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Yin Y, Chen C, Zhang D, Han Q, Wang Z, Huang Z, Chen H, Sun L, Fei S, Tao J, Han Z, Tan R, Gu M, Ju X. Construction of predictive model of interstitial fibrosis and tubular atrophy after kidney transplantation with machine learning algorithms. Front Genet 2023; 14:1276963. [PMID: 38028591 PMCID: PMC10646529 DOI: 10.3389/fgene.2023.1276963] [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: 08/13/2023] [Accepted: 10/11/2023] [Indexed: 12/01/2023] Open
Abstract
Background: Interstitial fibrosis and tubular atrophy (IFTA) are the histopathological manifestations of chronic kidney disease (CKD) and one of the causes of long-term renal loss in transplanted kidneys. Necroptosis as a type of programmed death plays an important role in the development of IFTA, and in the late functional decline and even loss of grafts. In this study, 13 machine learning algorithms were used to construct IFTA diagnostic models based on necroptosis-related genes. Methods: We screened all 162 "kidney transplant"-related cohorts in the GEO database and obtained five data sets (training sets: GSE98320 and GSE76882, validation sets: GSE22459 and GSE53605, and survival set: GSE21374). The training set was constructed after removing batch effects of GSE98320 and GSE76882 by using the SVA package. The differentially expressed gene (DEG) analysis was used to identify necroptosis-related DEGs. A total of 13 machine learning algorithms-LASSO, Ridge, Enet, Stepglm, SVM, glmboost, LDA, plsRglm, random forest, GBM, XGBoost, Naive Bayes, and ANNs-were used to construct 114 IFTA diagnostic models, and the optimal models were screened by the AUC values. Post-transplantation patients were then grouped using consensus clustering, and the different subgroups were further explored using PCA, Kaplan-Meier (KM) survival analysis, functional enrichment analysis, CIBERSOFT, and single-sample Gene Set Enrichment Analysis. Results: A total of 55 necroptosis-related DEGs were identified by taking the intersection of the DEGs and necroptosis-related gene sets. Stepglm[both]+RF is the optimal model with an average AUC of 0.822. A total of four molecular subgroups of renal transplantation patients were obtained by clustering, and significant upregulation of fibrosis-related pathways and upregulation of immune response-related pathways were found in the C4 group, which had poor prognosis. Conclusion: Based on the combination of the 13 machine learning algorithms, we developed 114 IFTA classification models. Furthermore, we tested the top model using two independent data sets from GEO.
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Affiliation(s)
- Yu Yin
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Congcong Chen
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Dong Zhang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Qianguang Han
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zijie Wang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhengkai Huang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hao Chen
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Li Sun
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shuang Fei
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jun Tao
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhijian Han
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ruoyun Tan
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Min Gu
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Department of Urology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaobing Ju
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Ciancio G, Gaynor JJ, Guerra G, Tabbara MM, Roth D, Kupin W, Mattiazzi A, Moni L, Burke GW. Long-term effects of average calcineurin inhibitor trough levels (over time) on renal function in a prospectively followed cohort of 150 kidney transplant recipients. Clin Transl Sci 2023; 16:2382-2393. [PMID: 37817405 PMCID: PMC10651634 DOI: 10.1111/cts.13639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 09/01/2023] [Indexed: 10/12/2023] Open
Abstract
More favorable clinical outcomes with medium-term follow-up have been reported among kidney transplant recipients receiving maintenance therapy consisting of "reduced-tacrolimus (TAC) dosing," mycophenolate mofetil (MMF), and low-dose corticosteroids. However, it is not clear whether long-term maintenance therapy with reduced-calcineurin inhibitor (CNI) dosing still leads to reduced renal function. A prospectively followed cohort of 150 kidney transplant recipients randomized to receive TAC/sirolimus (SRL) versus TAC/MMF versus cyclosporine microemulsion (CSA)/SRL, plus low-dose maintenance corticosteroids, now has 20 years of post-transplant follow-up. Average CNI trough levels over time among patients who were still alive with functioning grafts at 60, 120, and 180 months post-transplant were determined and ranked from smallest-to-largest for both TAC and CSA. Stepwise linear regression was used to determine whether these ranked average trough levels were associated with the patient's estimated glomerular filtration rate (eGFR) at those times, particularly after controlling for other significant multivariable predictors. Experiencing biopsy-proven acute rejection (BPAR) and older donor age were the two most significant multivariable predictors of poorer eGFR at 60, 120, and 180 months post-transplant (p < 000001 and 0.000003 for older donor age at 60 and 120 months; p = 0.00008 and <0.000001 for previous BPAR at 60 and 120 months). Assignment to CSA also implied a significantly poorer eGFR (but with less magnitudes of effect) in multivariable analysis at 60 and 120 months (p = 0.01 and 0.002). Higher ranked average CNI trough levels had no association with eGFR at any timepoint in either univariable or multivariable analysis (p > 0.70). Long-term maintenance therapy with reduced-CNI dosing does not appear to cause reduced renal function.
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Affiliation(s)
- Gaetano Ciancio
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
- Department of SurgeryLeonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
| | - Jeffrey J. Gaynor
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
- Department of SurgeryLeonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
| | - Giselle Guerra
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
- Division of Nephrology, Department of Medicine, Leonard M. Miller School of MedicineUniversity of MiamiMiamiFloridaUSA
| | - Marina M. Tabbara
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
| | - David Roth
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
- Division of Nephrology, Department of Medicine, Leonard M. Miller School of MedicineUniversity of MiamiMiamiFloridaUSA
| | - Warren Kupin
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
- Division of Nephrology, Department of Medicine, Leonard M. Miller School of MedicineUniversity of MiamiMiamiFloridaUSA
| | - Adela Mattiazzi
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
- Division of Nephrology, Department of Medicine, Leonard M. Miller School of MedicineUniversity of MiamiMiamiFloridaUSA
| | - Lissett Moni
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
- Department of SurgeryLeonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
| | - George W. Burke
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
- Department of SurgeryLeonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
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Cieślik A, Burban A, Gniewkiewicz M, Gozdowska J, Dęborska-Materkowska D, Perkowska-Ptasinska A, Kosieradzki M, Durlik M. The Importance of 1-Year Protocol Biopsy in the Long-Term Prognosis of Kidney Transplants-5-Years Follow-Up. Transplant Proc 2023; 55:2053-2057. [PMID: 37778932 DOI: 10.1016/j.transproceed.2023.08.022] [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: 03/14/2023] [Accepted: 08/01/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Protocol biopsies are performed to detect subclinical pathologies that may lead to future graft dysfunction. However, they are not routinely performed interventions in every transplant center. There is no established regimen for performing them. PURPOSE The study aimed to evaluate if protocol biopsies can improve long-term patient outcomes after detecting early disorders and modifying treatment. MATERIAL AND METHODS Our observational study included 61 patients who underwent protocol biopsy 12 months after the transplantation. Based on the biopsy results, patients with abnormal histologic material (n = 37) were divided into 3 study groups as follows: patients with mild inflammatory lesions (n = 21), patients with interstitial fibrosis and tubular atrophy (IFTA) grade II to III (n = 12), and patients with BK virus nephropathy (n = 4). The control group (n = 24) included kidney recipients with IFTA 0 to I grade. Outcomes after 5-year follow-up were evaluated. RESULTS Five years after the biopsy, patients in the control group had stable graft function (5-year change in serum creatinine was -0.09 mg/dL). An increase in serum creatinine levels was observed in patients with IFTA II to III compared with the control group (0.14 mg/dL, P = .04). Immunosuppressive treatment was modified in the group with mild inflammatory changes and in the BKV group after the biopsy result. In the group with mild inflammatory lesions, renal function was stable (change of serum creatinine was -0.01 mg/dL, P = .51). In the BKV nephropathy group, there was a significant reduction in serum creatine levels (-0.48 mg/dL, P = .016). The analysis showed no diagnostic value for serum creatinine concentration (95% CI 0.49-0.78, P = .08). CONCLUSIONS Protocol biopsies are useful for detecting early pathologies and preventing allograft failure. They greatly benefit patients with detectable pathology that can be treated or in whom therapy modification is possible.
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Affiliation(s)
- Aleksandra Cieślik
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Anna Burban
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Michał Gniewkiewicz
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Jolanta Gozdowska
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland.
| | - Dominika Dęborska-Materkowska
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | | | - Maciej Kosieradzki
- Department of General and Transplantation Surgery, The Medical University of Warsaw, Warsaw, Poland
| | - Magdalena Durlik
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
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Elsingergy MM, Viteri B, Otero HJ, Bhatti T, Morales T, Roberts TPL, Amaral S, Hartung E, Serai SD. Imaging fibrosis in pediatric kidney transplantation: A pilot study. Pediatr Transplant 2023; 27:e14540. [PMID: 37166372 PMCID: PMC10824264 DOI: 10.1111/petr.14540] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 04/01/2023] [Accepted: 04/28/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Noninvasive alternatives to biopsy for assessment of interstitial fibrosis and tubular atrophy (IFTA), the major determinant of kidney transplant failure, remain profoundly limited. Elastography is a noninvasive technique that propagates shear waves across tissues to measure their stiffness. We aimed to test utility of elastography for early detection of IFTA in pediatric kidney allografts. METHODS We compared ultrasound (USE) and MR elastography (MRE) stiffness measurements, performed on pediatric transplant recipients referred for clinically indicated biopsies, and healthy controls. RESULTS Ten transplant recipients (median age 16 years) and eight controls (median age 16.5 years) were enrolled. Three transplant recipients had "stable" allografts and seven had Banff Grade 1 IFTA. Median time from transplantation to biopsy was 12 months. Mean estimated glomerular filtration rate was 61.5 mL/min/1.73m2 by creatinine-cystatin-C CKiD equation at time of biopsy. Mean stiffness, calculated through one-way ANOVA, was higher for IFTA allografts (23.4 kPa USE/5.6 kPa MRE) than stable allografts (13.7 kPa USE/4.4 kPa MRE) and controls (9.1 kPa USE/3.6 kPa MRE). Pearson's coefficient between USE and MRE stiffness values was strong (r = .97). AUC for fibrosis prediction in transplanted kidneys was high for both modalities (0.91 USE and 0.89 MRE), although statistically nonsignificant (p > .05). Stiffness cut-off values for USE and MRE were 13.8 kPa and 4.6 kPa, respectively. Both values yielded a sensitivity of 100% but USE specificity (72%) was slightly higher than MRE (67%). CONCLUSION Elastography shows potential for detection of low-grade IFTA in allografts although a larger sample is imperative for clinical validation.
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Affiliation(s)
| | - Bernarda Viteri
- Department of Pediatrics, Division of Nephrology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Hansel J. Otero
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Tricia Bhatti
- Department of Pathology and Laboratory Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Tatiana Morales
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Timothy P L Roberts
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Sandra Amaral
- Department of Pediatrics, Division of Nephrology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Erum Hartung
- Department of Pediatrics, Division of Nephrology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Suraj D. Serai
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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5
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Tamargo CL, Kant S. Pathophysiology of Rejection in Kidney Transplantation. J Clin Med 2023; 12:4130. [PMID: 37373823 DOI: 10.3390/jcm12124130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/07/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Kidney transplantation has been the optimal treatment for end-stage kidney disease for almost 70 years, with increasing frequency over this period. Despite the prevalence of the procedure, allograft rejection continues to impact transplant recipients, with consequences ranging from hospitalization to allograft failure. Rates of rejection have declined over time, which has been largely attributed to developments in immunosuppressive therapy, understanding of the immune system, and monitoring. Developments in these therapies, as well as an improved understanding of rejection risk and the epidemiology of rejection, are dependent on a foundational understanding of the pathophysiology of rejection. This review explains the interconnected mechanisms behind antibody-mediated and T-cell-mediated rejection and highlights how these processes contribute to outcomes and can inform future progress.
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Affiliation(s)
- Christina L Tamargo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
| | - Sam Kant
- Division of Nephrology & Comprehensive Transplant Center, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
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Barreda P, Miñambres E, Ballesteros MÁ, Mazón J, Gómez-Román J, Gómez Ortega JM, Belmar L, Valero R, Ruiz JC, Rodrigo E. Controlled Donation After Circulatory Death Using Normothermic Regional Perfusion Does Not Increase Graft Fibrosis in the First Year Posttransplant Surveillance Biopsy. EXP CLIN TRANSPLANT 2022; 20:1069-1075. [PMID: 36718005 DOI: 10.6002/ect.2022.0171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES The number of kidney transplants obtained from controlled donations after circulatory death is increasing, with long-term outcomes similar to those obtained with donations after brain death. Extraction using normothermic regional perfusion can improve results with controlled donors after circulatory death; however, information on the histological impact and extraction procedure is scarce. MATERIALS AND METHODS We retrospectively investigated all kidney transplants performed from October 2014 to December 2019, in which a follow-up kidney biopsy had been performed at 1-year follow-up, comparing controlled procedures with donors after circulatory death and normothermic regional perfusion versus donors after brain death. Interstitial fibrosis/tubular atrophy was assessed by adding the values of interstitial fibrosis and tubular atrophy, according to the Banff classification of renal allograft pathology. RESULTS When we compared histological data from 66 transplants with donations after brain death versus 24 transplants with donations after circulatory death and normothermic regional perfusion, no differences were found in the degree of fibrosis in the 1-year follow-up biopsy (1.7 ± 1.3 vs 1.7 ± 1.1; P = .971) or in the ratio of patients with increased fibrosis calculated as interstitial fibrosis/tubular atrophy >2 (18% vs 13%; P = .522). In our multivariate analysis, which included acute rejection, expanded criteria donation, and the type of donation, no variable was independently related to an increased risk of interstitial fibrosis/tubular atrophy >2. CONCLUSIONS The outcomes of kidney grafts procured in our center using controlled procedures with donors after circulatory death and normothermic regional perfusion were indistinguishable from those obtained from donors after brain death, showing the same degree of fibrosis in the 1-year posttransplant surveillance biopsy. Our data support the conclusion that normothermic regional perfusion should be the method of choice for extraction in donors after circulatory death.
