1
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Wu Q, Ni X, Chen J, Cheng D, Zhang M, Xie K, Li X, Wen J. Similar incidence of graft glomerulonephritis in recipients with definitively diagnosed glomerulonephritis and those with unknown etiology: a retrospective observational study. Ren Fail 2024; 46:2325644. [PMID: 38445391 PMCID: PMC10919306 DOI: 10.1080/0886022x.2024.2325644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/26/2024] [Indexed: 03/07/2024] Open
Abstract
OBJECTIVE In China, most of the patients who underwent kidney transplants have unknown causes of end-stage renal disease (uESRD). However, little is known regarding the incidence of graft glomerulonephritis (GN) and graft survival in kidney transplant recipients (KTRs) with uESRD. METHODS In this retrospective cohort study, 473 of the 565 KTRs who underwent kidney transplantation (KTx) from 2015 to 2020 were included. We mainly observed the occurrence of graft GN between uESRD group and definitively diagnosed GN group, and repeatedly compared after propensity score matching (PSM). RESULTS The median follow-up was 50 months in 473 KTRs, and about 75% of KTRs of native kidney disease of unknown etiology. The total cumulative incidence of graft GN was 17%, and no difference was observed between the definitively diagnosed GN group and the uESRD group (p = 0.76). Further, PSM analysis also showed no difference in the incidence of graft GN between the 2 groups. Multivariable analysis disclosed males (p = 0.001), younger age (p = 0.03), and anti-endothelial cell anti-body (AECA) positive pre-KTx (p = 0.001) were independent risk factors for graft GN. CONCLUSIONS The incidence of graft GN was similar between uESRD and definitively diagnosed GN group. The allograft survival was also similar between two groups.
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Affiliation(s)
- Qianqian Wu
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China
| | - Xuefeng Ni
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China
| | - Jingsong Chen
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China
| | - Dongrui Cheng
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China
| | - Mingchao Zhang
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China
| | - Kenan Xie
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China
| | - Xue Li
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China
| | - Jiqiu Wen
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, PR China
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2
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Zhong Z, Ye Y, Xia L, Na N. Identification of RNA-binding protein genes associated with renal rejection and graft survival. Ren Fail 2024; 46:2360173. [PMID: 38874084 PMCID: PMC11182075 DOI: 10.1080/0886022x.2024.2360173] [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: 12/07/2023] [Accepted: 05/21/2024] [Indexed: 06/15/2024] Open
Abstract
Rejection is one of the major factors affecting the long-term prognosis of kidney transplantation, and timely recognition and aggressive treatment of rejection is essential to prevent disease progression. RBPs are proteins that bind to RNA to form ribonucleoprotein complexes, thereby affecting RNA stability, processing, splicing, localization, transport, and translation, which play a key role in post-transcriptional gene regulation. However, their role in renal transplant rejection and long-term graft survival is unclear. The aim of this study was to comprehensively analyze the expression of RPBs in renal rejection and use it to construct a robust prediction strategy for long-term graft survival. The microarray expression profiles used in this study were obtained from GEO database. In this study, a total of eight hub RBPs were identified, all of which were upregulated in renal rejection samples. Based on these RBPs, the renal rejection samples could be categorized into two different clusters (cluster A and cluster B). Inflammatory activation in cluster B and functional enrichment analysis showed a strong association with rejection-related pathways. The diagnostic prediction model had a high diagnostic accuracy for T cell mediated rejection (TCMR) in renal grafts (area under the curve = 0.86). The prognostic prediction model effectively predicts the prognosis and survival of renal grafts (p < .001) and applies to both rejection and non-rejection situations. Finally, we validated the expression of hub genes, and patient prognosis in clinical samples, respectively, and the results were consistent with the above analysis.
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Affiliation(s)
- Zhaozhong Zhong
- Department of Kidney Transplantation, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yongrong Ye
- Department of Kidney Transplantation, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Liubing Xia
- Department of Kidney Transplantation, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ning Na
- Department of Kidney Transplantation, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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3
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Mao K, Lin F, Pan Y, Li J, Ye J. Identification of glycosyltransferase genes for diagnosis of T-cell mediated rejection and prediction of graft loss in kidney transplantation. Transpl Immunol 2024; 87:102114. [PMID: 39243908 DOI: 10.1016/j.trim.2024.102114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Revised: 08/19/2024] [Accepted: 09/01/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND Glycosylation is a complex and fundamental metabolic biosynthetic process orchestrated by multiple glycosyltransferases (GT) and glycosidases enzymes. Functions of GT have been extensively examined in multiple human diseases. Our study investigated the potential role of GT genes in T-cell mediated rejection (TCMR) and possible prediction of graft loss of kidney transplantation. METHODS We downloaded the microarray datasets and GT genes from the GEO and the HUGO Gene Nomenclature Committee (HGNC) databases, respectively. Differentially expressed GT genes (DE-GTGs) were obtained by differential expression and Venn analysis. A TCMR diagnostic model was developed based on the hub DE-GTGs using LASSO regression and XGboost machine learning algorithms. In addition, a predictive model for graft survival was constructed by univariate Cox and LASSO Cox regression analysis. RESULTS We have obtained 15 DE-GTGs. Both GO and KEGG analyses showed that the DE-GTGs were mainly involved in the glycoprotein biosynthetic process. The TCMR diagnostic model exhibited high diagnostic potential with generally highly correlated accuracies [aera under the curve (AUC) of 0.83]. The immune characteristics analysis revealed that higher levels of immune cell infiltration and immune responses were observed in the high-risk group than in the low-risk group. In particular, the Kaplan-Meier survival analysis revealed that renal grafts in the high-risk group have poor prognostic outcomes than the low-risk group. The predictive AUC values of 1-, 2- and 3-year graft survival were 0.76, 0.81, and 0.70, respectively. CONCLUSION Our results indicated that GT genes could be used for diagnosis of TCMR and prediction of graft loss in kidney transplantation. These results provide new perspectives and tools for diagnosing, treating and predicting kidney transplant-related diseases.
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Affiliation(s)
- Kaifeng Mao
- Department of Kidney Transplantation, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Fenwang Lin
- Department of Kidney Transplantation, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yige Pan
- Division of Nephrology, Department of Nursing, The University of Hong Kong-Shenzhen Hospital, Shenzhen City, Guangdong Province, China
| | - Juan Li
- School of Nursing, Southern Medical University, Guangzhou, Guangdong Province, China.
| | - Junsheng Ye
- Department of Kidney Transplantation, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.
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4
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Hariharan S, Rogers N, Naesens M, Pestana JM, Ferreira GF, Requião-Moura LR, Foresto RD, Kim SJ, Sullivan K, Helanterä I, Goutaudier V, Loupy A, Kute VB, Cardillo M, Tanabe K, Åsberg A, Jensen T, Mahillo B, Jeong JC, Anantharaman V, Callaghan C, Ravanan R, Manas D, Israni AK, Mehta RB. Long-term Kidney Transplant Survival Across the Globe. Transplantation 2024; 108:e254-e263. [PMID: 38499511 DOI: 10.1097/tp.0000000000004977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
BACKGROUND The outcomes after kidney transplantation (KT), including access, wait time, and other issues around the globe, have been studied. However, issues do vary from one country to another. METHODS We obtained data from several countries from North America, South America, Europe, Asia, and Australia, including the number of patients awaiting KT from 2015, transplant rate per million population (pmp), proportion of living donor and deceased donor (LD/DD) KT, and posttransplant survival. We also sought opinions on key difficulties faced by each of these countries with respect to KT and long-term survival. RESULTS Variation in access to KT across the globe was noted. Countries with the highest rates of KT pmp included the United States (79%) and Spain (71%). A higher proportion of LD transplants was noted in Japan (93%), India (85%), Singapore (63%), and South Korea (63%). A higher proportion of DD KTs was noted in Spain (90%), Brazil (90%), France (85%), Italy (85%), Finland (85%), Australia-New Zealand (80%), and the United States (77%). The 5-y graft survival for LD was highest in South Korea (95%), Singapore (94%), Italy (93%), Finland (93%), and Japan (93%), whereas for DD, it was South Korea (93%), Italy (88%), Japan (86%), and Singapore (86%). The common issues surrounding KTs are access and a limited number of LDs and DDs. Key issues identified for long-term survival were increasing age of donors and recipients, higher recipient comorbidity, and posttransplant events, such as alloimmune injury to the kidney, infection, cancer, and suboptimal adherence to therapy. CONCLUSIONS A unified approach is necessary to improve issues surrounding KT as the demand continues to increase.
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Affiliation(s)
- Sundaram Hariharan
- Department of Medicine and Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Natasha Rogers
- Division of Nephrology and Transplantation, Department of Nephrology and Transplantation Medicine, Westmead Institute for Medical Research, Westmead, NSW, Australia
| | - Maarten Naesens
- Department of Medicine and Nephrology, University of KU Leuven, Leuven, Belgium
| | - J Medina Pestana
- Hospital do Rim, Fundação Oswaldo Ramos and Disciplina de Nefrologia, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Gustavo F Ferreira
- Hospital do Rim, Fundação Oswaldo Ramos and Disciplina de Nefrologia, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Lucio R Requião-Moura
- Hospital do Rim, Fundação Oswaldo Ramos and Disciplina de Nefrologia, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Renato D Foresto
- Hospital do Rim, Fundação Oswaldo Ramos and Disciplina de Nefrologia, Universidade Federal de São Paulo, São Paulo, Brazil
| | - S Joseph Kim
- Department of Medicine (Nephrology), University of Toronto, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | | | - Ilkka Helanterä
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Valentin Goutaudier
- Université Paris Cité, Paris Institute for Transplantation and Organ Regeneration, Paris, France
| | - Alexandre Loupy
- Department of Nephrology and Transplantation, Université Paris Cité, Paris Institute for Transplantation and Organ Regeneration, Paris, France
| | - Vivek B Kute
- Department of Nephology, Institute of Kidney Diseases and Research Centre, Ahmedabad, Gujarat, India
| | - Massimo Cardillo
- Centro Nazionale per i Trapianti, Istituto Superiore di Sanità, Roma, Italy
| | - Kazunari Tanabe
- Kidney Transplant/Robotic Surgery Center, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Anders Åsberg
- Section of Pharmacology and Pharmaceutical Bioscience, University of Oslo, Oslo, Norway
| | - Trond Jensen
- Department of Nephrology, University of Oslo, Oslo, Norway
| | | | - Jong Cheol Jeong
- Department of Medicine and Nephrology, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Vathsala Anantharaman
- National University Centre for Organ Transplantation, National University Hospital, Singapore, Singapore
| | - Chris Callaghan
- Department of Nephrology and Transplantation, Guy's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | | | - Derek Manas
- Newcastle Hospitals NHS Trust and Newcastle University, New Castle, United Kingdom
| | - Ajay K Israni
- Department of Medicine, Adjunct Faculty School of Public Health, University of Minnesota, Minneapolis, MN
| | - Rajil B Mehta
- Department of Medicine and Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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5
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Wong ETY, Pochinco D, Vathsala A, Koh WK, Lim A, Sran HK, D'Costa MR, Chang ZY, Nickerson PW, Wiebe C. HLA-DR/DQ eplet mismatch predicts de novo donor-specific antibody development in multi-ethnic Southeast Asian kidney transplant recipients on different immunosuppression regimens. Front Genet 2024; 15:1447141. [PMID: 39262421 PMCID: PMC11387181 DOI: 10.3389/fgene.2024.1447141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 08/14/2024] [Indexed: 09/13/2024] Open
Abstract
Eplet mismatch has been recognized as a more precise strategy for determining HLA compatibility by analyzing donor-recipient HLA differences at the molecular level. However, predicting post-transplant alloimmunity using single-molecule eplet mismatch categories has not been validated in Asian cohorts. We examined a cohort of Southeast Asian kidney transplant recipients (n = 234) to evaluate HLA-DR/DQ eplet mismatch as a predictor of de novo donor-specific antibody (dnDSA) development. HLA-DR/DQ single-molecule eplet mismatch was quantified using HLA Matchmaker, and we utilized previously published HLA-DR/DQ eplet mismatch thresholds to categorize recipients into alloimmune risk groups and evaluate their association with dnDSA development. Recognizing that the predominance of cyclosporine use (71%) may alter published eplet mismatch thresholds derived from a largely tacrolimus-based (87%) cohort, we evaluated cohort-specific thresholds for HLA-DR/DQ single-molecule eplet mismatch categories. Recipient ethnicities included Chinese (65%), Malays (17%), Indians (14%), and others (4%). HLA-DR/DQ dnDSA developed in 29/234 (12%) recipients after a median follow-up of 5.4 years, including against isolated HLA-DR (n = 7), isolated HLA-DQ (n = 11), or both (n = 11). HLA-DR/DQ single-molecule eplet mismatch risk categories correlated with dnDSA-free survival (p = 0.001) with low-risk recipients having a dnDSA prevalence of 1% over 5 years. The cohort-specific alloimmune risk categories improved correlation with HLA-DR/DQ dnDSA-free survival and remained significant after adjusting for calcineurin inhibitor and anti-metabolite immunosuppression (p < 0.001). We validated the performance of single-molecule eplet mismatch categories as a prognostic biomarker for HLA-DR/DQ dnDSA development in a cohort of predominantly Asian kidney transplant recipients after adjusting for different immunosuppression regimens.
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Affiliation(s)
- Emmett Tsz Yeung Wong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Hospital, Singapore, Singapore
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Anantharaman Vathsala
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Hospital, Singapore, Singapore
| | - Wee Kun Koh
- National University Centre for Organ Transplantation, National University Hospital, Singapore, Singapore
| | - Amy Lim
- National University Centre for Organ Transplantation, National University Hospital, Singapore, Singapore
| | - Hersharan Kaur Sran
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Hospital, Singapore, Singapore
| | - Matthew Ross D'Costa
- National University Centre for Organ Transplantation, National University Hospital, Singapore, Singapore
| | - Zi Yun Chang
- National University Centre for Organ Transplantation, National University Hospital, Singapore, Singapore
| | - Peter W Nickerson
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Shared Health Services Manitoba, Winnipeg, MB, Canada
- Department of Immunology, University of Manitoba, Winnipeg, MB, Canada
| | - Chris Wiebe
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Shared Health Services Manitoba, Winnipeg, MB, Canada
- Department of Immunology, University of Manitoba, Winnipeg, MB, Canada
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6
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Zakrocka I, Nair G, Soler MJ, Jhaveri KD, Kronbichler A. Paraneoplastic Syndrome After Kidney Transplantation: Frequency, Risk Factors, Differences to Paraneoplastic Occurrence of Glomerulonephritis in the Native Kidney, and Implications on Long-Term Kidney Graft Function. Transpl Int 2024; 37:12969. [PMID: 39119062 PMCID: PMC11306043 DOI: 10.3389/ti.2024.12969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 07/12/2024] [Indexed: 08/10/2024]
Abstract
Posttransplant malignancies are an important complication of solid organ transplantation. Kidney transplant recipients are at particularly high risk of cancer development. The most relevant risk factors of carcinogenesis are the use of immunosuppressive agents and oncogenic viral infections. Additionally, immune dysregulation caused by these factors may predispose to various types of organ damage. Paraneoplastic glomerular diseases are one of the most interesting and understudied cancer manifestations. The appropriate diagnosis of paraneoplastic glomerular damage can be challenging in kidney transplant recipients, due to factors inherent to concomitant medication and common comorbidities. Recent advances in the field of molecular and clinical nephrology led to a significant improvement in our understanding of glomerular diseases and their more targeted treatment. On the other hand, introduction of novel anticancer drugs tremendously increased patients' survival, at the cost of kidney-related side effects. Our review aims to provide insights into diagnosis and treatment of paraneoplastic glomerular diseases, with a special attention to kidney transplant recipients.
