABMR-free groups, respectively, P < .001). CONCLUSIONS Our findings indicated that early therapeutic intervention for patients with de novo DSAs may improve graft survival.
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Affiliation(s)
- Manabu Okada
- Department of Transplant and Endocrine Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, Nagoya, Japan.
| | - Toshihide Tomosugi
- Department of Transplant and Endocrine Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Kenta Futamura
- Department of Transplant and Endocrine Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takahisa Hiramitsu
- Department of Transplant and Endocrine Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Norihiko Goto
- Department of Transplant and Endocrine Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Shunji Narumi
- Department of Transplant and Endocrine Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Asami Takeda
- Department of Nephrology, Kidney Disease Center, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Yoshihiko Watarai
- Department of Transplant and Endocrine Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, Nagoya, Japan
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17
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Magnetic Resonance Imaging for Evaluation of Interstitial Fibrosis in Kidney Allografts. Transplant Direct 2020; 6:e577. [PMID: 33134501 PMCID: PMC7581173 DOI: 10.1097/txd.0000000000001009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/28/2020] [Indexed: 12/16/2022] Open
Abstract
Supplemental Digital Content is available in the text. Interstitial fibrosis (IF) is the common pathway of chronic kidney injury in various conditions. Magnetic resonance imaging (MRI) may be a promising tool for the noninvasive assessment of IF in renal allografts.
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18
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Parajuli S, Aziz F, Garg N, Panzer SE, Joachim E, Muth B, Mohamed M, Blazel J, Zhong W, Astor BC, Mandelbrot DA, Djamali A. Histopathological characteristics and causes of kidney graft failure in the current era of immunosuppression. World J Transplant 2019; 9:123-133. [PMID: 31750089 PMCID: PMC6851501 DOI: 10.5500/wjt.v9.i6.123] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/17/2019] [Accepted: 10/02/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The histopathological findings on the failing kidney allograft in the modern era is not well studied. In this study, we present our experience working with kidney transplant recipients with graft failure within one year of the biopsy. AIM To report the histopathological characteristics of failed kidney allografts in the current era of immunosuppression based on the time after transplant, cause of the end-stage renal disease and induction immunosuppressive medications. METHODS In a single-center observational study, we characterized the histopathological findings of allograft biopsies in kidney transplant recipients with graft failure within one year after the biopsy. RESULTS We identified 329 patients with graft failure that met the selection criteria between January 1, 2006 and December 31, 2016. The three most common biopsy findings were interstitial fibrosis and tubular atrophy (IFTA, 53%), acute rejection (AR, 43%) and transplant glomerulopathy (TG, 33%). Similarly, the three most common causes of graft failure based on the primary diagnosis were AR (40%), TG (17%), and IFTA (13%). Most grafts failed within two years of post-transplant (36%). Subsequently, approximately 10%-15% of grafts failed every two years: > 2-4 years (16%), > 4-6 years (13%), > 6-8 years (11%), > 8-10 years (9%) and > 10 years (16%). AR was the most common cause of graft failure in the first six years (48%), whereas TG was the most prevalent cause of graft failure after 6 years (32%) of transplant. CONCLUSION In the current era of immunosuppression, AR is still the most common cause of early graft failure, while TG is the most prevalent cause of late graft failure.
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Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Sarah E Panzer
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Emily Joachim
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Brenda Muth
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Maha Mohamed
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Justin Blazel
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin, Madison, WI 53705, United States
| | - Brad C Astor
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
- Department of Population Health Sciences, University of Wisconsin, Madison, WI 53705, United States
| | - Didier A Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
- Division of Transplantation, Department of Surgery, University of Wisconsin, Madison, WI 53705, United States
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19
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Banff lesions and renal allograft survival in chronic-active antibody mediated rejection. Transpl Immunol 2019; 56:101213. [DOI: 10.1016/j.trim.2019.101213] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/28/2019] [Accepted: 07/02/2019] [Indexed: 01/05/2023]
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20
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Grodsky JD, Craver RD, Ashoor IF. Early identification of transplant glomerulopathy in pediatric kidney transplant biopsies: A single-center experience with electron microscopy analysis. Pediatr Transplant 2019; 23:e13459. [PMID: 31062922 DOI: 10.1111/petr.13459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 02/09/2019] [Accepted: 04/03/2019] [Indexed: 01/06/2023]
Abstract
Banff 2013 criteria recommend performing ultrastructural studies with electron microscopy (EM) in kidney transplant biopsies if the technology is available. We sought to determine the impact of EM on enhancing diagnostic findings in pediatric kidney transplant biopsies and the prognostic information gained from the additional findings. All kidney transplant biopsies since routine EM use started on June 1, 2014, until October 31, 2016, were reviewed. Primary outcome measures included the positive yield frequency of EM use defined as an upgraded diagnosis based on EM findings relative to light microscopy, and 12-month kidney allograft outcome of progression to ESRD or doubling of serum creatinine stratified by transplant glomerulopathy (TG) status on EM. Eighty unique kidney transplant biopsies were reviewed. EM studies were completed for 61 biopsies (76%). Complication rate was low (3.7%). In 61 biopsies where EM was completed, EM findings included foot process fusion (62%), endothelial cell swelling (38%), subendothelial lucencies (31%), and glomerular basement membrane duplication (41%). EM confirmed FSGS recurrence in three cases. In the remaining 58 cases, there was a positive yield of 31% where 18 biopsies were upgraded to a worse category after TG identification on EM. Kidney allograft outcome was poor regardless whether TG was detected early on EM or advanced on LM. Routine EM use in analyzing pediatric kidney transplant biopsies proved safe and provided valuable additional diagnostic information in almost one-third of cases. Additional studies are needed to determine if clinical interventions for early TG identified on EM can improve long-term outcomes.
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Affiliation(s)
- Jacob D Grodsky
- Louisiana State University Health Sciences Center New Orleans, New Orleans, Louisiana
| | - Randall D Craver
- Pathology, Louisiana State University Health Sciences Center New Orleans, New Orleans, Louisiana
| | - Isa F Ashoor
- Pediatrics, Louisiana State University Health Sciences Center New Orleans, New Orleans, Louisiana
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21
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Treatment with intravenous immunoglobulins and methylprednisolone may significantly decrease loss of renal function in chronic-active antibody-mediated rejection. BMC Nephrol 2019; 20:218. [PMID: 31200654 PMCID: PMC6567552 DOI: 10.1186/s12882-019-1385-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 05/15/2019] [Indexed: 02/06/2023] Open
Abstract
Background Chronic-active antibody mediated rejection (c-aABMR) is a major contributor to long-term kidney allograft loss. We conducted a retrospective analysis to establish the efficacy of treatment with intravenous immunoglobulins (IVIG) and pulse methylprednisolone (MP) of patients with c-aABMR. Methods Sixty-nine patients, in the period 2005–2017, with the diagnosis (suspicious for) c-aABMR that were treated with IVIG and MP were included. Patients were administered three doses of 1 g intravenous MP combined with a single dose of IVIG (1 g/kg body weight). Primary outcome was the decline in allograft function one year post treatment. Responders to IVIG-MP therapy were defined by an eGFR one year after treatment which was at least 25% above the projected allograft function. Results Patients showed an average decline in eGFR of 9.8 ml/min/1.73m2 the year prior to treatment. Following treatment, a significant reduction (p < 0.001) in eGFR decline was observed (6.3 ml/min/1.73m2). Furthermore, a significant improvement in proteinuria was observed upon treatment (p < 0.001). Sixty-two percent (n = 43) of the patients were considered a responder and showed considerable slowing of graft function deterioration in the year after treatment (p < 0.001). Three and 5-year graft survival was significantly superior in responders. Conclusions More than 60% of patients with c-aABMR with a progressive decline in eGFR respond favorably to treatment with IVIG-MP resulting in a significant improvement of graft survival (Sablik, Am J Transplant 18, 2018). Electronic supplementary material The online version of this article (10.1186/s12882-019-1385-z) contains supplementary material, which is available to authorized users.
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22
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Sablik KA, Litjens NH, Klepper M, Betjes MG. Increased CD16 expression on NK cells is indicative of antibody-dependent cell-mediated cytotoxicity in chronic-active antibody-mediated rejection. Transpl Immunol 2019; 54:52-58. [DOI: 10.1016/j.trim.2019.02.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 02/11/2019] [Accepted: 02/12/2019] [Indexed: 01/01/2023]
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23
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Böhmig GA, Eskandary F, Doberer K, Halloran PF. The therapeutic challenge of late antibody-mediated kidney allograft rejection. Transpl Int 2019; 32:775-788. [PMID: 30955215 PMCID: PMC6850109 DOI: 10.1111/tri.13436] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/06/2019] [Accepted: 04/01/2019] [Indexed: 01/01/2023]
Abstract
Late antibody‐mediated rejection (ABMR) is a cardinal cause of kidney allograft failure, manifesting as a continuous and, in contrast with early rejection, often clinically silent alloimmune process. While significant progress has been made towards an improved understanding of its molecular mechanisms and the definition of diagnostic criteria, there is still no approved effective treatment. In recent small randomized controlled trials, therapeutic strategies with promising results in observational studies, such as proteasome inhibitor bortezomib, anti‐C5 antibody eculizumab, or high dose intravenous immunoglobulin plus rituximab, had no significant impact in late and/or chronic ABMR. Such disappointing results reinforce a need of new innovative treatment strategies. Potential candidates may be the interference with interleukin‐6 to modulate B cell alloimmunity, or innovative compounds that specifically target antibody‐producing plasma cells, such as antibodies against CD38. Given the phenotypic heterogeneity of ABMR, the design of adequate systematic trials to assess the safety and efficiency of such therapies, however, is challenging. Several trials are currently being conducted, and new developments will hopefully provide us with effective ways to counteract the deleterious impact of antibody‐mediated graft injury. Meanwhile, the weight of evidence would suggest that, when approaching using existing treatments for established antibody‐mediated rejection, “less may be more”.