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Affiliation(s)
- Paloma Barreda
- From the Nephrology Department/Transplantation and Autoimmunity Groupt, University Hospital Marqués de Valdecilla/IDIVAL, University of Cantabria, Cantabria, Spain
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7
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Qin C, Jin H, Zhang H, Zhang Y, Guan Z, Gao Y. Noninvasive Assessment of Interstitial Fibrosis and Tubular Atrophy in Renal Transplant by Combining Point-Shear Wave Elastography and Estimated Glomerular Filtration Rate. Diagnostics (Basel) 2021; 12:diagnostics12010018. [PMID: 35054186 PMCID: PMC8774870 DOI: 10.3390/diagnostics12010018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/02/2021] [Accepted: 12/09/2021] [Indexed: 11/16/2022] Open
Abstract
The purpose of this study was to evaluate the feasibility of the combination of point-shear wave elastography (p-SWE) and estimated glomerular filtration rate (eGFR) for assessing different stages of interstitial fibrosis and tubular atrophy (IF/TA) in patients with chronic renal allograft dysfunction (CAD). From September 2020 to August 2021, 47 patients who underwent renal biopsy and p-SWE examinations were consecutively enrolled in this study. The areas under the receiver operating characteristic curves (AUCs) were calculated to evaluate overall accuracy and to identify the optimal cutoff values for different IF/TA stages. A total of 43 patients were enrolled in this study. The renal cortical stiffness and eGFR showed a significant difference between IF/TA Grade 0–1 and Grade 2–3 (p < 0.001). Additionally, renal stiffness and eGFR were independent predictors for moderate-to-severe IF/TA (Grade ≥ 2) according to multiple logistic regression analysis. The combination of p-SWE and eGFR, with an optimal cutoff value of −1.63, was superior to eGFR alone in assessing moderate-to-severe interstitial fibrosis (AUC, 0.86 vs. 0.72, p = 0.02) or tubular atrophy (AUC, 0.88 vs. 0.74, p = 0.02). There was no difference between p-SWE and eGFR in assessing moderate-to-severe IF/TA (AUC, 0.85 vs. 0.79, p = 0.61). Therefore, combining p-SWE and eGFR is worthy of clinical popularization and application.
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Affiliation(s)
- Chi Qin
- The Training Site for Postgraduate of Jinzhou Medical University, Department of Ultrasound, The Third Medical Center of Chinese PLA General Hospital, 69 Yongding Road, Hai Dian, Beijing 100039, China;
| | - Hailong Jin
- Department of Organ Transplantation, The Third Medical Center of Chinese PLA General Hospital, 69 Yongding Road, Hai Dian, Beijing 100039, China;
- Correspondence: (H.J.); (Y.G.)
| | - Haixiang Zhang
- Department of Ultrasound, The Third Medical Center of Chinese PLA General Hospital, 69 Yongding Road, Hai Dian, Beijing 100039, China; (H.Z.); (Y.Z.)
| | - Yun Zhang
- Department of Ultrasound, The Third Medical Center of Chinese PLA General Hospital, 69 Yongding Road, Hai Dian, Beijing 100039, China; (H.Z.); (Y.Z.)
| | - Zhaojie Guan
- Department of Organ Transplantation, The Third Medical Center of Chinese PLA General Hospital, 69 Yongding Road, Hai Dian, Beijing 100039, China;
| | - Yongyan Gao
- Department of Ultrasound, The Third Medical Center of Chinese PLA General Hospital, 69 Yongding Road, Hai Dian, Beijing 100039, China; (H.Z.); (Y.Z.)
- Correspondence: (H.J.); (Y.G.)
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Abstract
With the incremental improvements in long-term kidney transplant survival, there is renewed focus on what causes failure of the transplanted allograft. Over the past decade, our understanding of the injuries that lead to loss of graft function over time has evolved. Chronic allograft injury includes both immune-mediated and nonimmune-mediated injuries, which may involve the organ donor, the recipient, or both. The targets of injury include the kidney tubular epithelium, the endothelium, and the glomerulus. As a response to injury, there are the expected tissue remodeling and repair processes. However, if inflammation persists, which is not uncommon in the transplant setting, the resulting maladaptive response is matrix deposition and/or fibrosis. This ultimately leads to declining graft function and, finally, failure. With our advancing knowledge of the multiple etiologies and mechanisms, enhanced by more recent cohort studies in humans, there is an opportunity to identify those at greater risk to initiate new strategies to ameliorate the process. Although the most recent studies focus on immune-mediated injuries, there is a critical need to identify both markers of injury and mechanisms of injury. In this review, we highlight the findings of recent studies, highlight the potential therapeutic targets, and identify the continued unmet need for understanding the mechanisms of late graft failure.
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Affiliation(s)
- Eric Langewisch
- Division of Nephrology, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Roslyn B. Mannon
- Division of Nephrology, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska,Medical Service, VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska
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9
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Zmijewska AA, Zmijewski JW, Becker EJ, Benavides GA, Darley-Usmar V, Mannon RB. Bioenergetic maladaptation and release of HMGB1 in calcineurin inhibitor-mediated nephrotoxicity. Am J Transplant 2021; 21:2964-2977. [PMID: 33724664 PMCID: PMC8429074 DOI: 10.1111/ajt.16561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 02/11/2021] [Accepted: 03/01/2021] [Indexed: 01/25/2023]
Abstract
Calcineurin inhibitors (CNIs) are potent immunosuppressive agents, universally used following solid organ transplantation to prevent rejection. Although effective, the long-term use of CNIs is associated with nephrotoxicity. The etiology of this adverse effect is complex, and effective therapeutic interventions remain to be determined. Using a combination of in vitro techniques and a mouse model of CNI-mediated nephrotoxicity, we found that the CNIs, cyclosporine A (CsA), and tacrolimus (TAC) share a similar mechanism of tubular epithelial kidney cell injury, including mitochondrial dysfunction and release of High-Mobility Group Box I (HMGB1). CNIs promote bioenergetic reprogramming due to mitochondrial dysfunction and a shift toward glycolytic metabolism. These events were accompanied by diminished cell-to-cell adhesion, loss of the epithelial cell phenotype, and release of HMGB1. Notably, Erk1/2 inhibitors effectively diminished HMGB1 release, and similar inhibitor was observed on inclusion of pan-caspase inhibitor zVAD-FMK. In vivo, while CNIs activate tissue proremodeling signaling pathways, MAPK/Erk1/2 inhibitor prevented nephrotoxicity, including diminished HMGB1 release from kidney epithelial cells and accumulation in urine. In summary, HMGB1 is an early indicator and marker of progressive nephrotoxicity induced by CNIs. We suggest that proremodeling signaling pathway and loss of mitochondrial redox/bioenergetics homeostasis are crucial therapeutic targets to ameliorate CNI-mediated nephrotoxicity.
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Affiliation(s)
- Anna A. Zmijewska
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jaroslaw W. Zmijewski
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Eugene J. Becker
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gloria A. Benavides
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Victor Darley-Usmar
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Roslyn B. Mannon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama,Medical Service, Veterans Affairs Medical Center, Birmingham, Alabama
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10
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Codina S, Manonelles A, Tormo M, Sola A, Cruzado JM. Chronic Kidney Allograft Disease: New Concepts and Opportunities. Front Med (Lausanne) 2021; 8:660334. [PMID: 34336878 PMCID: PMC8316649 DOI: 10.3389/fmed.2021.660334] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/10/2021] [Indexed: 12/12/2022] Open
Abstract
Chronic kidney disease (CKD) is increasing in most countries and kidney transplantation is the best option for those patients requiring renal replacement therapy. Therefore, there is a significant number of patients living with a functioning kidney allograft. However, progressive kidney allograft functional deterioration remains unchanged despite of major advances in the field. After the first post-transplant year, it has been estimated that this chronic allograft damage may cause a 5% graft loss per year. Most studies focused on mechanisms of kidney graft damage, especially on ischemia-reperfusion injury, alloimmunity, nephrotoxicity, infection and disease recurrence. Thus, therapeutic interventions focus on those modifiable factors associated with chronic kidney allograft disease (CKaD). There are strategies to reduce ischemia-reperfusion injury, to improve the immunologic risk stratification and monitoring, to reduce calcineurin-inhibitor exposure and to identify recurrence of primary renal disease early. On the other hand, control of risk factors for chronic disease progression are particularly relevant as kidney transplantation is inherently associated with renal mass reduction. However, despite progress in pathophysiology and interventions, clinical advances in terms of long-term kidney allograft survival have been subtle. New approaches are needed and probably a holistic view can help. Chronic kidney allograft deterioration is probably the consequence of damage from various etiologies but can be attenuated by kidney repair mechanisms. Thus, besides immunological and other mechanisms of damage, the intrinsic repair kidney graft capacity should be considered to generate new hypothesis and potential therapeutic targets. In this review, the critical risk factors that define CKaD will be discussed but also how the renal mechanisms of regeneration could contribute to a change chronic kidney allograft disease paradigm.
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Affiliation(s)
- Sergi Codina
- Department of Nephrology, Hospital Universitari Bellvitge, Barcelona, Spain
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Anna Manonelles
- Department of Nephrology, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Maria Tormo
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Anna Sola
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Josep M. Cruzado
- Department of Nephrology, Hospital Universitari Bellvitge, Barcelona, Spain
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
- Department of Clinical Sciences, University of Barcelona, Barcelona, Spain
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11
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van der Windt DJ, Mehta R, Jorgensen DR, Hariharan S, Randhawa PS, Sood P, Molinari M, Wijkstrom M, Ganoza A, Tevar AD. Donation after circulatory death is associated with increased fibrosis on 1-year post-transplant kidney allograft surveillance biopsy. Clin Transplant 2021; 35:e14399. [PMID: 34176169 DOI: 10.1111/ctr.14399] [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: 11/20/2020] [Revised: 02/28/2021] [Accepted: 06/14/2021] [Indexed: 11/29/2022]
Abstract
AIM The use of kidneys donated after circulatory death (DCD) provides an invaluable expansion of the organ supply for transplantation. Here, we investigated the effect of DCD on fibrotic changes on 1 1-year post 1-transplant surveillance kidney allograft biopsy. METHODS Recipients of a deceased donor kidney transplant between 2013 and 2017 at a single institution, who survived 1 year and underwent surveillance biopsy, were included in the analysis (n = 333: 87 DCD kidneys, 246 kidneys donated after brain death [DBD]). Banff scores for interstitial fibrosis and tubular atrophy were summed as IFTA and compared between the groups. RESULTS DCD and DBD groups were comparable for baseline characteristics. Delayed graft function was 39% in DCD versus 19% in DBD, P = .0002. Patient and graft survival were comparable for DCD and DBD cohorts. IFTA scores were higher in DCD compared to DBD (2.43±..13 vs. 2.01±..08, P = .0054). On multivariate analysis, the odds of IFTA > 2 in the DCD group was 2.5× higher (95%CI: 1.354.63) than in the DBD group. Within the DCD group, kidneys with IFTA > 2 had inferior 5-year graft survival (P = .037). CONCLUSION Compared to DBD kidneys, DCD kidneys developed a greater degree of fibrotic changes on 1-year post-transplant surveillance biopsy, which affected graft longevity within the DCD cohort.
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Affiliation(s)
- Dirk J van der Windt
- Division of Transplant Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Section of Transplant Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Rajil Mehta
- Division of Transplant Nephrology, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Dana R Jorgensen
- Division of Transplant Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sundaram Hariharan
- Division of Transplant Nephrology, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Parmjeet S Randhawa
- Division of Transplant Pathology, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Puneet Sood
- Division of Transplant Nephrology, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michele Molinari
- Division of Transplant Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Martin Wijkstrom
- Division of Transplant Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Armando Ganoza
- Division of Transplant Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amit D Tevar
- Division of Transplant Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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12
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Krejčí K, Tichý T, Bednaříková J, Bartková M, Žamboch K, Orság J, Zadražil J. Nephrotoxicity of calcineurin inhibitors as a risk factor for BK polyomavirus replication after kidney transplantation. J Med Virol 2021; 93:3871-3879. [PMID: 32940913 DOI: 10.1002/jmv.26520] [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: 06/04/2020] [Revised: 09/04/2020] [Accepted: 09/14/2020] [Indexed: 11/11/2022]
Abstract
BK polyomavirus-associated nephropathy (PyVAN) is responsible for a significant percentage of transplanted kidneys prematurely terminating their function. Its occurrence is closely related to the intensity of immunosuppressive therapy. In a group of 161 newly transplanted patients, we prospectively evaluated 457 protocol renal biopsies performed within the first year after transplantation. Using the calcineurin inhibitors (CI) nephrotoxicity score, the incidence of nephrotoxicity was monitored as a manifestation of excessive immunosuppression. Findings were correlated with clinical evidence of active BK polyomavirus (BKPyV) replication and PyVAN. Compared to the normal histology, nephrotoxicity was associated with more frequent BKPyV viremia and viruria (p = .01 and p < .01, respectively) and more common occurrence of PyVAN. The persistence of toxicity in the subsequent biopsy proved to be a negative risk factor of viremia and viruria (p = .03 and p < .01, respectively), independently of the initial BKPyV status. Toxicity could also be used as a predictor of viremia and viruria (p = .04 and p < .01, respectively) even in the absence of viral replication at the time of initial biopsy. The early histological manifestation of CI nephrotoxicity was associated with significant BKPyV reactivation in the risky first posttransplant year.