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Affiliation(s)
- Izabela Zakrocka
- Department of Nephrology, Medical University of Lublin, Lublin, Poland
| | - Gayatri Nair
- Northwell Health, New York, NY, United States
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Glomerular Center at Northwell Health, New York, NY, United States
| | - Maria Jose Soler
- Nephrology Department, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
- Nephrology Research Group, Vall d’Hebron Research Institute (VHIR), Barcelona, Spain
| | - Kenar D. Jhaveri
- Northwell Health, New York, NY, United States
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Glomerular Center at Northwell Health, New York, NY, United States
| | - Andreas Kronbichler
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
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7
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Zhanzak Z, Cina D, Johnson AC, Larsen CP. Implications of MHC-restricted immunopeptidome in transplantation. Front Immunol 2024; 15:1436233. [PMID: 39035001 PMCID: PMC11257886 DOI: 10.3389/fimmu.2024.1436233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 06/26/2024] [Indexed: 07/23/2024] Open
Abstract
The peptide presentation by donor and recipient major histocompatibility complex (MHC) molecules is the major driver of T-cell responses in transplantation. In this review, we address an emerging area of interest, the application of immunopeptidome in transplantation, and describe the potential opportunities that exist to use peptides for targeting alloreactive T cells. The immunopeptidome, the set of peptides presented on an individual's MHC, plays a key role in immune surveillance. In transplantation, the immunopeptidome is heavily influenced by MHC-derived peptides, delineating a key subset of the diverse peptide repertoire implicated in alloreactivity. A better understanding of the immunopeptidome in transplantation has the potential to open up new approaches to identify, characterize, longitudinally quantify, and therapeutically target donor-specific T cells and ultimately support more personalized immunotherapies to prevent rejection and promote allograft tolerance.
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Affiliation(s)
- Zhuldyz Zhanzak
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States
- Emory Transplant Center, Emory University School of Medicine, Atlanta, GA, United States
| | - Davide Cina
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States
- Emory Transplant Center, Emory University School of Medicine, Atlanta, GA, United States
| | - Aileen C. Johnson
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States
- Emory Transplant Center, Emory University School of Medicine, Atlanta, GA, United States
| | - Christian P. Larsen
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States
- Emory Transplant Center, Emory University School of Medicine, Atlanta, GA, United States
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8
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Geissbühler Y, Johnson JC, Gharbi H, Aubrun E, Kuessner D, Smolskis JM, Barcelos G, Prieto L. Treatment Switches, Patterns, and Outcomes in Adult and Pediatric Patients Undergoing Kidney Transplantation Between 2000 and 2019: A Retrospective United States Claims Database Study. Transplant Proc 2024; 56:1290-1299. [PMID: 39068098 DOI: 10.1016/j.transproceed.2024.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/24/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Immunosuppressive regimens are imperative for improving patient and graft survival following kidney transplantation in patients with kidney failure. However, real-world evidence regarding treatments and outcomes in these patients is scarce. We sought to describe the treatment switches (assessed by line of treatment [LOT]), patterns, and outcomes in patients who underwent kidney transplantation in the United States. METHODS This retrospective cohort study used claims data from the Optum Research Database in the United States. Adult and pediatric patients undergoing a kidney transplantation between January 1, 2000, and June 30, 2019, who had ≥1 year of baseline and follow-up visits and continuous enrollment in the Optum Research Database, were included. RESULTS Data from 7159 patients (6833, adult; 326, pediatric) were included. The mean age for adult and pediatric patients was 51.4 ± 12.8 years and 10.4 ± 5.1 years, respectively. The mean number of LOTs in patients with ≥1 LOT (n = 7004) was 4.1 ± 2.6 LOTs. Tacrolimus, antiproliferative agents, and prednisone were the most frequently prescribed immunosuppressants. No strong correlations were identified between switching from LOT1 to LOT2 and potential predictors of treatment switches. The proportion of patients who did not experience graft loss gradually decreased between month 3 and month 120 (72%-36%), driven by return to dialysis (66%-18%). A slower decrease was observed for graft rejection (98%-84%), retransplantation (98%-93%), and graft removal (98%-92%). CONCLUSIONS We described treatment switches, patterns, and outcomes in patients who underwent kidney transplantation in the United States. Future analytical studies are needed to test hypotheses derived from these observations.
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Affiliation(s)
| | | | | | | | | | | | - Giovanna Barcelos
- Novartis Pharma AG, Basel, Switzerland; Pfizer AG, Zurich, Switzerland
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9
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Scurt FG, Hammoud B, Bose K, Mertens PR, Chatzikyrkou C. Short-Term, Mid-Term, and Long-Term Outcomes after Deceased Donor Kidney Transplantation in Patients with AKI: A Systematic Review and Meta-Analysis. KIDNEY360 2024; 5:1012-1031. [PMID: 38668857 PMCID: PMC11296548 DOI: 10.34067/kid.0000000000000450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 04/17/2024] [Indexed: 07/26/2024]
Abstract
Key Points This study reviews the willingness to use kidneys from donors who have experienced AKI during transplantation and provides a thorough analysis of the existing literature. While delayed graft function is more common, primary nonfunction and acute rejection rates appear comparable, as do allograft function and graft survival compared with non-AKI donor kidneys. Considering the shortage of available organs and the high mortality rate of patients on dialysis, the use of donors with AKI as a source for kidney transplantation is a viable alternative. Background AKI is a common complication in hospitalized patients and may occur in potential kidney donors. Observational studies have suggested that kidney transplantation in patients with AKI is feasible and safe, but no systematic evaluation has been performed. Methods We performed a systematic review and meta-analysis to evaluate the outcomes of kidney transplantation in patients with AKI. We searched MEDLINE, Embase, Cochrane, Google Scholar, and other databases for studies reporting outcomes of donor kidneys with AKI. We included single-center, multicenter, and registry-based studies and analyzed them according to the definition and severity of AKI. End points were primary and delayed graft function (DGF), primary nonfunction (PNF), length of hospital stay, rejection, graft function, and patient and graft survival at 1, 3, 5, and 8–10 years after transplantation. This study was registered in PROSPERO, number CRD42021260088. Results We identified 33 single-center, four multicenter, and seven registry studies with more than 100,000 patients published between 2005 and 2022. Recipients from donors with AKI had a higher risk of DGF (relative risk, 1.51; 95% confidence interval [CI], 1.35 to 1.68). Graft function at discharge was worse in the AKI group (MDCrea [95% CI]: 0.96 mg/dl [0.36 to 1.56, I2=96%], MDGFR [95% CI]: −8.88 ml/min per 1.73 m2 [−15.32 to −2.44, I2=93%]), but improved thereafter and was similar in both groups at 3 months after transplantation (MDCrea [95% CI]: −0.05 mg/dl [−0.18 to 0.07, I2=0%], MDGFR [95% CI]: −1.83 ml/min per 1.73 m2 [−5.29 to 1.63, I2=91%]). Primary nonfunction and patient and graft survival were similar at 1, 3, 5, and 8–10 years after transplantation. There were no differences in rejections regardless of AKI definition and severity. Conclusions Transplantation of kidneys with AKI is associated with satisfactory short-term and long-term outcomes and should be pursued to increase the donor pool.
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Affiliation(s)
- Florian G. Scurt
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Ben Hammoud
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Katrin Bose
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Peter R. Mertens
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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10
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Sinha R, Zhu Z, Park S, Rebello C, Kinsella B, Friedewald J, Kleiboeker S. Combined Metagenomic Viral Detection and Donor-Derived Cell-Free DNA Quantification in Plasma From Kidney Transplant Recipients. Transplant Proc 2024; 56:1522-1530. [PMID: 38972761 DOI: 10.1016/j.transproceed.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 05/27/2024] [Accepted: 06/07/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND Kidney transplant recipients require potent immunosuppression and are predisposed to opportunistic infections, many of which have a viral etiology. Currently, viral assays detect and quantify single pathogens using PCR or qPCR. An unbiased sequencing method with comparable accuracy would allow simultaneous monitoring of multiple viral pathogens and nonpathogenic Anelloviridae. The quantification of donor-derived cell-free DNA (dd-cfDNA) is an established method for the detection of allograft rejection, and a single workflow combining dd-cfDNA quantification and viral detection represents an opportunity to improve patient monitoring and management. METHODS Whole genome sequencing of cell-free DNA was performed using 1,980 plasma samples from 256 subjects enrolled in a multi-center study. Non-human sequences underwent reference-assisted assembly and taxonomic annotation of the viral DNA pathogens. RESULTS Of the 1,980 samples tested, 1,453 (73.4%) had ≥1 viral detection(s), either a known viral pathogen or torque teno virus (TTV), with positivity rates generally declining 12-18 months post-transplant. Concordance of metagenomic NGS (mNGS) viral detection with qPCR detection was 97.7% (94.1% sensitivity, 98.2% specificity), and a linear relationship was demonstrated between mNGS viral quantitation and qPCR results. BK virus, cytomegalovirus, and Epstein-Barr virus were detected by sequencing up to 60 days prior to independently established clinical diagnoses. CONCLUSIONS Whole-genome sequencing allows simultaneous quantification of dd-cfDNA as well as sensitive and early detection of viral infection through secondary analysis of the same sequencing results. In combination with dd-cfDNA, mNGS viral detection may provide additional pathogen surveillance results and serve as a useful biomarker for both over- and under-immunosuppression.
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Affiliation(s)
- Rohita Sinha
- Eurofins Viracor Clinical Diagnostics, Lenexa, Kansas
| | - Zixuan Zhu
- Eurofins Viracor Clinical Diagnostics, Lenexa, Kansas
| | - Sookhyeon Park
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | | | - Bradley Kinsella
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - John Friedewald
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois
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11
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Füessl L, Kreuzer L, Nierychlewski K, Seibt T, Stangl MJ, Koliogiannis D, Meiser B, Schwarz M, Fischereder M, Kemmner S. The use of extended-release tacrolimus twice a day might be beneficial for selected kidney transplant recipients: a case report. Front Med (Lausanne) 2024; 11:1336035. [PMID: 38988355 PMCID: PMC11233442 DOI: 10.3389/fmed.2024.1336035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 05/03/2024] [Indexed: 07/12/2024] Open
Abstract
The calcineurin inhibitor tacrolimus, which is available as an immediate- or extended-release formulation, is the standard-of-care immunosuppression after kidney transplantation with low rejection rates, especially in the first year after transplantation. However, its highly variable metabolism rate, narrow therapeutic window, and nephrotoxic side effects require close drug monitoring and individual dosing. Here, we describe first the application of extended-release tacrolimus (ER-Tac) twice daily with beneficial effects in a kidney transplant recipient under extensive therapeutic drug monitoring. A 47-year-old female kidney transplant recipient, who was identified as a fast metabolizer for tacrolimus, presented with declining allograft function and low tacrolimus through levels over time and 8 years after a second kidney transplantation despite the administration of high doses of ER-Tac once daily. Therefore, the area under the concentration-time curve (AUC) showed exceedingly high blood levels of ER-Tac. The latest biopsy of the kidney transplant showed arteriolar hyalinosis with pole vessel stenosis as a sign of chronic transplant vasculopathy and transplant glomerulopathy as a sign of chronic humoral rejection. After the exclusion of other options for immunosuppressive therapy due to the patient's high immunological risk, the patient was switched from ER-Tac once daily to ER-Tac twice daily. After switching to ER-Tac twice daily, the AUC for oral tacrolimus decreased and the transplant function improved despite higher tacrolimus trough levels and a lower total dose administered. This case highlights the importance of careful therapeutic drug monitoring with the performance of an AUC in the follow-up management of kidney transplant recipients.
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Affiliation(s)
- Louise Füessl
- Transplant Center, University Hospital Munich, Ludwig-Maximilians-University (LMU), Munich, Germany
- Division of Nephrology, Department of Medicine IV, University Hospital Munich, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Lena Kreuzer
- Department of Nephrology and Rheumatology, Augustinum Klinik München, Munich, Germany
| | - Kajetan Nierychlewski
- Institute of Laboratory Medicine, University Hospital Munich, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Tobias Seibt
- Transplant Center, University Hospital Munich, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Manfred Johannes Stangl
- Department of General, Visceral and Transplantation Surgery, University Hospital Munich, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Dionysios Koliogiannis
- Department of General, Visceral and Transplantation Surgery, University Hospital Munich, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Bruno Meiser
- Transplant Center, University Hospital Munich, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Markus Schwarz
- Institute of Laboratory Medicine, University Hospital Munich, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Michael Fischereder
- Division of Nephrology, Department of Medicine IV, University Hospital Munich, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Stephan Kemmner
- Transplant Center, University Hospital Munich, Ludwig-Maximilians-University (LMU), Munich, Germany
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12
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Santos AH, Mehta R, Alquadan K, Ibrahim H, Leghrouz MA, Belal A, Wen X. Age-modified risk factors for mortality of non-elderly adult kidney transplant recipients: a retrospective database analysis. Int Urol Nephrol 2024:10.1007/s11255-024-04132-3. [PMID: 38922533 DOI: 10.1007/s11255-024-04132-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Accepted: 06/18/2024] [Indexed: 06/27/2024]
Abstract
PURPOSE We aimed to investigate the role of the recipient's age strata in modifying the associations between risk factors and mortality in non-elderly adult kidney transplant (KT) recipients (KTR). METHODS We stratified 108,695 adult KTRs between 2000 and 2016 with conditional 1-year survival after KT into cohorts based on age at transplant: 18-49 years and 50-64 years. We excluded KTRs aged < 18 years or > / = 65 years. KTRs were observed for 5 years during the 2nd through 6th years post-KT for the outcome, all-cause mortality. RESULTS Increasing recipient age strata (18-49-year-old and 50-64-year-old) correlated with decreasing 6-year post-KT survival rates conditional on 1-year survival (79% and 57%, respectively, p < 0.0001). Middle adult age stratum was associated with a higher risk of all-cause mortality than young adult age stratum in KTRs of Hispanic/Latino and other races [HR = 1.23, 95% CI = 1.04-1.45 and HR = 1.51, 95% CI = 1.16-1.97, respectively] and with a primary native renal diagnosis of hypertension or glomerulonephritis [HR = 1.32, 95% CI = 1.12-1.55 and HR = 1.29, 95% CI = 1.10-151, respectively]. When compared with the young adult age stratum, the middle adult age stratum had a mitigating effect on the higher risk of mortality associated with sirolimus-mycophenolate or sirolimus-tacrolimus than the standard calcineurin inhibitor-mycophenolate regimen [HR = 0.75, 95% CI = 0.57-0.99 and HR = 0.71, 95% CI = 0.57-0.89, respectively]. CONCLUSION Among adult non-elderly KTRs, the age strata, 18-49 years, and 50-64 years, have varying modifying effects on the strength and direction of associations between some specific risk factors and all-cause mortality.
