Thrombophilic factors do not predict outcomes in renal transplant recipients under prophylactic acetylsalicylic acid

How to Deal With Kidney Retransplantation-Second, Third, Fourth, and Beyond

Kidney transplantation is the best health option for patients with end-stage kidney disease. Ideally, a kidney transplant would last for the lifetime of each recipient. However, depending on the age of the recipient and details of the kidney transplant, there may be a need for a second, third, fourth, or even more kidney transplants. In this overview, the outcome of multiple kidney transplants for an individual is presented. Key issues include surgical approach and immunologic concerns. Included in the surgical approach is an analysis of transplant nephrectomy, with indications, timing, and immunologic impact. Allograft thrombosis, whether related to donor or recipient factors merits investigation to prevent it from happening again. Other posttransplant events such as rejection, viral illness (polyomavirus hominis type I), recurrent disease (focal segmental glomerulosclerosis), and posttransplant lymphoproliferative disease may lead to the need for retransplantation. The pediatric recipient is especially likely to need a subsequent kidney transplant. Finally, noncompliance/nonadherence can affect both adults and children. Innovative approaches may reduce the need for retransplantation in the future.

Effect of Thrombophilic Factors on Renal Graft Function: A Single-Center Experience

BACKGROUND

Optimization of immunosuppressive therapy reduced the incidence of acute rejection, and therefore vascular complications, including graft thrombosis, which have emerged as the main cause of graft loss in the early post-transplant period. A thrombophilic condition may lead to renal graft loss. The aim of the study was to assess renal graft function in thrombophilic renal recipients receiving anticoagulation treatment.

METHODS

This is a retrospective study including 29 renal recipients (ktx group) with a history of thrombosis and confirmed thrombophilic factor. Graft function was evaluated by median serum creatinine concentration at the third month after ktx (SCr₁) and at the end of the observation (SCr₂) with respect to hypercoagulability (factor V Leiden [FVL], mutation G20210A, antiphospholipid antibodies, deficiency of protein S [PS] or C [PC], factor VIII >200%).

RESULTS

Recipients underwent retransplantation because of graft thrombosis (P < .001). They more often underwent urgent transplantation (P = .008), received induction therapy (P = .021), underwent an indication other than protocol biopsy (P = .001), or experienced acute rejection (P = .042). Differences in graft function (SCr₂) were found at the end of observation (ktx group vs controls 1.9 mg/dL vs 1.3 mg/dL, respectively, P = .014). Multivariate analysis revealed inferior thrombophilic graft function in the model with SCr₁ <2 mg/dL (odds ratio 0.07, 95% confidence interval 0.01-0.57, P = .014) and in the model with SCr₂ <2 mg/dL (odds ratio 0.15; 95% confidence interval 0.04-0.54, P = .004). The incidence of antiphospholipid syndrome was 31%; FVIII, 31%; FVL, 24.1%; and PC/PS, 13.8%. After anticoagulation was introduced no thromboembolic events or bleeding complications occurred.

CONCLUSION

Hypercoagulability is not a contraindication to ktx but may worsen graft function. Post-transplant care in thrombophilic recipients is demanding (retransplantation, immunization, protocol biopsy, anticoagulation), but is the only means by which to maintain a graft.

Molecularly targeted therapies for p53-mutant cancers

The tumor suppressor p53 is lost or mutated in approximately half of human cancers. Mutant p53 not only loses its anti-tumor transcriptional activity, but also often acquires oncogenic functions to promote tumor proliferation, invasion, and drug resistance. Traditional strategies have been taken to directly target p53 mutants through identifying small molecular compounds to deplete mutant p53, or to restore its tumor suppressive function. Accumulating evidence suggest that cancer cells with mutated p53 often exhibit specific functional dependencies on secondary genes or pathways to survive, providing alternative targets to indirectly treat p53-mutant cancers. Targeting these genes or pathways, critical for survival in the presence of p53 mutations, holds great promise for cancer treatment. In addition, mutant p53 often exhibits novel gain-of-functions to promote tumor growth and metastasis. Here, we review and discuss strategies targeting mutant p53, with focus on targeting the mutant p53 protein directly, and on the progress of identifying genes and pathways required in p53-mutant cells.

Hypercoagulability in Kidney Transplant Recipients

Thrombosis remains an important complication after kidney transplantation. Outcomes for graft and deep vein thrombosis are not favorable. The majority of early kidney transplant failure in adults is due to allograft thrombosis. Risk stratification, early diagnosis, and appropriate intervention are critical to the management of thrombotic complications of transplant. In patients with end-stage renal disease, the prevalence of acquired risk factors for thrombosis is significantly high. Because of hereditary and acquired risk factors, renal transplant recipients manifest features of a chronic prothrombotic state. Identification of hereditary thrombotic risk factors before transplantation may be a useful tool for selecting appropriate candidates for thrombosis prophylaxis immediately after transplantation. Short-term anticoagulation may be appropriate for all patients after kidney transplantation.

End-stage renal disease and thrombophilia

Chronic kidney disease is an established risk factor for arterial and venous thromboembolism (TE). Whereas the overall risk of TE in moderately decreased kidney function is approximately 2.5-fold higher compared to patients with normal renal function, the risk increase is 5.5-fold in patients with severe renal dysfunction. In patients with renal dysfunction and arterial thrombosis (OR: 4.9), malignancy (OR: 5.8) surgery (OR: 14.0) or thrombophilia (OR: 4.3) the risk to suffer from venous TE is higher compared to the risk associated to the baseline renal dysfunction alone. The treatment options for end-stage renal diseases include hemodialysis, peritoneal dialysis and kidney transplantation. During all treatment modalities thrombotic complications have been described, namely catheter malfunction and shunt thrombosis in patients undergoing hemodialysis in up to 25% of patients, and TE, pulmonary embolism or graft vessel thrombosis in approximately 8% of patients. The reported incidence of reno-vascular thrombosis following renal transplantation leading to hemorrhagic infarction with organ rejection or organ loss varied between 2-12%. Keeping in mind the multifactorial etiology of TE in patients with kidney dysfunction a general screening for thrombophilia in this patient group is not indicated. Selected screening on an individual patient basis should be discussed if the family history for TE is positive or the patient itself had suffered one thrombosis before the onset of the renal disease or multiple TEs during hemodialysis or post kidney transplantation in patients waiting for living donor kidney transplantation.