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Affiliation(s)
- Karel Krejčí
- Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Tomáš Tichý
- Department of Clinical and Molecular Pathology, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Jana Bednaříková
- Department of Clinical Biochemistry, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Margita Bartková
- Department of Microbiology, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Kamil Žamboch
- Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Jiří Orság
- Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Josef Zadražil
- Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
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13
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Lai X, Zheng X, Mathew JM, Gallon L, Leventhal JR, Zhang ZJ. Tackling Chronic Kidney Transplant Rejection: Challenges and Promises. Front Immunol 2021; 12:661643. [PMID: 34093552 PMCID: PMC8173220 DOI: 10.3389/fimmu.2021.661643] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 04/27/2021] [Indexed: 01/09/2023] Open
Abstract
Despite advances in post-transplant management, the long-term survival rate of kidney grafts and patients has not improved as approximately forty percent of transplants fails within ten years after transplantation. Both immunologic and non-immunologic factors contribute to late allograft loss. Chronic kidney transplant rejection (CKTR) is often clinically silent yet progressive allogeneic immune process that leads to cumulative graft injury, deterioration of graft function. Chronic active T cell mediated rejection (TCMR) and chronic active antibody-mediated rejection (ABMR) are classified as two principal subtypes of CKTR. While significant improvements have been made towards a better understanding of cellular and molecular mechanisms and diagnostic classifications of CKTR, lack of early detection, differential diagnosis and effective therapies continue to pose major challenges for long-term management. Recent development of high throughput cellular and molecular biotechnologies has allowed rapid development of new biomarkers associated with chronic renal injury, which not only provide insight into pathogenesis of chronic rejection but also allow for early detection. In parallel, several novel therapeutic strategies have emerged which may hold great promise for improvement of long-term graft and patient survival. With a brief overview of current understanding of pathogenesis, standard diagnosis and challenges in the context of CKTR, this mini-review aims to provide updates and insights into the latest development of promising novel biomarkers for diagnosis and novel therapeutic interventions to prevent and treat CKTR.
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Affiliation(s)
- Xingqiang Lai
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Organ Transplant Center, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xin Zheng
- Department of Urology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - James M Mathew
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Lorenzo Gallon
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Department of Medicine, Nephrology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Joseph R Leventhal
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Zheng Jenny Zhang
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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14
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Clinical Relevance of Corticosteroid Withdrawal on Graft Histological Lesions in Low-Immunological-Risk Kidney Transplant Patients. J Clin Med 2021; 10:jcm10092005. [PMID: 34067039 PMCID: PMC8125434 DOI: 10.3390/jcm10092005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/30/2021] [Accepted: 05/03/2021] [Indexed: 12/14/2022] Open
Abstract
The impact of corticosteroid withdrawal on medium-term graft histological changes in kidney transplant (KT) recipients under standard immunosuppression is uncertain. As part of an open-label, multicenter, prospective, phase IV, 24-month clinical trial (ClinicalTrials.gov, NCT02284464) in low-immunological-risk KT recipients, 105 patients were randomized, after a protocol-biopsy at 3 months, to corticosteroid continuation (CSC, n = 52) or corticosteroid withdrawal (CSW, n = 53). Both groups received tacrolimus and MMF and had another protocol-biopsy at 24 months. The acute rejection rate, including subclinical inflammation (SCI), was comparable between groups (21.2 vs. 24.5%). No patients developed dnDSA. Inflammatory and chronicity scores increased from 3 to 24 months in patients with, at baseline, no inflammation (NI) or SCI, regardless of treatment. CSW patients with SCI at 3 months had a significantly increased chronicity score at 24 months. HbA1c levels were lower in CSW patients (6.4 ± 1.2 vs. 5.7 ± 0.6%; p = 0.013) at 24 months, as was systolic blood pressure (134.2 ± 14.9 vs. 125.7 ± 15.3 mmHg; p = 0.016). Allograft function was comparable between groups and no patients died or lost their graft. An increase in chronicity scores at 2-years post-transplantation was observed in low-immunological-risk KT recipients with initial NI or SCI, but CSW may accelerate chronicity changes, especially in patients with early SCI. This strategy did, however, improve the cardiovascular profiles of patients.
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15
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Hruba P, Madill-Thomsen K, Mackova M, Maluskova J, Voska L, Slatinska J, Halloran PF, Viklicky O. Three-month course of intragraft transcriptional changes in kidney allografts with early histological minimal injury - a cohort study. Transpl Int 2021; 34:974-985. [PMID: 33650206 DOI: 10.1111/tri.13856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/08/2021] [Accepted: 02/24/2021] [Indexed: 11/30/2022]
Abstract
The tubulitis with/without interstitial inflammation not meeting criteria for T-cell-mediated rejection (minimal allograft injury) is the most frequent histological findings in early transplant biopsies. The course of transcriptional changes in sequential kidney graft biopsies has not been studied yet. Molecular phenotypes were analyzed using the Molecular Microscope® Diagnostic System (MMDx) in 46 indication biopsies (median 13 postoperative days) diagnosed as minimal allograft injury and in corresponding follow-up biopsies at 3 months. All 46 patients with minimal injury in early biopsy received steroid pulses. MMDx interpreted indication biopsies as no-rejection in 34/46 (74%), T-cell-mediated rejection (TCMR) in 4/46 (9%), antibody-mediated rejection in 6/46 (13%), and mixed rejection in 2/46 (4%) cases. Follow-up biopsies were interpreted by MMDx in 37/46 (80%) cases as no-rejection, in 4/46 (9%) as TCMR, and in 5/46 (11%) as mixed rejection. Follow-up biopsies showed a decrease in MMDx-assessed acute kidney injury (P = 0.001) and an increase of atrophy-fibrosis (P = 0.002). The most significant predictor of MMDx rejection scores in follow-up biopsies was the tubulitis classifier score in initial biopsies (AUC = 0.84, P = 0.002), confirmed in multivariate binary regression (OR = 16, P = 0.016). Molecular tubulitis score at initial biopsy has the potential to discriminate patients at risk for molecular rejection score at follow-up biopsy.
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Affiliation(s)
- Petra Hruba
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Katelynn Madill-Thomsen
- Alberta Transplant Applied Genomics Centre, Edmonton, AB, Canada.,University of Alberta, Edmonton, AB, Canada
| | - Martina Mackova
- Alberta Transplant Applied Genomics Centre, Edmonton, AB, Canada
| | - Jana Maluskova
- Department of Pathology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ludek Voska
- Department of Pathology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Janka Slatinska
- Department of Nephrology and Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Philip F Halloran
- Alberta Transplant Applied Genomics Centre, Edmonton, AB, Canada.,University of Alberta, Edmonton, AB, Canada
| | - Ondrej Viklicky
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Department of Nephrology and Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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16
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KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation 2021; 104:S11-S103. [PMID: 32301874 DOI: 10.1097/tp.0000000000003136] [Citation(s) in RCA: 257] [Impact Index Per Article: 85.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, and immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence, and the strengths of recommendations are provided. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.
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17
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Abstract
Interstitial fibrosis with tubule atrophy (IF/TA) is the response to virtually any sustained kidney injury and correlates inversely with kidney function and allograft survival. IF/TA is driven by various pathways that include hypoxia, renin-angiotensin-aldosterone system, transforming growth factor (TGF)-β signaling, cellular rejection, inflammation and others. In this review we will focus on key pathways in the progress of renal fibrosis, diagnosis and therapy of allograft fibrosis. This review discusses the role and origin of myofibroblasts as matrix producing cells and therapeutic targets in renal fibrosis with a particular focus on renal allografts. We summarize current trends to use multi-omic approaches to identify new biomarkers for IF/TA detection and to predict allograft survival. Furthermore, we review current imaging strategies that might help to identify and follow-up IF/TA complementary or as alternative to invasive biopsies. We further discuss current clinical trials and therapeutic strategies to treat kidney fibrosis.Supplemental Visual Abstract; http://links.lww.com/TP/C141.
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18
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Chen CC, Lin WC, Lee CY, Yang CY, Tsai MK. Two-year protocol biopsy after kidney transplantation in clinically stable recipients - a retrospective study. Transpl Int 2020; 34:185-193. [PMID: 33152140 DOI: 10.1111/tri.13785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/14/2020] [Accepted: 11/02/2020] [Indexed: 12/25/2022]
Abstract
The idea of protocol biopsy is to detect subclinical pathologies, including rejection, recurrent disease, or infection for early intervention and adjustment of immunosuppressants. Nevertheless, it is not adopted by most clinicians because of its low yield rate and uncertain long-term benefits. This retrospective study evaluated the impact of protocol biopsy on renal function and allograft survival. A two-year protocol biopsy was proposed for 190 stable patients; 68 of them accepted [protocol biopsy (PB) group], while 122 did not [nonprotocol biopsy (NPB) group]. The rejection diagnosis was made in 13 patients by protocol biopsy, and 11 of them had borderline rejection. In the following 5 years, graft survival was better in the PB group than in the NPB group (P = 0.0143). A total of 4 and 17 patients in the PB and NPB groups, respectively, had rejection events proven by indication biopsy. Renal function was better preserved in the PB group than in the NPB group (P = 0.0107) for patients with rejection events. Nevertheless, the survival benefit disappeared by a longer follow-up period (12-year, P = 0.2886). In conclusion, 2-year protocol biopsy detects subclinical pathological changes in rejection and preserves renal function by early intervention so as to prolong graft survival within 5 years.
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Affiliation(s)
- Chien-Chia Chen
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Chou Lin
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Yuan Lee
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Yao Yang
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Meng-Kun Tsai
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.,Division of General Surgery, Department of Surgery, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan
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19
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Odum JD, Kats A, VanSickle JS, Chadha V, Brewer B, Staggs VS, Warady BA. Characterizing the frequency of modifiable histological changes observed on surveillance biopsies in pediatric kidney allograft recipients. Pediatr Nephrol 2020; 35:2173-2182. [PMID: 32556543 DOI: 10.1007/s00467-020-04624-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Rejection is responsible for just under 50% of graft loss in the pediatric kidney transplant population. Early identification and treatment of allograft injury, specifically modifiable pathologies such as subclinical rejection (SCR), calcineurin inhibitor toxicity, and BK virus nephropathy, may improve allograft survival. Protocol surveillance biopsy (SB) currently offers the earliest opportunity for targeted interventions. METHODS This is a single-center retrospective review of 215 kidney SBs obtained from 2008 to 2016 in 97 pediatric kidney transplant recipients. SBs were obtained at 6, 12, and 24 months post-transplantation. Frequency of abnormal histologic findings, estimated glomerular filtration rate at time of SB, and SB-related complications were recorded. Data were analyzed to investigate possible time trends and the presence of demographic or clinical associations with abnormal histologic findings. RESULTS Potentially modifiable histologic findings were seen in 38.1% of all SBs. SCR was found with increasing frequency across all time points with an estimated 49% increase in the odds of a SCR finding per additional 6 months post-transplantation (aOR 1.49, 95% CI 1.06-2.09, p = 0.022). Among follow-up biopsies in patients who underwent treatment for SCR, 50% had no SCR and 18.8% showed histologic improvement. The complication rate associated with SB was 1.9% (4/215 SBs) and consisted of only minor complications. CONCLUSIONS SBs are safe and offer the opportunity to identify and treat modifiable histologic changes in the pediatric kidney transplant population. The performance of SBs for up to 2 years after transplantation can have meaningful clinical impact.
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Affiliation(s)
- James D Odum
- Division of Graduate Medical Education, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Alexander Kats
- Department of Pathology and Laboratory Medicine, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Judith Sebestyen VanSickle
- Division of Pediatric Nephrology, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Vimal Chadha
- Division of Pediatric Nephrology, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Brenda Brewer
- Division of Pediatric Nephrology, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Vincent S Staggs
- Biostatistics & Epidemiology Core, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA.