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Affiliation(s)
- Alfonso H Santos
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Medical Science Bldg., Room NG-4, Gainesville, FL, 32610, USA.
| | - Rohan Mehta
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Medical Science Bldg., Room NG-4, Gainesville, FL, 32610, USA
| | - Kawther Alquadan
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Medical Science Bldg., Room NG-4, Gainesville, FL, 32610, USA
| | - Hisham Ibrahim
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Medical Science Bldg., Room NG-4, Gainesville, FL, 32610, USA
| | - Muhannad A Leghrouz
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Medical Science Bldg., Room NG-4, Gainesville, FL, 32610, USA
| | - Amer Belal
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Medical Science Bldg., Room NG-4, Gainesville, FL, 32610, USA
| | - Xuerong Wen
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
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13
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Udomkarnjananun S, Schagen MR, Hesselink DA. A review of landmark studies on maintenance immunosuppressive regimens in kidney transplantation. ASIAN BIOMED 2024; 18:92-108. [PMID: 39175954 PMCID: PMC11338012 DOI: 10.2478/abm-2024-0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
Immunosuppressive medications play a pivotal role in kidney transplantation, and the calcineurin inhibitors (CNIs), including cyclosporine A (CsA) and tacrolimus (TAC), are considered as the backbone of maintenance immunosuppressive regimens. Since the introduction of CNIs in kidney transplantation, the incidence of acute rejection has decreased, and allograft survival has improved significantly. However, CNI nephrotoxicity has been a major concern, believed to heavily impact long-term allograft survival and function. To address this concern, several CNI-sparing regimens were developed and studied in randomized, controlled, clinical trials, aiming to reduce CNI exposure and preserve long-term allograft function. However, more recent information has revealed that CNI nephrotoxicity is not the primary cause of late allograft failure, and its histopathology is neither specific nor pathognomonic. In this review, we discuss the historical development of maintenance immunosuppressive regimens in kidney transplantation, covering the early era of transplantation, the CNI-sparing era, and the current era where the alloimmune response, rather than CNI nephrotoxicity, appears to be the major contributor to late allograft failure. Our goal is to provide a chronological overview of the development of maintenance immunosuppressive regimens and summarize the most recent information for clinicians caring for kidney transplant recipients (KTRs).
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Affiliation(s)
- Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok10330, Thailand
- Excellence Center for Solid Organ Transplantation, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok10330, Thailand
- Renal Immunology and Transplantation Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok10330, Thailand
- Center of Excellence on Translational Research in Inflammation and Immunology (CETRII), Department of Microbiology, Chulalongkorn University, Bangkok10330, Thailand
| | - Maaike R. Schagen
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam3000, The Netherlands
| | - Dennis A. Hesselink
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam3000, The Netherlands
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14
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Laroche C, Engen RM. Immune monitoring in pediatric kidney transplant. Pediatr Transplant 2024; 28:e14785. [PMID: 38766986 DOI: 10.1111/petr.14785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 04/25/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Long-term outcomes in pediatric kidney transplantation remain suboptimal, largely related to chronic rejection. Creatinine is a late marker of renal injury, and more sensitive, early markers of allograft injury are an active area of current research. METHODS This is an educational review summarizing existing strategies for monitoring for rejection in kidney transplant recipients. RESULTS We summarize supporting currently available clinical tests, including surveillance biopsy, donor specific antibodies, and donor-derived cell free DNA, as well as the potential limitations of these studies. In addition, we review the current avenues of active research, including transcriptomics, proteomics, metabolomics, and torque tenovirus levels. CONCLUSION Advancing the use of noninvasive immune monitoring will depend on well-designed multicenter trials that include patients with stable graft function, include biopsy results on all patients, and can demonstrate both association with a patient-relevant clinical endpoint such as graft survival or change in glomerular filtration rate and a potential timepoint for intervention.
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Affiliation(s)
| | - Rachel M Engen
- University of Wisconsin Madison, Madison, Wisconsin, USA
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15
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Ramalhete L, Vieira MB, Araújo R, Vigia E, Aires I, Ferreira A, Calado CRC. Predicting Cellular Rejection of Renal Allograft Based on the Serum Proteomic Fingerprint. Int J Mol Sci 2024; 25:3844. [PMID: 38612654 PMCID: PMC11011520 DOI: 10.3390/ijms25073844] [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: 09/21/2023] [Revised: 03/14/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Kidney transplantation is an essential medical procedure that significantly enhances the survival rates and quality of life for patients with end-stage kidney disease. However, despite advancements in immunosuppressive therapies, allograft rejection remains a leading cause of organ loss. Notably, predictions of cellular rejection processes primarily rely on biopsy analysis, which is not routinely performed due to its invasive nature. The present work evaluates if the serum proteomic fingerprint, as acquired by Fourier Transform Infrared (FTIR) spectroscopy, can predict cellular rejection processes. We analyzed 28 serum samples, corresponding to 17 without cellular rejection processes and 11 associated with cellular rejection processes, as based on biopsy analyses. The leave-one-out-cross validation procedure of a Naïve Bayes model enabled the prediction of cellular rejection processes with high sensitivity and specificity (AUC > 0.984). The serum proteomic profile was obtained in a high-throughput mode and based on a simple, rapid, and economical procedure, making it suitable for routine analyses and large-scale studies. Consequently, the current method presents a high potential to predict cellular rejection processes translatable to clinical scenarios, and that should continue to be explored.
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Affiliation(s)
- Luís Ramalhete
- Blood and Transplantation Center of Lisbon, Instituto Português do Sangue e da Transplantação, Alameda das Linhas de Torres, n° 117, 1769-001 Lisboa, Portugal
- NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1169-056 Lisbon, Portugal
- iNOVA4Health—Advancing Precision Medicine, RG11: Reno-Vascular Diseases Group, NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1169-056 Lisbon, Portugal
| | - Miguel Bigotte Vieira
- Serviço de Nefrologia, Nova Medical School, Hospital Curry Cabral, Centro Hospitalar de Lisboa Central, 1050-099 Lisbon, Portugal
| | - Rúben Araújo
- NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1169-056 Lisbon, Portugal
| | - Emanuel Vigia
- NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1169-056 Lisbon, Portugal
- Hepatobiliopancreatic and Transplantation Center, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, 1050-099 Lisbon, Portugal
| | - Inês Aires
- Serviço de Nefrologia, Nova Medical School, Hospital Curry Cabral, Centro Hospitalar de Lisboa Central, 1050-099 Lisbon, Portugal
| | - Aníbal Ferreira
- NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1169-056 Lisbon, Portugal
- Serviço de Nefrologia, Nova Medical School, Hospital Curry Cabral, Centro Hospitalar de Lisboa Central, 1050-099 Lisbon, Portugal
| | - Cecília R. C. Calado
- ISEL—Instituto Superior de Engenharia de Lisboa, Instituto Politécnico de Lisboa, R. Conselheiro Emídio Navarro 1, 1959-007 Lisbon, Portugal
- Institute for Bioengineering and Biosciences (iBB), The Associate Laboratory Institute for Health and Bioeconomy (i4HB), Instituto Superior Técnico (IST), Universidade de Lisboa (UL), Av. Rovisco Pais, 1049-001 Lisbon, Portugal
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16
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Bhardwaj A, Pirlamarla P, Brailovsky Y, Nair A, Rajapreyar I. Combined Heart Kidney Transplantation Versus Heart Transplant in Patients with Renal Failure: Contemporary Insights and Future Perspectives. Curr Cardiol Rep 2024; 26:83-90. [PMID: 38294626 DOI: 10.1007/s11886-023-02017-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2023] [Indexed: 02/01/2024]
Abstract
PURPOSE OF REVIEW In this review, we aim to outline the criteria regarding the evaluation of patients with chronic renal disease (CKD) awaiting heart transplantation and discuss the outcomes of combined heart/kidney transplantation. Herein, we also review pathophysiology and risk factors that predispose to chronic kidney disease (CKD) and acute kidney injury (AKI) in patients with HF and after OHT. RECENT FINDINGS In patients with end-stage systolic heart failure (HF) and an estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m2, orthotopic heart transplantation (OHT) alone is a relative contraindication, with a consensus that these patients are better served with heart-kidney transplant (HKT). However, there is significant variation between institutions regarding timing and indication for heart/kidney transplantation, with little data available to predict post-transplant outcomes. A Scientific Statement from American Heart Association was published detailing the indications, evaluation, and outcomes for Heart-Kidney Transplantation, and noted a steady rise in the incidence of heart/kidney dual organ transplants. Recently, the Organ Procurement and Transplantation Network (OPTN) Multi-Organ Transplantation Committee implemented a safety net policy for heart transplant recipients who do need meet criteria for simultaneous heart-kidney transplant in 2023 but with a likely need for sequential kidney transplantation. Optimization of organ distribution and patient outcomes after cardiac transplantation requires appropriate recipient selection. This review also outlines the criteria regarding the evaluation of patients with CKD awaiting heart transplantation and outcomes of combined HKT.
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Affiliation(s)
- Anju Bhardwaj
- Texas Medical Center, University of Texas/McGoven Medical School, Houston, TX, USA
| | - Preethi Pirlamarla
- University of Washington Medical Center, University of Washington School of Medicine, Seattle, WA, USA.
| | | | - Ajith Nair
- Baylor College of Medicine, Texas Heart Institute, Dallas, TX, USA
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17
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Swolinsky JS, Hinz RM, Markus CE, Singer E, Bachmann F, Halleck F, Kron S, Naik MG, Schmidt D, Obermeier M, Gebert P, Rauch G, Kropf S, Haase M, Budde K, Eckardt KU, Westhoff TH, Schmidt-Ott KM. Plasma NGAL levels in stable kidney transplant recipients and the risk of allograft loss. Nephrol Dial Transplant 2024; 39:483-495. [PMID: 37858309 PMCID: PMC11024820 DOI: 10.1093/ndt/gfad226] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND The objective of this study was to investigate the utility of neutrophil gelatinase-associated lipocalin (NGAL) and calprotectin (CPT) to predict long-term graft survival in stable kidney transplant recipients (KTR). METHODS A total of 709 stable outpatient KTR were enrolled >2 months post-transplant. The utility of plasma and urinary NGAL (pNGAL, uNGAL) and plasma and urinary CPT at enrollment to predict death-censored graft loss was evaluated during a 58-month follow-up. RESULTS Among biomarkers, pNGAL showed the best predictive ability for graft loss and was the only biomarker with an area under the curve (AUC) > 0.7 for graft loss within 5 years. Patients with graft loss within 5 years (n = 49) had a median pNGAL of 304 [interquartile range (IQR) 235-358] versus 182 (IQR 128-246) ng/mL with surviving grafts (P < .001). Time-dependent receiver operating characteristic analyses at 58 months indicated an AUC for pNGAL of 0.795, serum creatinine-based Chronic Kidney Disease Epidemiology Collaboration estimated glomerular filtration rate (eGFR) had an AUC of 0.866. pNGAL added to a model based on conventional risk factors for graft loss with death as competing risk (age, transplant age, presence of donor-specific antibodies, presence of proteinuria, history of delayed graft function) had a strong independent association with graft loss {subdistribution hazard ratio (sHR) for binary log-transformed pNGAL [log2(pNGAL)] 3.4, 95% confidence interval (CI) 2.24-5.15, P < .0001}. This association was substantially attenuated when eGFR was added to the model [sHR for log2(pNGAL) 1.63, 95% CI 0.92-2.88, P = .095]. Category-free net reclassification improvement of a risk model including log2(pNGAL) in addition to conventional risk factors and eGFR was 54.3% (95% CI 9.2%-99.3%) but C-statistic did not improve significantly. CONCLUSIONS pNGAL was an independent predictor of renal allograft loss in stable KTR from one transplant center but did not show consistent added value when compared with baseline predictors including the conventional marker eGFR. Future studies in larger cohorts are warranted.
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Affiliation(s)
- Jutta S Swolinsky
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany
- Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Ricarda M Hinz
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany
- Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Carolin E Markus
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany
- Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Eugenia Singer
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany
- Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Friederike Bachmann
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany
| | - Susanne Kron
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany
| | - Marcel G Naik
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin
| | - Danilo Schmidt
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany
| | | | - Pimrapat Gebert
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology
| | - Geraldine Rauch
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology
| | - Siegfried Kropf
- Institute of Biometry and Medical Informatics, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Michael Haase
- Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
- Diaverum Renal Services, MVZ Potsdam, Potsdam, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany
| | - Timm H Westhoff
- Medical Department I, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Bochum, Germany
| | - Kai M Schmidt-Ott
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany
- Max Delbrück Center for Molecular Medicine, Berlin, Germany
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
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18
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Ramalhete L, Araújo R, Ferreira A, Calado CRC. Exosomes and microvesicles in kidney transplantation: the long road from trash to gold. Pathology 2024; 56:1-10. [PMID: 38071158 DOI: 10.1016/j.pathol.2023.10.004] [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: 12/21/2022] [Revised: 09/26/2023] [Accepted: 10/19/2023] [Indexed: 01/24/2024]
Abstract
Kidney transplantation significantly enhances the survival rate and quality of life of patients with end-stage kidney disease. The ability to predict post-transplantation rejection events in their early phases can reduce subsequent allograft loss. Therefore, it is critical to identify biomarkers of rejection processes that can be acquired on routine analysis of samples collected by non-invasive or minimally invasive procedures. It is also important to develop new therapeutic strategies that facilitate optimisation of the dose of immunotherapeutic drugs and the induction of allograft immunotolerance. This review explores the challenges and opportunities offered by extracellular vesicles (EVs) present in biofluids in the discovery of biomarkers of rejection processes, as drug carriers and in the induction of immunotolerance. Since EVs are highly complex structures and their composition is affected by the parent cell's metabolic status, the importance of defining standardised methods for isolating and characterising EVs is also discussed. Understanding the major bottlenecks associated with all these areas will promote the further investigation of EVs and their translation into a clinical setting.
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Affiliation(s)
- Luis Ramalhete
- Blood and Transplantation Center of Lisbon, Instituto Português do Sangue e da Transplantação, Alameda das Linhas de Torres, Lisbon, Portugal; NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisbon, Portugal; iNOVA4Health - Advancing Precision Medicine, RG11: Reno-Vascular Diseases Group, NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisbon, Portugal.
| | - Ruben Araújo
- NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Aníbal Ferreira
- NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisbon, Portugal; Centro Hospitalar Universitário Lisboa Central, Hospital Curry Cabral, Serviço de Nefrologia, NOVA Medical School, Lisbon, Portugal
| | - Cecília R C Calado
- ISEL - Instituto Superior de Engenharia de Lisboa, Instituto Politécnico de Lisboa, R. Conselheiro Emídio Navarro 1, Lisbon, Portugal; CIMOSM - Centro de Investigação em Modelação e Otimização de Sistemas Multifuncionais, Lisbon, Portugal
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19
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Karatas M, Tatar E, Okut G, Yildirim AM, Kocabas E, Tasli Alkan F, Simsek C, Dogan SM, Uslu A. Efficacy of mTOR Inhibitors and Intravenous Immunoglobulin for Treatment of Polyoma BK Nephropathy in Kidney Transplant Recipients: A Biopsy-Proven Study. EXP CLIN TRANSPLANT 2024; 22:118-127. [PMID: 38385385 DOI: 10.6002/ect.mesot2023.o29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
OBJECTIVES We investigated the efficacy of a predetermined protocol that consisted of immunosuppressive drug reduction/withdrawal and intravenous immunoglobulin administration for the treatment of polyoma BK virus nephropathy. MATERIALS AND METHODS Patients with biopsy-proven polyoma BK virus nephropathy received a treatment regimen based on discontinuation of both calcineurin inhibitors and antiproliferative agents and switching to mTOR inhibitors accompanied by intravenous immunoglobulin administration. RESULTS Our study included 508 patients, with polyoma BK viremia detected in 80 patients. The mean age was 45.3 ± 9.5 years (range, 18-71 y), 64% were male, and mean follow-up was 37 ± 21 months (6-94 mo). All 16 patients who developed polyoma BK virus nephropathy and 9 patients who had highgrade polyoma BK viremia without nephropathy received intravenous immunoglobulin treatment. Compared with patients with viremia, patients with polyoma BK virus nephropathy had significantly higher rates of graft loss due to rejection (18.8% vs 1.6%; P = .024) and all-cause graft loss (31.2% vs 6.3%; P = .014). Histopathologically, viral inclusion bodies disappeared and SV40 became negative after treatment in all 13 patients who underwent protocol biopsies. Unfortunately, histopathologically complete recovery without chronic tubular and interstitial tissue damage was achieved in only 4 patients after treatment. In addition, 3 patients lost their grafts due to acute antibody-mediated or mixed-type rejection (18.8%). CONCLUSIONS In patients with polyoma BK virus nephropathy, clearance of viremia and SV40 should not be the sole outcomes to obtain. Aggressive reductions in maintenance immunosuppression and switching to double-drug therapy combined with high-dose intravenous immunoglobulin leads to high rates of graft loss/rejection and sequalae of chronic histological changes.