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Affiliation(s)
- Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Konstantin Doberer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Philip F Halloran
- Alberta Transplant Applied Genomics Centre (ATAGC), University of Alberta, Edmonton, AB, Canada
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24
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Long-Term Outcomes among Kidney Transplant Recipients and after Graft Failure: A Single-Center Cohort Study in Brazil. BIOMED RESEARCH INTERNATIONAL 2019; 2019:7105084. [PMID: 31061825 PMCID: PMC6466891 DOI: 10.1155/2019/7105084] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 03/12/2019] [Accepted: 03/14/2019] [Indexed: 12/29/2022]
Abstract
Background The results of kidney transplantation are impacted by the categories of events responsible for patient death and graft failure. The objective of this study was to evaluate the causes of death and graft failure and outcomes after graft failure among kidney transplant recipients. Methodology A retrospective cohort study was conducted with 944 patients who underwent kidney transplantation. Outcomes were categorized in a managed and hierarchical manner. Results The crude mortality rate was 10.8% (n=102): in 35.3% cause of death was infection, in 30.4% cardiovascular disease, and in 15.7% neoplasia and in 6.8%, it was not possible to determine the cause of death. The rate of graft loss was 10.6%. The main causes of graft failure were chronic rejection (40%), acute rejection (18.3%), thrombosis (17.3%), and recurrence of primary disease (16.5%). Failures due to an acute rejection occurred earlier than those due to chronic rejection and recurrence (p<0.0001). As late causes of graft loss, death with the functioning kidney occurred earlier than recurrence and chronic rejection (p=0.008). The outcomes after graft failure were retransplantation in 26.1% and death in 21.4%, at a mean of 25.5 and 21.4 months, respectively. Conclusion It was possible to identify more than 90% of the events responsible for the deaths of transplanted patients, predominantly infectious and cardiovascular diseases. Among the causes of graft failure, chronic and acute rejections and recurrence were the main causes of graft failure which were followed more frequently by retransplantation than by death on dialysis.
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25
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Yamashita M, Haas M. Transplant Glomerulopathy With Glomerular C3 Deposits: Why the Worse Outcome? Kidney Int Rep 2019; 4:516-519. [PMID: 30993226 PMCID: PMC6451154 DOI: 10.1016/j.ekir.2019.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Michifumi Yamashita
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
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26
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Aubert O, Higgins S, Bouatou Y, Yoo D, Raynaud M, Viglietti D, Rabant M, Hidalgo L, Glotz D, Legendre C, Delahousse M, Shah N, Sis B, Campbell P, Mengel M, Jouven X, Duong Van Huyen JP, Lefaucheur C, Loupy A. Archetype Analysis Identifies Distinct Profiles in Renal Transplant Recipients with Transplant Glomerulopathy Associated with Allograft Survival. J Am Soc Nephrol 2019; 30:625-639. [PMID: 30872323 DOI: 10.1681/asn.2018070777] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 01/24/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Transplant glomerulopathy, a common glomerular lesion observed after kidney transplant that is associated with poor prognosis, is not a specific entity but rather the end stage of overlapping disease pathways. Its heterogeneity has not been precisely characterized to date. METHODS Our study included consecutive kidney transplant recipients from three centers in France and one in Canada who presented with a diagnosis of transplant glomerulopathy (Banff cg score ≥1 by light microscopy), on the basis of biopsies performed from January of 2004 through December of 2014. We used an unsupervised archetype analysis of comprehensive pathology findings and clinical, immunologic, and outcome data to identify distinct groups of patients. RESULTS Among the 8207 post-transplant allograft biopsies performed during the inclusion period, we identified 552 biopsy samples (from 385 patients) with transplant glomerulopathy (incidence of 6.7%). The median time from transplant to transplant glomerulopathy diagnosis was 33.18 months. Kidney allograft survival rates at 3, 5, 7, and 10 years after diagnosis were 69.4%, 57.1%, 43.3%, and 25.5%, respectively. An unsupervised learning method integrating clinical, functional, immunologic, and histologic parameters revealed five transplant glomerulopathy archetypes characterized by distinct functional, immunologic, and histologic features and associated causes and distinct allograft survival profiles. These archetypes showed significant differences in allograft outcomes, with allograft survival rates 5 years after diagnosis ranging from 88% to 22%. Based on those results, we built an online application, which can be used in clinical practice on the basis of real patients. CONCLUSIONS A probabilistic data-driven archetype analysis approach applied in a large, well defined multicenter cohort refines the diagnostic and prognostic features associated with cases of transplant glomerulopathy. Reducing heterogeneity among such cases can improve disease characterization, enable patient-specific risk stratification, and open new avenues for archetype-based treatment strategies and clinical trials optimization.
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Affiliation(s)
- Olivier Aubert
- Paris Translational Research Center for Organ Transplantation, Institut national de la santé et de la recherche médicale, Unité mixte de recherche-S970, Paris, France.,Paris Cite and Kidney Transplantation Department, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University Sorbonne, Paris, France
| | - Sarah Higgins
- Paris Translational Research Center for Organ Transplantation, Institut national de la santé et de la recherche médicale, Unité mixte de recherche-S970, Paris, France.,Department of Nephrology, Sherbrooke University, Sherbrooke, Québec, Canada
| | - Yassine Bouatou
- Paris Translational Research Center for Organ Transplantation, Institut national de la santé et de la recherche médicale, Unité mixte de recherche-S970, Paris, France.,Department of Pathology, Academic Medical Center-University of Amsterdam, Amsterdam, The Netherlands.,Department of Nephrology and Organ Transplantation, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Daniel Yoo
- Paris Translational Research Center for Organ Transplantation, Institut national de la santé et de la recherche médicale, Unité mixte de recherche-S970, Paris, France
| | - Marc Raynaud
- Paris Translational Research Center for Organ Transplantation, Institut national de la santé et de la recherche médicale, Unité mixte de recherche-S970, Paris, France
| | - Denis Viglietti
- Paris Translational Research Center for Organ Transplantation, Institut national de la santé et de la recherche médicale, Unité mixte de recherche-S970, Paris, France.,Department of Nephrology and Organ Transplantation, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marion Rabant
- Department of Pathology, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Luis Hidalgo
- Department of Laboratory Medicine and Pathology and
| | - Denis Glotz
- Paris Translational Research Center for Organ Transplantation, Institut national de la santé et de la recherche médicale, Unité mixte de recherche-S970, Paris, France.,Department of Nephrology and Organ Transplantation, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Christophe Legendre
- Paris Translational Research Center for Organ Transplantation, Institut national de la santé et de la recherche médicale, Unité mixte de recherche-S970, Paris, France.,Paris Cite and Kidney Transplantation Department, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University Sorbonne, Paris, France
| | - Michel Delahousse
- Department of Transplantation, Nephrology and Clinical Immunology, Hôpital Foch, Suresnes, France; and
| | - Nikhil Shah
- Division of Nephrology and Transplant Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Banu Sis
- Department of Laboratory Medicine and Pathology and
| | - Patricia Campbell
- Department of Laboratory Medicine and Pathology and.,Division of Nephrology and Transplant Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Xavier Jouven
- Paris Translational Research Center for Organ Transplantation, Institut national de la santé et de la recherche médicale, Unité mixte de recherche-S970, Paris, France.,Department of Cardiology, Georges Pompidou European Hospital, Paris, France
| | - Jean-Paul Duong Van Huyen
- Paris Translational Research Center for Organ Transplantation, Institut national de la santé et de la recherche médicale, Unité mixte de recherche-S970, Paris, France.,Department of Pathology, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Carmen Lefaucheur
- Paris Translational Research Center for Organ Transplantation, Institut national de la santé et de la recherche médicale, Unité mixte de recherche-S970, Paris, France.,Department of Nephrology and Organ Transplantation, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, Institut national de la santé et de la recherche médicale, Unité mixte de recherche-S970, Paris, France; .,Paris Cite and Kidney Transplantation Department, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University Sorbonne, Paris, France
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27
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Goutaudier V, Perrochia H, Mucha S, Bonnet M, Delmas S, Garo F, Garrigue V, Lepreux S, Pernin V, Serre JE, Szwarc I, Merville P, Ramounau-Pigot A, René C, Visentin J, Morgan BP, Frémeaux-Bacchi V, Mourad G, Couzi L, Le Quintrec M. C5b9 Deposition in Glomerular Capillaries Is Associated With Poor Kidney Allograft Survival in Antibody-Mediated Rejection. Front Immunol 2019; 10:235. [PMID: 30906289 PMCID: PMC6418012 DOI: 10.3389/fimmu.2019.00235] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/28/2019] [Indexed: 12/17/2022] Open
Abstract
C4d deposition in peritubular capillaries (PTC) reflects complement activation in antibody-mediated rejection (ABMR) of kidney allograft. However, its association with allograft survival is controversial. We hypothesized that capillary deposition of C5b9-indicative of complement-mediated injury-is a severity marker of ABMR. This pilot study aimed to determine the frequency, location and prognostic impact of these deposits in ABMR. We retrospectively selected patients diagnosed with ABMR in two French transplantation centers from January 2005 to December 2014 and performed C4d and C5b9 staining by immunohistochemistry. Fifty-four patients were included. Median follow-up was 52.5 (34.25-73.5) months. Thirteen patients (24%) had C5b9 deposits along glomerular capillaries (GC). Among these, seven (54%) had a global and diffuse staining pattern. Twelve of the C5b9+ patients also had deposition of C4d in GC and PTC. C4d deposits along GC and PTC were not associated with death-censored allograft survival (p = 0.42 and 0.69, respectively). However, death-censored allograft survival was significantly lower in patients with global and diffuse deposition of C5b9 in GC than those with a segmental pattern or no deposition (median survival after ABMR diagnosis, 6 months, 40.5 months and 44 months, respectively; p = 0.015). Double contour of glomerular basement membrane was diagnosed earlier after transplantation in C5b9+ ABMR than in C5b9- ABMR (median time after transplantation, 28 vs. 85 months; p = 0.058). In conclusion, we identified a new pattern of C5b9+ ABMR, associated with early onset of glomerular basement membrane duplication and poor allograft survival. Complement inhibitors might be a therapeutic option for this subgroup of patients.