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20
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Gupta G, Raynaud M, Kumar D, Sanghi P, Chang J, Kimball P, Kang L, Levy M, Sharma A, Bhati CS, Kamal L, Yakubu I, Massey HD, Kidd C, King AL, Halloran PF. Impact of belatacept conversion on kidney transplant function, histology, and gene expression - a single-center study. Transpl Int 2020; 33:1458-1471. [PMID: 32790889 DOI: 10.1111/tri.13718] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/28/2020] [Accepted: 08/07/2020] [Indexed: 11/28/2022]
Abstract
Prior studies on belatacept conversion from calcineurin inhibitor (CNI) have been limited by an absence of postconversion surveillance biopsies that could underestimate subclinical rejection, or a case-controlled design. A total of 53 adult patients with allograft dysfunction underwent belatacept conversion (median: 6 months) post-transplant. At a median follow-up = 2.5 years, patient survival was 94% with a death-censored graft survival of 85%. Seven (13%) patients had acute rejection (including 3 subclinical) at median 6 months postconversion. Overall, eGFR improved (P = <0.001) from baseline = 31±15 to 40.2 ± 17.6 ml/min/1.73m2 by 6 months postconversion, but then stayed stable. This improvement was also observed (P < 0.001) in comparison with a propensity matched control cohort on CNI, where eGFR stayed stable (mean ~ 32ml/min/1.72m2 ) over 2-year follow-up. Patients converted < 6 months post-transplant were more likely to have a long-term improvement in kidney function. Paired gene expression analysis of 30 (of 53) consecutive pre- and postconversion surveillance biopsies did not reveal changes in inflammation/acute injury; although atrophy-fibrosis score worsened (mean = 0.28 to 0.44; P = 0.005). Thus, improvement in renal function with belatacept conversion occurred early and then sustained in comparison with controls where renal function remained unchanged overtime. We were unable to show molecular signals that could be related to CNI administration and regressed after withdrawal.
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Affiliation(s)
- Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Dhiren Kumar
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | - Pooja Sanghi
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | - Jessica Chang
- Alberta Transplant Applied Genomics Center, Edmonton, AB, Canada
| | - Pam Kimball
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Le Kang
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Marlon Levy
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Amit Sharma
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Chandra S Bhati
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Layla Kamal
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | - Idris Yakubu
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Hugh D Massey
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Chelsea Kidd
- Department of Pathology, Virginia Commonwealth University, Richmond, VA, USA
| | - Anne L King
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
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21
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Urinary MicroRNA-21-5p as Potential Biomarker of Interstitial Fibrosis and Tubular Atrophy (IFTA) in Kidney Transplant Recipients. Diagnostics (Basel) 2020; 10:diagnostics10020113. [PMID: 32092939 PMCID: PMC7168003 DOI: 10.3390/diagnostics10020113] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/11/2020] [Accepted: 02/17/2020] [Indexed: 12/29/2022] Open
Abstract
Chronic renal allograft dysfunction (CAD) is a major limiting factor of long-term graft survival. The hallmarks of progressive CAD are interstitial fibrosis and tubular atrophy (IFTA). MicroRNAs are small, regulatory RNAs involved in many immunological processes. In particular, microRNA-21-5p (miR-21) is considered to be strongly associated with pathogenesis regarding tubulointerstitium. The aim of this study was to assess urinary miR-21 expression levels in the kidney transplant recipients and determine their application in the evaluation of IFTA and kidney allograft function. The expression levels of miR-21 were quantified in the urine of 31 kidney transplant recipients with biopsy-assessed IFTA (IFTA 0 + I: n = 17; IFTA II + III: n = 14) by real-time quantitative PCR. Urine samples were collected at the time of protocolar biopsies performed 1 or 2 years after kidney transplantation. MicroRNA-191-5p was used as reference gene. MiR-21 was significantly up-regulated in IFTA II + III group compared to IFTA 0 + I group (p = 0.003). MiR-21 correlated significantly with serum concentration of creatinine (r = 0.52, p = 0.003) and eGFR (r = -0.45; p = 0.01). ROC analysis determined the diagnostic value of miR-21 with an area under curve (AUC) of 0.80 (p = 0.0002), sensitivity of 0.86 and specificity of 0.71. miR-21 is associated with renal allograft dysfunction and IFTA. Therefore, it could be considered as a potential diagnostic, non-invasive biomarker for monitoring renal graft function.
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22
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Windt DJ, Mehta R, Jorgensen DR, Bou‐Samra P, Hariharan S, Randhawa PS, Sood P, Molinari M, Wijkstrom M, Ganoza A, Tevar AD. Donor acute kidney injury and its effect on 1‐year post‐transplant kidney allograft fibrosis. Clin Transplant 2020; 34:e13770. [DOI: 10.1111/ctr.13770] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 11/27/2019] [Accepted: 12/04/2019] [Indexed: 01/03/2023]
Affiliation(s)
- Dirk J. Windt
- Division of Transplant Surgery Thomas E. Starzl Transplantation Institute University of Pittsburgh Medical Center Pittsburgh PA USA
| | - Rajil Mehta
- Division of Transplant Nephrology Thomas E. Starzl Transplantation Institute University of Pittsburgh Medical Center Pittsburgh PA USA
| | - Dana R. Jorgensen
- Division of Transplant Surgery Thomas E. Starzl Transplantation Institute University of Pittsburgh Medical Center Pittsburgh PA USA
| | - Patrick Bou‐Samra
- Division of Transplant Surgery Thomas E. Starzl Transplantation Institute University of Pittsburgh Medical Center Pittsburgh PA USA
| | - Sundaram Hariharan
- Division of Transplant Nephrology Thomas E. Starzl Transplantation Institute University of Pittsburgh Medical Center Pittsburgh PA USA
| | - Parmjeet S. Randhawa
- Division of Transplant Pathology Thomas E. Starzl Transplantation Institute University of Pittsburgh Medical Center Pittsburgh PA USA
| | - Puneet Sood
- Division of Transplant Nephrology Thomas E. Starzl Transplantation Institute University of Pittsburgh Medical Center Pittsburgh PA USA
| | - Michele Molinari
- Division of Transplant Surgery Thomas E. Starzl Transplantation Institute University of Pittsburgh Medical Center Pittsburgh PA USA
| | - Martin Wijkstrom
- Division of Transplant Surgery Thomas E. Starzl Transplantation Institute University of Pittsburgh Medical Center Pittsburgh PA USA
| | - Armando Ganoza
- Division of Transplant Surgery Thomas E. Starzl Transplantation Institute University of Pittsburgh Medical Center Pittsburgh PA USA
| | - Amit D. Tevar
- Division of Transplant Surgery Thomas E. Starzl Transplantation Institute University of Pittsburgh Medical Center Pittsburgh PA USA
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23
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Denic A, Morales MC, Park WD, Smith BH, Kremers WK, Alexander MP, Cosio FG, Rule AD, Stegall MD. Using computer-assisted morphometrics of 5-year biopsies to identify biomarkers of late renal allograft loss. Am J Transplant 2019; 19:2846-2854. [PMID: 30947386 PMCID: PMC8214914 DOI: 10.1111/ajt.15380] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/20/2019] [Accepted: 03/28/2019] [Indexed: 01/25/2023]
Abstract
The current Banff scoring system was not developed to predict graft loss and may not be ideal for use in clinical trials aimed at improving allograft survival. We hypothesized that scoring histologic features of digitized renal allograft biopsies using a continuous, more objective, computer-assisted morphometric (CAM) system might be more predictive of graft loss. We performed a nested case-control study in kidney transplant recipients with a surveillance biopsy obtained 5 years after transplantation. Patients that developed death-censored graft loss (n = 67) were 2:1 matched on age, gender, and follow-up time to controls with surviving grafts (n = 134). The risk of graft loss was compared between CAM-based models vs a model based on Banff scores. Both Banff and CAM identified chronic lesions associated with graft loss (chronic glomerulopathy, arteriolar hyalinosis, and mesangial expansion). However, the CAM-based models predicted graft loss better than the Banff-based model, both overall (c-statistic 0.754 vs 0.705, P < .001), and in biopsies without chronic glomerulopathy (c-statistic 0.738 vs 0.661, P < .001) where it identified more features predictive of graft loss (% luminal stenosis and % mesangial expansion). Using 5-year renal allograft surveillance biopsies, CAM-based models predict graft loss better than Banff models and might be developed into biomarkers for future clinical trials.
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Affiliation(s)
- Aleksandar Denic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Martha C. Morales
- Department of Surgery and Immunology, Mayo Clinic, Rochester, Minnesota
| | - Walter D. Park
- Department of Surgery and Immunology, Mayo Clinic, Rochester, Minnesota
| | - Byron H. Smith
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Walter K. Kremers
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Mariam P. Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Fernando G. Cosio
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Andrew D. Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Mark D. Stegall
- Department of Surgery and Immunology, Mayo Clinic, Rochester, Minnesota
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24
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Schinstock CA, Bentall AJ, Smith BH, Cornell LD, Everly M, Gandhi MJ, Stegall MD. Long-term outcomes of eculizumab-treated positive crossmatch recipients: Allograft survival, histologic findings, and natural history of the donor-specific antibodies. Am J Transplant 2019; 19:1671-1683. [PMID: 30412654 PMCID: PMC6509017 DOI: 10.1111/ajt.15175] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 10/30/2018] [Accepted: 11/01/2018] [Indexed: 01/25/2023]
Abstract
We aimed to determine the long-term outcomes of eculizumab-treated, positive crossmatch (+XM) kidney transplant recipients compared with +XM and age-matched negative crossmatch (-XM) controls. We performed an observational retrospective study and examined allograft survival, histologic findings, long-term B-cell flow cytometric XM (BFXM), and allograft-loss-associated factors. The mean (SD) posttransplant follow-up was 6.3 (2.5) years in the eculizumab group; 7.6 (3.5), +XM control group; 7.9 (2.5), -XM control group. The overall and death-censored allograft survival rates were similar in +XM groups (P = .73, P = .48) but reduced compared with -XM control patients (P < .001, P < .001). In the eculizumab-treated group, 57.9% (11/19) of the allografts had chronic antibody-mediated rejection, but death-censored allograft survival was 76.6%, 5 years; 75.4%, 7 years. Baseline IgG3 positivity and BFXM ≥300 were associated with allograft loss. C1q positivity was also associated with allograft loss but did not reach statistical significance. Donor-specific antibodies appeared to decrease in eculizumab-treated patients. After excluding patients with posttransplant plasmapheresis, 42.3% (9/21) had negative BFXMs; 31.8% (7/22), completely negative single-antigen beads 1 year posttransplant. Eculizumab-treated +XM patients had reduced allograft survival compared with -XM controls but similar survival to +XM controls. BFXM and complement-activating donor-specific antibodies (by IgG3 and C1q testing) may be used for risk stratification in +XM transplantation.
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Affiliation(s)
- Carrie A. Schinstock
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Andrew J. Bentall
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Byron H. Smith
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Lynn D. Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Manish J. Gandhi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Mark D. Stegall
- William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA,Division of Transplantation Surgery, Mayo Clinic, Rochester, MN, USA
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25
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Clinical aspects of tacrolimus use in paediatric renal transplant recipients. Pediatr Nephrol 2019; 34:31-43. [PMID: 29479631 DOI: 10.1007/s00467-018-3892-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/08/2018] [Accepted: 01/10/2018] [Indexed: 12/30/2022]
Abstract
The calcineurin inhibitor tacrolimus, cornerstone of most immunosuppressive regimens, is a drug with a narrow therapeutic window: underexposure can lead to allograft rejection and overexposure can result in an increased incidence of infections, toxicity and malignancies. Tacrolimus is metabolised in the liver and intestine by the cytochrome P450 3A (CYP3A) isoforms CYP3A4 and CYP3A5. This review focusses on the clinical aspects of tacrolimus pharmacodynamics, such as efficacy and toxicity. Factors affecting tacrolimus pharmacokinetics, including pharmacogenetics and the rationale for routine CYP3A5*1/*3 genotyping in prospective paediatric renal transplant recipients, are also reviewed. Therapeutic drug monitoring, including pre-dose concentrations and pharmacokinetic profiles with the available "reference values", are discussed. Factors contributing to high intra-patient variability in tacrolimus exposure and its impact on clinical outcome are also reviewed. Lastly, suggestions for future research and clinical perspectives are discussed.
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26
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Reischig T, Kacer M, Hruba P, Hermanova H, Hes O, Lysak D, Kormunda S, Bouda M. Less renal allograft fibrosis with valganciclovir prophylaxis for cytomegalovirus compared to high-dose valacyclovir: a parallel group, open-label, randomized controlled trial. BMC Infect Dis 2018; 18:573. [PMID: 30442095 PMCID: PMC6238264 DOI: 10.1186/s12879-018-3493-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 11/01/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) prophylaxis may prevent CMV indirect effects in renal transplant recipients. This study aimed to compare the efficacy of valganciclovir and valacyclovir prophylaxis for CMV after renal transplantation with the focus on chronic histologic damage within the graft. METHODS From November 2007 through April 2012, adult renal transplant recipients were randomized, in an open-label, single-center study, at a 1:1 ratio to 3-month prophylaxis with valganciclovir (n = 60) or valacyclovir (n = 59). The primary endpoint was moderate-to-severe interstitial fibrosis and tubular atrophy assessed by protocol biopsy at 3 years evaluated by a single pathologist blinded to the study group. The analysis was conducted in an intention-to-treat population. RESULTS Among the 101 patients who had a protocol biopsy specimen available, the risk of moderate-to-severe interstitial fibrosis and tubular atrophy was significantly lower in those treated with valganciclovir (22% versus 34%; adjusted odds ratio, 0.31; 95% confidence interval, 0.11-0.90; P = 0.032 by multivariate logistic regression). The incidence of CMV disease (9% versus 2%; P = 0.115) and CMV DNAemia (36% versus 42%; P = 0.361) were not different at 3 years. CONCLUSIONS Valganciclovir prophylaxis, as compared with valacyclovir, was associated with a reduced risk of moderate-to-severe interstitial fibrosis and tubular atrophy in patients after renal transplantation. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ( ACTRN12610000016033 ). Registered on September 26, 2007.