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Affiliation(s)
- Murat Karatas
- From the Department of General Surgery and Transplantation, University of Health Sciences, Izmir Bozyaka Education and Research Hospital, Izmir, Turkey
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20
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Betjes MGH, Kal-van Gestel J, Roodnat JI, de Weerd AE. The Incidence of Antibody-Mediated Rejection Is Age-Related, Plateaus Late After Kidney Transplantation, and Contributes Little to Graft Loss in the Older Recipients. Transpl Int 2023; 36:11751. [PMID: 38188697 PMCID: PMC10768842 DOI: 10.3389/ti.2023.11751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 11/27/2023] [Indexed: 01/09/2024]
Abstract
It is not known whether antibody-mediated rejection (ABMR) is age-related, whether it plateaus late after transplantation, and to what extent it contributes to graft loss in older recipients. Patients transplanted between 2010 and 2015 (n = 1,054) in a single center had regular follow-up until January 2023. Recipients were divided into age groups at transplantation: 18-39 years ("young"), 40-55 years ("middle age"), and >55 years ("elderly"). Ten years after transplantation the cumulative % of recipients with ABMR was 17% in young, 15% in middle age, and 12% in elderly recipients (p < 0.001). The cumulative incidence of ABMR increased over time and plateaued 8-10 years after transplantation. In the elderly, with a median follow-up of 7.5 years, on average 30% of the recipients with ABMR died with a functional graft and ABMR contributed only 4% to overall graft loss in this group. These results were cross-validated in a cohort of recipients with >15 years follow-up. Multivariate cox-regression analysis showed that increasing recipient age was independently associated with decreasing risk for ABMR. In conclusion, the cumulative risk for ABMR is age-dependent, plateaus late after transplantation, and contributes little to overall graft loss in older recipients.
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Affiliation(s)
- Michiel G. H. Betjes
- Rotterdam Transplantation Institute, Department of Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, Netherlands
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21
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Khalil M, Gadelkareem RA, Abdallah MA, Sayed MAB, Elanany FG, Fornara P, Mohammed N. Predictors of graft function and survival in second kidney transplantation: A single center experience. World J Transplant 2023; 13:331-343. [PMID: 38174152 PMCID: PMC10758684 DOI: 10.5500/wjt.v13.i6.331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/19/2023] [Accepted: 11/03/2023] [Indexed: 12/15/2023] Open
Abstract
BACKGROUND The increasing kidney retransplantation rate has created a parallel field of research, including the risk factors and outcomes of this advanced form of renal replacement therapy. The presentation of experiences from different kidney transplantation centers may help enrich the literature on kidney retransplantation, as a specific topic in the field of kidney transplantation. AIM To identify the risk factors affecting primary graft function and graft survival rates after second kidney transplantation (SKT). METHODS The records of SKT cases performed between January 1977 and December 2014 at a European tertiary-level kidney transplantation center were retrospectively reviewed and analyzed. Beside the descriptive characteristics, the survivals of patients and both the first and second grafts were described using Kaplan-Meier curves. In addition, Kaplan-Meier analyses were also used to estimate the survival probabilities at 1, 3, 5, and 10 post-operative years, as well as at the longest follow-up duration available. Moreover, bivariate associations between various predictors and the categorical outcomes were assessed, using the suitable biostatistical tests, according to the predictor type. RESULTS Out of 1861 cases of kidney transplantation, only 48 cases with SKT were eligible for studying, including 33 men and 15 women with a mean age of 42.1 ± 13 years. The primary non-function (PNF) graft occurred in five patients (10.4%). In bivariate analyses, a high body mass index (P = 0.009) and first graft loss due to acute rejection (P = 0.025) were the only significant predictors of PNF graft. The second graft survival was reduced by delayed graft function in the first (P = 0.008) and second (P < 0.001) grafts. However, the effect of acute rejection within the first year after the first transplant did not reach the threshold of significance (P = 0.053). The mean follow-up period was 59.8 ± 48.6 mo. Censored graft/patient survival rates at 1, 3, 5 and 10 years were 90.5%/97.9%, 79.9%/95.6%, 73.7%/91.9%, and 51.6%/83.0%, respectively. CONCLUSION Non-immediate recovery modes of the first and second graft functions were significantly associated with unfavorable second graft survival rates. Patient and graft survival rates of SKT were similar to those of the first kidney transplantation.
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Affiliation(s)
- Mahmoud Khalil
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Assiut, Egypt
| | - Rabea Ahmed Gadelkareem
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Assiut, Egypt
| | - Medhat Ahmed Abdallah
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Assiut, Egypt
| | - Mohamed Abdel-Basir Sayed
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Assiut, Egypt
| | - Fathy Gaber Elanany
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Assiut, Egypt
| | - Paolo Fornara
- Department of Urology and Kidney Transplantation, Martin Luther University, Halle (Saale) 71515, Germany
| | - Nasreldin Mohammed
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Assiut, Egypt
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22
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Zhong C, Chen J, Yan Z, Xia R, Zeng W, Deng W, Xu J, Wang Y, Miao Y. Therapeutic strategies against BK polyomavirus infection in kidney transplant recipients: Systematic review and meta-analysis. Transpl Immunol 2023; 81:101953. [PMID: 37931665 DOI: 10.1016/j.trim.2023.101953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND The selection of antiviral therapy for BK polyomavirus (BKPyV) infection has been extensively debated. Our study aimed to assess the efficacy and safety of various treatments for BKPyV infection. METHODS We searched PubMed, EMBASE, and Web of Science databases for relevant studies regarding drug treatments for BKPyV viremia/DNAemia published between January 1, 1970 and September 30, 2022. Two independent authors screened the published studies, extracted pertinent data, and evaluated their methodological quality. A meta-analysis was performed using the RevMan software version 4.2.2. RESULTS A total of 33 published studies involving 986 patients were included in the meta-analysis. Overall, therapeutic interventions comprised immunosuppression reduction alone or in combination with leflunomide, intravenous immunoglobulin (IVIG), cidofovir, or mTOR inhibitor (mTORi) therapy. The meta-analysis revealed that the efficacy of immunosuppression reduction alone for serum BKPyV clearance was 68% (95% confidence interval [CI]: 0.58-0.77; I2 = 78%). Moreover, the efficacy of immunosuppression reduction in combination with leflunomide, cidofovir, IVIG, or mTORi therapy for serum BKPyV clearance was 61% (95% CI: 0.47-0.74; I2 = 83%), 71% (95% CI: 0.63-0.78; I2 = 0), 87% (95% CI: 0.82-0.93; I2 = 45%), and 80% (95% CI: 0.59-1.00; I2 = 58%), respectively. Compared to immunosuppression reduction alone, immunosuppression reduction combined with IVIG therapy offered a statistically significant benefit in serum BKPyV clearance (P < 0.01) with minimal adverse reactions, whereas other adjunctive drug treatments did not demonstrate considerable effects. CONCLUSIONS Reducing immunosuppression remains the primary approach for treating BKPyV infection. Although the combination treatment with IVIG proved to be most effective, other agents might offer varied antiviral advantages of high heterogeneity, which should be substantiated in future long-term randomized controlled trials.
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Affiliation(s)
- Cuiyu Zhong
- Department of Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Jiayi Chen
- Department of Biostatistics, School of Public Health (Guangdong Provincial Key Laboratory of Tropical Disease Research), Southern Medical University, Guangzhou 510515, China
| | - Ziyan Yan
- Department of Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Renfei Xia
- Department of Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Wenli Zeng
- Department of Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Wenfeng Deng
- Department of Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Jian Xu
- Department of Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Yuchen Wang
- Department of Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China.
| | - Yun Miao
- Department of Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China.
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23
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Zhang TY, Yan J, Wu J, Yang W, Zhang S, Xia J, Che X, Li H, Li D, Ying L, Yuan X, Zhou Y, Zhang M, Mou S. Shear wave elastography parameters adds prognostic value to adverse outcome in kidney transplantation recipients. Ren Fail 2023; 45:2235015. [PMID: 37462113 DOI: 10.1080/0886022x.2023.2235015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/05/2023] [Accepted: 07/05/2023] [Indexed: 07/20/2023] Open
Abstract
INTRODUCTION The tissue stiffness of donor kidneys in transplantation may increase due to pathological changes such as glomerulosclerosis and interstitial fibrosis, and those changes associate worse outcomes in kidney transplantation recipients. Ultrasound elastography is a noninvasive imaging examination with the ability to quantitatively reflect tissue stiffness. Aim of this study was to evaluate the prognostic value of ultrasound elastography for adverse kidney outcome in kidney transplantation recipients. METHODS Shear wave elastography (SWE) examinations were performed by two independent operators in kidney transplantation recipients. The primary outcome was a composite of kidney graft deterioration, all-cause re-hospitalization, and all-cause mortality. Survival analysis was calculated by Kaplan-Meier curves with the log-rank test and Cox regression analysis. RESULTS A total of 161 patients (mean age 46 years, 63.4% men) were followed for a median of 20.1 months. 27 patients (16.77%) reached the primary endpoint. The mean and median tissue stiffness at the medulla (hazard ratio: 1.265 and 1.229, respectively), estimated glomerular filtration rate (eGFR), and serum albumin level were associated with the primary outcome in univariate Cox regression. Adding mean or median medulla SWE to a baseline model containing eGFR and albumin significantly improved its discrimination (C-statistics: 0.736 for the baseline, 0.766 and 0.772 for the model added mean and median medulla SWE, respectively). CONCLUSION The medullary tissue stiffness of kidney allograft measured by shear wave elastography may provide incremental prognostic value to adverse outcomes in kidney transplantation recipients. Including SWE parameters in kidney transplantation recipients management could be considered to improve risk stratification.
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Affiliation(s)
- Tian-Yi Zhang
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Shanghai Peritoneal Dialysis Research Center, Ren Ji Hospital, Uremia Diagnosis and Treatment Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiayi Yan
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Shanghai Peritoneal Dialysis Research Center, Ren Ji Hospital, Uremia Diagnosis and Treatment Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Academy of Integrative Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jiajia Wu
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Shanghai Peritoneal Dialysis Research Center, Ren Ji Hospital, Uremia Diagnosis and Treatment Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenqi Yang
- Department of Ultrasound, Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Shijun Zhang
- Department of Ultrasound, Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Jia Xia
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Shanghai Peritoneal Dialysis Research Center, Ren Ji Hospital, Uremia Diagnosis and Treatment Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiajing Che
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Shanghai Peritoneal Dialysis Research Center, Ren Ji Hospital, Uremia Diagnosis and Treatment Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongli Li
- Department of Ultrasound, Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Dawei Li
- Department of Urology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Liang Ying
- Department of Urology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Xiaodong Yuan
- Department of Urology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Yin Zhou
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Shanghai Peritoneal Dialysis Research Center, Ren Ji Hospital, Uremia Diagnosis and Treatment Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ming Zhang
- Department of Urology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Shan Mou
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Shanghai Peritoneal Dialysis Research Center, Ren Ji Hospital, Uremia Diagnosis and Treatment Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Academy of Integrative Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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24
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Fernando SC, Polkinghorne KR, Lim WH, Mulley WR. Early Versus Late Acute AMR in Kidney Transplant Recipients-A Comparison of Treatment Approaches and Outcomes From the ANZDATA Registry. Transplantation 2023; 107:2424-2432. [PMID: 37322595 DOI: 10.1097/tp.0000000000004700] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) is a major cause of kidney allograft failure and demonstrates different properties depending on whether it occurs early (<6 mo) or late (>6 mo) posttransplantation. We aimed to compare graft survival and treatment approaches for early and late AMR in Australia and New Zealand. METHODS Transplant characteristics were obtained for patients with an AMR episode reported to the Australia and New Zealand Dialysis and Transplant Registry from January 2003 to December 2019. The primary outcome of time to graft loss from AMR diagnosis, with death considered a competing risk, was compared between early and late AMR using flexible parametric survival models. Secondary outcomes included treatments used, response to treatment, and time from AMR diagnosis to death. RESULTS After adjustment for other explanatory factors, late AMR was associated with twice the risk of graft loss relative to early AMR. The risk was nonproportional over time, with early AMR having an increased early risk. Late AMR was also associated with an increased risk of death. Early AMR was treated more aggressively than late with more frequent use of plasma exchange and monoclonal/polyclonal antibodies. There was substantial variation in treatments used by transplant centers. Early AMR was reported to be more responsive to treatment than late. CONCLUSIONS Late AMR is associated with an increased risk of graft loss and death compared with early AMR. The marked heterogeneity in the treatment of AMR highlights the need for effective, new therapeutic options for these conditions.
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Affiliation(s)
- Sanduni C Fernando
- Department of Nephrology, Monash Medical Centre, Clayton, VIC, Australia
- Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, VIC, Australia
| | - Kevan R Polkinghorne
- Department of Nephrology, Monash Medical Centre, Clayton, VIC, Australia
- Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
- School of Medicine, University of Western Australia, Perth, WA, Australia
| | - William R Mulley
- Department of Nephrology, Monash Medical Centre, Clayton, VIC, Australia
- Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, VIC, Australia
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25
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Sun Z, Zhang Z, Banu K, Gibson IW, Colvin RB, Yi Z, Zhang W, De Kumar B, Reghuvaran A, Pell J, Manes TD, Djamali A, Gallon L, O’Connell PJ, He JC, Pober JS, Heeger PS, Menon MC. Multiscale genetic architecture of donor-recipient differences reveals intronic LIMS1 mismatches associated with kidney transplant survival. J Clin Invest 2023; 133:e170420. [PMID: 37676733 PMCID: PMC10617779 DOI: 10.1172/jci170420] [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: 03/13/2023] [Accepted: 09/06/2023] [Indexed: 09/09/2023] Open
Abstract
Donor-recipient (D-R) mismatches outside of human leukocyte antigens (HLAs) contribute to kidney allograft loss, but the mechanisms remain unclear, specifically for intronic mismatches. We quantified non-HLA mismatches at variant-, gene-, and genome-wide scales from single nucleotide polymorphism (SNP) data of D-Rs from 2 well-phenotyped transplant cohorts: Genomics of Chronic Allograft Rejection (GoCAR; n = 385) and Clinical Trials in Organ Transplantation-01/17 (CTOT-01/17; n = 146). Unbiased gene-level screening in GoCAR uncovered the LIMS1 locus as the top-ranked gene where D-R mismatches associated with death-censored graft loss (DCGL). A previously unreported, intronic, LIMS1 haplotype of 30 SNPs independently associated with DCGL in both cohorts. Haplotype mismatches showed a dosage effect, and minor-allele introduction to major-allele-carrying recipients showed greater hazard of DCGL. The LIMS1 haplotype and the previously reported LIMS1 SNP rs893403 are expression quantitative trait loci (eQTL) in immune cells for GCC2 (not LIMS1), which encodes a protein involved in mannose-6-phosphase receptor (M6PR) recycling. Peripheral blood and T cell transcriptome analyses associated the GCC2 gene and LIMS1 SNPs with the TGF-β1/SMAD pathway, suggesting a regulatory effect. In vitro GCC2 modulation impacted M6PR-dependent regulation of active TGF-β1 and downstream signaling in T cells. Together, our data link LIMS1 locus D-R mismatches to DCGL via GCC2 eQTLs that modulate TGF-β1-dependent effects on T cells.