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Affiliation(s)
- Valentin Goutaudier
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France
| | - Hélène Perrochia
- Department of Pathology, Gui de Chauliac Hospital, Montpellier University Hospital, Montpellier, France
| | - Simon Mucha
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin Hospital, Bordeaux University Hospital, Bordeaux, France
| | - Marie Bonnet
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France
| | - Sylvie Delmas
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France
| | - Florian Garo
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France
| | - Valérie Garrigue
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France
| | - Sébastien Lepreux
- Department of Pathology, Pellegrin Hospital, Bordeaux University Hospital, Bordeaux, France
| | - Vincent Pernin
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France.,INSERM U1183, Institute for Regenerative Medicine and Biotherapy, Saint-Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Jean-Emmanuel Serre
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France
| | - Ilan Szwarc
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France
| | - Pierre Merville
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin Hospital, Bordeaux University Hospital, Bordeaux, France.,UMR CNRS 5164, ImmunoConcEpT, Bordeaux University, Bordeaux, France
| | - Annie Ramounau-Pigot
- Department of Immunology, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Céline René
- Department of Immunology, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Jonathan Visentin
- UMR CNRS 5164, ImmunoConcEpT, Bordeaux University, Bordeaux, France.,Department of Immunology and Immunogenetics, Pellegrin Hospital, Bordeaux University Hospital, Bordeaux, France
| | - Bryan Paul Morgan
- School of Medicine, Systems Immunity Research Institute, Cardiff University, Cardiff, United Kingdom
| | | | - Georges Mourad
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France
| | - Lionel Couzi
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin Hospital, Bordeaux University Hospital, Bordeaux, France.,UMR CNRS 5164, ImmunoConcEpT, Bordeaux University, Bordeaux, France
| | - Moglie Le Quintrec
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France.,INSERM U1183, Institute for Regenerative Medicine and Biotherapy, Saint-Eloi Hospital, Montpellier University Hospital, Montpellier, France
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28
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Markell M, Brar A, Bhela S, Patel A, Salifu M. Use of Repository Corticotropin Gel (Acthar) in Progressive Nephrotic Syndrome Secondary to Transplant Glomerulopathy: A Report of Three Cases. Kidney Med 2019; 1:31-35. [PMID: 32734181 PMCID: PMC7380415 DOI: 10.1016/j.xkme.2018.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Transplant glomerulopathy is a feared complication of kidney transplantation, often resulting in rapid loss of kidney function and ultimate graft failure. The underlying cause is unclear, with both antibody and cell-mediated immune mechanisms postulated, as well as intrinsic glomerular factors. At the present time, there is no known therapy. We report here 3 cases in which corticotropin gel (Acthar) was used with varying response of proteinuria and stabilization of graft function with continued graft survival as long as 10 years following the diagnosis. Future randomized controlled trials are warranted to examine the efficacy and safety of ACTH gel therapy in nephrotic patients with transplant glomerulopathy.
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Affiliation(s)
| | | | | | | | - Moro Salifu
- SUNY-Downstate School of Medicine, Brooklyn, NY
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29
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Novel markers of graft outcome in a cohort of kidney transplanted patients: a cohort observational study. J Nephrol 2019; 32:139-150. [PMID: 30628019 DOI: 10.1007/s40620-018-00580-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/27/2018] [Indexed: 12/16/2022]
Abstract
Renal biopsy (RBx) informs about kidney transplantation (KTx) prognosis. In our observational study the prevalence of histological anomalies and the prognostic role of CD45, vimentin (VIM) and periostin (POSTN) in KTx-RBx have been evaluated. One hundred forty-six KTx-RBx (2009-2012) were analysed for general histology and in immunohistochemistry for CD45, VIM and POSTN. Clinical data of the 146-KTx patients were collected at the RBx time (T0), 6 and 12 months before and after RBx. Follow-up time was 21 ± 14 months. Glomerulosclerosis was 20% glomeruli/biopsy. Tubular atrophy (TA), Interstitial infiltrate (I-Inf) and interstitial fibrosis (IF) were slight in 21-18% and 25%, moderate in 22-30% and 26% and severe in 30-18% and 28% of patients. Fifty-eight percent of patients had lesions compatible with IF-TA. CD45, VIM and POSTN correlated to each-other and to TA, I-Inf and IF. VIM and POSTN correlated to GS. CD45 and VIM correlated directly to renal function (RF) and 25(OH)VitD, while POSTN inversely to 25(OH)VitD. Thirty patients restarted dialysis (HD+). HD+ had lower T0-eGFR, and higher CD45, VIM and POSTN than HD-. POSTN resulted the strongest in discriminate for HD+ . CD45, VIM and POSTN correlate to each-other and predict graft outcome. POSTN was the strongest in discriminate for HD+. 25(OH)VitD might influence inflammation and fibrosis in KTx.
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30
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Haas M. The relationship between pathologic lesions of active and chronic antibody-mediated rejection in renal allografts. Am J Transplant 2018; 18:2849-2856. [PMID: 30133953 DOI: 10.1111/ajt.15088] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/15/2018] [Accepted: 08/16/2018] [Indexed: 01/25/2023]
Abstract
The Banff classification of renal allograft pathology defines specific morphologic lesions that are used in the diagnosis of active (glomerulitis, peritubular capillaritis, endarteritis) and chronic (transplant glomerulopathy, peritubular capillary basement membrane multilayering, transplant arteriopathy) antibody-mediated rejection (ABMR). However, none of these individual lesions are specific for ABMR, and for this reason Banff requires 1 or more additional findings, including C4d deposition in peritubular capillaries, presence of circulating donor-specific antibodies (DSAs), and/or expression in the tissue of transcripts strongly associated with ABMR, for a definitive diagnosis of ABMR to be made. In addition, while animal studies examining serial biopsies have established the progression of morphologic lesions of active to chronic ABMR as well as intermediate forms (chronic active ABMR) exhibiting features of both, clear documentation that lesions of chronic ABMR require the earlier presence of corresponding active and intermediate lesions is less well established in human renal allografts. This review examines temporal relationships between key morphologic lesions of active and chronic ABMR in biopsies of human grafts, likely intermediate forms, and findings for and possibly against direct and potentially interruptible progression from active to chronic lesions.