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Affiliation(s)
- Tomas Reischig
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Czech Republic and Teaching Hospital, 30460, Pilsen, Czech Republic. .,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic.
| | - Martin Kacer
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Czech Republic and Teaching Hospital, 30460, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic
| | - Petra Hruba
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic.,Transplant Laboratory, Institute for Clinical and Experimental Medicine, 14021, Prague, Czech Republic
| | - Hana Hermanova
- Department of Hemato-oncology, Teaching Hospital, 30460, Pilsen, Czech Republic
| | - Ondrej Hes
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic.,Department of Pathology, Faculty of Medicine in Pilsen, Charles University, Czech Republic and Teaching Hospital, 30460, Pilsen, Czech Republic
| | - Daniel Lysak
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic.,Department of Hemato-oncology, Teaching Hospital, 30460, Pilsen, Czech Republic
| | - Stanislav Kormunda
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic.,Division of Information Technologies and Statistics, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic
| | - Mirko Bouda
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Czech Republic and Teaching Hospital, 30460, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic
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27
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Carmona-Escamilla MA, Queipo G, García-Mosqueda LA, García-Covarrubias L, Fonseca-Sánchez MA, Villanueva-Ortega E, Prieto P, Lascurain R. Peripheral Blood Regulatory T Cells Are Diminished in Kidney Transplant Patients With Chronic Allograft Nephropathy. Transplant Proc 2018; 50:444-448. [PMID: 29579824 DOI: 10.1016/j.transproceed.2018.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/04/2018] [Accepted: 01/04/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Our aim in this study was to assess peripheral blood CD4+CD25+FOXP3+ regulatory T cell (Treg) levels in patients with chronic allograft nephropathy (CAN) 1 year after kidney transplantation. METHODS Twelve renal transplant patients with an initial onset of CAN, 12 patients with chronic kidney disease (CKD) stage G5 on dialysis, and 13 healthy control individuals were evaluated regarding the proportion of Tregs in their peripheral blood via flow cytometry. RESULTS The renal transplant patients with CAN had a significantly lower proportion of Tregs than the hemodialysis CKD patients and healthy controls (P < .0001). In contrast, the hemodialysis CKD patients showed higher levels of Tregs than the renal transplant patients with CAN and the healthy controls (P < .0001). CONCLUSION The high level of peripheral blood Tregs in the hemodialysis CKD patients suggests a chronic inflammatory state. However, the low frequency of Tregs in the peripheral blood from the renal transplant patients with CAN suggests an unfavorable prognosis for allograft immune tolerance.
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Affiliation(s)
- M A Carmona-Escamilla
- Programa de posgrado en Ciencias Médicas, Facultad de Medicina, Universidad Nacional Autónoma de México, México City, México
| | - G Queipo
- Departamento de Genética Humana, Hospital General de México Dr. Eduardo Liceaga, México City, México; Programa de posgrado en Ciencias Biológicas, Facultad de Medicina, Universidad Nacional Autónoma de México, México City, México; Departamento de Trasplante de Órganos, Hospital General de México Dr. Eduardo Liceaga, México City, México; Departamento de Bioquímica, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, México
| | - L A García-Mosqueda
- Programa de posgrado en Ciencias Biológicas, Facultad de Medicina, Universidad Nacional Autónoma de México, México City, México
| | - L García-Covarrubias
- Programa de posgrado en Ciencias Biológicas, Facultad de Medicina, Universidad Nacional Autónoma de México, México City, México
| | - M A Fonseca-Sánchez
- Departamento de Genética Humana, Hospital General de México Dr. Eduardo Liceaga, México City, México
| | - E Villanueva-Ortega
- Departamento de Genética Humana, Hospital General de México Dr. Eduardo Liceaga, México City, México
| | - P Prieto
- Departamento de Trasplante de Órganos, Hospital General de México Dr. Eduardo Liceaga, México City, México
| | - R Lascurain
- Departamento de Bioquímica, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, México; Hospital Nacional Homeopático, Secretaría de Salud, Mexico City, Mexico.
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28
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Giral M, Renaudin K, Naesens M, Luning R, Anglicheau D, Morelon E, Huneau A, Paul C, Brouard S, Couvrat-Desvergnes G, Foucher Y, Dantan E. The 1-year Renal Biopsy Index: a scoring system to drive biopsy indication at 1-year post-kidney transplantation. Transpl Int 2018; 31:947-955. [PMID: 29893433 DOI: 10.1111/tri.13290] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/26/2018] [Accepted: 06/07/2018] [Indexed: 11/27/2022]
Abstract
Surveillance biopsies after renal transplantation remain debatable. To drive the decision of such intervention, we propose a predictive score of abnormal histology at 1-year post-transplantation, named 1-year Renal Biopsy Index (1-RBI). We studied 466 kidney recipients from the DIVAT cohort alive with a functioning graft and a surveillance biopsy at 1-year post-transplantation. Patients displaying abnormal histology (49%) (borderline, acute rejection, interstitial fibrosis and tubular atrophy [IFTA] grade 2 or 3, glomerulonephritis) were compared to the normal or subnormal (IFTA grade 1) histology group. Obtained from a lasso penalized logistic regression, the 1-RBI was composed of recipient gender, serum creatinine at 3, 6, and 12 month post-transplantation and anticlass II immunization at transplantation (internal validation: AUC = 0.71, 95% CI [0.53-0.83]; external validation: AUC = 0.62, 95% CI [0.58-0.66]). While we could not determinate a threshold able to identify patients at high chance of normal or subnormal histology, we estimated and validated a discriminating threshold capable of identifying a subgroup of 15% of the patients with a risk of abnormal histology higher than 80%. The 1-RBI is computable online at www.divat.fr. The 1-RBI could be a useful tool to standardize 1-year biopsy proposal and may for instance help to indicate one in case of high risk of abnormal histology.
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Affiliation(s)
- Magali Giral
- CRTI UMR 1064, Inserm, Université de Nantes, ITUN, CHU Nantes, RTRS Centaure, Nantes, France
- Centre d'Investigation Clinique en Biothérapie, Labex Transplantex, Nantes, France
| | - Karine Renaudin
- Pathological Anatomy and Cytology, CHU Hôtel-Dieu, Nantes, France
| | - Maarten Naesens
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Redmer Luning
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Dany Anglicheau
- Kidney Transplant Center, Necker University Hospital, APHP, RTRS "Centaure", Paris Descartes and Sorbonne Paris Cité Universities, Paris, France
| | - Emmanuel Morelon
- Nephrology, Transplantation and Clinic Immunology Department, RTRS "Centaure", Edouard Herriot University Hospital, Hospices Civils, Lyon, France
| | - Alexandre Huneau
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
| | - Chloé Paul
- CRTI UMR 1064, Inserm, Université de Nantes, ITUN, CHU Nantes, RTRS Centaure, Nantes, France
- Centre d'Investigation Clinique en Biothérapie, Labex Transplantex, Nantes, France
| | - Sophie Brouard
- CRTI UMR 1064, Inserm, Université de Nantes, ITUN, CHU Nantes, RTRS Centaure, Nantes, France
- Centre d'Investigation Clinique en Biothérapie, Labex Transplantex, Nantes, France
| | - Grégoire Couvrat-Desvergnes
- CRTI UMR 1064, Inserm, Université de Nantes, ITUN, CHU Nantes, RTRS Centaure, Nantes, France
- Department of Nephrology, Dialysis and Transplantation, Departmental Hospital of Vendée, La Roche-sur-Yon, France
| | - Yohann Foucher
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
- CHU NANTES, Nantes, France
| | - Etienne Dantan
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
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29
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Defining kidney allograft benefit from successful pancreas transplant: separating fact from fiction. Curr Opin Organ Transplant 2018; 23:448-453. [PMID: 29878910 DOI: 10.1097/mot.0000000000000547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW To define the natural history of kidney allograft loss related to recurrent diabetes following transplant, and to understand the potential benefit of pancreas transplantation upon kidney allograft survival. RECENT FINDINGS A postulated benefit of simultaneous pancreas kidney transplant is that, unlike kidney transplant alone, euglycemia from the added pancreas allograft may confer a nephroprotective benefit and prevent recurrent diabetic nephropathy in the renal allograft. Recent large database analyses and long-term histological assessments have been published that assist in quantifying the problem of recurrent diabetic nephropathy and answering the question of the potential benefits of euglycemia. Further data may be extrapolated from larger single-center series that follow the prognosis of early posttransplant diabetes mellitus as another barometer of risk from diabetic nephropathy and graft loss. SUMMARY Recurrent diabetic nephropathy following kidney transplant is a relatively rare, late occurrence and its clinical significance is significantly diminished by the competing risks of death and chronic alloimmune injury. Although there are hints of a protective effect upon kidney graft survival with pancreas transplant, these improvements are small and may take decades to appreciate. Clinical decision-making regarding pancreas transplant solely based upon nephroprotective effects of the kidney allograft should be avoided.
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30
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Heylen L, Thienpont B, Naesens M, Busschaert P, Depreeuw J, Smeets D, Jochmans I, Monbaliu D, Pirenne J, Lerut E, Ghesquiere B, Kuypers D, Lambrechts D, Sprangers B. Ischemia-Induced DNA Hypermethylation during Kidney Transplant Predicts Chronic Allograft Injury. J Am Soc Nephrol 2018; 29:1566-1576. [PMID: 29610404 DOI: 10.1681/asn.2017091027] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 02/26/2018] [Indexed: 12/28/2022] Open
Abstract
Background Ischemia during kidney transplant causes chronic allograft injury and adversely affects outcome, but the underlying mechanisms are incompletely understood. In tumors, oxygen shortage reduces the DNA demethylating activity of the ten-11 translocation (TET) enzymes, yielding hypermethylated genomes that promote tumor progression. We investigated whether ischemia similarly induces DNA hypermethylation in kidney transplants and contributes to chronic injury.Methods We profiled genome-wide DNA methylation in three cohorts of brain-dead donor kidney allograft biopsy specimens: a longitudinal cohort with paired biopsy specimens obtained at allograft procurement (preischemia; n=13), after implantation and reperfusion (postischemia; n=13), and at 3 or 12 months after transplant (n=5 each); a cross-sectional cohort with preimplantation biopsy specimens (n=82); and a cross-sectional cohort with postreperfusion biopsy specimens (n=46).Results Analysis of the paired preischemia and postischemia specimens revealed that methylation increased drastically in all allografts on ischemia. Hypermethylation was caused by loss of 5-hydroxymethylcytosine, the product of TET activity, and it was stable 1 year after transplant. In the preimplantation cohort, CpG hypermethylation directly correlated with ischemia time and for some CpGs, increased 2.6% per additional hour of ischemia. Hypermethylation preferentially affected and reduced the expression of genes involved in suppressing kidney injury and fibrosis. Moreover, CpG hypermethylation in preimplantation specimens predicted chronic injury, particularly fibrosis and glomerulosclerosis, 1 year after transplant. This finding was validated in the independent postreperfusion cohort, in which hypermethylation also predicted reduced allograft function 1 year after transplant, outperforming established clinical variables.Conclusions We highlight a novel epigenetic basis for ischemia-induced chronic allograft injury with biomarker potential.
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Affiliation(s)
- Line Heylen
- Departments of Nephrology.,Laboratories of Experimental Transplantation.,Laboratory for Translational Genetics, Department of Human Genetics, and
| | - Bernard Thienpont
- Laboratory for Translational Genetics, Department of Human Genetics, and.,VIB Center for Cancer Biology, VIB, Leuven, Belgium
| | | | - Pieter Busschaert
- VIB Center for Cancer Biology, VIB, Leuven, Belgium.,Division of Gynaecological Oncology, Leuven Cancer Institute, University of Leuven, Belgium; and
| | - Jeroen Depreeuw
- VIB Center for Cancer Biology, VIB, Leuven, Belgium.,Division of Gynaecological Oncology, Leuven Cancer Institute, University of Leuven, Belgium; and
| | - Dominiek Smeets
- Laboratory for Translational Genetics, Department of Human Genetics, and.,VIB Center for Cancer Biology, VIB, Leuven, Belgium
| | - Ina Jochmans
- Abdominal Transplantation, Department of Microbiology and Immunology.,Abdominal Transplant Surgery, and
| | - Diethard Monbaliu
- Abdominal Transplantation, Department of Microbiology and Immunology.,Abdominal Transplant Surgery, and
| | - Jacques Pirenne
- Abdominal Transplantation, Department of Microbiology and Immunology.,Abdominal Transplant Surgery, and
| | - Evelyne Lerut
- Pathology, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Diether Lambrechts
- Laboratory for Translational Genetics, Department of Human Genetics, and .,VIB Center for Cancer Biology, VIB, Leuven, Belgium
| | - Ben Sprangers
- Departments of Nephrology.,Laboratories of Experimental Transplantation
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31
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Einecke G, Reeve J, Halloran PF. A molecular biopsy test based on arteriolar under-hyalinosis reflects increased probability of rejection related to under-immunosuppression. Am J Transplant 2018; 18:821-831. [PMID: 28985016 DOI: 10.1111/ajt.14532] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 09/15/2017] [Accepted: 09/26/2017] [Indexed: 01/25/2023]
Abstract
Calcineurin inhibitor immunosuppressive drugs induce changes such as arteriolar hyalinosis (ah) in kidney transplants, raising the possibility that molecular changes in biopsies related to histologic ah can provide information about drug exposure. We hypothesized that molecular changes associated with less-than-expected hyalinosis might highlight a subpopulation of patients with under-immunosuppression/nonadherence at intermediate times of biopsy posttransplant (TxBx). Using gene expression data from 562 indication biopsies, we developed a molecular classifier for predicting the expected ah lesions (Mah ) at a particular TxBx. Mah -scores increased linearly with log(TxBx), but some biopsies had lower scores than expected for TxBx. The deviation of individual Mah -scores below the predicted regression line of Mah -scores vs TxBx is defined as "low hyalinosis index." Low hyalinosis indices were frequent in biopsies between 3 months and 3 years posttransplant, particularly among biopsies lacking histologic hyalinosis (ah0), and were associated with T cell-mediated rejection and a subset of recent-onset antibody-mediated rejection without glomerular double contours. In patients with medical records available for review, low hyalinosis indices were frequently associated with physician-recorded concerns about nonadherence (suspected or proven). We conclude that the Mah classifier and hyalinosis index identify indication biopsies with rejection for which the possibility of patient nonadherence should be considered.