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Affiliation(s)
- Zeguo Sun
- Division of Nephrology, Department of Medicine
| | - Zhongyang Zhang
- Department of Genetics and Genomic Science, and
- Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Khadija Banu
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ian W. Gibson
- Max Rady college of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Zhengzi Yi
- Division of Nephrology, Department of Medicine
| | | | - Bony De Kumar
- Yale Center for Genomics, New Haven, Connecticut, USA
| | - Anand Reghuvaran
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - John Pell
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Thomas D. Manes
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Lorenzo Gallon
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Philip J. O’Connell
- The Westmead Institute for Medical Research, University of Sydney, New South Wales, Australia
| | | | - Jordan S. Pober
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Madhav C. Menon
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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26
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Nair S, Ravichandran R, Heilman R, Jaramillo A, Buras M, Kaplan B, Itabashi Y, Ramon D, Hacke K, Smith B, Mohanakumar T. Study of association between antibodies to non-HLA kidney self-antigens and progression to chronic immune injury after kidney transplantation. Hum Immunol 2023; 84:509-514. [PMID: 37507262 DOI: 10.1016/j.humimm.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 07/02/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Immune response to several kidney self-antigens (KSAg) such as Collagen IV (Col-IV), Perlecan (PL), and Fibronectin (FN) have been associated with antibody-mediated damage and poor allograft survival. Thus, the aim of this study was to determine if humoral immune responses to KSAg correlates with progression of chronic immune injury (CII) changes at 1 year or 2 years. METHODS Kidney transplant recipients who underwent 1- or 2-year biopsies, with chronic interstitial inflammation (ci > 1) and/or glomerular membrane double contouring (cg > 0) were analyzed with matched controls. Sera were analyzed retrospectively for antibodies against KSAg using ELISA. The presence of antibodies to KSAg were compared at 0, 4, 12, and 24 months using logistic regression. RESULTS We identified a cohort of 214 kidney transplant recipients. Of these, we identified 33 cases and matched 66 controls. Logistical regression showed an odds ratio of 1 with the confidence interval crossing 1 for the presence of response to KSAg at all the time points. CONCLUSIONS Humoral immune responses to either KSAg alone or in combination with donor-specific anti-HLA antibodies are not associated with progression to CII at 1 and 2 years after kidney transplantation.
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Affiliation(s)
- Sumi Nair
- Department of Medicine, Mayo Clinic, Phoenix, AZ, United States.
| | | | - Raymond Heilman
- Department of Medicine, Mayo Clinic, Phoenix, AZ, United States
| | - Andrés Jaramillo
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, AZ, United States
| | - Matthew Buras
- Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ, United States
| | - Bruce Kaplan
- University of Colorado, Aurora, CO, United States
| | - Yoshihiro Itabashi
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Daniel Ramon
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Katrin Hacke
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, AZ, United States
| | - Byron Smith
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States
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27
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Zaidan M, Lakkis FG. Tracking kidney transplant fitness. Science 2023; 381:1048-1049. [PMID: 37676961 DOI: 10.1126/science.adj9517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
An implantable bioelectronic device detects the early signs of kidney transplant rejection in rats.
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Affiliation(s)
- Mohamad Zaidan
- Assistance Publique des Hôpitaux de Paris, INSERM, Université Paris-Saclay, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
- Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Fadi G Lakkis
- Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
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28
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Gorbacheva V, Fan R, Miyairi S, Fairchild RL, Baldwin WM, Valujskikh A. Autoantibodies against DNA topoisomerase I promote renal allograft rejection by increasing alloreactive T cell responses. Am J Transplant 2023; 23:1307-1318. [PMID: 37084848 PMCID: PMC10524310 DOI: 10.1016/j.ajt.2023.03.027] [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: 03/11/2023] [Accepted: 03/29/2023] [Indexed: 04/23/2023]
Abstract
Antibodies reactive to self-antigens are an important component of posttransplant immune responses. The generation requirements and functions of autoantibodies, as well as the mechanisms of their influence on alloimmune responses, still remain to be determined. Our study investigated the contribution of autoimmunity during rejection of renal allografts. We have previously characterized a mouse model in which the acute rejection of a life-supporting kidney allograft is mediated by antibodies. At rejection, recipient sera screening against >4000 potential autoantigens revealed DNA topoisomerase I peptide 205-219 (TI-I205-219) as the most prominent epitope. Subsequent analysis showed TI-I205-219-reactive autoantibodies are induced in nonsensitized recipients of major histocompatibility complex-mismatched kidney allografts in a T cell-dependent manner. Immunization with TI-I205-219 broke self-tolerance, elicited TI-I205-219 immunoglobin G autoantibodies, and resulted in acute rejection of allogeneic but not syngeneic renal transplants. The graft loss was associated with increased priming of donor-reactive T cells but not with donor-specific alloantibodies elevation. Similarly, passive transfer of anti-TI-I205-219 sera following transplantation increased donor-reactive T cell activation with minimal effects on donor-specific alloantibody levels. The results identify DNA topoisomerase I as a novel self-antigen in transplant settings and demonstrate that autoantibodies enhance activation of donor-reactive T cells following renal transplantation.
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Affiliation(s)
- Victoria Gorbacheva
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ran Fan
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Satoshi Miyairi
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert L Fairchild
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - William M Baldwin
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anna Valujskikh
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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Kohei N, Tanaka T, Miyairi S, Tsuda H, Abe T, Su CA, Kish DD, Tanabe K, Valujskikh A, Min B, Fairchild RL. Failure of Costimulatory Blockade-induced Regulatory T Cells to Sustain Long-term Survival of High Ischemic Allografts. Transplantation 2023; 107:1935-1944. [PMID: 36978228 PMCID: PMC10514235 DOI: 10.1097/tp.0000000000004570] [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] [Indexed: 03/30/2023]
Abstract
BACKGROUND Costimulatory blockade-induced allograft tolerance has been achieved in rodent models, but these strategies do not translate well to nonhuman primate and clinical transplants. One confounder that may underlie this discrepancy is the greater ischemic inflammation imposed on the transplants. In mice, cardiac allografts subjected to prolonged cold ischemic storage (CIS) before transplant have increased ischemia-reperfusion injury, which amplifies infiltrating endogenous memory CD8 T-cell activation within hours after transplantation to mediate acute graft inflammation and cytotoxic lymphocyte-associated molecule-4 immunoglobulin-resistant rejection. This study tested strategies inhibiting memory CD8 T-cell activation within such high ischemic allografts to achieve long-term survival. METHODS A/J (H-2 a ) hearts subjected to 0.5 or 8 h of CIS were transplanted to C57BL/6 (H-2 b ) recipients and treatment with peritransplant costimulatory blockade. At 60 d posttransplant, regulatory T cells (Treg) were depleted in recipients of high ischemic allografts with anti-CD25 monoclonal antibody (mAb) or diphtheria toxin. RESULTS Whereas peritransplant (days 0 and +1) anti-lymphocyte function-associated antigen-1 mAb and anti-CD154 mAb prolonged survival of >60% allografts subjected to minimal CIS for >100 d, only 20% of allografts subjected to prolonged CIS survived beyond day 80 posttransplant and rejection was accompanied by high titers of donor-specific antibody. Peritransplant anti-lymphocyte function-associated antigen-1, anti-tumor necrosis factor-α, and anti-CD154 mAb plus additional anti-CD154 mAb on days 14 and 16 obviated this donor-specific antibody and promoted Treg-mediated tolerance and survival of 60% of high ischemic allografts beyond day 100 posttransplant, but all allografts failed by day 120. CONCLUSIONS These studies indicate a strategy inducing prolonged high ischemic allograft survival through Treg-mediated tolerance that is not sustained indefinitely.
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Affiliation(s)
- Naoki Kohei
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Tokyo Women’s Medical University, Tokyo, Japan
| | - Toshiaki Tanaka
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Satoshi Miyairi
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Tokyo Women’s Medical University, Tokyo, Japan
| | - Hidetoshi Tsuda
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Department of Urology, Osaka University School of Medicine, Osaka, Japan
| | - Toyofumi Abe
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Department of Urology, Osaka University School of Medicine, Osaka, Japan
| | - Charles A. Su
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH
| | | | | | | | - Booki Min
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Robert L. Fairchild
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH
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30
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Heilman RL, Fleming JN, Mai M, Smith B, Park WD, Holman J, Stegall MD. Multiple abnormal peripheral blood gene expression assay results are correlated with subsequent graft loss after kidney transplantation. Clin Transplant 2023; 37:e14987. [PMID: 37026820 DOI: 10.1111/ctr.14987] [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: 12/30/2022] [Revised: 03/16/2023] [Accepted: 03/26/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND The aim of this study was to correlate peripheral blood gene expression profile (GEP) results during the first post-transplant year with outcomes after kidney transplantation. METHODS We conducted a prospective, multicenter observational study of obtaining peripheral blood at five timepoints during the first post-transplant year to perform a GEP assay. The cohort was stratified based on the pattern of the peripheral blood GEP results: Tx-all GEP results normal, 1 Not-TX had one GEP result abnormal and >1 Not-TX two or more abnormal GEP results. We correlated the GEP results with outcomes after transplantation. RESULTS We enrolled 240 kidney transplant recipients. The cohort was stratified into the three groups: TX n = 117 (47%), 1 Not-TX n = 59 (25%) and >1 Not-TX n = 64 (27%). Compared to the TX group, the >1 Not-TX group had lower eGFR (p < .001) and more chronic changes on 1-year surveillance biopsy (p = .007). Death censored graft survival showed inferior graft survival in the >1 Not-TX group (p < .001) but not in the 1 Not-TX group. All graft losses in the >1 Not-TX group occurred after 1-year post-transplant. CONCLUSIONS We conclude that a pattern of persistently Not-TX GEP assay correlates with inferior graft survival.
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Affiliation(s)
| | - James N Fleming
- Medical Affairs, Transplant Genomics, Inc, Framingham, Massachusetts, USA
| | - Martin Mai
- Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Byron Smith
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Walter D Park
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - John Holman
- Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Mark D Stegall
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
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31
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Hirt-Minkowski P, Handschin J, Stampf S, Hopfer H, Menter T, Senn L, Hönger G, Wehmeier C, Amico P, Steiger J, Koller M, Dickenmann M, Schaub S. Randomized Trial to Assess the Clinical Utility of Renal Allograft Monitoring by Urine CXCL10 Chemokine. J Am Soc Nephrol 2023; 34:1456-1469. [PMID: 37228005 PMCID: PMC10400101 DOI: 10.1681/asn.0000000000000160] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 04/12/2023] [Indexed: 05/27/2023] Open
Abstract
SIGNIFICANCE STATEMENT This study is the first randomized controlled trial to investigate the clinical utility of a noninvasive monitoring biomarker in renal transplantation. Although urine CXCL10 monitoring could not demonstrate a beneficial effect on 1-year outcomes, the study is a rich source for future design of trials aiming to explore the clinical utility of noninvasive biomarkers. In addition, the study supports the use of urine CXCL10 to assess the inflammatory status of the renal allograft. BACKGROUND Urine CXCL10 is a promising noninvasive biomarker for detection of renal allograft rejection. The aim of this study was to investigate the clinical utility of renal allograft monitoring by urine CXCL10 in a randomized trial. METHODS We stratified 241 patients, 120 into an intervention and 121 into a control arm. In both arms, urine CXCL10 levels were monitored at three specific time points (1, 3, and 6 months post-transplant). In the intervention arm, elevated values triggered performance of an allograft biopsy with therapeutic adaptations according to the result. In the control arm, urine CXCL10 was measured, but the results concealed. The primary outcome was a combined end point at 1-year post-transplant (death-censored graft loss, clinical rejection between month 1 and 1-year, acute rejection in 1-year surveillance biopsy, chronic active T-cell-mediated rejection in 1-year surveillance biopsy, development of de novo donor-specific HLA antibodies, or eGFR <25 ml/min). RESULTS The incidence of the primary outcome was not different between the intervention and the control arm (51% versus 49%; relative risk (RR), 1.04 [95% confidence interval, 0.81 to 1.34]; P = 0.80). When including 175 of 241 (73%) patients in a per-protocol analysis, the incidence of the primary outcome was also not different (55% versus 49%; RR, 1.11 [95% confidence interval, 0.84 to 1.47]; P = 0.54). The incidence of the individual end points was not different as well. CONCLUSIONS This study could not demonstrate a beneficial effect of urine CXCL10 monitoring on 1-year outcomes (ClinicalTrials.gov_ NCT03140514 ).
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Affiliation(s)
- Patricia Hirt-Minkowski
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Joelle Handschin
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
- Molecular Immune Regulation, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Susanne Stampf
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Helmut Hopfer
- Department of Pathology, University Hospital Basel, Basel, Switzerland
| | - Thomas Menter
- Department of Pathology, University Hospital Basel, Basel, Switzerland
| | - Lisa Senn
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Gideon Hönger
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
- Molecular Immune Regulation, Department of Biomedicine, University of Basel, Basel, Switzerland
- HLA-Diagnostics and Immunogenetics, Department of Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| | - Caroline Wehmeier
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Patrizia Amico
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Jürg Steiger
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
- Molecular Immune Regulation, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Michael Koller
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Michael Dickenmann
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Stefan Schaub
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
- Molecular Immune Regulation, Department of Biomedicine, University of Basel, Basel, Switzerland
- HLA-Diagnostics and Immunogenetics, Department of Laboratory Medicine, University Hospital Basel, Basel, Switzerland
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32
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Mayrdorfer M, Liefeldt L, Osmanodja B, Naik MG, Schmidt D, Duettmann W, Hammett C, Schrezenmeier E, Friedersdorff F, Wu K, Halleck F, Budde K. A single centre in-depth analysis of death with a functioning kidney graft and reasons for overall graft failure. Nephrol Dial Transplant 2023; 38:1857-1866. [PMID: 36477607 PMCID: PMC10387383 DOI: 10.1093/ndt/gfac327] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND High numbers of unknown classifications and inconsistent methodologies in previous studies make the interpretation of causes leading to graft loss difficult. In addition, data on a holistic view looking at both death with a functioning graft (DWFG) and death-censored graft failure (DCGF) are sparse. METHODS In this single-centre study we included 1477 adult kidney transplants performed between 1997 and 2017, of which all 286 DWFGs until the end of observation were analysed and causes for death assigned. Additionally, the results were compared with the causes of 303 DCGFs of the same cohort to evaluate the impact of causes for overall graft loss. RESULTS The most frequent causes for DWFG were cardiovascular disease (CVD) in 30.8%, malignancy in 28.3% and infections in 21%. Only 9.4% of reasons for DWFG were unknown. Sudden death occurred in 40% (35/88) of patients classified as DWFG due to CVD. Overall graft loss was related to the effect of immunosuppression in 36.2% [infection 20.9% (123/589), malignancy 15.3% (90/589)] and CVD in 22.4% (132/589). In 27.4% (161/589), graft failure was associated with underimmunosuppression (rejection). For infections (60 DWFG, 63 DCGF) and CVD (88 DWFG, 44 DCGF), a considerable overlap was observed between DWFG and DCGF. For patients >70 years of age at transplantation, medical events accounted for 78% of overall graft losses and only 6.5% were associated with rejection. CONCLUSIONS DWFG and DCGF share more causes for graft loss than previously reported and sudden death plays an underestimated role in death with a functioning graft.