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Affiliation(s)
- Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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31
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Hossain MM, Selzo MR, Hinson RM, Baggesen LM, Detwiler RK, Chong WK, Burke LM, Caughey MC, Fisher MW, Whitehead SB, Gallippi CM. Evaluating Renal Transplant Status Using Viscoelastic Response (VisR) Ultrasound. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:1573-1584. [PMID: 29754702 PMCID: PMC6026561 DOI: 10.1016/j.ultrasmedbio.2018.03.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 02/20/2018] [Accepted: 03/16/2018] [Indexed: 05/03/2023]
Abstract
Chronic kidney disease is most desirably and cost-effectively treated by renal transplantation, but graft survival is a major challenge. Although irreversible graft damage can be averted by timely treatment, intervention is delayed when early graft dysfunction goes undetected by standard clinical metrics. A more sensitive and specific parameter for delineating graft health could be the viscoelastic properties of the renal parenchyma, which are interrogated non-invasively by Viscoelastic Response (VisR) ultrasound, a new acoustic radiation force (ARF)-based imaging method. Assessing the performance of VisR imaging in delineating histologically confirmed renal transplant pathologies in vivo is the purpose of the study described here. VisR imaging was performed in patients with (n = 19) and without (n = 25) clinical indication for renal allograft biopsy. The median values of VisR outcome metrics (τ, relative elasticity [RE] and relative viscosity [RV]) were calculated in five regions of interest that were manually delineated in the parenchyma (outer, center and inner) and in the pelvis (outer and inner). The ratios of a given VisR metric for all possible region-of-interest combinations were calculated, and the corresponding ratios were statistically compared between biopsied patients subdivided by diagnostic categories versus non-biopsied, control allografts using the two-sample Wilcoxon test (p <0.05). Although τ ratios non-specifically differentiated allografts with vascular disease, tubular/interstitial scarring, chronic allograft nephropathy and glomerulonephritis from non-biopsied control allografts, RE distinguished only allografts with vascular disease and tubular/interstitial scarring, and RV distinguished only vascular disease. These results suggest that allografts with scarring and vascular disease can be identified using non-invasive VisR RE and RV metrics.
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Affiliation(s)
- Md Murad Hossain
- Joint Department of Biomedical Engineering, University of North Carolina and North Carolina State University, Chapel Hill, North Carolina, USA
| | - Mallory R Selzo
- Ultrasound Business Unit, Siemens Healthcare, Issaquah, Washington, USA
| | - Robert M Hinson
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Leslie M Baggesen
- Kaiser Permanente, Northern California Regional Program Office, Berkeley, California, USA
| | - Randal K Detwiler
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Wui K Chong
- Department of Radiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Lauren M Burke
- Department of Radiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Melissa C Caughey
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Melrose W Fisher
- Joint Department of Biomedical Engineering, University of North Carolina and North Carolina State University, Chapel Hill, North Carolina, USA
| | - Sonya B Whitehead
- Department of Radiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Caterina M Gallippi
- Joint Department of Biomedical Engineering, University of North Carolina and North Carolina State University, Chapel Hill, North Carolina, USA; Department of Electrical and Computer Engineering, North Carolina State University, Raleigh, North Carolina, USA; Biomedical Research Imaging Center, University of North Carolina, Chapel Hill, North Carolina, USA.
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32
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Weiner DE, Park M, Tighiouart H, Joseph AA, Carpenter MA, Goyal N, House AA, Hsu CY, Ix JH, Jacques PF, Kew CE, Kim SJ, Kusek JW, Pesavento TE, Pfeffer MA, Smith SR, Weir MR, Levey AS, Bostom AG. Albuminuria and Allograft Failure, Cardiovascular Disease Events, and All-Cause Death in Stable Kidney Transplant Recipients: A Cohort Analysis of the FAVORIT Trial. Am J Kidney Dis 2018; 73:51-61. [PMID: 30037726 DOI: 10.1053/j.ajkd.2018.05.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 05/23/2018] [Indexed: 12/30/2022]
Abstract
RATIONALE & OBJECTIVE Cardiovascular disease (CVD) is common and overall graft survival is suboptimal among kidney transplant recipients. Although albuminuria is a known risk factor for adverse outcomes among persons with native chronic kidney disease, the relationship of albuminuria with cardiovascular and kidney outcomes in transplant recipients is uncertain. STUDY DESIGN Post hoc longitudinal cohort analysis of the Folic Acid for Vascular Outcomes Reduction in Transplantation (FAVORIT) Trial. SETTING & PARTICIPANTS Stable kidney transplant recipients with elevated homocysteine levels from 30 sites in the United States, Canada, and Brazil. PREDICTOR Urine albumin-creatinine ratio (ACR) at randomization. OUTCOMES Allograft failure, CVD, and all-cause death. ANALYTICAL APPROACH Multivariable Cox models adjusted for age; sex; race; randomized treatment allocation; country; systolic and diastolic blood pressure; history of CVD, diabetes, and hypertension; smoking; cholesterol; body mass index; estimated glomerular filtration rate (eGFR); donor type; transplant vintage; medications; and immunosuppression. RESULTS Among 3,511 participants with complete data, median ACR was 24 (Q1-Q3, 9-98) mg/g, mean eGFR was 49±18 (standard deviation) mL/min/1.73m2, mean age was 52±9 years, and median graft vintage was 4.1 (Q1-Q3, 1.7-7.4) years. There were 1,017 (29%) with ACR < 10mg/g, 912 (26%) with ACR of 10 to 29mg/g, 1,134 (32%) with ACR of 30 to 299mg/g, and 448 (13%) with ACR ≥ 300mg/g. During approximately 4 years, 282 allograft failure events, 497 CVD events, and 407 deaths occurred. Event rates were higher at both lower eGFRs and higher ACR. ACR of 30 to 299 and ≥300mg/g relative to ACR < 10mg/g were independently associated with graft failure (HRs of 3.40 [95% CI, 2.19-5.30] and 9.96 [95% CI, 6.35-15.62], respectively), CVD events (HRs of 1.25 [95% CI, 0.96-1.61] and 1.55 [95% CI, 1.13-2.11], respectively), and all-cause death (HRs of 1.65 [95% CI, 1.23-2.21] and 2.07 [95% CI, 1.46-2.94], respectively). LIMITATIONS No data for rejection; single ACR assessment. CONCLUSIONS In a large population of stable kidney transplant recipients, elevated baseline ACR is independently associated with allograft failure, CVD, and death. Future studies are needed to evaluate whether reducing albuminuria improves these outcomes.
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Affiliation(s)
| | - Meyeon Park
- Division of Nephrology, University of California, San Francisco, San Francisco, CA
| | | | - Alin A Joseph
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Myra A Carpenter
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC
| | - Nitender Goyal
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Andrew A House
- Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada
| | - Chi-Yuan Hsu
- Division of Nephrology, University of California, San Francisco, San Francisco, CA
| | - Joachim H Ix
- Division of Nephrology-Hypertension, University of California, San Diego, San Diego, CA
| | - Paul F Jacques
- Human Nutrition Research Center on Aging, Tufts University, Boston, MA
| | - Clifton E Kew
- Division of Nephrology, University of Alabama, Birmingham, AL
| | - S Joseph Kim
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - John W Kusek
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | | | - Matthew R Weir
- Division of Nephrology, University of Maryland, Baltimore, MD
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Andrew G Bostom
- Division of Hypertension and Kidney Diseases, Rhode Island Hospital, Providence, RI
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Lee DR, Kim BC, Kim JP, Kim IG, Jeon MY. C3d-binding Donor-specific HLA Antibody Is Associated With a High Risk of Antibody-mediated Rejection and Graft Loss in Stable Kidney Transplant Recipients: A Single-center Cohort Study. Transplant Proc 2018; 50:3452-3459. [PMID: 30503524 DOI: 10.1016/j.transproceed.2018.06.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 06/27/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND One risk factor for antibody-mediated rejection (ABMR) and poor outcome after kidney transplantation is donor-specific anti‒human leukocyte antigen (anti-HLA) antibodies (DSAs). In this study we sought to determine whether the presence of DSAs that bind complement component C3d could better predict ABMR and graft loss in stable kidney transplant recipients (KTRs). METHODS We included 220 stable KTRs in this study and screened them for DSAs from July 2013 to July 2016. RESULTS Of the 220 KTRs, DSAs were detected in 24 (10.9%). The incidence of ABMR was 3.6% (8 of 220) overall, and C3d-DSA‒positive KTRs had a significantly higher incidence than SA-DSA‒positive KTRs (63.3% vs 38.9%, P = .03). Most C3d-binding DSAs were anti-HLA class II antibodies (11 of 13, 84.6%). Class II C3d-binding DSA was also significantly associated with graft failure on multivariate analysis, as were ABMR, chronic ABMR, and high serum creatinine. Class II C3d-binding DSA was also significantly associated with lower graft survival after ABMR. CONCLUSION C3d-binding DSA, especially class II, was significantly associated with the risk of ABMR and graft loss in stable KTRs. We suggest that monitoring of stable KTRs for C3d-binding DSA, followed by biopsy, could aid in early recognition of ABMR and prevention of graft loss.