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Affiliation(s)
- Gunilla Einecke
- Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Jeff Reeve
- Alberta Transplant Applied Genomics Centre Edmonton, Edmonton, AB, Canada
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Philip F Halloran
- Alberta Transplant Applied Genomics Centre Edmonton, Edmonton, AB, Canada
- Department of Medicine, Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, AB, Canada
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32
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Lv D, Zhou Q, Xia Y, You X, Zhao Z, Li Y, Zou H. The Association Between Oxidative Stress Alleviation via Sulforaphane-Induced Nrf2-HO-1/NQO-1 Signaling Pathway Activation and Chronic Renal Allograft Dysfunction Improvement. Kidney Blood Press Res 2018; 43:191-205. [DOI: 10.1159/000487501] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 02/08/2018] [Indexed: 11/19/2022] Open
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33
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Stegall MD, Cornell LD, Park WD, Smith BH, Cosio FG. Renal Allograft Histology at 10 Years After Transplantation in the Tacrolimus Era: Evidence of Pervasive Chronic Injury. Am J Transplant 2018; 18:180-188. [PMID: 28710896 DOI: 10.1111/ajt.14431] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 07/04/2017] [Accepted: 07/06/2017] [Indexed: 01/25/2023]
Abstract
Improving long-term renal allograft survival remains an important unmet need. To assess the extent of histologic injury at 10 years after transplantation in functioning grafts, we studied 575 consecutive adult solitary renal transplants performed between 2002 and 2005: 77% from living donors and 81% maintained on tacrolimus-based immunosuppression. Ten-year graft survival was 59% and death-censored graft survival was 74%. Surveillance allograft biopsies were assessed at implantation, 5 years, and 10 years from 145 patients who reached 10 years. At implantation, 5% of biopsies had major histologic abnormalities (chronic transplant glomerulopathy score > 0, other chronic Banff scores ≥ 2, global glomerulosclerosis > 20%, or mesangial sclerosis ≥ 2). This increased to 54% at 5 years and 82% at 10 years. Major lesions at 10 years included the following: arteriolar hyalinosis (66%), mesangial sclerosis (67%), and global glomerulosclerosis > 20% (43%), with 48% of grafts having more than one major lesion. Transplant glomerulopathy and moderate-to-severe interstitial fibrosis were uncommon (12% each). Major lesions were associated with increased proteinuria and decreased graft function. In patients with diabetes at baseline, 52% had diabetic nephropathy/mesangial sclerosis at 10 years. We conclude that almost all renal allografts sustain major histologic injury by 10 years after transplantation. Much damage appears nonimmunologic, suggesting that new approaches are needed to decrease late injury.
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Affiliation(s)
- M D Stegall
- Department of Surgery and Immunology, Mayo Clinic, Rochester, MN
| | - L D Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - W D Park
- Department of Surgery and Immunology, Mayo Clinic, Rochester, MN
| | - B H Smith
- Department of Biostatics, Mayo Clinic, Rochester, MN
| | - F G Cosio
- Department of Medicine, Mayo Clinic, Rochester, MN
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Zachariah MS, Dwivedi AK, Yip CS, Chang SS, Gundroo A, Venuto RC, Tomaszewski J, Patel SK, Sharma R. Utility of Serial Protocol Biopsies Performed After 1 Year in Predicting Long-Term Kidney Allograft Function According to Histologic Phenotype. EXP CLIN TRANSPLANT 2017; 16:391-400. [PMID: 29206090 DOI: 10.6002/ect.2016.0323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Prognostic implications of early protocol biopsies have been studied; however, the value of late protocol biopsy in predicting graft outcome has not been well defined. Here, we compared the effects of early and late protocol biopsy histologic findings in stable kidney allografts and aimed to understand the significance of "borderline" rejection on allograft function. MATERIALS AND METHODS We studied 261 biopsies from 159 renal transplant recipients who were on a steroid-free, calcineurin inhibitor and mycophenolate mofetil regimen and who received transplants between 2004 and 2012 with mean follow-up of 5 years. Early (between 3 and 9 mo) and subsequent late (between 12 and 24 mo) protocol biopsies were performed. Biopsies were classified as normal, interstitial fibrosis and/or tubular atrophy, subclinical acute rejection with interstitial fibrosis and/or tubular atrophy, and borderline rejection with interstitial fibrosis and/or tubular atrophy. A linear mixed-effects model was used to determine the effects of early and late protocol biopsies on estimated glomerular filtration rate changes, with baseline time for estimated glomerular filtration rate fixed at 12 months. RESULTS The adjusted model showed that estimated glomerular filtration rate at 3 months, donor age, delayed graft function, and early protocol biopsies were associated with baseline estimated glomerular filtration rate at 12 months. Estimated glomerular filtration rate changes over time were associated with findings of interstitial fibrosis and/or tubular atrophy at early biopsy and subclinical acute rejection and borderline rejection at late biopsy. At last follow-up, final estimated glomerular filtration rate was significantly associated with interstitial fibrosis and/or tubular atrophy at early biopsy and with subclinical acute rejection at late biopsy. CONCLUSIONS Although early protocol biopsy predicted baseline estimated glomerular filtration rate, late biopsy was important for predicting changes in function over time. In addition, a diagnosis of "borderline" rejection on protocol biopsies predicted long-term graft function.
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Affiliation(s)
- Mareena S Zachariah
- From Department of Internal Medicine, Division of Nephrology, SUNY at the University at Buffalo, Buffalo, NY, USA
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Gosset C, Viglietti D, Rabant M, Vérine J, Aubert O, Glotz D, Legendre C, Taupin JL, Duong Van-Huyen JP, Loupy A, Lefaucheur C. Circulating donor-specific anti-HLA antibodies are a major factor in premature and accelerated allograft fibrosis. Kidney Int 2017; 92:729-742. [DOI: 10.1016/j.kint.2017.03.033] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 02/21/2017] [Accepted: 03/16/2017] [Indexed: 11/24/2022]
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Medeiros M, Velásquez-Jones L, Hernández AM, Ramón-García G, Valverde S, Fuentes Y, Vargas A, Patiño M, Pérez-Villalva R, Ortega-Trejo JA, Barrera-Chimal J, Bobadilla NA. Randomized Controlled Trial of Mineralocorticoid Receptor Blockade in Children with Chronic Kidney Allograft Nephropathy. Clin J Am Soc Nephrol 2017; 12:1291-1300. [PMID: 28536123 PMCID: PMC5544507 DOI: 10.2215/cjn.05300516] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 04/19/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND OBJECTIVES We showed that mineralocorticoid receptor blockade (MRB) prevented acute and chronic cyclosporine nephropathy (CsA-Nx) in the rat. The aim of this translational study was to investigate the effect of long-term eplerenone administration on renal allograft function in children with biopsy-proven chronic allograft nephropathy (CAN). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Renal transplant children <18 years, biopsy-proven CAN, and a GFR>40 ml/min per 1.73 m2 were included. Patients with BK virus active nephritis, recurrence of renal disease, GFR decline in previous 3 months, or treated with calcium antagonists or antifungal drugs were excluded. They were randomized to receive placebo (n=10) or eplerenone 25 mg/d for 24 months (n=13). Visits were scheduled at baseline, 6, 12, and 24 months. At each period, a complete clinical examination was performed and blood and urine samples were taken. Urine creatinine, 8-hydroxylated-guanosine, heat shock protein 72 (HSP72), and kidney injury molecule (KIM-1) levels were also assessed. In kidney biopsy samples, the tubulo-interstitial area affected by fibrosis (TIF) and glomerulosclerosis were measured at baseline and after 24 months. RESULTS The baseline eGFR was 80±6 in the placebo and 86±6 ml/min per 1.73 m2 in the eplerenone group; at 24 months it was 66±8 and 81±7 ml/min per 1.73 m2, respectively (P=0.33; 95% confidence intervals, -18 to 33 at baseline, and -11 to 40 after 24 months). The albumin-to-creatinine ratio was 110±74 in the placebo, and 265±140 mg/g in the eplerenone group; and after 24 months it was 276±140 and 228±88 mg/g, respectively (P=0.15; 95% confidence intervals, -283 to 593, and -485 to 391, respectively). In addition, the placebo exhibited a greater TIF, glomerulosclerosis, and urinary HSP72 compared with the eplerenone group. CONCLUSIONS Although this study was underpowered to provide definitive evidence that long-term eplerenone administration attenuates the progression of CAN in pediatric transplant patients, it encourages testing the potential benefit of MRB in this pediatric population.
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Affiliation(s)
- Mara Medeiros
- Nephrology and Mineral Metabolism Research Unit
- Department of Nephrology, and
| | | | | | | | | | | | | | | | - Rosalba Pérez-Villalva
- Molecular Physiology Unit, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico; and
- Department of Nephrology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Juan Antonio Ortega-Trejo
- Molecular Physiology Unit, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico; and
- Department of Nephrology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Jonatan Barrera-Chimal
- Molecular Physiology Unit, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico; and
- Department of Nephrology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Norma A. Bobadilla
- Molecular Physiology Unit, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico; and
- Department of Nephrology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Torres IB, Reisaeter AV, Moreso F, Âsberg A, Vidal M, Garcia-Carro C, Midtvedt K, Reinholt FP, Scott H, Castellà E, Salcedo M, Dörje C, Sellarés J, Azancot MA, Perello M, Holdaas H, Serón D. Tacrolimus and mycophenolate regimen and subclinical tubulo-interstitial inflammation in low immunological risk renal transplants. Transpl Int 2017; 30:1119-1131. [PMID: 28667664 DOI: 10.1111/tri.13002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 05/08/2017] [Accepted: 06/23/2017] [Indexed: 10/19/2022]
Abstract
The aim was to evaluate the relationship between maintenance immunosuppression, subclinical tubulo-interstitial inflammation and interstitial fibrosis/tubular atrophy (IF/TA) in surveillance biopsies performed in low immunological risk renal transplants at two transplant centers. The Barcelona cohort consisted of 109 early and 66 late biopsies in patients receiving high tacrolimus (TAC-C0 target at 1-year 6-10 ng/ml) and reduced MMF dose (500 mg bid at 1-year). The Oslo cohort consisted of 262 early and 237 late biopsies performed in patients treated with low TAC-C0 (target 3-7 ng/ml) and standard MMF dose (750 mg bid). Subclinical inflammation, adjusted for confounders, was associated with low TAC-C0 in the early (OR: 0.75, 95% CI: 0.61-0.92; P = 0.006) and late biopsies (OR: 0.69, 95% CI: 0.50-0.95; P = 0.023) from Barcelona. In the Oslo cohort, it was associated with low MMF in early biopsies (OR: 0.90, 95% CI: 0.83-0.98; P = 0.0101) and with low TAC-C0 in late biopsies (OR: 0.77, 95% CI: 0.61-0.97; P = 0.0286). MMF dose was significantly reduced in Oslo between early and late biopsies. IF/TA was not associated with TAC-C0 or MMF dose in the multivariate analysis. Our data suggest that in TAC- and MMF-based regimens, TAC-C0 levels are associated with subclinical inflammation in patients receiving reduced MMF dose.