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Affiliation(s)
- Manuel Mayrdorfer
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, Austria
| | - Lutz Liefeldt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Bilgin Osmanodja
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Marcel G Naik
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Danilo Schmidt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Wiebke Duettmann
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Charlotte Hammett
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Eva Schrezenmeier
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Frank Friedersdorff
- Department of Urology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Kaiyin Wu
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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33
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Alasfar S, Kodali L, Schinstock CA. Current Therapies in Kidney Transplant Rejection. J Clin Med 2023; 12:4927. [PMID: 37568328 PMCID: PMC10419508 DOI: 10.3390/jcm12154927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Despite significant advancements in immunosuppressive therapies, kidney transplant rejection continues to pose a substantial challenge, impacting the long-term survival of grafts. This article provides an overview of the diagnosis, current therapies, and management strategies for acute T-cell-mediated rejection (TCMR) and antibody-mediated rejection (ABMR). TCMR is diagnosed through histological examination of kidney biopsy samples, which reveal the infiltration of mononuclear cells into the allograft tissue. Corticosteroids serve as the primary treatment for TCMR, while severe or steroid-resistant cases may require T-cell-depleting agents, like Thymoglobulin. ABMR occurs due to the binding of antibodies to graft endothelial cells. The most common treatment for ABMR is plasmapheresis, although its efficacy is still a subject of debate. Other current therapies, such as intravenous immunoglobulins, anti-CD20 antibodies, complement inhibitors, and proteasome inhibitors, are also utilized to varying degrees, but their efficacy remains questionable. Management decisions for ABMR depend on the timing of the rejection episode and the presence of chronic changes. In managing both TCMR and ABMR, it is crucial to optimize immunosuppression and address adherence. However, further research is needed to explore newer therapeutics and evaluate their efficacy.
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Affiliation(s)
- Sami Alasfar
- Department of Medicine, Mayo Clinic, Phoenix, AZ 85054, USA;
| | - Lavanya Kodali
- Department of Medicine, Mayo Clinic, Phoenix, AZ 85054, USA;
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34
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Rostaing LPE, Böhmig GA, Gibbons B, Taqi MM. Post-Transplant Surveillance and Management of Chronic Active Antibody-Mediated Rejection in Renal Transplant Patients in Europe. Transpl Int 2023; 36:11381. [PMID: 37529383 PMCID: PMC10389272 DOI: 10.3389/ti.2023.11381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/27/2023] [Indexed: 08/03/2023]
Abstract
Antibody mediated rejection (ABMR) is the leading cause of immune-related allograft failure following kidney transplantation. Chronic active ABMR (CABMR) typically occurs after one-year post-transplant and is the most common cause of late allograft failure. This study was designed to assess common practices in Europe for post-transplant surveillance 1 year after kidney transplant, as well as the diagnosis and management of CABMR. A 15-minute online survey with 58 multiple choice or open-ended questions was completed by EU transplant nephrologists, transplant surgeons and nephrologists. Survey topics included patient caseloads, post-transplant routine screening and treatment of CABMR. The results indicated that observing clinical measures of graft function form the cornerstone of post-transplant surveillance. This may be suboptimal, leading to late diagnoses and untreatable disease. Indeed, less than half of patients who develop CABMR receive treatment beyond optimization of immune suppression. This is attributable to not only late diagnoses, but also a lack of proven efficacious therapies. Intravenous Immunoglobulin (IVIG), steroid pulse and apheresis are prescribed by the majority to treat CABMR. While biologics can feature as part of treatment, there is no single agent that is being used by more than half of physicians.
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Affiliation(s)
- Lionel P. E. Rostaing
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
| | - Georg A. Böhmig
- Clinical Department of Nephrology and Dialysis, University Clinic for Internal Medicine III, Medical University of Vienna, Vienna, Austria
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35
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Mak ML, Reid KT, Crome SQ. Protective and pathogenic functions of innate lymphoid cells in transplantation. Clin Exp Immunol 2023; 213:23-39. [PMID: 37119279 PMCID: PMC10324558 DOI: 10.1093/cei/uxad050] [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: 02/03/2023] [Revised: 03/27/2023] [Accepted: 04/28/2023] [Indexed: 05/01/2023] Open
Abstract
Innate lymphoid cells (ILCs) are a family of lymphocytes with essential roles in tissue homeostasis and immunity. Along with other tissue-resident immune populations, distinct subsets of ILCs have important roles in either promoting or inhibiting immune tolerance in a variety of contexts, including cancer and autoimmunity. In solid organ and hematopoietic stem cell transplantation, both donor and recipient-derived ILCs could contribute to immune tolerance or rejection, yet understanding of protective or pathogenic functions are only beginning to emerge. In addition to roles in directing or regulating immune responses, ILCs interface with parenchymal cells to support tissue homeostasis and even regeneration. Whether specific ILCs are tissue-protective or enhance ischemia reperfusion injury or fibrosis is of particular interest to the field of transplantation, beyond any roles in limiting or promoting allograft rejection or graft-versus host disease. Within this review, we discuss the current understanding of ILCs functions in promoting immune tolerance and tissue repair at homeostasis and in the context of transplantation and highlight where targeting or harnessing ILCs could have applications in novel transplant therapies.
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Affiliation(s)
- Martin L Mak
- Department of Immunology, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Toronto General Hospital Research Institute, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Kyle T Reid
- Department of Immunology, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Toronto General Hospital Research Institute, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Sarah Q Crome
- Department of Immunology, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Toronto General Hospital Research Institute, Ajmera Transplant Centre, University Health Network, Toronto, Canada
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36
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Mizera J, Pilch J, Giordano U, Krajewska M, Banasik M. Therapy in the Course of Kidney Graft Rejection-Implications for the Cardiovascular System-A Systematic Review. Life (Basel) 2023; 13:1458. [PMID: 37511833 PMCID: PMC10381422 DOI: 10.3390/life13071458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/20/2023] [Accepted: 06/26/2023] [Indexed: 07/30/2023] Open
Abstract
Kidney graft failure is not a homogenous disease and the Banff classification distinguishes several types of graft rejection. The maintenance of a transplant and the treatment of its failure require specific medications and differ due to the underlying molecular mechanism. As a consequence, patients suffering from different rejection types will experience distinct side-effects upon therapy. The review is focused on comparing treatment regimens as well as presenting the latest insights into innovative therapeutic approaches in patients with an ongoing active ABMR, chronic active ABMR, chronic ABMR, acute TCMR, chronic active TCMR, borderline and mixed rejection. Furthermore, the profile of cardiovascular adverse effects in relation to the applied therapy was subjected to scrutiny. Lastly, a detailed assessment and comparison of different approaches were conducted in order to identify those that are the most and least detrimental for patients suffering from kidney graft failure.
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Affiliation(s)
- Jakub Mizera
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-551 Wroclaw, Poland
| | - Justyna Pilch
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-551 Wroclaw, Poland
| | - Ugo Giordano
- University Clinical Hospital, Wroclaw Medical University, 50-551 Wroclaw, Poland
| | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-551 Wroclaw, Poland
| | - Mirosław Banasik
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-551 Wroclaw, Poland
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37
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McDaniels JM, Shetty AC, Kuscu C, Kuscu C, Bardhi E, Rousselle T, Drachenberg C, Talwar M, Eason JD, Muthukumar T, Maluf DG, Mas VR. Single nuclei transcriptomics delineates complex immune and kidney cell interactions contributing to kidney allograft fibrosis. Kidney Int 2023; 103:1077-1092. [PMID: 36863444 PMCID: PMC10200746 DOI: 10.1016/j.kint.2023.02.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 01/16/2023] [Accepted: 02/07/2023] [Indexed: 03/04/2023]
Abstract
Chronic allograft dysfunction (CAD), characterized histologically by interstitial fibrosis and tubular atrophy, is the major cause of kidney allograft loss. Here, using single nuclei RNA sequencing and transcriptome analysis, we identified the origin, functional heterogeneity, and regulation of fibrosis-forming cells in kidney allografts with CAD. A robust technique was used to isolate individual nuclei from kidney allograft biopsies and successfully profiled 23,980 nuclei from five kidney transplant recipients with CAD and 17,913 nuclei from three patients with normal allograft function. Our analysis revealed two distinct states of fibrosis in CAD; low and high extracellular matrix (ECM) with distinct kidney cell subclusters, immune cell types, and transcriptional profiles. Imaging mass cytometry analysis confirmed increased ECM deposition at the protein level. Proximal tubular cells transitioned to an injured mixed tubular (MT1) phenotype comprised of activated fibroblasts and myofibroblast markers, generated provisional ECM which recruited inflammatory cells, and served as the main driver of fibrosis. MT1 cells in the high ECM state achieved replicative repair evidenced by dedifferentiation and nephrogenic transcriptional signatures. MT1 in the low ECM state showed decreased apoptosis, decreased cycling tubular cells, and severe metabolic dysfunction, limiting the potential for repair. Activated B, T and plasma cells were increased in the high ECM state, while macrophage subtypes were increased in the low ECM state. Intercellular communication between kidney parenchymal cells and donor-derived macrophages, detected several years post-transplantation, played a key role in injury propagation. Thus, our study identified novel molecular targets for interventions aimed to ameliorate or prevent allograft fibrogenesis in kidney transplant recipients.
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Affiliation(s)
- Jennifer M McDaniels
- Division of Surgical Sciences, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Amol C Shetty
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Cem Kuscu
- Transplant Research Institute, James D. Eason Transplant Institute, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Department of Surgery, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Canan Kuscu
- Transplant Research Institute, James D. Eason Transplant Institute, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Department of Surgery, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Elissa Bardhi
- Division of Surgical Sciences, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Thomas Rousselle
- Division of Surgical Sciences, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Cinthia Drachenberg
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Manish Talwar
- Transplant Research Institute, James D. Eason Transplant Institute, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - James D Eason
- Transplant Research Institute, James D. Eason Transplant Institute, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Thangamani Muthukumar
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Daniel G Maluf
- Division of Surgical Sciences, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA; Program in Transplantation, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Valeria R Mas
- Division of Surgical Sciences, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.
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38
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Yoo D, Goutaudier V, Divard G, Gueguen J, Astor BC, Aubert O, Raynaud M, Demir Z, Hogan J, Weng P, Smith J, Garro R, Warady BA, Zahr RS, Sablik M, Twombley K, Couzi L, Berney T, Boyer O, Duong-Van-Huyen JP, Giral M, Alsadi A, Gourraud PA, Morelon E, Le Quintrec M, Brouard S, Legendre C, Anglicheau D, Villard J, Zhong W, Kamar N, Bestard O, Djamali A, Budde K, Haas M, Lefaucheur C, Rabant M, Loupy A. An automated histological classification system for precision diagnostics of kidney allografts. Nat Med 2023; 29:1211-1220. [PMID: 37142762 DOI: 10.1038/s41591-023-02323-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 03/28/2023] [Indexed: 05/06/2023]
Abstract
For three decades, the international Banff classification has been the gold standard for kidney allograft rejection diagnosis, but this system has become complex over time with the integration of multimodal data and rules, leading to misclassifications that can have deleterious therapeutic consequences for patients. To improve diagnosis, we developed a decision-support system, based on an algorithm covering all classification rules and diagnostic scenarios, that automatically assigns kidney allograft diagnoses. We then tested its ability to reclassify rejection diagnoses for adult and pediatric kidney transplant recipients in three international multicentric cohorts and two large prospective clinical trials, including 4,409 biopsies from 3,054 patients (62.05% male and 37.95% female) followed in 20 transplant referral centers in Europe and North America. In the adult kidney transplant population, the Banff Automation System reclassified 83 out of 279 (29.75%) antibody-mediated rejection cases and 57 out of 105 (54.29%) T cell-mediated rejection cases, whereas 237 out of 3,239 (7.32%) biopsies diagnosed as non-rejection by pathologists were reclassified as rejection. In the pediatric population, the reclassification rates were 8 out of 26 (30.77%) for antibody-mediated rejection and 12 out of 39 (30.77%) for T cell-mediated rejection. Finally, we found that reclassification of the initial diagnoses by the Banff Automation System was associated with an improved risk stratification of long-term allograft outcomes. This study demonstrates the potential of an automated histological classification to improve transplant patient care by correcting diagnostic errors and standardizing allograft rejection diagnoses.ClinicalTrials.gov registration: NCT05306795 .
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Affiliation(s)
- Daniel Yoo
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
| | - Valentin Goutaudier
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
- Department of Kidney Transplantation, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Gillian Divard
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
- Kidney Transplant Department, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Juliette Gueguen
- Néphrologie-Immunologie Clinique, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Brad C Astor
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Olivier Aubert
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
- Department of Kidney Transplantation, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Marc Raynaud
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
| | - Zeynep Demir
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
- Pediatric Hepatology Unit-Liver Transplantation, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Julien Hogan
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
- Division of Pediatric Nephrology, Robert Debré Hospital, APHP, Paris, France
| | - Patricia Weng
- Pediatric Nephrology, David Geffen School of Medicine at UCLA, UCLA Mattel Children's Hospital, Los Angeles, CA, USA
| | - Jodi Smith
- Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Rouba Garro
- Division of Pediatric Nephrology, Emory University School of Medicine, Children's Pediatric Institute, Atlanta, GA, USA
| | - Bradley A Warady
- Division of Pediatric Nephrology, University of Kansas City, Children's Mercy Hospital, Kansas City, MO, USA
| | - Rima S Zahr
- Division of Pediatric Nephrology and Hypertension, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Marta Sablik
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
| | - Katherine Twombley
- Acute Dialysis Units, Pediatric Kidney Transplant, Medical University of South Carolina, Charleston, SC, USA
| | - Lionel Couzi
- Department of Nephrology, Transplantation, Dialysis and Apheresis, CHU Bordeaux, Bordeaux, France
| | - Thierry Berney
- Division of Abdominal and Transplantation Surgery, Department of Surgery, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Olivia Boyer
- Division of Pediatric Nephrology, Necker Hospital, Université Paris Cité, Paris, France
| | - Jean-Paul Duong-Van-Huyen
- Department of Pathology, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Magali Giral
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes, France
| | - Alaa Alsadi
- Department of Pathology, University of Wisconsin, Madison, WI, USA
| | - Pierre A Gourraud
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes, France
| | - Emmanuel Morelon
- Department of Transplantation, Edouard Herriot University Hospital, Hospices Civils de Lyon, University Lyon, University of Lyon I, Lyon, France
| | - Moglie Le Quintrec
- Department of Nephrology, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Sophie Brouard
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes, France
| | - Christophe Legendre
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
- Department of Kidney Transplantation, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Dany Anglicheau
- Department of Kidney Transplantation, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Jean Villard
- Division of Transplantation Immunology, University Hospital of Geneva, Geneva, Switzerland
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin, Madison, WI, USA
| | - Nassim Kamar
- Department of Nephrology-Dialysis-Transplantation, Centre Hospitalier, Universitaire de Toulouse, Toulouse, France
| | - Oriol Bestard
- Department of Nephrology and Kidney Transplantation, Vall d'Hebrón University Hospital, Barcelona, Spain
| | - Arjang Djamali
- Department of Medicine, Maine Medical Center, Portland, ME, USA
| | - Klemens Budde
- Department of Nephrology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Berlin Institute of Health, Berlin, Germany
| | - Mark Haas
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Carmen Lefaucheur
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
- Kidney Transplant Department, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Marion Rabant
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
- Department of Pathology, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Alexandre Loupy
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France.