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Affiliation(s)
- D R Lee
- Division of Nephrology, Medicine, Maryknoll General Hospital, Busan, Republic of Korea.
| | - B C Kim
- Department of Laboratory Medicine, Maryknoll General Hospital, Busan, Republic of Korea
| | - J P Kim
- Department of Surgery, Maryknoll General Hospital, Busan, Republic of Korea
| | - I G Kim
- Department of Urology, Maryknoll General Hospital, Busan, Republic of Korea
| | - M Y Jeon
- Department of Pathology, Maryknoll General Hospital, Busan, Republic of Korea
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Sablik KA, Clahsen-van Groningen MC, Hesselink DA, van Gelder T, Betjes MGH. Tacrolimus intra-patient variability is not associated with chronic active antibody mediated rejection. PLoS One 2018; 13:e0196552. [PMID: 29746495 PMCID: PMC5944964 DOI: 10.1371/journal.pone.0196552] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 04/16/2018] [Indexed: 01/14/2023] Open
Abstract
Background Chronic active antibody mediated rejection (c-aABMR) is a major cause of long-term kidney allograft loss. It is hypothesized that frequent sub-therapeutic exposure to immunosuppressive drugs, in particular tacrolimus (Tac), is a risk factor for the development of c-aABMR. The intra-patient variability (IPV) in Tac exposure may serve as a substitute biomarker for underexposure and/or non-adherence. In this study, the association between Tac IPV and the development of c-aABMR was investigated. Methods We retrospectively included 59 patients diagnosed with c-aABMR and compared them to 189 control patients matched for age, year of transplantation and type of kidney donor. The Tac IPV was calculated from pre-dose tacrolimus concentrations measured over a 3 year period preceding the diagnosis of c-aABMR. The mean Tac predose concentrations (C0), Tac IPV, renal allograft function and graft survival were compared between the groups. Results Tac IPV was 24.4% for the cases versus 23.6% for the controls (p = 0.47). The mean Tac C0 was comparable for the cases (5.8 ng/mL) and control patients (6.1 ng/mL, p = 0.08). Only in the c-aABMR group a significant decline in both mean Tac C0 and allograft function over the timespan of 3 years was observed (p = 0.03 and p<0.001). Additionally, in the group of c-aABMR patients a high IPV was associated with inferior graft survival (p = 0.03). Conclusions A high Tac IPV per se does not predispose to the development of c-aABMR but is associated with inferior graft survival once c-aABMR is diagnosed.
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Affiliation(s)
- Kasia A. Sablik
- Department of Nephrology and Transplantation, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- * E-mail:
| | | | - Dennis A. Hesselink
- Department of Nephrology and Transplantation, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Teun van Gelder
- Department of Nephrology and Transplantation, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Michiel G. H. Betjes
- Department of Nephrology and Transplantation, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Sablik KA, Clahsen-van Groningen MC, Looman CWN, Damman J, Roelen DL, van Agteren M, Betjes MGH. Chronic-active antibody-mediated rejection with or without donor-specific antibodies has similar histomorphology and clinical outcome - a retrospective study. Transpl Int 2018; 31:900-908. [PMID: 29570868 DOI: 10.1111/tri.13154] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 01/06/2018] [Accepted: 03/14/2018] [Indexed: 12/12/2022]
Abstract
Chronic-active antibody-mediated rejection (c-aABMR) is defined as histological evidence of chronic endothelial injury (cg), also known as transplant glomerulopathy, and either microvascular inflammation (MVI) or positivity for C4d. Importantly, the presence of donor-specific antibodies (DSA) is currently still mandatory for the diagnosis of c-aABMR. This retrospective study of 41 c-aABMR patients investigates whether cases suspicious for c-aABMR (DSA negative, n = 24) differ from cases of c-aABMR (DSA positive, n = 17) with respect to renal histology, allograft function and long-term graft survival. All included patients had progressive loss of allograft function and were diagnosed by for cause biopsy and scored according to the Banff '15 criteria. In all DSApos cases, DSA were de novo and the majority was directed against HLA-II being mostly anti-HLA-DQ antibodies. There were no statistically significant differences in clinical characteristics, decline in allograft function and renal allograft survival in cases with or without DSAs. All cases showed chronic histomorphological damage and inflammation, irrespective of the presence of DSA. Renal histology and clinical outcome of patients suspicious for c-aABMR (DSAneg) do not significantly differ from patients with a diagnosis of c-aABMR (DSApos). We believe that our study adds to the ongoing debate regarding the need for DSAs to be present for the diagnosis of c-aABMR.
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Affiliation(s)
- Kasia A Sablik
- Department of Nephrology and Transplantation, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Caspar W N Looman
- Department of Biostatistics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Jeffrey Damman
- Department of Pathology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Dave L Roelen
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
| | - Madelon van Agteren
- Department of Nephrology and Transplantation, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Michiel G H Betjes
- Department of Nephrology and Transplantation, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Vazquez Martul E. [The pathology of renal transplants]. REVISTA ESPAÑOLA DE PATOLOGÍA : PUBLICACIÓN OFICIAL DE LA SOCIEDAD ESPAÑOLA DE ANATOMÍA PATOLÓGICA Y DE LA SOCIEDAD ESPAÑOLA DE CITOLOGÍA 2018; 51:110-123. [PMID: 29602372 DOI: 10.1016/j.patol.2017.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 10/01/2017] [Indexed: 11/15/2022]
Abstract
In order to make an objective assessment of the histopathology of a renal biopsy during a kidney transplant, all the various elements involved in the process must be understood. It is important to know the characteristics of the donor organ, especially if the donor is older than 65. The histopathological features of the donor biopsy, especially its vascular status, are often related to an initial poor function of the transplanted kidney. The T lymphocyte inflammatory response is characteristic in acute cellular rejection; the degree of tubulitis, together with the amount of affected parenchyme, are important factors. The proportion of cellular sub-populations, such as plasma cells and macrophages, is also important, as they can be related to antibody-mediated humoral rejection. Immunofluorescent or immunohistochemical studies are necessary to rule out C4d deposits or immunogloblulins. The presence of abundant deposits of C4d in tubular basement membranes supports a diagnosis of humoral rejection, as does the presence of capillaritis, glomerulitis which, together with vasculitis, are typical diagnostic findings in C4d negative cases. Interstitial fibrosis, tubular atrophy and glomerular sclerosis, although non-specific, imply a chronic phase. Transplant glomerulopathy and multilamination in more than 6 layers of the tubular and glomerular basement membranes are quasi-specific characteristics of chronic humoral rejection. Electron microscopy is essential to identify of these pathologies as well as to demonstrate the presence of other glomerular renal diseases.
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Affiliation(s)
- Eduardo Vazquez Martul
- Ex Jefe de Servicio de Anatomía Patológica, Hospital Universitario A Coruña (retirado), A Coruña, España; Ex profesor asociado de la Facultad de Medicina, Universidad de Santiago de Compostela, Santiago de Compostela, A Coruña, España; Miembro del Club de Nefropatología (Sociedad Española de Nefrología), España.
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Chung BH, Kim JH, Choi BS, Park CW, Kim JI, Moon IS, Kim YS, Choi YJ, Oh EJ, Yang CW. Clinical significance of the presence of anti-human leukocyte antigen-donor specific antibody in kidney transplant recipients with allograft dysfunction. Korean J Intern Med 2018; 33:157-167. [PMID: 27764540 PMCID: PMC5768540 DOI: 10.3904/kjim.2016.107] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 05/19/2016] [Accepted: 05/28/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS This study investigated the clinical significance of detecting anti-human leukocyte antigen-donor specific antibody (HLA-DSA) in kidney transplant recipients (KTRs) requiring indication biopsy owing to allograft dysfunction. METHODS We analyzed the presence of HLA-DSA in 210 KTRs who took indication biopsy. We divided these cases into two groups, HLA-DSA (+) (n = 52) and HLA-DSA (-) (n = 158) group, and compared the clinical characteristics, pathological findings, and clinical outcomes of the two groups. RESULTS The rates of retransplant, pretransplant sensitization, and HLA-mismatch were significantly higher in HLA-DSA (+) group than in HLA-DSA (-) group (p < 0.05 for each comparison). In histologic finding, all types of rejections were more frequent in the former group. Besides, scores of both the T-cell injury markers such as tubulitis, interstitial inf lammation, and vasculitis and antibody-mediated injury markers such as peritubular C4d deposition and microvascular inflammation (glomerulitis plus peritubular capillaritis) were higher in HLA-DSA (+) group (p < 0.05 for each). Notably, allograft outcomes were worse in HLA-DSA (+) group. Further, multivariate analysis showed that presence of HLA-DSA, advanced interstitial fibrosis/tubular atrophy (interstitial fibrosis plus tubular atrophy ≥ 2), and allograft rejection in biopsy were independent risk factors for allograft failure. CONCLUSIONS The results of this study showed that presence of HLA-DSA in a case of allograft dysfunction adversely influences allograft outcome, and its detection, irrespective of the result of the allograft biopsy, necessitates intensive monitoring and treatment.