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Affiliation(s)
- Irina B Torres
- Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Anna V Reisaeter
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Francesc Moreso
- Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Anders Âsberg
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,School of Pharmacy, University of Oslo, Norway
| | - Marta Vidal
- Department of Pathology, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Clara Garcia-Carro
- Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Karsten Midtvedt
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Finn P Reinholt
- Department of Pathology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Helge Scott
- Department of Pathology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Eva Castellà
- Department of Radiology, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Maite Salcedo
- Department of Pathology, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Christina Dörje
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Joana Sellarés
- Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria A Azancot
- Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manel Perello
- Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Hallvard Holdaas
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Daniel Serón
- Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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Abstract
All causes of renal allograft injury, when severe and/or sustained, can result in chronic histological damage of which interstitial fibrosis and tubular atrophy are dominant features. Unless a specific disease process can be identified, what drives interstitial fibrosis and tubular atrophy progression in individual patients is often unclear. In general, clinicopathological factors known to predict and drive allograft fibrosis include graft quality, inflammation (whether "nonspecific" or related to a specific diagnosis), infections, such as polyomavirus-associated nephropathy, calcineurin inhibitors (CNI), and genetic factors. The incidence and severity of chronic histological damage have decreased substantially over the last 3 decades, but it is difficult to disentangle what effects individual innovations (eg, better matching and preservation techniques, lower CNI dosing, BK viremia screening) may have had. There is little evidence that CNI-sparing/minimization strategies, steroid minimization or renin-angiotensin-aldosterone system blockade result in better preservation of intermediate-term histology. Treatment of subclinical rejections has only proven beneficial to histological and functional outcome in studies in which the rate of subclinical rejection in the first 3 months was greater than 10% to 15%. Potential novel antifibrotic strategies include antagonists of transforming growth factor-β, connective tissue growth factor, several tyrosine kinase ligands (epidermal growth factor, platelet-derived growth factor, vascular endothelial growth factor), endothelin and inhibitors of chemotaxis. Although many of these drugs are mainly being developed and marketed for oncological indications and diseases, such as idiopathic pulmonary fibrosis, a number may hold promise in the treatment of diabetic nephropathy, which could eventually lead to applications in renal transplantation.
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Affiliation(s)
- Thomas Vanhove
- 1 Department of Microbiology and Immunology, KU Leuven-University of Leuven, Leuven, Belgium. 2 Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium. 3 Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
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Einecke G, Reeve J, Halloran PF. Hyalinosis Lesions in Renal Transplant Biopsies: Time-Dependent Complexity of Interpretation. Am J Transplant 2017; 17:1346-1357. [PMID: 27873464 DOI: 10.1111/ajt.14136] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 10/28/2016] [Indexed: 01/25/2023]
Abstract
Because calcineurin inhibitor (CNI) immunosuppressive drugs induce arteriolar hyalinosis (ah) in kidney transplants, ah lesions can potentially provide information about drug exposure. We studied the relationship of ah lesions to findings and outcomes in 562 indication biopsies taken 3 days to 35 years after transplant. Prevalence of ah lesions increased with time of biopsy after transplant (TxBx). The ah scores correlated with arterial intimal thickening and atrophy-fibrosis but, unlike atrophy-fibrosis, did not increase until after 500 days because of a background of ah1 lesions in early biopsies reflecting donor aging. Correlation of ah scores with other features varied with TxBx-in early biopsies, donor age and related changes, and in very late biopsies, chronic antibody-mediated rejection and glomerulonephritis and associated lesions. After correction for TxBx, ah0 in intermediate time periods was associated with increased risk of T cell-mediated rejection and graft loss, probably because of underimmunosuppression and nonadherence. Thus, ah lesions in indication biopsies have multiple associations: donor age (early, usually ah1), chronic glomerular diseases (late, often ah2/3), and adequate exposure to CNIs at intermediate times. This threefold TxBx-dependent complexity must be considered when interpreting indication biopsies: ah lesions often indicate adequate CNI exposure, not toxicity, and unexpected ah0 should increase vigilance for nonadherence and underimmunosuppression.
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Affiliation(s)
- G Einecke
- Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - J Reeve
- Alberta Transplant Applied Genomics Centre, Edmonton, AB, Canada.,Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - P F Halloran
- Alberta Transplant Applied Genomics Centre, Edmonton, AB, Canada.,Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada.,Division of Nephrology and Transplant Immunology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Baffour FI, Hickson LJ, Stegall MD, Dean PG, Gunderson TM, Atwell TD, Kurup AN, Schmitz JJ, Park WD, Schmit GD. Effects of Aspirin Therapy on Ultrasound-Guided Renal Allograft Biopsy Bleeding Complications. J Vasc Interv Radiol 2016; 28:188-194. [PMID: 27993506 DOI: 10.1016/j.jvir.2016.10.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 10/20/2016] [Accepted: 10/21/2016] [Indexed: 02/01/2023] Open
Abstract
PURPOSE To determine if patient aspirin exposure and timing affect bleeding risk after renal allograft biopsy. MATERIALS AND METHODS Review of 6,700 renal allograft biopsies (in 2,362 unique patients) was performed. Median patient age was 53.0 years [interquartile range 43.0, 62.0]; 56.2% of patients were male. Of biopsies, 4,706 (70.2%) were performed in patients with no aspirin exposure within 10 days of biopsy; 664 (9.9%), were performed within 8-10 days of aspirin exposure; 855 (12.8%), within 4-7 days; and 475 (7.1%), within 0-3 days. Follow-up to 3 months after the procedure was completed in all patients. Biopsies were categorized as protocol or indication; 19.7% were indication biopsies. Bleeding complications were graded based on SIR criteria. Logistic regression models examined the association between aspirin use and bleeding events. RESULTS Rate [95% confidence interval] of major bleeding complications was 0.24% [0.14, 0.39], and rate of any bleeding complication was 0.66% [0.46, 0.90]. Bleeding events were significantly associated with patients undergoing indication biopsies compared with protocol biopsies (odds ratio [OR] 2.27, P = .012). Patient factors associated with major bleeding complications in multivariate models included estimated glomerular filtration rate (OR 0.61, P = .016) and platelet count (OR 0.64, P = .033). Aspirin use was not significantly associated with increased risk of bleeding complication except for use of 325 mg of aspirin within 3 days of biopsy (any complication OR 3.87 [1.12, 13.4], P = .032; major complication OR 6.30 [1.27, 31.3], P = .024). CONCLUSIONS Renal allograft biopsy bleeding complications are very rare, particularly for protocol biopsies. Use of 325 mg of aspirin within 3 days of renal allograft biopsy was associated with increased bleeding complications.
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Affiliation(s)
| | - LaTonya J Hickson
- Division of Nephrology and Hypertension, 200 First Street SW, Rochester, MN 55905
| | - Mark D Stegall
- Department of Medicine, Division of Transplant Surgery, 200 First Street SW, Rochester, MN 55905
| | - Patrick G Dean
- Department of Medicine, Division of Transplant Surgery, 200 First Street SW, Rochester, MN 55905
| | - Tina M Gunderson
- Department of Surgery, Division of Biomedical Statistics and Informatics, 200 First Street SW, Rochester, MN 55905
| | - Thomas D Atwell
- Division of Ultrasound, 200 First Street SW, Rochester, MN 55905
| | - A Nicholas Kurup
- Division of Ultrasound, 200 First Street SW, Rochester, MN 55905
| | - John J Schmitz
- Division of Abdominal Imaging, 200 First Street SW, Rochester, MN 55905
| | - Walter D Park
- Division of Surgery Research Services, 200 First Street SW, Rochester, MN 55905; Department of Health Sciences Research, and William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Grant D Schmit
- Division of Abdominal Imaging, 200 First Street SW, Rochester, MN 55905
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41
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Affiliation(s)
- Rainer Oberbauer
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
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42
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Early Kidney Allograft Dysfunction (Threatened Allograft): Comparative Effectiveness of Continuing Versus Discontinuation of Tacrolimus and Use of Sirolimus to Prevent Graft Failure: A Retrospective Patient-Centered Outcome Study. Transplant Direct 2016; 2:e98. [PMID: 27795990 PMCID: PMC5068206 DOI: 10.1097/txd.0000000000000585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/14/2016] [Indexed: 12/02/2022] Open
Abstract
Supplemental digital content is available in the text. Background Due to lack of treatment options for early acute allograft dysfunction in the presence of tubular-interstitial injury without histological features of rejection, kidney transplant recipients are often treated with sirolimus-based therapy to prevent cumulative calcineurin inhibitor exposure and to prevent premature graft failure. Methods We analyzed transplant recipients treated with sirolimus-based (n = 220) compared with continued tacrolimus-based (n = 276) immunosuppression in recipients of early-onset graft dysfunction (threatened allograft) with the use of propensity score-based inverse probability treatment weighted models to balance for potential confounding by indication between 2 nonrandomized groups. Results Weighted odds for death-censored graft failure (odds ratio [OR], 1.20; 95% confidence interval [95% CI], 0.66-2.19, P = 0.555) was similar in the 2 groups, but a trend for increased risk of greater than 50% loss in estimated glomerular filtration rate from baseline in sirolimus group (OR, 1.90; 95% CI, 0.96-3.76; P = 0.067) compared with tacrolimus group. Sirloimus group compared with tacrolimus group had increased risk for death with functioning graft (OR, 2.01; 95% CI, 1.29-3.14; P = 0.002) as well as increased risk of late death (death after graft failure while on dialysis) (OR, 2.39; 95% CI, 1.59-3.59; P < 0.001). Analysis of subgroups based on the absence or presence of T cell–mediated rejection or tubulointerstitial inflammation in the index biopsy, or the use of different types of induction agents, and all subgroups had increased risk of death with functioning graft and late death if exposed to sirolimus-based therapy. Conclusions Use of sirolimus compared with tacrolimus in recipients with early allograft dysfunction during the first year of transplant may not prevent worsening of allograft function and could potentially lead to poor survival along with increased risk of late death.
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O'Connell PJ, Zhang W, Menon MC, Yi Z, Schröppel B, Gallon L, Luan Y, Rosales IA, Ge Y, Losic B, Xi C, Woytovich C, Keung KL, Wei C, Greene I, Overbey J, Bagiella E, Najafian N, Samaniego M, Djamali A, Alexander SI, Nankivell BJ, Chapman JR, Smith RN, Colvin R, Murphy B. Biopsy transcriptome expression profiling to identify kidney transplants at risk of chronic injury: a multicentre, prospective study. Lancet 2016; 388:983-93. [PMID: 27452608 PMCID: PMC5014570 DOI: 10.1016/s0140-6736(16)30826-1] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic injury in kidney transplants remains a major cause of allograft loss. The aim of this study was to identify a gene set capable of predicting renal allografts at risk of progressive injury due to fibrosis. METHODS This Genomics of Chronic Allograft Rejection (GoCAR) study is a prospective, multicentre study. We prospectively collected biopsies from renal allograft recipients (n=204) with stable renal function 3 months after transplantation. We used microarray analysis to investigate gene expression in 159 of these tissue samples. We aimed to identify genes that correlated with the Chronic Allograft Damage Index (CADI) score at 12 months, but not fibrosis at the time of the biopsy. We applied a penalised regression model in combination with permutation-based approach to derive an optimal gene set to predict allograft fibrosis. The GoCAR study is registered with ClinicalTrials.gov, number NCT00611702. FINDINGS We identified a set of 13 genes that was independently predictive for the development of fibrosis at 1 year (ie, CADI-12 ≥2). The gene set had high predictive capacity (area under the curve [AUC] 0·967), which was superior to that of baseline clinical variables (AUC 0·706) and clinical and pathological variables (AUC 0·806). Furthermore routine pathological variables were unable to identify which histologically normal allografts would progress to fibrosis (AUC 0·754), whereas the predictive gene set accurately discriminated between transplants at high and low risk of progression (AUC 0·916). The 13 genes also accurately predicted early allograft loss (AUC 0·842 at 2 years and 0·844 at 3 years). We validated the predictive value of this gene set in an independent cohort from the GoCAR study (n=45, AUC 0·866) and two independent, publically available expression datasets (n=282, AUC 0·831 and n=24, AUC 0·972). INTERPRETATION Our results suggest that this set of 13 genes could be used to identify kidney transplant recipients at risk of allograft loss before the development of irreversible damage, thus allowing therapy to be modified to prevent progression to fibrosis. FUNDING National Institutes of Health.
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Affiliation(s)
- Philip J O'Connell
- Renal Unit, University of Sydney at Westmead Hospital, Sydney, NSW, Australia
| | - Weijia Zhang
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Madhav C Menon
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Zhengzi Yi
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bernd Schröppel
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lorenzo Gallon
- Department of Medicine-Nephrology and Surgery-Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Yi Luan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ivy A Rosales
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yongchao Ge
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bojan Losic
- Department of Genetics and Genomic Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Caixia Xi
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher Woytovich
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Karen L Keung
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Chengguo Wei
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ilana Greene
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jessica Overbey
- Department of Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emilia Bagiella
- Department of Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nader Najafian
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Milagros Samaniego
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI, USA
| | - Stephen I Alexander
- Discipline of Child & Adolescent Health, The Children's Hospital at Westmead Clinical School, The University of Sydney, NSW, Australia
| | - Brian J Nankivell
- Renal Unit, University of Sydney at Westmead Hospital, Sydney, NSW, Australia
| | - Jeremy R Chapman
- Renal Unit, University of Sydney at Westmead Hospital, Sydney, NSW, Australia
| | - Rex Neal Smith
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert Colvin
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Barbara Murphy
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Abstract
As both T cell and antibody-mediated rejection can have a subclinical phase, protocol biopsies provide an early opportunity to intervene before the onset of clinical allograft dysfunction. Protocol biopsies are usually done after reperfusion to establish baseline, between 3 and 6 months to identify subclinical rejection, and at 6-12 months to assess chronicity and persistent inflammation that have prognostic implication. Treatment of both subclinical T cell and antibody-mediated rejection prevents progression of rejection and development of interstitial fibrosis/tubular atrophy or transplant glomerulopathy. Although subclinical rejection has become less frequent in low-risk patients on triple immunosuppression containing tacrolimus, protocol biopsies may still be useful in selected population. Protocol biopsies are more likely to benefit patients at higher risk for rejection, including those who are highly sensitized, transplanted across donor-specific antibody barriers, or on calcineurin inhibitor/corticosteroids sparing regimens. Interstitial fibrosis on protocol biopsies, especially in conjunction with persistent inflammation, predicts lower allograft survival.