- Department of Kidney Transplantation, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.
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Redondo-Pachón D, Calatayud E, Buxeda A, Pérez-Sáez MJ, Arias-Cabrales C, Gimeno J, Burballa C, Mir M, Llinàs-Mallol L, Outon S, Pascual J, Crespo M. Evolution of kidney allograft loss causes over 40 years (1979-2019). Nefrologia 2023; 43:316-327. [PMID: 37507293 DOI: 10.1016/j.nefroe.2023.07.003] [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: 07/23/2021] [Accepted: 12/01/2021] [Indexed: 07/30/2023] Open
Abstract
INTRODUCTION The improvement of kidney allograft recipient and graft survival showed a decrease over the last 40 years. Long-term graft loss rate remained stable during a 25-year time span. Knowing the changing causes and the risk factors associated with graft loss requires special attention. The present study aimed to assess the causes of graft loss and kidney allograft recipient death. Also, we aimed to compare two different periods (1979-1999 and 2000-2019) to identify changes in the characteristics of the failed allografts and recipient and donors profile. METHODS AND PATIENTS We performed a single-center cohort study. We included all the kidney transplant recipients at the Hospital del Mar (Barcelona) between May 1979 and December 2019. Graft loss was defined as recipient death with functioning graft and as loss of graft function (return to dialysis or retransplantation). We assessed the causes of graft loss using clinical and histological information. We also analyzed the results of the two different transplant periods (1979-1999 and 2000-2019). RESULTS Between 1979 and 2019, 1522 transplants were performed. The median follow-up time was 56 (IQR 8-123) months. During follow-up, 722 (47.5%) grafts were lost: 483 (66.9%) due to graft failure and 239 (33.1%) due to death with functioning graft. The main causes of death were cardiovascular (25.1%), neoplasms (25.1%), and infectious diseases (21.8%). These causes were stable between the two periods of time. Only the unknown cause of death has decreased in the last period. The main cause of graft failure (loss of graft function) was the allograft chronic dysfunction (75%). When histologic information was available, antibody-mediated rejection (ABMR) and interstitial fibrosis/tubular atrophy (IF/TA) were the most frequent specific causes (15.9% and 12.6%). Of the graft failures, 213 (29.5%) were early (<1 year of transplantation). Vascular thrombosis was the main cause of early graft failure in the second period (2000-2019) (46.7%) and T-cell-mediated rejection (TCMR) was the main cause (31.3%) in the first period (1979-1999). The causes of late graft loss were similar between the two periods. CONCLUSIONS The causes of kidney allograft recipient death are still due to cardiovascular and malignant diseases. Vascular thrombosis has emerged as a frequent cause of early graft loss in the most recent years. The evaluation of the causes of graft loss is necessary to improve kidney transplantation outcomes.
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Affiliation(s)
| | - Emma Calatayud
- Servicio de Nefrología, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Anna Buxeda
- Servicio de Nefrología, Hospital del Mar, Barcelona, Spain
| | | | | | - Javier Gimeno
- Servicio de Anatomía Patológica, Hospital del Mar, Barcelona, Spain
| | - Carla Burballa
- Servicio de Nefrología, Hospital del Mar, Barcelona, Spain
| | - Marisa Mir
- Servicio de Nefrología, Hospital del Mar, Barcelona, Spain
| | | | - Sara Outon
- Servicio de Nefrología, Hospital del Mar, Barcelona, Spain
| | - Julio Pascual
- Servicio de Nefrología, Hospital del Mar, Barcelona, Spain
| | - Marta Crespo
- Servicio de Nefrología, Hospital del Mar, Barcelona, Spain
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Virmani S, Rao A, Menon MC. Allograft tissue under the microscope: only the beginning. Curr Opin Organ Transplant 2023; 28:126-132. [PMID: 36787238 PMCID: PMC10214011 DOI: 10.1097/mot.0000000000001052] [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] [Indexed: 02/15/2023]
Abstract
PURPOSE OF REVIEW To review novel modalities for interrogating a kidney allograft biopsy to complement the current Banff schema. RECENT FINDINGS Newer approaches of Artificial Intelligence (AI), Machine Learning (ML), digital pathology including Ex Vivo Microscopy, evaluation of the biopsy gene expression using bulk, single cell, and spatial transcriptomics and spatial proteomics are now available for tissue interrogation. SUMMARY Banff Schema of classification of allograft histology has standardized reporting of tissue pathology internationally greatly impacting clinical care and research. Inherent sampling error of biopsies, and lack of automated morphometric analysis with ordinal outputs limit its performance in prognostication of allograft health. Over the last decade, there has been an explosion of newer methods of evaluation of allograft tissue under the microscope. Digital pathology along with the application of AI and ML algorithms could revolutionize histopathological analyses. Novel molecular diagnostics such as spatially resolved single cell transcriptomics are identifying newer mechanisms underlying the pathologic diagnosis to delineate pathways of immunological activation, tissue injury, repair, and regeneration in allograft tissues. While these techniques are the future of tissue analysis, costs and complex logistics currently limit their clinical use.
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Affiliation(s)
- Sarthak Virmani
- Section of Nephrology, Division of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Silva BDPC, Lasmar MF, Nascimento E, Fabreti-Oliveira RA. Impact of early blood transfusion after kidney transplantation on the clinical outcomes and allograft survival. Transpl Immunol 2023; 77:101807. [PMID: 36842568 DOI: 10.1016/j.trim.2023.101807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 02/21/2023] [Accepted: 02/21/2023] [Indexed: 02/26/2023]
Abstract
INTRODUCTION Anemia in chronic kidney disease is of great concern regarding blood transfusions and the possibility of allosensitization for future kidney transplants and the occurrence of rejection and allograft loss in the post-transplant period. The aim of this study was to evaluate the effect of early blood transfusion on the occurrence of rejections, allograft function and survival in the first year after transplantation. MATERIAL AND METHODS This retrospective study was carried out with 445 patients submitted to kidney transplant allocated to two groups. The first group received early blood transfusions after transplant (n = 125, 28.09%), and the second group did not receive blood transfusions (n = 320, 71.91%). The patient outcomes were evaluated during a 1-year follow-up. RESULTS 14 patients given blood transfusion (11.2%) lost their allograft in the first year in comparison with 8 (2.5%) without transfusion (p < 0.001). There were 9 deaths in each group, which corresponded to 7.2% of the patients who received blood transfusions and 2.81% of those who did not (p < 0.035). Patient hospitalization lasted 15 days in transfusion group and 8.5 days in non-transfusion group (p < 0.001). Creatinine levels were higher in the patients who received blood transfusion than in those without transfusion in the first and third months after transplantation (p = 0.012 and 0.038, respectively). During the first year, the patients who received blood products experienced more antibody-mediated rejection (ABMR) (13.60%) than patients who did not (4.38%) (p < 0.001). Those who received blood transfusions also developed de novo DSA in higher proportion than those without transfusion against both class I and class II HLA (p < 0.001). CONCLUSION This study showed that blood transfusions in the first month after transplantation had a negative impact on kidney function, graft survival, and contributed to the development of de novo DSA, an increased risk of ABMR and infections.
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Affiliation(s)
- Bernardo D P C Silva
- Faculty of Medical Sciences, Belo Horizonte, Minas Gerais, Brazil; University Hospital of the Faculty of Medical Sciences, Belo Horizonte, Minas Gerais, Brazil.
| | - Marcus Faria Lasmar
- Faculty of Medical Sciences, Belo Horizonte, Minas Gerais, Brazil; University Hospital of the Faculty of Medical Sciences, Belo Horizonte, Minas Gerais, Brazil
| | - Evaldo Nascimento
- IMUNOLAB - Laboratory of Histocompatibility, Belo Horizonte, Minas Gerais, Brazil; Institute of Research and Education of the Hospital Santa Casa, Belo Horizonte, Minas Gerais, Brazil..
| | - Raquel A Fabreti-Oliveira
- Faculty of Medical Sciences, Belo Horizonte, Minas Gerais, Brazil; IMUNOLAB - Laboratory of Histocompatibility, Belo Horizonte, Minas Gerais, Brazil.
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Lim MA, Bloom RD. How to maximize graft survival. Curr Opin Organ Transplant 2023; 28:55-63. [PMID: 36579685 DOI: 10.1097/mot.0000000000001039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW Kidney transplant failure results in significant patient morbidity and mortality, increased financial burden and exacerbates the organ shortage faced by kidney transplant candidates. The different strategies to maximize graft survival in kidney transplant recipients is presented in this review. RECENT FINDINGS Maximizing kidney graft survival requires optimizing immunosuppression, preventing and managing recurrent disease and using general chronic kidney disease strategies to slow allograft injury. Herein, we review: 1) strategies to tailor immunosuppression to the individual patient to avoid over and underimmunosuppression, and avoid immunosuppression-related drug toxicities, 2) latest findings in the following recurrent diseases: focal segmental glomerulosclerosis, membranous nephropathy, complement-mediated kidney disease and monoclonal gammopathy of renal significance, and, 3) approaches to slow allograft injury including BP control, and the use of antiproteinuric agents and SGLT-2 inhibitors. SUMMARY The last two decades has seen significant improvement in allograft outcomes resulting from advances in immunosuppression. With the federal government's renewed focus on kidney disease and transplantation, and recent advances in biomarkers, genetic testing, big data analytics and machine learning, we hope to see further outcome improvements in the next decade.
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Affiliation(s)
- Mary Ann Lim
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Yang D, Wang Y, Zhuang B, Xu M, Wang C, Xie X, Huang G, Zheng Y, Xie X. Nomogram based on high-frequency shear wave elastography (SWE) to evaluate chronic changes after kidney transplantation. Eur Radiol 2023; 33:763-773. [PMID: 36064980 DOI: 10.1007/s00330-022-09054-1] [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: 02/17/2022] [Revised: 07/18/2022] [Accepted: 07/24/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To construct a nomogram with high-frequency shear wave elastography (SWE) as a noninvasive method to accurately assess chronic changes in renal allografts. METHODS A total of 191 renal transplantation patients (127 cases in the training group and 64 cases in the verification group) were included in this study. All patients received conventional ultrasound and high-frequency SWE examination, followed directly by biopsy the next day. The chronic changes were divided into mild, moderate, and severe. Multivariate logistic analyses were used to select significant variables, which were used to develop the nomogram. Nomogram models were assessed by receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA). RESULTS The cutoff value of SWE in mild, moderate, and severe chronic changes was 18.9, 22.5, and 27.6 kPa, respectively. The areas under the curve (AUCs) of SWE in the differential diagnosis of mild and moderate to severe chronic changes and mild to moderate and severe chronic changes were 0.817 and 0.870, respectively. Multivariate analysis showed that time since transplantation, proteinuria, glomerular filtration rate, echogenicity, and SWE were independent diagnostic factors for moderate to severe chronic changes (all p < 0.05); thus, a nomogram was successfully developed. The AUCs of the nomogram in the training and validation groups were 0.905 and 0.938, respectively. The high agreement between the model predictions and the actual observations was confirmed by calibration plot and DCA. CONCLUSIONS Based on SWE, the nomogram provided an insightful and applicable tool to evaluate chronic changes in renal allografts. KEY POINTS • In kidney transplantation, compared with acute changes, chronic changes are significantly correlated with cortical stiffness. • SWE shows good performance in identifying mild to moderate and severe chronic changes, with an AUC of 0.870. • Time since transplantation, proteinuria, glomerular filtration rate, echogenicity, and SWE are independent diagnostic factors for moderate to severe chronic changes in renal allografts.
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Affiliation(s)
- Daopeng Yang
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, NO. 58 Zhongshan Road 2, Guangzhou, 510080, People's Republic of China
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-Sen University, NO. 58 Zhongshan Road 2, Guangzhou, 510080, People's Republic of China
| | - Yan Wang
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, NO. 58 Zhongshan Road 2, Guangzhou, 510080, People's Republic of China
| | - Bowen Zhuang
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, NO. 58 Zhongshan Road 2, Guangzhou, 510080, People's Republic of China
| | - Ming Xu
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, NO. 58 Zhongshan Road 2, Guangzhou, 510080, People's Republic of China
| | - Changxi Wang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-Sen University, NO. 58 Zhongshan Road 2, Guangzhou, 510080, People's Republic of China
| | - Xiaoyan Xie
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, NO. 58 Zhongshan Road 2, Guangzhou, 510080, People's Republic of China
| | - Gang Huang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-Sen University, NO. 58 Zhongshan Road 2, Guangzhou, 510080, People's Republic of China
| | - Yanling Zheng
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, NO. 58 Zhongshan Road 2, Guangzhou, 510080, People's Republic of China
| | - Xiaohua Xie
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, NO. 58 Zhongshan Road 2, Guangzhou, 510080, People's Republic of China.
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Khairallah P, Robbins-Juarez S, Patel S, Shah V, Toma K, Fernandez H, Dube GK, King K, Mohan S, Husain SA, Morris H, Crew RJ. Tocilizumab for the treatment of chronic antibody mediated rejection in kidney transplant recipients. Clin Transplant 2023; 37:e14853. [PMID: 36398915 DOI: 10.1111/ctr.14853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 09/28/2022] [Accepted: 11/04/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic active antibody-mediated rejection (CAAMR) constitutes a dominant form of late allograft failure. Several treatment strategies directed at CAAMR have been attempted but proven ineffective at delaying kidney function decline or reducing donor-specific antibodies (DSA). We describe our single-center experience using tocilizumab in patients with CAAMR. METHODS This is a retrospective analysis using electronic medical records. 38 kidney transplant recipients at Columbia University Irving Medical Center who had been prescribed tocilizumab and followed for at least 3 months between August 2013 through December 2019 were included. RESULTS Tocilizumab use was associated with a decrease in the rate of estimated glomerular filtration rate (eGFR) decline in the 6 months following treatment initiation as compared to the 3 months before tocilizumab was initiated (difference between slopes before and after initiation of treatment = 2.6 mL/min/1.73 m2 (SE = .8, p = .002) per month for up to 6 months following Tocilizumab initiation). Allograft biopsies showed significant improvement in interstitial inflammation scores (score 1(0,1) to 0 (0,1), p = .03) while other histologic scores remained stable. There was no significant change in proteinuria or DSA titers post-treatment with tocilizumab. CONCLUSIONS Treatment of CAAMR with tocilizumab was associated with a decrease in the rate of eGFR decline and a reduction in interstitial inflammation scores in patients with CAAMR.
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Affiliation(s)
| | - Shelief Robbins-Juarez
- Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Shefali Patel
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Vaqar Shah
- Department of Medicine, SUNY University at Buffalo, Buffalo, New York, USA
| | - Katherine Toma
- Jersey Coast Nephrology and Hypertension Associates, Brick, New Jersey, USA
| | - Hilda Fernandez
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Geoffrey K Dube
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Kristen King
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Sumit Mohan
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Syed Ali Husain
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Heather Morris
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Russell John Crew
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
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Iwahara N, Hotta K, Iwami D, Tanabe T, Tanaka Y, Ito YM, Otsuka T, Murai S, Takada Y, Higuchi H, Sasaki H, Hirose T, Harada H, Shinohara N. Analysis of T-cell alloantigen response via a direct pathway in kidney transplant recipients with donor-specific antibodies. Front Immunol 2023; 14:1164794. [PMID: 37207202 PMCID: PMC10189043 DOI: 10.3389/fimmu.2023.1164794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/19/2023] [Indexed: 05/21/2023] Open
Abstract
Donor-specific antibodies (DSAs) are the main cause of graft loss over time. The direct pathway of alloantigen recognition is important in the pathogenesis of acute rejection. Recent studies have suggested that the direct pathway also contributes to the pathogenesis of chronic injury. Nevertheless, there are no reports on T-cell alloantigen response via the direct pathway in kidney recipients with DSAs. We analyzed the T-cell alloantigen response via the direct pathway in kidney recipients with DSAs (DSA+) or without DSAs (DSA-). A mixed lymphocyte reaction assay was implemented to assess the direct pathway response. DSA+ patients showed significantly higher CD8+ and CD4+ T cell responses to donor cells than DSA- patients. Furthermore, proliferating CD4+ T cells showed a marked increase in Th1 and Th17 responses in DSA+ patients than in DSA- patients. In a comparison between anti-donor and third-party responses, the anti-donor CD8+ and CD4+ T cell response was significantly lower than the anti-third-party response. In contrast, the donor-specific hyporesponsiveness was absent in DSA+ patients. Our study demonstrated that DSA+ recipients have a greater potential for developing immune responses against the donor tissues via the direct alloantigen recognition pathway. These data contribute to an understanding of DSAs pathogenicity during kidney transplantation.