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Affiliation(s)
- Byung Ha Chung
- Transplant Research Center, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Jeong Ho Kim
- Transplant Research Center, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Bum Soon Choi
- Transplant Research Center, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Cheol Whee Park
- Transplant Research Center, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Ji-Il Kim
- Department of Surgery, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - In Sung Moon
- Department of Surgery, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Yong-Soo Kim
- Transplant Research Center, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Yeong Jin Choi
- Department of Hospital Pathology, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Eun-Jee Oh
- Transplant Research Center, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
- Department of Laboratory Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Chul Woo Yang
- Transplant Research Center, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
- Correspondence to Chul Woo Yang, M.D. Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea Tel: +82-2-2258-6037 Fax: +82-2-536-0323 E-mail:
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Kühne L, Jung B, Poth H, Schuster A, Wurm S, Ruemmele P, Banas B, Bergler T. Renal allograft rejection, lymphocyte infiltration, and de novo donor-specific antibodies in a novel model of non-adherence to immunosuppressive therapy. BMC Immunol 2017; 18:52. [PMID: 29258420 PMCID: PMC5735914 DOI: 10.1186/s12865-017-0236-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 12/07/2017] [Indexed: 12/18/2022] Open
Abstract
Background Non-adherence has been associated with reduced graft survival. The aim of this study was to investigate the immunological mechanisms underlying chronic renal allograft rejection using a model of non-adherence to immunosuppressive therapy. We used a MHC (major histocompatibility complex) -mismatched rat model of renal transplantation (Brown Norway to Lewis), in which rats received daily oral cyclosporine A. In analogy to non-adherence to therapy, one group received cyclosporine A on alternating days only. Rejection was histologically graded according to the Banff classification. We quantified fibrosis by trichrome staining and intra-graft infiltration of T cells, B cells, and monocytes/macrophages by immunohistochemistry. The distribution of B lymphocytes was assessed using immunofluorescence microscopy. Intra-graft chemokine, chemokine receptor, BAFF (B cell activating factor belonging to the TNF family), and immunoglobulin G transcription levels were analysed by RT-PCR. Finally, we evaluated donor-specific antibodies (DSA) and complement-dependent cytotoxicity using flow cytometry. Results After 28 days, cellular rejection occurred during non-adherence in 5/6 animals, mixed with humoral rejection in 3/6 animals. After non-adherence, the number of T lymphocytes were elevated compared to daily immunosuppression. Monocyte numbers declined over time. Accordingly, lymphocyte chemokine transcription was significantly increased in the graft, as was the transcription of BAFF, BAFF receptor, and Immunoglobulin G. Donor specific antibodies were elevated in non-adherence, but did not induce complement-dependent cytotoxicity. Conclusion Cellular and humoral rejection, lymphocyte infiltration, and de novo DSA are induced in this model of non-adherence. Electronic supplementary material The online version of this article (doi: 10.1186/s12865-017-0236-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Louisa Kühne
- Department of Nephrology, University Hospital Regensburg, Franz-Josef-Strauß Allee 11, D-93053, Regensburg, Germany.
| | - Bettina Jung
- Department of Nephrology, University Hospital Regensburg, Franz-Josef-Strauß Allee 11, D-93053, Regensburg, Germany
| | - Helen Poth
- Department of Nephrology, University Hospital Regensburg, Franz-Josef-Strauß Allee 11, D-93053, Regensburg, Germany
| | - Antonia Schuster
- Department of Nephrology, University Hospital Regensburg, Franz-Josef-Strauß Allee 11, D-93053, Regensburg, Germany
| | - Simone Wurm
- Department of Nephrology, University Hospital Regensburg, Franz-Josef-Strauß Allee 11, D-93053, Regensburg, Germany
| | - Petra Ruemmele
- Department of Pathology, University Hospital Erlangen, Erlangen, Germany
| | - Bernhard Banas
- Department of Nephrology, University Hospital Regensburg, Franz-Josef-Strauß Allee 11, D-93053, Regensburg, Germany
| | - Tobias Bergler
- Department of Nephrology, University Hospital Regensburg, Franz-Josef-Strauß Allee 11, D-93053, Regensburg, Germany
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Lion J, Burbach M, Cross A, Poussin K, Taflin C, Kaveri S, Haziot A, Glotz D, Mooney N. Endothelial Cell Amplification of Regulatory T Cells Is Differentially Modified by Immunosuppressors and Intravenous Immunoglobulin. Front Immunol 2017; 8:1761. [PMID: 29312302 PMCID: PMC5735077 DOI: 10.3389/fimmu.2017.01761] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 11/27/2017] [Indexed: 01/01/2023] Open
Abstract
Immunosuppressive treatment is a prerequisite for both organ transplantation and tolerance of the allograft. However, long-term immunosuppression has been associated with a higher incidence of malignancies and infections. Immunosuppressors mainly target circulating immune cells and little is known of their “off-target” effects, such as their impact on endothelial cells (ECs). In chronic antibody-mediated rejection (AMR), the allograft endothelium is a target of damage, histologically detected as transplant glomerulopathy, and which correlates with poor graft survival. Under inflammatory conditions, EC expression of HLA class II antigens can lead to CD4+-T lymphocyte alloactivation and selective expansion of pro-inflammatory Th17 and pro-tolerance Treg subsets. This response can be modified and preactivation of the EC by HLA-DR antibody binding promoted a proinflammatory Th17 response. However, whether or not immunosuppressors alter EC immunogenicity has not been examined. In alloimmunized patients with AMR, cyclosporine A (CsA) and mycophenolic acid (MPA) are often combined with intravenous immunoglobulins (IVIgs). This study reports changes in the microvascular EC phenotype and function after treatment with CsA, MPA, or IVIg. Both CsA and MPA decreased HLA-DR and increased CD54 expression, whereas IVIg increased HLA-DR expression. Interleukin 6 secretion was reduced by all three immunomodulators. Preincubation of ECs with CsA or MPA limited, while IVIg amplified, Treg expansion. Because CsA, MPA, and IVIg are known for their ability to act upon leukocytes, we confirmed that ECs maintained their immunoregulatory role when allogeneic leukocytes were pretreated with CsA, MPA, or IVIg. The results reveal that individual immunosuppressors, used in the induction and maintenance of renal allograft tolerance, had direct and distinct effects on ECs. Results of experiments associating IVIg with either CsA or MPA underlined the differences observed using individual immunosuppressors. Paradoxically, CsA or MPA may increase EC mediated inflammatory responses and long-term exposure may contribute to limitation of allograft tolerance. In contrast, IVIg interaction with the endothelium may mediate some of its immunosuppressive effects through promotion of Treg expansion, contributing to the maintenance of allograft tolerance.