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Rose EM, Kennedy SE, Mackie FE. Surveillance biopsies after paediatric kidney transplantation: A review. Pediatr Transplant 2016; 20:748-55. [PMID: 27306873 DOI: 10.1111/petr.12733] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/11/2016] [Indexed: 11/28/2022]
Abstract
Kidney transplantation is the most effective means of treating children with end-stage kidney disease, and yet, there continues to be a limited "life span" of transplanted kidneys in paediatric recipients. Early graft monitoring, using the surveillance biopsy, has the potential to extend renal allograft survival in paediatric recipients. The surveillance biopsy provides important and timely information about acute and chronic graft pathology, particularly SCR and calcineurin inhibitor-induced nephrotoxicity, which can subsequently guide management decisions and improve long-term graft survival. The ostensible value of the surveillance biopsy is furthered by the limitations of conventional renal functional studies. However, there is still much debate surrounding the surveillance biopsy in paediatric recipients, particularly in regard to its overall utility, safety and timing. This review discusses the current literature regarding the utility, safety, and potential predictive value of surveillance biopsies for guiding post-transplant management in paediatric renal allograft recipients, as well as the viability of other potentially newer non-invasive strategies for renal allograft monitoring.
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Affiliation(s)
- Edward M Rose
- School of Women's & Children's Health, UNSW Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Sean E Kennedy
- School of Women's & Children's Health, UNSW Medicine, University of New South Wales, Sydney, NSW, Australia.,Nephrology, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Fiona E Mackie
- School of Women's & Children's Health, UNSW Medicine, University of New South Wales, Sydney, NSW, Australia.,Nephrology, Sydney Children's Hospital, Randwick, NSW, Australia
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Sosa Peña MDP, Lopez-Soler R, Melendez JA. Senescence in chronic allograft nephropathy. Am J Physiol Renal Physiol 2016; 315:F880-F889. [PMID: 27306980 DOI: 10.1152/ajprenal.00195.2016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Despite increasing numbers of patients on dialysis, the numbers of renal transplants performed yearly have remained relatively static. During the last 50 years, there have been many advances in the pharmacology of prevention of organ rejection. However, most patients will suffer from a slow but steady decline in renal function leading to graft loss. The most common cause of long-term graft loss is chronic allograft nephropathy (CAN). Therefore, elucidating and understanding the mechanisms involved in CAN is crucial for achieving better posttransplant outcomes. It is thought that the development of epithelial to mesenchymal transition (EMT) in proximal tubules is one of the first steps towards CAN, and has been shown to be a result of cellular senescence. Cells undergoing senescence acquire a senescence associated secretory phenotype (SASP) leading to the production of interleukin-1 alpha (IL-1α), which has been implicated in several degenerative and inflammatory processes including renal disease. A central mediator in SASP activation is the production of reactive oxygen species (ROS), which are produced in response to numerous physiological and pathological stimuli. This review explores the connection between SASP and the development of EMT/CAN in an effort to suggest future directions for research leading to improved long-term graft outcomes.
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Affiliation(s)
| | - Reynold Lopez-Soler
- Albany Medical Center, Department of Surgery, Division of Transplantation, Albany, New York
| | - J Andrés Melendez
- SUNY Polytechnic Institute, Colleges of Nanoscale Science and Engineering, Albany, New York
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Dörje C, Reisaeter AV, Dahle DO, Mjøen G, Midtvedt K, Holdaas H, Flaa-Johnsen L, Syversveen T, Hartmann A, Jenssen T, Scott H, Reinholt FP. Total inflammation in early protocol kidney graft biopsies does not predict progression of fibrosis at one year post-transplant. Clin Transplant 2016; 30:802-9. [PMID: 27101801 DOI: 10.1111/ctr.12753] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2016] [Indexed: 11/26/2022]
Abstract
INTRODUCTION There is an uncertainty whether total inflammation in early protocol kidney graft biopsies is associated with fibrosis progression. We investigated whether total inflammation, both in fibrotic and non-fibrotic areas, at week 6 would predict fibrosis progression at one yr post-transplant. METHODS We included 156 single adult ABO compatible kidney recipients with adequate week 6 and one yr transplant protocol biopsies (312 biopsies). Biopsies were scored according to the current Banff criteria. In addition, fibrosis and inflammation in fibrotic and non-fibrotic areas were scored in a 10-grade semi-quantitative eyeballing system from 0% to 100%. RESULTS Fibrosis increased significantly from week 6 to one yr both by the 10-grade scoring system from 0.69 ± 1.07 to 1.45 ± 1.86, (mean ± SD), p < 0.001 and by Banff interstitial fibrosis (ci) scoring 0.81 ± 0.65 to 1.13 ± 0.87, p < 0.001. The 10-grade scoring system detected a larger proportion of fibrosis progressors than the Banff scoring 40.4% vs. 35.5%, p < 0.001. No significant positive association was found between inflammation at week 6 and progression of fibrosis in either of the scoring systems. CONCLUSIONS Total inflammation in kidney transplant biopsies at week 6 did not predict progression of fibrosis at one yr post-transplant.
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Affiliation(s)
- Christina Dörje
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Dag Olav Dahle
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Geir Mjøen
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Karsten Midtvedt
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Hallvard Holdaas
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Linda Flaa-Johnsen
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Anders Hartmann
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Trond Jenssen
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,Metabolic and Renal Research Group, UiT, The Arctic University of Norway, Tromsø, Norway
| | - Helge Scott
- Department of Pathology, Oslo University Hospital, Rikshospitalet, University of Oslo, Oslo, Norway
| | - Finn P Reinholt
- Department of Pathology, Oslo University Hospital, Rikshospitalet, University of Oslo, Oslo, Norway
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48
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Gonzales MM, Bentall A, Kremers WK, Stegall MD, Borrows R. Predicting Individual Renal Allograft Outcomes Using Risk Models with 1-Year Surveillance Biopsy and Alloantibody Data. J Am Soc Nephrol 2016; 27:3165-3174. [PMID: 26961348 DOI: 10.1681/asn.2015070811] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 01/11/2016] [Indexed: 11/03/2022] Open
Abstract
The ability to predict outcomes for individual patients would be a significant advance for not only counseling, but also identifying those for whom interventions may be needed. The goals of this study were to validate an existing risk prediction score that incorporates easily obtainable clinical factors and determine if histologic findings at 1-year surveillance biopsy and/or serum donor-specific alloantibody status could improve predictability of graft loss by 5 years. We retrospectively studied 1465 adults who received a solitary kidney transplant between January of 1999 and December of 2008 and had sufficiently detailed 5-year follow-up data for modeling. In this cohort, the Birmingham risk model (incorporating recipient factors at 1 year, including age, sex, ethnicity, renal function, proteinuria, and prior acute rejection) predicted death-censored and overall graft survival (c statistics =0.84 and 0.78, respectively). The presence of glomerulitis or chronic interstitial fibrosis (g and ci scores by Banff, respectively) on 1-year biopsy specimens independently correlated with graft loss by 5 years. Adding these variables to the model for death-censored graft loss increased predictability (c statistic =0.90), improved calibration (ability to stratify risk from high to low), and reclassified risk of failure in 29% of patients. Adding the presence of donor-specific alloantibody at 1 year did not improve predictability or reclassification but did improve calibration marginally. We conclude that, at 1 year after kidney transplant, a risk model of graft survival that incorporates clinical factors and histologic findings at surveillance biopsy is highly predictive of individual risk and well calibrated.
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Affiliation(s)
- Manuel Moreno Gonzales
- Division of Transplantation Surgery, William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Andrew Bentall
- Department of Renal Medicine, Queen Elizabeth Hospital, Birmingham, United Kingdom; and.,School of Immunity and Infection, University of Birmingham, Birmingham, United Kingdom
| | - Walter K Kremers
- Division of Transplantation Surgery, William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Mark D Stegall
- Division of Transplantation Surgery, William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota;
| | - Richard Borrows
- Department of Renal Medicine, Queen Elizabeth Hospital, Birmingham, United Kingdom; and.,School of Immunity and Infection, University of Birmingham, Birmingham, United Kingdom
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Taner T, Heimbach JK, Rosen CB, Nyberg SL, Park WD, Stegall MD. Decreased chronic cellular and antibody-mediated injury in the kidney following simultaneous liver-kidney transplantation. Kidney Int 2016; 89:909-17. [PMID: 26924059 DOI: 10.1016/j.kint.2015.10.016] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 09/28/2015] [Accepted: 10/22/2015] [Indexed: 12/12/2022]
Abstract
In simultaneous liver-kidney transplantation (SLK), the liver can protect the kidney from hyperacute rejection and may also decrease acute cellular rejection rates. Whether the liver protects against chronic injury is unknown. To answer this we studied renal allograft surveillance biopsies in 68 consecutive SLK recipients (14 with donor-specific alloantibodies at transplantation [DSA+], 54 with low or no DSA, [DSA-]). These were compared with biopsies of a matched cohort of kidney transplant alone (KTA) recipients (28 DSA+, 108 DSA-). Overall 5-year patient and graft survival was not different: 93.8% and 91.2% in SLK, and 91.9% and 77.1% in KTA. In DSA+ recipients, KTA had a significantly higher incidence of acute antibody-mediated rejection (46.4% vs. 7.1%) and chronic transplant glomerulopathy (53.6% vs. 0%). In DSA- recipients at 5 years, KTA had a significantly higher cumulative incidence of T cell-mediated rejection (clinical plus subclinical, 30.6% vs. 7.4%). By 5 years, DSA+ KTA had a 44% decline in mean GFR while DSA+SLK had stable GFR. In DSA- KTA, the incidence of a combined endpoint of renal allograft loss or over a 50% decline in GFR was significantly higher (20.4% vs. 7.4%). Simultaneously transplanted liver allograft was the most predictive factor for a significantly lower incidence of cellular (odds ratio 0.13, 95% confidence interval 0.06-0.27) and antibody-mediated injury (odds ratio 0.11, confidence interval 0.03-0.32), as well as graft functional decline (odds ratio 0.22, confidence interval 0.06-0.59). Thus, SLK is associated with reduced chronic cellular and antibody-mediated alloimmune injury in the kidney allograft.
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Affiliation(s)
- Timucin Taner
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA.
| | - Julie K Heimbach
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Charles B Rosen
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Scott L Nyberg
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Walter D Park
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark D Stegall
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
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50
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Venner JM, Famulski KS, Reeve J, Chang J, Halloran PF. Relationships among injury, fibrosis, and time in human kidney transplants. JCI Insight 2016; 1:e85323. [PMID: 27699214 DOI: 10.1172/jci.insight.85323] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Kidney transplant biopsies offer an opportunity to understand the pathogenesis of organ fibrosis. We studied the relationships between the time of biopsy after transplant (TxBx), histologic fibrosis, diseases, and transcript expression. METHODS Expression microarrays from 681 kidney transplant indication biopsies taken either early (n = 282, <1 year) or late (n = 399, >1 year) after transplant were used to analyze the molecular landscape of fibrosis in relationship to histologic fibrosis and diseases. RESULTS Fibrosis was absent at transplantation but was present in some early biopsies by 4 months after transplant, apparently as a self-limited response to donation implantation injury not associated with progression to failure. The molecular phenotype of early biopsies represented the time sequence of the response to wounding: immediate expression of acute kidney injury transcripts, followed by fibrillar collagen transcripts after several weeks, then by the appearance of immunoglobulin and mast cell transcripts after several months as fibrosis appeared. Fibrosis in late biopsies correlated with injury, fibrillar collagen, immunoglobulin, and mast cell transcripts, but these were independent of time. Pathway analysis revealed epithelial response-to-wounding pathways such as Wnt/β-catenin. CONCLUSION Fibrosis in late biopsies had different associations because many kidneys had potentially progressive diseases and subsequently failed. Molecular correlations with fibrosis in late biopsies were independent of time, probably because ongoing injury obscured the response-to-wounding time sequence. The results indicate that fibrosis in kidney transplants is driven by nephron injury and that progression to failure reflects continuing injury, not autonomous fibrogenesis. TRIAL REGISTRATION INTERCOM study (www.clinicalTrials.gov; NCT01299168). FUNDING Canada Foundation for Innovation and Genome Canada.
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Affiliation(s)
- Jeffery M Venner
- Alberta Transplant Applied Genomics Centre, Edmonton, Alberta, Canada.,Department of Medicine, Division of Nephrology and Transplant Immunology, Edmonton, Alberta, Canada
| | - Konrad S Famulski
- Alberta Transplant Applied Genomics Centre, Edmonton, Alberta, Canada.,Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Jeff Reeve
- Alberta Transplant Applied Genomics Centre, Edmonton, Alberta, Canada.,Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Jessica Chang
- Alberta Transplant Applied Genomics Centre, Edmonton, Alberta, Canada
| | - Philip F Halloran
- Alberta Transplant Applied Genomics Centre, Edmonton, Alberta, Canada.,Department of Medicine, Division of Nephrology and Transplant Immunology, Edmonton, Alberta, Canada
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