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Affiliation(s)
- Naoya Iwahara
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | - Kiyohiko Hotta
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
- *Correspondence: Kiyohiko Hotta,
| | - Daiki Iwami
- Division of Renal Surgery and Transplantation, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Tatsu Tanabe
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | - Yuka Tanaka
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | - Yoichi M. Ito
- Data Science Center, Promotion Unit, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Takuya Otsuka
- Department of surgical pathology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Sachiyo Murai
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | - Yusuke Takada
- Departments of Kidney Transplant Surgery, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Haruka Higuchi
- Departments of Kidney Transplant Surgery, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Hajime Sasaki
- Departments of Kidney Transplant Surgery, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Takayuki Hirose
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | - Hiroshi Harada
- Departments of Kidney Transplant Surgery, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Nobuo Shinohara
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
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Huang X, Nie F, Zhu J, Liu L, Wang N. Application value of shear-wave elastography combined with monochrome superb microvascular imaging in renal allograft chronic rejection. Clin Hemorheol Microcirc 2022; 82:303-311. [PMID: 36057814 DOI: 10.3233/ch-221443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Conventional ultrasound (US), which include gray scale US and Doppler US, is the first-line imaging modality for the evaluation of renal allograft; however, conventional US indicators have limitations. OBJECTIVE To explore the application value of shear-wave elastography (SWE) combined with monochrome superb microvascular imaging (mSMI) in renal allograft chronic rejection (CR). METHODS From November 2021 to February 2022 in the Lanzhou University Second Hospital, the US features of 54 patients with renal allograft were retrospectively analyzed. Patients were categorized into two groups: stable group(n = 44) and CR group(n = 10), with clinical diagnosis as reference standard. The vascular index (VI) on mSMI and parenchymal stiffness were measured in the middle cortex of all renal allografts and receiver operating characteristic (ROC) curves were drawn to evaluate the feasibility of differentiation. Statistically significant US features and biochemical indicators such as creatinine were scored, and the results of the scores were analyzed by ROC curve. RESULTS The VI on mSMI of the stable group (49.5±2.0) was significantly greater than that of the CR group (33.8±5.9) (P = 0.028). There was a statistically significant difference in parenchymal stiffness between stable group (16.2kPa±1.2) and CR group (33.9kPa±6.6) (P = 0.027). The sensitivity was 90% and specificity was 81.8% of the scores in the differentiation of stable group from CR group (cut-off value, 2; P = 0.000). CONCLUSION SWE combined with mSMI may help differentiate stable renal allograft from renal allograft CR and have the potential application value in the diagnosis of renal allograft CR.
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Affiliation(s)
- Xiao Huang
- Ultrasound Medical Center, Lanzhou University Second Hospital, Cuiyingmen, Chengguan District, Lanzhou, China.,Gansu Province Clinical Research Center for Ultrasonography, Lanzhou, China
| | - Fang Nie
- Ultrasound Medical Center, Lanzhou University Second Hospital, Cuiyingmen, Chengguan District, Lanzhou, China.,Gansu Province Clinical Research Center for Ultrasonography, Lanzhou, China
| | - Ju Zhu
- Ultrasound Medical Center, Lanzhou University Second Hospital, Cuiyingmen, Chengguan District, Lanzhou, China.,Gansu Province Clinical Research Center for Ultrasonography, Lanzhou, China
| | - Luping Liu
- Ultrasound Medical Center, Lanzhou University Second Hospital, Cuiyingmen, Chengguan District, Lanzhou, China.,Gansu Province Clinical Research Center for Ultrasonography, Lanzhou, China
| | - Nan Wang
- Ultrasound Medical Center, Lanzhou University Second Hospital, Cuiyingmen, Chengguan District, Lanzhou, China.,Gansu Province Clinical Research Center for Ultrasonography, Lanzhou, China
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47
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Leung T, Cober T, Hickey J, Stach L, Kawano A, Szczepanik A, Watson A, Imamura Y, Weems J, West-Thielke P. Clinical Utility of the OmniGraf Biomarker Panel in the Care of Kidney Transplant Recipients (CLARITY): Protocol for a Prospective, Multisite Observational Study. JMIR Res Protoc 2022; 11:e41020. [PMID: 36515980 PMCID: PMC9798265 DOI: 10.2196/41020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/23/2022] [Accepted: 09/30/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Death with a functioning allograft has become the leading category of graft loss in kidney transplant recipients at all time points. Previous analyses have demonstrated that causes of death in kidney transplant recipients are predominated by comorbidities strongly associated with immunosuppressant medications. Adverse drug events (ADEs) have been strongly associated with nonadherence, health care utilization, and graft loss; clinicians face a difficult decision on whether making immunosuppressant adjustments in the face of ADEs will improve symptomology or simply increase the risk of acute rejection. Clinicians also face a treatment quandary in 50% of kidney transplant recipients with stage 3 or worse chronic kidney disease at 1 year post transplantation, as progressive decline in renal function has been strongly associated with inferior allograft survival. OBJECTIVE The primary objective of the CLinical Utility of the omnigrAf biomarkeR Panel In The Care of kidneY Transplant Recipients (CLARITY) trial is to evaluate change in renal function over time in kidney transplant recipients who are undergoing OmniGraf monitoring in conjunction with monitoring of their medication-related symptom burden (MRSB). A secondary objective of this study is to identify the impact of OmniGraf use in conjunction with patient-reported MRSB as part of clinical care on patients' self-efficacy and quality of life. METHODS CLARITY is a 3-year prospective, multisite, observational study of 2000 participants with a matched control, measuring the impact of real-time patients' MRSB and the OmniGraf biomarker panel on change in renal function over time. Secondary outcome measures include the Patient-Reported Outcomes Measurement Information System (PROMIS) Self-Efficacy for Managing Chronic Conditions-Managing Medications and Treatment-Short Form 4a; the PROMIS-29 Profile (version 2.1); the PROMIS Depression Scale, hospitalizations-subcategorized for hospitalizations owing to infections; treated rejections, MRSB, and proportion of participants with overall graft survival at year 3 post transplantation; graft loss or death during the 3-year study follow-up period; and change in provider satisfaction. RESULTS The primary outcome measure of the study will be a comparison of the slope change in estimated glomerular filtration rate from baseline to the end of follow-up between study participants and a matched control group. Secondary outcome measures include changes over time in PROMIS Self-Efficacy for Managing Chronic Conditions-Managing Medications and Treatment-Short Form 4a, the PROMIS-29 Profile (version 2.1), and PROMIS Depression Scale in the study group, as well as a comparison of hospitalizations and causes, rejections, and graft and patient survival compared between participants and a matched cohort. The anticipated first enrollment in the study is October 2022 with data analysis and publication expected in October 2027. CONCLUSIONS Through this report, we describe the study design, methods, and outcome measures that will be utilized in the ongoing CLARITY trial. TRIAL REGISTRATION ClinicalTrials.gov NCT05482100; https://clinicaltrials.gov/ct2/show/NCT05482100. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/41020.
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Affiliation(s)
| | - Timothy Cober
- Transplant Genomics, Inc, Framingham, MA, United States
| | | | - Leslie Stach
- Transplant Genomics, Inc, Framingham, MA, United States
| | | | | | - Alicia Watson
- Transplant Genomics, Inc, Framingham, MA, United States
| | - Yuka Imamura
- Transplant Genomics, Inc, Framingham, MA, United States
| | - Juston Weems
- Transplant Genomics, Inc, Framingham, MA, United States
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Unraveling complexity of antibody-mediated rejections, the mandatory way towards an accurate diagnosis and a personalized treatment. Presse Med 2022; 51:104141. [PMID: 36209931 DOI: 10.1016/j.lpm.2022.104141] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 09/29/2022] [Indexed: 11/09/2022] Open
Abstract
Antibody-mediated rejection (ABMR) remains one of the most challenging issues after organ transplantation and particularly after kidney transplantation. Despite many progresses during the last decade, ABMR is still the main cause of kidney graft loss and this all over the post- transplant period. In this review, we describe the recent knowledge about molecular and cellular mechanisms involved in ABMR. We focused our report on the role of the complement pathway in the process of ABMR and we give some insights into the role of inflammatory cells, NK lymphocytes and the role of endothelial cells. We further describe the potential role of non-HLA antibodies, of which the importance has been increasingly emphasized in recent years. Overall, this report could be of interest for all physicians who are working in the field of organ transplantation or who are working in the field of immunology. It gives essential information to understand new diagnosis advances and further therapeutic approaches. Antibody-mediated rejection (ABMR) is the leading cause of graft failure ([1,2]). In contrast to T-cell mediated rejection usually sensitive to steroids, active ABMR remains a therapeutic challenge. ABMR diagnosis relies on the presence of renal injuries and donor-specific antibodies (DSA) (HLA and non HLA antibodies) with sometimes the evidence of interaction between DSA and graft endothelium. Regularly revised during expert conferences, ABMR definition is currently categorized as active or chronic active. [3] The emergence of validated molecular assays targeting a better phenotyping of ABMR and the recent advances regarding the detrimental effect of DSA directed against minor antigens open the way to a better assessment of the heterogeneity of ABMR. In this review, we will address new aspects of ABMR regarding its mechanisms, diagnosis and treatments.
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49
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Jordan SC, Ammerman N, Huang E, Vo A. Importance of IL-6 inhibition in prevention and treatment of antibody-mediated rejection in kidney allografts. Am J Transplant 2022; 22 Suppl 4:28-37. [PMID: 36453709 DOI: 10.1111/ajt.17207] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/30/2022] [Accepted: 09/23/2022] [Indexed: 12/03/2022]
Abstract
Interleukin-6 (IL-6) is a cytokine critical for innate and adaptive immune responses. However, persistent expression of high levels of IL-6 are associated with a number of pathologic conditions including autoimmune diseases and capillary leak syndrome. Importantly, in kidney transplant patients, IL-6 may play a role in mediation of cell-mediated rejection (CMR) and antibody-mediated rejection (AMR). This is likely due to the importance of IL-6 in stimulating B cell responses with pathogenic donor-specific antibody (DSA) generation and stimulation of T effector cell responses while inhibiting T regulatory cells. Data from preliminary clinical trials and clinical observations show that tocilizumab (anti-IL-6R) and clazakizumab (anti-IL-6) may have promise in treatment of CMR, AMR and chronic (cAMR). This has led to a phase 3 placebo, randomized clinical trial of clazakizumab for treatment of cAMR, a condition for which there is currently no treatment. The identification of IL-6 production in vascular endothelia cells after alloimmune activation reveals another potential pathway for vasculitis as endothelia cell IL-6 may stimulate immune cell responses that are potentially inhibitable with anti-IL-6/IL-6R treatment. Importantly, anti-IL-6/IL-6R treatments have shown the ability to induce Treg and Breg cells in vivo which may have potential importance for prevention and treatment of DSA development and allograft rejection.
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Affiliation(s)
- Stanley C Jordan
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, West Hollywood, California, USA
| | - Noriko Ammerman
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, West Hollywood, California, USA
| | - Edmund Huang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, West Hollywood, California, USA
| | - Ashley Vo
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, West Hollywood, California, USA
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50
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Pang Q, Chen H, Wu H, Wang Y, An C, Lai S, Xu J, Wang R, Zhou J, Xiao H. N6-methyladenosine regulators-related immune genes enable predict graft loss and discriminate T-cell mediate rejection in kidney transplantation biopsies for cause. Front Immunol 2022; 13:1039013. [PMID: 36483557 PMCID: PMC9722771 DOI: 10.3389/fimmu.2022.1039013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/01/2022] [Indexed: 11/23/2022] Open
Abstract
Objective The role of m6A modification in kidney transplant-associated immunity, especially in alloimmunity, still remains unknown. This study aims to explore the potential value of m6A-related immune genes in predicting graft loss and diagnosing T cell mediated rejection (TCMR), as well as the possible role they play in renal graft dysfunction. Methods Renal transplant-related cohorts and transcript expression data were obtained from the GEO database. First, we conducted correlation analysis in the discovery cohort to identify the m6A-related immune genes. Then, lasso regression and random forest were used respectively to build prediction models in the prognosis and diagnosis cohort, to predict graft loss and discriminate TCMR in dysfunctional renal grafts. Connectivity map (CMap) analysis was applied to identify potential therapeutic compounds for TCMR. Results The prognostic prediction model effectively predicts the prognosis and survival of renal grafts with clinical indications (P< 0.001) and applies to both rejection and non-rejection situations. The diagnostic prediction model discriminates TCMR in dysfunctional renal grafts with high accuracy (area under curve = 0.891). Meanwhile, the classifier score of the diagnostic model, as a continuity index, is positively correlated with the severity of main pathological injuries of TCMR. Furthermore, it is found that METTL3, FTO, WATP, and RBM15 are likely to play a pivotal part in the regulation of immune response in TCMR. By CMap analysis, several small molecular compounds are found to be able to reverse TCMR including fenoldopam, dextromethorphan, and so on. Conclusions Together, our findings explore the value of m6A-related immune genes in predicting the prognosis of renal grafts and diagnosis of TCMR.
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Affiliation(s)
- Qidan Pang
- Department of Nephrology, Bishan Hospital of Chongqing Medical University, Chongqing, China
| | - Hong Chen
- Department of General Surgery/Gastrointestinal Surgery, Bishan Hospital of Chongqing Medical University, Chongqing, China
| | - Hang Wu
- Department of Nephrology, Bishan Hospital of Chongqing Medical University, Chongqing, China
| | - Yong Wang
- Department of General Surgery/Gastrointestinal Surgery, Bishan Hospital of Chongqing Medical University, Chongqing, China
| | - Changyong An
- Department of General Surgery/Gastrointestinal Surgery, Bishan Hospital of Chongqing Medical University, Chongqing, China
| | - Suhe Lai
- Department of General Surgery/Gastrointestinal Surgery, Bishan Hospital of Chongqing Medical University, Chongqing, China
| | - Jia Xu
- Department of Nephrology, Bishan Hospital of Chongqing Medical University, Chongqing, China
| | - Ruiqiong Wang
- Department of Nephrology, Bishan Hospital of Chongqing Medical University, Chongqing, China
| | - Juan Zhou
- Department of Nephrology, Bishan Hospital of Chongqing Medical University, Chongqing, China,*Correspondence: Hanyu Xiao, ; Juan Zhou,
| | - Hanyu Xiao
- Department of General Surgery/Gastrointestinal Surgery, Bishan Hospital of Chongqing Medical University, Chongqing, China,*Correspondence: Hanyu Xiao, ; Juan Zhou,
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