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Affiliation(s)
- Julien Lion
- U1160, Alloimmunité-Autoimmunité-Transplantation, Institut national de la santé et de la recherche médicale, Hôpital Saint Louis, Paris, France
| | - Maren Burbach
- U1160, Alloimmunité-Autoimmunité-Transplantation, Institut national de la santé et de la recherche médicale, Hôpital Saint Louis, Paris, France.,Department of Nephrology and Transplantation, APHP, Hopital Saint Louis, Paris, France
| | - Amy Cross
- U1160, Alloimmunité-Autoimmunité-Transplantation, Institut national de la santé et de la recherche médicale, Hôpital Saint Louis, Paris, France
| | - Karine Poussin
- U1160, Alloimmunité-Autoimmunité-Transplantation, Institut national de la santé et de la recherche médicale, Hôpital Saint Louis, Paris, France
| | - Cécile Taflin
- Department of Nephrology and Transplantation, APHP, Hopital Saint Louis, Paris, France
| | - Srini Kaveri
- U1138, Institut national de la santé et de la recherche médicale, Centre de Recherche des Cordeliers, Paris, France
| | - Alain Haziot
- U1160, Alloimmunité-Autoimmunité-Transplantation, Institut national de la santé et de la recherche médicale, Hôpital Saint Louis, Paris, France
| | - Denis Glotz
- U1160, Alloimmunité-Autoimmunité-Transplantation, Institut national de la santé et de la recherche médicale, Hôpital Saint Louis, Paris, France.,Department of Nephrology and Transplantation, APHP, Hopital Saint Louis, Paris, France.,Université Sorbonne Paris Cité, Paris, France.,LabEx Transplantex, Strasbourg, France
| | - Nuala Mooney
- U1160, Alloimmunité-Autoimmunité-Transplantation, Institut national de la santé et de la recherche médicale, Hôpital Saint Louis, Paris, France.,Université Sorbonne Paris Cité, Paris, France.,LabEx Transplantex, Strasbourg, France
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40
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Van Loon E, Lerut E, Naesens M. The time dependency of renal allograft histology. Transpl Int 2017; 30:1081-1091. [DOI: 10.1111/tri.13042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 07/05/2017] [Accepted: 08/21/2017] [Indexed: 01/27/2023]
Affiliation(s)
- Elisabet Van Loon
- Laboratory of Nephrology; Department of Microbiology and Immunology; KU Leuven; Leuven Belgium
- Department of Nephrology and Renal Transplantation; University Hospitals Leuven; Leuven Belgium
| | - Evelyne Lerut
- Translational Cell and Tissue Research; Department of Imaging and Pathology; KU Leuven; Leuven Belgium
- Department of Morphology and Molecular Pathology; University Hospitals Leuven; Leuven Belgium
| | - Maarten Naesens
- Laboratory of Nephrology; Department of Microbiology and Immunology; KU Leuven; Leuven Belgium
- Department of Nephrology and Renal Transplantation; University Hospitals Leuven; Leuven Belgium
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41
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Mulley WR, Huang LL, Ramessur Chandran S, Longano A, Amos LAR, Polkinghorne KR, Nikolic-Paterson DJ, Kanellis J. Long-term graft survival in patients with chronic antibody-mediated rejection with persistent peritubular capillaritis treated with intravenous immunoglobulin and rituximab. Clin Transplant 2017. [DOI: 10.1111/ctr.13037] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- William R. Mulley
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
- Department of Medicine; Centre for Inflammatory Diseases; Monash University; Clayton Vic. Australia
| | - Louis L. Huang
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
| | - Sharmila Ramessur Chandran
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
- Department of Medicine; Centre for Inflammatory Diseases; Monash University; Clayton Vic. Australia
| | - Anthony Longano
- Department of Anatomical Pathology; Monash Medical Centre; Clayton Vic. Australia
| | - Liv A. R. Amos
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
- Department of Medicine; Centre for Inflammatory Diseases; Monash University; Clayton Vic. Australia
| | - Kevan R. Polkinghorne
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
- Department of Medicine; Centre for Inflammatory Diseases; Monash University; Clayton Vic. Australia
- Department of Epidemiology and Preventive Medicine; Monash University; Prahran Vic. Australia
| | - David J. Nikolic-Paterson
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
- Department of Medicine; Centre for Inflammatory Diseases; Monash University; Clayton Vic. Australia
| | - John Kanellis
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
- Department of Medicine; Centre for Inflammatory Diseases; Monash University; Clayton Vic. Australia
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Abstract
Understanding the events leading to allorecognition and the subsequent effector pathways engaged is key for the development of strategies to prolong graft survival. Optimizing patient outcomes will require 2 major advancements: (1) minimizing premature death with a functioning graft in the patients with stable graft function, and (2) maximizing graft survival by avoiding the aforementioned allorecognition. This necessitates personalized immunosuppression to avoid known metabolic side effects, risk for infection, and malignancy, while holding the alloimmune system in check. Since the beginning of transplant a key strategy to achieve this goal is to minimize HLA mismatching between donor and recipient. What has not evolved is any refinement in our evaluation of HLA relatedness between donor and recipient when HLA mismatch exists. Donor-recipient HLA mismatch at the amino acid level can now be determined. These mismatches serve as potential epitopes for de novo donor specific antibody development and correlate with late rejection and graft loss. It is in this context that HLA epitope analysis is considered as a strategy to permit safe immunosuppression minimization to improve patient outcomes through: (1) improved allocation schemes that favor donor-recipient pairs with a low HLA epitope mismatch load (especially at the class II loci) or avoiding specific epitope mismatches known to be highly immunogenic and (2) immunosuppressive minimization in patients with low epitope mismatch loads or without highly immunogenic epitope mismatches.
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van Eijs MJM, van Zuilen AD, de Boer A, Froeling M, Nguyen TQ, Joles JA, Leiner T, Verhaar MC. Innovative Perspective: Gadolinium-Free Magnetic Resonance Imaging in Long-Term Follow-Up after Kidney Transplantation. Front Physiol 2017; 8:296. [PMID: 28559850 PMCID: PMC5432553 DOI: 10.3389/fphys.2017.00296] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 04/24/2017] [Indexed: 12/23/2022] Open
Abstract
Since the mid-1980s magnetic resonance imaging (MRI) has been investigated as a non- or minimally invasive tool to probe kidney allograft function. Despite this long-standing interest, MRI still plays a subordinate role in daily practice of transplantation nephrology. With the introduction of new functional MRI techniques, administration of exogenous gadolinium-based contrast agents has often become unnecessary and true non-invasive assessment of allograft function has become possible. This raises the question why application of MRI in the follow-up of kidney transplantation remains restricted, despite promising results. Current literature on kidney allograft MRI is mainly focused on assessment of (sub) acute kidney injury after transplantation. The aim of this review is to survey whether MRI can provide valuable diagnostic information beyond 1 year after kidney transplantation from a mechanistic point of view. The driving force behind chronic allograft nephropathy is believed to be chronic hypoxia. Based on this, techniques that visualize kidney perfusion and oxygenation, scarring, and parenchymal inflammation deserve special interest. We propose that functional MRI mechanistically provides tools for diagnostic work-up in long-term follow-up of kidney allografts.
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Affiliation(s)
- Mick J M van Eijs
- Department of Nephrology and Hypertension, University Medical Center UtrechtUtrecht, Netherlands
| | - Arjan D van Zuilen
- Department of Nephrology and Hypertension, University Medical Center UtrechtUtrecht, Netherlands
| | - Anneloes de Boer
- Department of Radiology, University Medical Center UtrechtUtrecht, Netherlands
| | - Martijn Froeling
- Department of Radiology, University Medical Center UtrechtUtrecht, Netherlands
| | - Tri Q Nguyen
- Department of Pathology, University Medical Center UtrechtUtrecht, Netherlands
| | - Jaap A Joles
- Department of Nephrology and Hypertension, University Medical Center UtrechtUtrecht, Netherlands
| | - Tim Leiner
- Department of Radiology, University Medical Center UtrechtUtrecht, Netherlands
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Center UtrechtUtrecht, Netherlands
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Vanhove T, Goldschmeding R, Kuypers D. Kidney Fibrosis: Origins and Interventions. Transplantation 2017; 101:713-726. [PMID: 27941433 PMCID: PMC7228593 DOI: 10.1097/tp.0000000000001608] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 10/24/2016] [Accepted: 11/10/2016] [Indexed: 02/06/2023]
Abstract
All causes of renal allograft injury, when severe and/or sustained, can result in chronic histological damage of which interstitial fibrosis and tubular atrophy are dominant features. Unless a specific disease process can be identified, what drives interstitial fibrosis and tubular atrophy progression in individual patients is often unclear. In general, clinicopathological factors known to predict and drive allograft fibrosis include graft quality, inflammation (whether "nonspecific" or related to a specific diagnosis), infections, such as polyomavirus-associated nephropathy, calcineurin inhibitors (CNI), and genetic factors. The incidence and severity of chronic histological damage have decreased substantially over the last 3 decades, but it is difficult to disentangle what effects individual innovations (eg, better matching and preservation techniques, lower CNI dosing, BK viremia screening) may have had. There is little evidence that CNI-sparing/minimization strategies, steroid minimization or renin-angiotensin-aldosterone system blockade result in better preservation of intermediate-term histology. Treatment of subclinical rejections has only proven beneficial to histological and functional outcome in studies in which the rate of subclinical rejection in the first 3 months was greater than 10% to 15%. Potential novel antifibrotic strategies include antagonists of transforming growth factor-β, connective tissue growth factor, several tyrosine kinase ligands (epidermal growth factor, platelet-derived growth factor, vascular endothelial growth factor), endothelin and inhibitors of chemotaxis. Although many of these drugs are mainly being developed and marketed for oncological indications and diseases, such as idiopathic pulmonary fibrosis, a number may hold promise in the treatment of diabetic nephropathy, which could eventually lead to applications in renal transplantation.
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Affiliation(s)
- Thomas Vanhove
- 1 Department of Microbiology and Immunology, KU Leuven-University of Leuven, Leuven, Belgium. 2 Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium. 3 Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
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Go H, Shin S, Kim YH, Han DJ, Cho YM. Refinement of the criteria for ultrastructural peritubular capillary basement membrane multilayering in the diagnosis of chronic active/acute antibody-mediated rejection. Transpl Int 2017; 30:398-409. [PMID: 28109026 DOI: 10.1111/tri.12921] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 08/06/2016] [Accepted: 01/12/2017] [Indexed: 12/17/2022]
Abstract
Chronic active/acute antibody-mediated rejection (cABMR) is the main cause of late renal allograft loss. Severe peritubular capillary basement membrane multilayering (PTCML) assessed on electron microscopy is one diagnostic feature of cABMR according to the Banff 2013 classification. We aimed to refine the PTCML criteria for an earlier diagnosis of cABMR. We retrospectively investigated ultrastructural features of 159 consecutive renal allografts and 44 nonallografts. The presence of serum donor-specific antibodies at the time of biopsy of allografts was also examined. Forty-three patients (27.0%) fulfilled the criteria of cABMR, regardless of PTCML, and comprised the cABMR group. Forty-one patients (25.8%) did not exhibit cABMR features and comprised the non-cABMR allograft control group. In addition, 15 zero-day wedge resections and 29 native kidney biopsies comprised the nonallograft control group. When the diagnostic accuracies of various PTCML features were assessed using the cABMR and non-cABMR allograft control groups, ≥4 PTCML, either circumferential or partial, in ≥2 peritubular capillaries of the three most affected capillaries exhibited the highest AUC value (0.885), greater than the Banff 2013 classification (0.640). None of the nonallograft control groups exhibited PTCML features. We suggest that ≥4 PTCML in ≥2 peritubular capillaries of the three most affected cortical capillaries represents the proper cutoff for cABMR.
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Affiliation(s)
- Heounjeong Go
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Shin
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Hoon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duck Jong Han
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Mee Cho
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Haas M, Mirocha J, Reinsmoen NL, Vo AA, Choi J, Kahwaji JM, Peng A, Villicana R, Jordan SC. Differences in pathologic features and graft outcomes in antibody-mediated rejection of renal allografts due to persistent/recurrent versus de novo donor-specific antibodies. Kidney Int 2017; 91:729-737. [DOI: 10.1016/j.kint.2016.10.040] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 10/06/2016] [Accepted: 10/27/2016] [Indexed: 10/20/2022]
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Toki D, Inui M, Ishida H, Okumi M, Shimizu T, Shirakawa H, Omoto K, Unagami K, Setoguchi K, Koike J, Honda K, Yamaguchi Y, Tanabe K. Interstitial fibrosis is the critical determinant of impaired renal function in transplant glomerulopathy. Nephrology (Carlton) 2017; 21 Suppl 1:20-5. [PMID: 26970313 DOI: 10.1111/nep.12765] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2016] [Indexed: 11/27/2022]
Abstract
AIM Transplant glomerulopathy (TG) is a feature of chronic antibody-mediated injury in the glomerular capillaries in renal transplant recipients. TG is generally associated with proteinuria; however, renal function at the diagnosis of TG varies. This study aimed to determine which morphological abnormalities are associated with renal function and proteinuria at the diagnosis of TG. METHODS A total of 871 renal transplantations were performed at Tokyo Women's Medical University between 2005 and 2013. TG was diagnosed in 127 biopsies from 58 (6.7%) recipients. Renal function was evaluated by the estimated glomerular filtration rate (eGFR). Proteinuria was assessed by a dipstick test: positive for +1 and over. RESULTS At diagnosis, of 127 biopsies, 72, 37, and 18 had mild, moderate, and severe TG (Banff cg). The severity of TG was not associated with decreased eGFR at the time of biopsy (cg1: 36.1 ± 14.8, cg2-3: 38.8 ± 14.5 mL/min per 1.73 m(2) , P = 0.25), whereas the severity of interstitial fibrosis (IF) (Banff ci) was significantly associated with decreased eGFR (ci0-1: 42.75 ± 13.32, ci2-3: 27.69 ± 11.94 mL/min per 1.73 m(2) , P < 0.0001). The multivariate analysis revealed that IF was the only independent risk factors for decreased eGFR (OR = 4.38, P = 0.0006). Meanwhile, TG was identified as the only independent risk factor for the incidence of proteinuria (OR = 2.67, P = 0.014). CONCLUSION Interstitial fibrosis was a critical determinant of impaired renal function at the diagnosis of TG. The severity of TG was significantly associated with proteinuria, but did not contribute to renal dysfunction.
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Affiliation(s)
- Daisuke Toki
- Department of Urology, Tokyo Women's Medical University, Yachiyo Medical Center, Chiba, Japan
| | - Masashi Inui
- Department of Urology, Tokyo Women's Medical University, Yachiyo Medical Center, Chiba, Japan
| | - Hideki Ishida
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayoshi Okumi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | | | | | - Kazuya Omoto
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kohei Unagami
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kiyoshi Setoguchi
- Department of Urology, Tokyo Women's Medical University, Yachiyo Medical Center, Chiba, Japan
| | - Junki Koike
- Department of Pathology, Kawasaki City Tama-Hospital, Kanagawa, Japan
| | - Kazuho Honda
- Department of Pathology, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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Patri P, Seshan SV, Matignon M, Desvaux D, Lee JR, Lee J, Dadhania DM, Serur D, Grimbert P, Hartono C, Muthukumar T. Development and validation of a prognostic index for allograft outcome in kidney recipients with transplant glomerulopathy. Kidney Int 2017; 89:450-8. [PMID: 26422505 PMCID: PMC4814368 DOI: 10.1038/ki.2015.288] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 07/05/2015] [Accepted: 07/31/2015] [Indexed: 01/29/2023]
Abstract
We studied 92 patients with transplant glomerulopathy to develop a prognostic index based on the risk factors for allograft failure within five years of diagnosis (Development cohort). During 60 months (median) follow up, 64 patients developed allograft failure. A chronic-inflammation score generated by combining Banff ci, ct and ti scores, serum creatinine and proteinuria at biopsy, were independent risk factors for allograft failure. Based on the Cox model, we developed a prognostic index and classified patients into risk groups. Compared to the low risk group (median allograft survival over 60 months from diagnosis), patients in the medium risk group had a hazard ratio of 2.83 (median survival 25 months), while those in the high risk group had a hazard ratio of 5.96 (median survival 3.7 months). We next evaluated the performance of the prognostic index in an independent external cohort of 47 patients with transplant glomerulopathy (Validation cohort). The hazard ratios were 2.18 (median survival 19 months) and 16.27 (median survival 1.6 months), respectively, for patients in the medium and high risk groups, compared to the low risk group (median survival 47 months). Our prognostic index model did well in measures of discrimination and calibration. Thus, risk stratification of transplant glomerulopathy based on our prognostic index may provide informative insight for both the patient and physician regarding prognosis and treatment.
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Verghese PS, Reed RC, Lihong B, Matas AJ, Kim Y. The clinical implications of the unique glomerular complement deposition pattern in transplant glomerulopathy. J Nephrol 2016; 31:157-164. [PMID: 27848227 DOI: 10.1007/s40620-016-0365-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 11/05/2016] [Indexed: 11/25/2022]
Abstract
The etiology and treatment of transplant glomerulopathy (TG) is not clear. TG is associated with donor-specific antibodies but the lack of C4d deposition in the peritubular capillaries (ptc-C4d) in some cases has caused the role of complement in the pathogenesis of TG to be debated. There is however, little information on C4d deposition in the glomerulus itself. We retrieved random frozen sections from 25 cases with well-established TG by light microscopy (LM) and 25 cases without TG as controls and reviewed the LM and immunofluorescence (nine biopsies were excluded due to inadequate samples). Glomerular complement deposition was assessed in all included biopsies. Glomerular C3d and C4d deposition occurred in a distinct pattern in all TG biopsies: segmental or global double linear staining of the glomerular capillary wall in 23 (100%). This pattern was not present in any NON-TG biopsies. The distinct glomerular complement deposition patterns in all TG cases are suggestive that TG is a proximal complement-mediated process and therapies should focus on proximal complement inhibition.
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Affiliation(s)
- Priya S Verghese
- Division of Pediatric Nephrology, University of Minnesota, Minneapolis, USA.
| | - Robin C Reed
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, USA
| | - Bu Lihong
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, USA
| | - Arthur J Matas
- Department of Surgery, University of Minnesota, Minneapolis, USA
| | - Youngki Kim
- Division of Pediatric Nephrology, University of Minnesota, Minneapolis, USA
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Kahwaji J, Jordan SC, Najjar R, Wongsaroj P, Choi J, Peng A, Villicana R, Vo A. Six-year outcomes in broadly HLA-sensitized living donor transplant recipients desensitized with intravenous immunoglobulin and rituximab. Transpl Int 2016; 29:1276-1285. [PMID: 27529314 DOI: 10.1111/tri.12832] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 05/15/2016] [Accepted: 08/02/2016] [Indexed: 11/29/2022]
Abstract
Desensitization with intravenous immunoglobulin (IVIG) and rituximab can improve transplantation rates in broadly sensitized kidney transplant recipients. However, long-term outcomes are lacking. Here we analyze long-term outcomes in living donor kidney transplant recipients desensitized with this regimen and compare them to low-risk recipients. Living donor kidney transplants that took place between July 2006 and December 2010 were considered retrospectively. The primary end point of the study was death-censored allograft survival at last follow-up. Secondary end points included patient survival, incidence of rejection, glomerular filtration rate (GFR), and proteinuria. There were 66 sensitized and 111 low-risk patients included. Average follow-up was 68 months. There was no difference in long-term patient or graft survival. The rate of rejection was similar in the groups with more early rejection in the sensitized group and more late rejection in the low-risk group. There was more antibody-mediated rejection in the sensitized group. Estimated GFR was similar during the follow-up period. Risk factors for rejection included a positive cross-match (HR: 2.4 CI: 1.35-4.40) and age (HR: 0.97 CI: 0.95-0.99). Desensitization with IVIG and rituximab has good long-term results with graft outcomes similar to non-HLA-sensitized patients despite higher immunologic risk.
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Affiliation(s)
- Joseph Kahwaji
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
| | - Stanley C Jordan
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
| | - Reiad Najjar
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
| | - Patarapha Wongsaroj
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
| | - Jua Choi
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
| | - Alice Peng
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
| | - Rafael Villicana
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
| | - Ashley Vo
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
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